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Full text of "Year-Book of Treatment; a critical review for practitioners of medicine and surgery"

THE 

YEAR-BOOK OF 
TREATM ENT 
For 18 98. 




A Ration al Dietary fo r Infants. 



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JFor^-s-BETHNAL Green, E. city House-vZovG-a Court. Lombard Street E C 

SwA/"^:7/?C,f7,7""' "^ '"';';^""'- a" -^«-'--'«-LoNovrAND™KrER.T;D; 



DR. RENNER'S ESTABLISHMENT 



■V A. C C 1 3V A.T I O 3V 



CALF LYMPH, 

186, MARYLEBONE ROAD, LONDON, N.W. 



TUBES 



PRICE OF CALF LYMPH. 

[Large 2s. each, or 3 for 5s. 6d. 

I Small Is. each, or 3 for 2s. 9d. 

[ SuflB.cient for One Vaccination only : 

2 for Is., or 6 for 2s. 9d. 
SQUARES 2s. 6d. each. 

Registered Telegraj^hic Address : " Vaccine, London." 
Sent on receipt of remittance addressed to the Manager of the Establishment. 





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JMATURAL 


•POTASH/^fi 
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^^^^ waters'^ ^^ 

These are the best Mineral Waters for mixing with Brandy or Whisky. 

Bottled at the famous Malvern Springs, 

A real security against bad or doubtful Water. 



Address — 



W. & J. BURROW, THE SPRINGS, MALVERN. 

Telegrams—" SPRINGS, MALVERN." 



ADVERTISEMENTS, 



A 

DELICIOUS 
FAT 




GOD LIVER OIL 

WITHOUT ITS 
DISAGREEABLE 



" Maltine " with 

Cod Liver Oil 

compared with 

Emulsions. 



FOOD. With Cod Liver Oil FEATURES. 



Contains a satisfactory proi)ortion of the best Cud Liver Oil rendered 
easy of assimilation and acceptable to the palate by perfect incor- 
poration with a palatable, digestive food — " ^Ialtink." The question 
of a " substitute for Cod Liver Oil " (which has not yet been satis- 
factorily settled) need not disturb the physician who prescribes 
" Maltine " with Cod Liver Oil. It is not only the most palatable 
and digestible Fat-Food, but it contains the .specific properties of 
Cod Liver Oil, deprived of all disagreeable features, though un- 
altered as regards chemical constitution. This 
last is a most important point, and differentiates 
" iMaltine " with Cod Liver Oil unmistakably 
from the various Emulsions of Cod Liver Oil. As 
is well known, the method of procedure in their 
case is to saponify the oil with an alkali. The result of this chemical 
treatment is to completely change the characteristics of the oil and, 
probably, to destroy some of its most important factors. These emul- 
sions, too, are broken up by the addition of acid, and consequently, 
when acted upon by the gastric juice, the oil is liberated, giving rise 
to all the inconveniences that follow the ingestion of the plain oil. 

The union of the oil with the " Maltine " is effected 
"1ilaltoe"^with ^^ ^ special mechanical process. The combination is 
Cod Liver Oil. stable, being unaffected by acid or alkaline reagents. 
The chemical constitution of the oil is unaltered. 
It is the most palatable preparation of Cod Liver Oil. It never 
occasions the slightest inconvenience but, on the contrary, is readily 
tolerated and appears to be thoroughly assimilated. 

The various advantages of " Maltine " with Cod Liver Oil have 
secured for it the general support of medical men, who can confirm 
from their own experience the dictum of the British Medical Journal : 



"Patients unable to tolerate the purest and most carefully prepared Cod 
Liver Oil can readily digest and assimilate it when combined with 'Jlaltine.'" 



In prescribing please specify "MALTINE COMPANY." 
Sample Bottles free and carriage paid to Medical Men. 



THE lALTINE MAMACTURIIG CO., L^^- 

24 and 25, Hart Street, Bloonishiiry, London. 

c 



ADVERTISEMENTS. 



The Latest Improvement in Trusses. 




WM. COLES & CO, 

INVENTORS AND MAKERS 

OF THE 

Spiral Spring 
Truss. 

225, PICCADILLY, LONDON, W. (late 3, Charing Cross), 

Two Doors from ^^ The Criterion." 
PARTICULARS, &c., GRATIS BY POST. 

Established 1819. 



BRIDGES' EMULSION 

OF PURE GOD LIVER OIL, 

WITH LACTOPHOSPHATES. 



Synonym : Einidsio 01. Morrhuce cum Lactophosph. (Bridges.) 

Containing 50 per cent, of Pure Cod Liver Oil with a medium 
dose of the Lactophosphates of Lime and Soda. The agreeable 
taste and digestive properties of this Emulsion enable chikh'en and 
delicate patients to easily assimilate it, and it has been success- 
fully presciibed by eminent Physicians where all other preparations 
of Cod Liver Oil have disagreed. Physician's sample bottle sent 
free on application. May be obtained through any Chemist, or 
from the Sole Manufacturer — [Price, 2/6 per bot. 



PHARMACEUTICAL CHEMIST, 

24, SLOANE STREET, LONDON. 



ADVERTISEMENTS. 




erums and 



o 

O 

o 



Telephone Humber :— " HOLBORN, 601." 

Cable & Telegrpphic Address:— "BURCOMB, lONDON." 



Serum-therapy. 



THE great expansion of serum-therapy is one 
of the most remarkable characteristics of 
modern medicine. Burroughs Wellcome and 
Co. have been from the first intimately associated 
with the development and application of modern 
knowledge of micro-organisms to the production 
of therapeutic serums. 

The Wellcome Physiological 

Laboratories ensure promptness of supply and a 
reliability which has been widely appreciated. 

LIST OF THERAPEUTIC SERUMS. 

AntUdiphtheria Serum (B. W. & Co.), Liquid or 
Dried. In phials or tubes containing ISOOBehn'ng 
immunity units •• •• .. .. ..1/- each. 

Anti^streptococcus Serum (B. W. & Co.), Liquid 
or Dried. In 10 c.c. phials, or in tubes containing 
the equivalent of 1 c.c 2/6 each. 

Anti=tetanus Serum, Liquid. In phials containing 

10 c.c. 6/- each. 

Anti==tetanus Serum, Dried. In tubes containing 

the equivalent of 10 c.c 10/- each. 

Anti=typhoid Serum (B. W. & Co.), Liquid or 
Dried. In 10 c.c. phials, or in tubes containing 
the equivalent of 1 c.c 5/- each. 

Anti=venom Serum, Liquid. In 10 c.c. phials .. 5/- each. 

All the B. W. & Co. Serums bear the signature of the medical expert 
under whose immediate personal direction they are prepared and tested. 

The B. W. & Co. Serum Syringe, for use with all serums, is 

supplied in two sizes — 10 c.c. and 5 c.c. — at 25s. each, in metal 

case with two special platino-iridium needles. 

Clinical reports and serum pamphlet forwarded on request. 
Orders will be executed immediately on receipt of letter or telegram. 



Burroughs Wellcome and Co., 
Snow Hill Buildlngs, London, 
AND 108, Pitt Street, Sydney. 

F 40 



ADVERTISEMENTS. 




roiiiilis Wellcome & Co., 

London and Sydney. 



ADVERTISEMENTS. 



^^^^^dt^^^ 




ORGANO-THERAPY. 

N THE PRACTICE of organo-therapy Burroughs 
Wellcome and Co. have always strenuously 
advocated the employment of the whole gland 
substance until clinical evidence should fully 
demonstrate the possibility of isolating the 
active principles without deterioration. The 
wonderful results of cases treated with 'Tab- 
loid' Thyroid Gland Substance as reported in the medical journals 
during the last few months again confirm this general principle. 
Such articles, however, as that in the British Medical Journal of 
October 2, 1897, on the treatment of obesity, justify the hope thac 
'Tabloid' Thyroid Colloid Substance marks a further advance, and 
will be found of great value in this disease. 

The following 'Tabloid' Animal Substances can now be supplied. 
Whilst definite therapeutic action has been assigned to some of 
these, others are still the subjects of clinical research. 'Tabloid' 
Lymphatic, Mammary, Pineal, Prostate, Pituitary, Salivary, Supra- 
renal, Thymus, and Thyroid Gland Substances; Thyroid Colloid, 
Uterine Wall, Spleen, Spinal Cord, Pancreas and Ovarian Substances ; 
Bone-Marrow, Cerebrinin, Didymin, Ox-Bile, Pig-Bile, and Residuum 
Rubrum (Arterial and Venous). 



Burroughs Wellcome and Co., london and Sydney. 



%^ ^^ <i^ 



ADVERTISEM ENTS. 




AOVKini.SKMKNTS. 



MIDGLEY'S ENGLISH - MADE 

MEDICATED SOAPS. 

These Soaps are used by all the leading Dermatologists. 



EXTRACT from the "YEAR-BOOK OF TREATMENT" for 1896:- 

" CliAiUvKS MiDGLEY, (>[ Muiicliustcr, has eanioil the gratitude of the 
Medicril Profession of Eni^land by his enterprise in supply inu; MEDICATED 
iSOAl'S— the vahie of which in the treatment of Skin Diseases is now 
generally recon-nised-— of native manufacture. 

" Hitlierto Medicated Soaps have had to be procuroil from abroad, at 
considoraljle expense, and their quality has had to be taken largely on trust. 
Mr. IVIidgley now supplies Medicated Soaps, vv'hich, wliile fully of]iia] in quality 
to the products of the foreign manufacturer, are considerably cheaper." 



Alkaline Base. ' 


Superfatted Base. 


Ichthyol and Sulphur. 


White Rose. 


Ichthyol and Tar. 


Sulphur. 


White Heliotrope. 


Menthol. 


„ and Marble 


Sulphur. 


and Eucalyptus 


Sand. 


Ichthyol. 


Naphthol and Sulphur. 


Marble Sand. 


Birch Tar and Sulphur. 


Sulphur Camphor. 


White Birch Tar. 


Sublimate. 


and Bals. Peru 


Boracic Acid. i 


Eucalyptol. 


Thymol. 


Silicon. 


Creolin. 


White Precipitate. 



Most of these are prepared in a powdered form in Is. hottles. 



Medicated BATH POWDERS. 

These are introduced as a cleanly, convenient, and rapid method of 
preparing Emollient and Medicated Baths for use in the treatment of 
Diseases of the Skin. 

By means of these Powders a Medicated Bath can at once be prepared 
by patient, nurse, or any untrained assistant. 

The Emollient Bath Powder, Plain. This is also prepared in con- 
junction with the following medicaments :— 

Sulphur. 

Camohor and 
Carbolic Acid. 
„ „ and Menthol. 

Other coiabinations can he prepared upon iiigl ructions receiccd from any mernher of 
the Medical profession.. 

List and Prices sent on application. 



White Birch Tar. 
„ „ „ and 
Sulphur. 
Pine Extract. 



Resorcin. 

,, and Sulphur, 
Sublimate. 
Ichthyol. 



PREPARED BY 

CHARLES MIDGLEY Ltd., Dispensing Chemists, 

23, ST. ANN'S SQUAHE, M ANClIESTEIi. 

Wholesale Agents— EDWARDS & SON, 167, Queen Yictori.a Street, Loudon; EVANS, 
SONS & CO., Hanover Street, Liverpool; J. WOOLI^EY, SONS & CO., Ltd., Mauchester, 

I 



ADVERTISEMENTS. 



LEWIS'S STANDARD PUBLICATIONS, 



Ringer and Sainsbury's Handbook of Therapeutics. 13th Edition. 16s. 
Lewers' Diseases of Women. 5th Edition. ThowiKjldy Revised. 10s. 6d. 
Swanzy's Diseases of the Eye. Gth Edition. 12.s. Gd. 
Parkes' Hygiene and Public Health, oth Edition. 10s. 6d. 
Abbott's Principles of Bacteriology. 4th Edition. l'2s. 6d. nett. 
Goodall and Washbourn's Infectious Diseases. With Plates. 15s. 
Duhrssen's Manual of Obstetric Practice. 6s. 

Aldersmith's Ringworm and Alopecia Areata. 4th Edition. 10s. 6d. 
Snell's Compressed Air Illness. With Ilhistrations. 10s. 6d. 
Gould's Student's Medical Dictionary. 10th Edition. 14s. )tett. 
Elder's Aphasia and the Cerebral Speech Mechanism. 10s. 6d. 
Roberts' Handbook of Medicine. Oth Edition. 21s. 
Pritchard's Diseases of the Ear. 3rd Edition. With Ilhistrations. 6s. 
Barrett's Dental Surgery. 3rd Edition. With Illustrations. 3s. 6d. 
Carter's Elements of Practical Medicine. 7th Edition. 10s. 
Crocker's Diseases of the Skin. 2nd Edition. With Illustrations. 24s. 
Lusk's Science and Art of Midwifery. 4th Edition. 18s. 
Murrell's What to do in Cases of Poisoning. 8th Edition. 3s. 6d. 
Anderson's Notes on Medical Nursing. 3rd Edition. 2s. 6d. 
Powell's Diseases of the Lungs and Pleurae. 4th Edition. 18s. 
Windle and Manners-Smith's Surface Anatomy. 2nd Edition. 3s. 6d. 
Colman's Section Cutting and Staining. 2nd Edition. 3s. 6d. 
Murray's Rough Notes on Remedies. 2nd Edition. 3s. 6d. 
Harris and Beaie's Pulmonary Consumption. 10s. 6d. 
Corfield's Defective House Sanitation. With Illustrations. 2s. 
Power's Surgical Diseases of Children. With Illustrations. 10s. 6d. 
Jones' Medical Electricity. 2nd Edition. With Illustrations. 10s. 6d. 
Boyce's Text-book of Morbid Histology. Coloured Plates. 31s. 6d. 
Goodhart's Common Neuroses. 2nd Edition. 3s. 6d. 
Parkes' Infectious Diseases, Notification and Prevention. 2s. 6d. 
Duhrssen's Manual of Gynaecological Practice. 6s. 
Onodi's Atlas of the Nasal Cavity. Platos. Gs. nctt. 
Schimmelbusch's Aseptic Treatment of Wounds. 5s. 
Hall's Diseases of the Nose and Throat. With Illustrations. 10s. 6d. 
Buxton's Anaesthetics. 2nd Edition. 5s. 
Wethered's Medical Microscopy. With Illustrations. 9s. 
Lewis's Pocket Medical Vocabulary. 2nd Edition. 3s. Gd. 
Lewis's Temperature Charts. 50s. per 1,000 ; 7s. per 100 ; or Is. per doz. 
Lewis's Nursing Charts. 20 for Is.; 100, 3s. 6d. ; 500, 14s.; 1,000, 2os. 
Lewis's Diet Charts. 5s. per packet of 100 charts (assorted), post free. 
Chart for Recording the Examination of Urine. Is. per 10. 



Cumiilctc Calalo(juc of Mr. Lewis's Publications post /iyc on application. 



LONDON: H. K. LEWIS, 136, GOWER STREET, W.C. 

J 



ADVERTISEMENTS. 



BONTHRON'S 

Diabetic Bread and Biscuits. 

DR. PAVY, in his recent work on "DIABETES," p. 245, says : — 

"Mr. Eontliroii, of 106, Eegent Street, has recently succeeded in producing 
some Gluten ]iiscuit.s and Bread which are more eataVjle than anything of the 
kind I have ever yet met with. The Biscuits jiresent somewhat the character of 
a cracknel ; they eat short and cris]), and are readily reducible in the mouth ; 
have no unpleasant taste ; and, consumed with other food, possess the power of 
cleansing the palate. The Bread is moist, and will keep good for about ten 
days. Its consumption, therefore, involves a frequent supjily. It serves to 
increase the variety at the command of the Diabetic ; and, independently of 
this, possesses the advantage of presenting an approach to the condition of 
ordinary bread." 

The LANCET, under the head of Analytical Records, says :— 
" We have received from the above well-known maker no less than six different 
samples of Biscuits, &c., intended for dietetic treatment. No. 1 is calle<l the 
'Diabetic Biscuit,' and contains much gluten and very little starch. No. 2 is the 
'Eegent Biscuit,' made from gluten and prepared bran. No. 3 is an 'Almond 
Biscuit,' and the rest are modifications of the first two. They are excellent pre- 
parations ; and though, of course, they are not so palatable as if they contained 
the normal quantity of starch, they can be eaten without difficulty or repulsion. 
Indeed, it is not easy to see how they could be improved. " 

The Bread is made fresh daily, but its keeping quality is .such that a 
week's supply can he forwarded in one delivery. The Biscuits, if kept in a 
dry warm place, will remain crisp for a long time. 

While the Bread, Rusks, and larger hiscuits form the staple dietary, 
Messrs. Bonthron recommend, as a change of diet, their Cressini, Almond, 
Sponge Cakes — varied in flavour, Sponge Drops, Almond Shoots, Brazils, 
and other varieties. 

Price Lists on application. 

The Gluten Porridge Meal, recently introduced, with directions for 
making, makes an appetising dish. 

Gluten Flour, 2s. 6d. per lb. Biscuits, 3s. 6d. per lb. Loaves, 9d. each. 
Bran, Is. per lb. The Loa\-es can ie sent through the 2)ost, Is. each. 



It is with much satisfaction that Messrs. Boxthron & Co. are able to 
state that they are now regularly supplpng customers who have used these 
preparations for years, and from whom they receive testimony of the great 
advantage they continue to derive from them. 

For our Gluten preparations the highest award — Silver Sledal — was given 
at Edinburgh. 

As Gluten pieparations are costly, and are hest when freshest, it is 
cheapest and best to communicate dii'ect with the Makers, 

BONTHEON & CO., 106, Eegent St., London. 



ADVERTISEMENTS. 



GRIFFIN S S TANDABD T EXT-BOOKS. 

CLINICAL DIAGNOSIS : the Chemical, Microscopical, and Bacteriological 

E\itlenct! of Piseasf. By Dr. Von Jaksch. Translated by James Caoney, M.A., 
M.D. Thir.l Edition. l'Ss. 
'■ A s LAMIA nil \MniK ... a? TRUST woKTHV as it is SCIENTIFIC."— rae Lancet 
CLINICAL MEDICINE. A Practical Handhook. By JuDSON Bury, M.D , 
F.R.C.P., Senior A.ssistant Physician, Mancliester Royal Infirmary. 21s. 
" A very safe ami valiialile book." — Edinbiir<ih Medical Joarnul. 

FIBROID DISEASES OF THE LUNG, including Fibroid Phthisis. By Sir 
Andrew Cf.ark, Bart., M.D., LL.D., F.R.S., late Consulting; Physician and Lecturer 
on Clinical Medicine to the London Hospital ; and W.J. IIadley, M.D. , and Arsold 
Chaplin, M.D., Assistant Physician to the City of London Hospital for Diseases of 
the Chest. 21s. net. 
"A rKioiAXENT RKCoanof .Sir Andrew Clark's most important pikcb op pathological 

and CLixicAi, woiuc, ... A voIuimo which will be highly valued by every clinical 

I'lIYSlclAN."— Bi-(7iS/i Mcilictil Jiiiirnal. 

DISEASES OF THE HEART (The Diagnosis of). By A. Ernest Sansom, 

M,D., F.R.C.P., Physician to tlie London Hospital, etc. With 13 Plates, 28s. 

" Iir. Sansom lias opened to us a TUEAsuRE-iiofSE of KNoWLEniiE,"— /'raffi/iOHec. 

GOUT (A Treatise on). By Sir Dyce Duckworth, M.D. Edin., F.R.C.P., 

Physician to, and Lecturer on Clinical Medicine at, St. Bartholomew's Hospital. 25s. 

" .\t once thoroughly [iractJcal and hi^'hly philosophical. Contains an enormous amount of 

INFORMATION. '—Praf(/f(i)«ec . 

RHEUMATISM AND RHEUMATOID ARTHRITIS. By A. E. Garrod, 

.M.A., M. 1). O.xon., Assistant Physician to tiie West London Hospital, etc. 21s. 

" Will take laiik with the best treatises ou special subjects in the language."— /Ju^iiu Medical 
Journal. 

THE DISEASES OF CHILDHOOD (Medical). By H. Bryan Donkin, M. A., 

M.D., F.R.C.P., Physician to Westminster Hospital and the East London Hospital 
for Children, etc. lOs. 
" In every sense of the word a fresh and original work, recording the results of the author's 

OWN LAUciE KXriatlENCE." — 7'/(r Laiicct. 

DISEASES OF THE SKIN. By T. M'Call Anderson, M.D., Prof, of Clinical 

Medicine in the University of Glasgow. Second Edition, Revised and Enlarged, 25s. 
" B.yoml doubt the MOST IMPORTANT WORK ou Skin Diseasos that has appeared lu England 
fnr many ycnrs/'—Uritiah Medical .lonrnai. 

THE BRAIN AND SPINAL CORD. By Victor Horsley, F.R.C.S., 

F.R.S., Professor of Pathology, University College; Assistant Surgeon, University 
College Hospital, etc. 10s. (Jd. 
'■ We HEAttTii.Y COMMEND the book to all renders and to all classes op stfdeni'S alike, as 
being almost the only lucid account extant emhodyiug the Latest reskakchks and their ccni- 
clusions."— Z>'n7i,-7/ Midical Juanntt. 

THE CENTRAL NERVOUS ORGANS (The Anatomy of) IN HEALTH 

and DLSEASE. By Prof. Obersteiner. Translated by Ale.x. Hill, MA., M.D., 

Vice-Chancellor of the University of Cambridge. 25s. 
"Dr. Hill lia< iMirirhfil the work with many notes of his own. . . . Invaluable as a tk.xt- 
HiioK."—l:riti.'h .1/' d,,-.,i J.'i rnal. 

MENTAL DISEASES. By W. Bevan Lewis, L.R.C.P. Lond., M.E.G.S. Eng., 

Medical Director of the West Riding Asylujn. With 18 Plates. 28s. 
" The BEST WORK in English of its kind."— /o"/-H(!( of MenUd Science. 
"To the student the work is indispensable."- /'m.ct/Ji'.mcc. 

PERIPHERAL NEURITIS. By Dr. James Ross and Judson Bury, 1\LD., 

.Senior Assistant Physician, Manchester Royal Infirmary. 21s. 
■Will fur iii:niy .\e:ir^ n'lii.-iiii the \itiio1!i-iati VE ■I'Exr-n )oK on Periiihcral Neiiiil Is." — 

r.ntisli M.diral ./.■iinml. 

ASYLUM MANAGEMENT AND ORGANISATION. By Charles Mercier, 

M.B., F.R.C.S., Lecturer on Neurology and Insanity, Westminster Hospital Medical 
School. Itis. 
"Well worthy of thoughtful study. . . . Contains an immense amount of useful and in- 
teresting iufonuation."— -Vci/icdf I'reas. 

*,* A. Complete III u.tt rated Catalogue post free on applicafion. 

London: CHARLES GRIFFIN & CO., Ltd., Exeter St., Strand. 

L 



ADVKHTISKMKNTS. 



"An improvement on the old-fashioned Violet Powders."— BriH«fc Medical 

f^u Journal. 

ANTISEPTIC DUSTING POWDER 
PREPARED WITH BORIC ACID. 

F-r use in casts of ENURESIS 
and for NURSERY and TOILET 

USE generally. 

"Entirely deserves the excellent 

IN BOXES, I/- EACH, OF ALL CHEMISTS. reputation it has gained.;- 

LARCE BOTTLES, FOR HOSPITAL ANO FAMILY USE, 5;'- EACH. •* '"■'t't'oner. 

Proprietors: JAMES WOaLLEY, SONS & Co., Ltd., MANCHESTER. 

ixiEoii SHOT HOXJSE, 

ST. MARGARET'S, TWICKENHAM. 




Resident Medical Superintendent — 

F. H. BROMHEAD,B.A.,M.B.Camb., M.R.C.S.Eng., &c. 



TTOR Gentlemen suffering from Alcoholism, Morphinism, and 
the abuse of Drugs. Patients admitted under the Acts 
and privately. Terms, 2^ to 5 Guineas. 

For fidl particulars apply to the Medical Superintendent. 



LONDON FEVER HOSPITAL, 

ISLINGTON, N. 



SUFFERERS FROM INFECTIOUS FEVERS are 
Received for Treatment 

(«) In the Wards, on payment of cC3 3Sa each, which is cciual to 
about a fourth of their cost, and covers the whoh> period during 
which they are under treatment (the balance falling upon the 
Funds of the Institution) ; and 

{f>) In Private Eooms at =£3 3s. a week. 

Domestic Servants of Governors and certain EmjAoijes of Suhgerihinf/ 
Finiix, C'luhs, and Ifofels, are Treated Free of Cliarge. 

ADDITIOlSTAIi HELP IS MUCH NEEDED. 

22,000 Sufferers have been Treated here in the last 25 
Years. 

UONATIOX.S AND ,SUB.SC11IPTI0N8 gratefully received by the 
Secretary at the Hospital, 

MAJOR W. CHRISTIE. 

Bankers— VR^>iCOTT & CO., 50, Cornhill, E.G. 
M 



ADVERTISKMENTS. 



DEFECTS OF SPEECH. 



Mh. ^VILLIAM VAN PRAAGH'S System for the Cure 
of all Defects of Speech, both Acquired and Coxgenital. 

For information, apply to Mr. William Van Praagh, 11, 
Fitzroy Square, and 51, AVarrington Ci'escent, London, W. 

Consultations by appointment. 



TBEATMENT OF INEBKIETY. 



Dalrymple Home, 

IlICK3IANSWOItTII, HERTS. 

FOR GENTLEMEN, UNDER THE ACT AND PRIVATELY. 

For Particulars apply to 
R. WELSH BRANTHWAITE, M.D., Medical Superintendent. 



UNIVEBSITY OF EDINBUBQH. 

FACULTY OF MEDICINE. 

The Winter Sessiov begins in October, and the Summer Session at the beginning of May. 

Chemistbt Prof. CRUM BROWN, M.D. 

Uatcral, History . Prof. EWART, M.D. 

BOTAXY Prop. BAYLEY BALFOUR, M.D. 

Physics Prof. TAIT, D.Sp. 

ASATOMT Prof, .'^iu WILLIAM TURNER, M.B. 

Fhysioloby Prof. la'THKIlKOHD, M.D. 

Materia Medica Prof. TIIOM.vs i;. fr.aser, M.D. 

Pathology Prof. (iliEKXKIKLD, M.D. 

Forensic Medicine Prof. Sii; iii.XKY D. LITTLEJOHN, M.D. 

Medicisb Prof. Sir T. (JL.VINGER STEWART, M.D. 

Surgery Prof, ciiiexe, M.D. 

MiD\viPERY Prof. SIMPSON. M.D. 

(CLINICAL Surgery Prof. ANNANDALE. M.D. 

fPjjOF.s. Sir T. GRAINGER STEWART, 
iCLINICAL MEDICINE .. .. J. FRASER, AND GREENFIELD, AND 

I SIMPSON ON Diseases op Women. 

UNIVERSITY LECTURERS. 

Physics C. G. KNOTT, D.Sc. 

Mental Diseases T. S. C'LOrsTON, M.D. 

Diseases OF the Eye .. G. A. BEliKV, Jl.l',. 

■Clinical Instruction on Di.seases ofI JAMES t'ARMU^HAEL, M.D., and JOHN 

Children J PLAYF.VlPi, M.I). 

Experimental PuYSioLOOY E. W. OAItLIEIl, 3I.D., B.Sc. 

EJUiKYOLOGY AND Vertebrate Zoology .. JOHN BE.-VRD, D.Sc. 

RE(iiONAL A.VATOJIY DAVID HEPBUUN, M.D. 

Experimental Pharmacology W. C. SILLAR, M.Ii., B.Sc. 

Pathological Bacteriology ROhert MUlR, M.D. 

Larynx. Ear AND Nose P. McBRIDE, M.D. 

The annual value of the Fellowships, Si-liolar.*hips, Bursaries, and Prizes in the Faculty of 
Medicine amounts to about £3,4()0. A copy of the Regulations for (iraduation iu Medicine and 
Surgery may be had on application to the Dean of the Faculty of Medicine or the Clerk of Senatus. 
Practical Tnetruction is nffordcd in Laboratories furnished with allthe 7iecessary Aiiplianres, and in 
Tutorial ■oAid Praciicat T' . - .;,;,:,, ,■■,,,/ n-ith all the above Chairs and under the superintendence 
of the Professors. 8tu'_h > ' - i i l^ave access, forpurposesofClinicali)istruclion,toupivards 

<of'[,M0'bed'Siiii1fne van" • i! . ; - - / i ahiirgh. 

Uimersiity.qf £dinbi(r,j:\ Y ':,.:!'' ,. i-iv. J,. J. GHA^T, Secretary of Senatus. 

N 



ADVERTISEJIENTS. 



ST. BARTHOLOMEW'S HOSPITAL AND COLLEGE. 

■ FOUXDKI) UY llAYHKIlK, A.D. lll'S. 

Tin: ciiiiii-alpnirticeof tliisnosi)ital com prises, iservi re of 744 BcdK.of wliich23.'iarpallotte(! totlie 
Miiliiiil I a-.-, :'.;ii to the Surgical Cases, 25 to Oi-ca-rs of the Eye,:H to DiseaiseB of Wonii-n, ancl4fl 
to Is il:ii hii mhI Ceneral ; while 7ii are for CoiiVali-rtcnrit i'aiionis at Swanley, Kent. The Hoeiiltal 
rei-ii\ r> w iihiM Us Wards nearly 7,o«i Patients- an una My, wiiilsl l!i« On t-I'atienis amount to more 
than I.Ml.oiM. PUPILS' APPOINTMENTS. 

Ten Honse-I'hysicians, each linlilint; olllci- for on.- year, are apiiointert by the I'hysiciani5. 
Kach llonse-l'liysician is provi<lc.l uiili pmuhs Ii.v llic ll.is|,iial avithonlies. Ten Hoiise-Suri-'eons. 
each hohliiiK olllce for one year, arc apiioiiiud l.y ih.- Siirtreons. Each House-Surgcon is provided 
with rooms I. V the llo-pitai aulhoritu-s. . . 

The .Miilwifery-AssisI.iTii hoMs office for six months, and Is appointed by the Physician- 
Accoucheur. Ill- is provided with rooms by the Hospital authorities. 

The Kxiern M ul wifery-.\^si.-ilaiit is appointed every three monllis. 

The opiii hal nii I louse-Surgeon is appointed every six months by the Ophthalmic Surgeons. 
All theai"). '■ iMIei rs receive a salary of £80 per annum wliilst resident. 

Two It'sid. ni A s-1- tan tChloroformistsareappointed annually; the Senior receiving£I2nand the 
Junior iliHi. Tk,, .\-~:<rMit IClcctricians, with a salary of i:2."i. are api>o:nted every three months. 

The ln-1'aticTit lii --.r-. the Clinical Clerks, tho Obstetric Clerks, the Clerks to the Out- 
patients, the Drc^-i i> I I !lie out-Patients, ana the Clerks and Dressers in the Special Depart- 
ments are chosen from lii" iiiiitreiit .Students. Ko fee is paid for any of these ai)pointment6. 
MEDICAI. AND SURGICAL STAFF. 



T. Smith, Bart., Mr. Willett, Mr. 
Lair-'i'iii, Mr. M.arsh. Mr. Butlin. 
JS6(.s(«)/(-.y/.'./-i,'ru)is— Mr.Walsham.Mr.Cripps, Mr. 

Bruce Clarke, Mr. Bowlby, .Mr. Lockwood. 
Physician-Accoucheur— Dr. Cbarapneys. 
AssMant Physician- Accoucheur— Dr. Griffith. 
Ophthalmic Surgeons— yiv. Vernon, Mr. Jessop. 
THE COLLEGE. 

Students attending the Practice of the Hospital, or the Lectures in the Medical School, are 
admitted to residence in the College within the Hosiiital walls, subject to the College regulations. 

LECTURES. 



Phi/siclans—T)r. Church, Or. tirr. Sir Dyrc Diu k 

'worth. Dr. Hensley, Dr. liruuion. F. U.S. 
Assiatant-Phvsicidiis—])^ Xorniau Moore, Dr. S. 

West,Dr.Oruierod,Dr.IJcrriiighara,Dr.Tooth. 
ConsnItiiKi Surgeon fi-f^u- J. Paset, Bart., D.C.L., 

I'\R.S., Luther Holden, Esi). 
Cunsultimj Ophthalmic Sunjeun—'HT. Power. 



Medicine— Sir Dyce Duckworth, Dr. Moore. 
Surgery— Mr. Marsh, Mr. Walsham. 
Descriptive and Surgical Anatomy— Mr. Bruce 

Clarke, Mr. Lockwood. 
General Anatomy and Physiology, with His- 

tolog.v— Dr. Klein, F.R.S. 
Chemistry and Practical Chemistry— Dr. Cbatta- 

way. 
Midwifery— Dr. Champueys, 



Phv.^ics— Mr. F. Womact. 

Materia Medica— Dr. Brunton, F.R.S. 

Botany— Rev. George Henslow. 

Forensic Medicine— Dr. Hensle.v. 

Hygiene- Sir R. Thorne. 

Bioloiry and Comparative Anatomy— Dr. Shore. 

Patholot-'ii-.al Anatomy— Dr. Andrewes. 

(ililiih.aliuir Surgery— Mr. Vernon. 

Psvilioi,,t.'H:il Medicine- Dr. Claye Shaw. 



CLINICAL LECTURES 

Are given during the Winter and Summer Session. 
Clinical Medicine-Dr. Church, Dr. Gee, Sir Dyce Duckworth, Dr. Hensley. Dr. Brunton. 
Clinical Surgery— Sir T. Smith. B.art., Mr. Willett, :Mr. Langton, Mr. Marsh, Mr. Butlin. 

Midwifery and Diseases of Women— Dr. Chaniiiueys. 
SPECIAL DEPARTMENTS. 



Diseases of the Skin— Dr. S. West. 
Orthopaedic Surs-ery— Mr. Walsham. 
Diseases of the Ear— Mr. Cumberliatch. 
Diseases of the Eye— Mr. Vernon, Mr. Jessop. 
Practical Surgery— Mr. Berry, Mr. Power. 
Practical Anatomy— Mr. Waring, Mr. Bailey. 
Assistant Demonstrators— Mr. Furnivall, Mr. 
Sloiine, Mr. Miles. 



. -Dr. Edkins. 

.Assistant Deiiiuusiiators- Dr. Clarke, Dr. Mor- 



rison. 
Operative Surgery- Mr. Berry, Mr. Wanng, 

Mr. Eccles. 
Practical Medicine— Dr. West, Dr. Fletcher, Dr. 

Horton Smith. 
Practical Midwifery— Dr. Roberts. 
Medical Eeijistrars—T)rs. Calvert and Garrod. Siirnical Rcfiistrar-Mr. Berry. 

ScilOLARSHiP.s AXD PRIZES.— Open Scliolarsliips in Scieuce(founde(l Isr,'!). These scholarships, 
four in number, of the value of Xl.io, ,£7.-., £7.-., £.")0. .are tenahie for one ye.ar. Candidates must not >e 
more than twenty-five years of age for those of £7,-., and not more than twenty years of ageforthe 
others, and must not have entered to the medical or suigical practice of any London medical 
school. The subjects of examination are Physics, Chemistry, for one of £73; Biology and Physiology 
for the other of £73 ; and for the Junior, Physics, Chemistry, and Biology.— Preliminary Scientific 
Exhibition (founded 18731. The subjects of examination are Identical with those of the Open 
Scholarship in Science. This Exhibition, of the value of £50, is tenable for one year.— The Jeaf- 
f reson Exhibition, of the value of £20, is .an open Exhibition lU Classics, Mathematics, and Modern 
Languages.— A Shuter Scholarship, £30, in Anatomy, Physiology, and Materia Medica, at entrance 
I limited to graduates in arts of Cambridge).— A Senior Scholarship, £.io, in Anatomy, Phy.siology, 
and Chemistry.— Lawrence Scholarship and Gold .Medal, of the value of 40 guineas (founded 1873 
by the family of the late Sir William Lawrence).-Two Brackenbury Scholarships, each 30 guineas, 
ill Medicine and Surgery.— Four Junior Scholarships in the subjects of study of the first year: 
1 £30- 2 £20-3. £2.5; 4. £15.— The Wix Prize is awarded for the best essay on the following subject : 
"The Life and Works of Sir C. Bell."— The Bentley Prize for the best report of cases occu-r- 
rini-' m the wards of the Hospital during the previous year.— The Kirkes Gold Medal and Scholar- 
■sbip of .to guineas for Clinical Medicine.— The Hichens Prize for the best examination in " Butler s 
Analogy."— Foster Prize for the best examination in Practical Anatomy (senior).— The Treasurer s 
Prize for the best examination in Practical Anatomy (junior).— The Harvey Prize for the best 
ex.amination in Practical Physiology. , .„ .... . », 

Special Classes are held for the Preliminary Scientific, and for other Examinations at the 
University of London. Students preparing for other Examining Boards are arranged in classes 
and examined by the Lecturers, Demonstrators, and Assistant Demonstrators. . , , , ^-, 

Fee for Lectures and Hospital Practice, 150 guineas if paid in one sum, or 160 guineas if paid by Instair 

merits. Payment in either of these ways entitles a Student to a Perpetual Ticket. 
Communications to be addressed : Dr. T. W. Shore, Warden of the College, St. Bartholomew sHosp. 



ADVERTISEMENTS. 



W. H. Bailey & Son's 

Patent AMominal Belts, 




Exhibited before the Obstetrical Scciety. 

No. 1.— For General Support. 
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BAILEY'S CLINICAL THERMOMETERS. 



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No. 0. Hospital 
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Wholesale Depot for Surgeons' Instruments i Appliances, Invalidt' Requisite, ic. 

W. H. BAILEY & SON. 38, Oxford Street, W. 

Telegrams— " BAYLEAF, LONDON." 



ADVERTISEMENTS. 



Charing Cross Hospital 
Medical School. 

The Livingstone Scliolarship, 100 guineas, the Huxley Sdiolarship, 55 
guineas, and six other Entrance Scholarships (total value £550,) will be 
awarded in October. 

Two Scholarships of the value of 60 guineas each are reserved for 
Students of Oxford, Cambridge, or London Universities. 

Fees. — For the five years' curriculum of study required by the various 
Examining Bodies and for hospital practice, 110 guineas in one sum, or 121 
guineas in five instalments. 

The composition fee for sons of registered medical practitioners is 100 
guineas, and the fee by instalments 110 guineas in five payments. 

The composition fee for Dental Students is 54 guineas, or 60 guineas, 
payable in two instalments of 30 guineas each. 

A proportionate reduction of the above Fees is made to Students who 
have completed part of the curriculum elsewhere. 

THE SCHOOL PEOSPECTUS, containing full information concern- 
ing the classes, prizes, and all other arrangements connected with the 
Medical School, will be sent on application to the Dean, Chandos Street, 
Strand, W.C. jj MONTAGUE MURRAY, Bean. 

THE DENTAL HOSPITAL OF LONDON 
MEDICAL SCHOOL, 

LEICESTER SQUARE. 

LECTURES. 
Dental Anatomy and Physiology (Human and Comparative) — Charles S. 
Tomes, F.R.S., M.A. Oxon.', M.R.C.S., L.D.S., on Tuesdays and 
Thursdays, at 5 p.m. (Summer.) 
Dental Sui-gery and Patholog3'—Storer Bennett, F.R.C.S., L.E.C. P., L.D.S., 

on Wednesdays and Fridays, at 8 a.m. (Summer.) 
Mechanical Dentistry— E. Lloyd Williams, L.R.C.P., L.S.A., M.R.C.S., 

L.D.S., on Wednesdays at 5.30 p.m. (AVinter. ) 
Metallmgy in its application to Dental Purposes — Dr. Forster jMorley, 
M.A., F.LC, F.C.S., on Tuesdays at 4.30 p.m. (Winter.) 
The Hospital is open both morning and afternoon. 

During the Sessions the Surgeons of the day will give demonstrations at 
stated hours. 

The Medical Tutor holds classes before each Examination for the L.D.S. 
The House Surgeons attend daily while the Hospital is open. 
The Saunders Scholarship of £20 per annum and prizes are open for 
competition. 

Fee for two years' Hospital Practice required by the curriculum, including 
Lectures, £50 in one payment, or 50 guineas in two j-early instalments. 
The curriculum requires two years to be passed at a General Hospital. The 
fee for this is about £55. Both Hospitals can be attended simultaneously. 

The Calendar may be obtained on application to the Dean, who attends at 
the Hospital on Wednesday mornings from 10.30 till 12 thi-oughout the 

ye^- MORTON SMALE, Bern. 



ADVERTISEMENTS. 



HOME AND EDUCATION 

BACKWARD AND FEEBLE-MINDED. 

Under the personal supervision and management of 

MRS. LANQDON=DOWN, 

who has given thirty years to this work. 



Medical Superintendents : — 

REGINALD L. LANGDON-DOWN, M.A., M.B., M.R.C.P. 
PERCIVAL L. LANGDON-DOAVX, M.A., M.B., B.C. 



This home, which stands in extensive and heautiful grounds of forty 
acres, has been especially designed to provide the most complete facilities 
for the care, education, and treatment of those of good social position who 
present anj" degree of mental deficiency. It is divided into a Main Building 
and a number of separate houses, standing in their own grounds, and 
thus affords exceptional scope for the proper classification of the various 
cases received. 

NORMANSFIELD.— A Training Home for the Feeble-Minded 
of either sex and any age, including quite young children. 

TREMATON. — A School Home for the education of exceptional 
boys unsuited for ordinary schools. 

CONIFERS. — A School Home for Girls on the same lines as 
Trematon. A few ladies needing oversight under medical 
guidance are also received. 

Four VILLA RESIDENCES provide accommodation for 
special cases, or a complete establishment if so desired. 



Experienced Governesses and Masters. 



Instruction in Kindergarten, Slojd, Drill, Dancing, Gymnastics, Music, 

Languages, &c., as required. 

Occupation in Garden, Farm, and Workshops. 

Driving, Riding, Cycling, Cricket, Tennis, Football, Bathing, Boating. 

Entertainments. Seaside Visits. 

Gravel soil, healthy locality, near Bushy and Richmond Parks. 

Easy access from London by L. & S.W.R., or by road. 



For terms and particulars address — 

NORMANSFIELD, HAMPTON WICK. 



ADVERTISEMENTS 



A Great 
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HE handiest, simplest, and most reliable for taking snap-shots of 
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It takes 12 Quarter Plates, 

wliirh are- brouglit in succession in front of the Lens by merely pressing a 
knob, at the same time registering the number of the e.xposed plate. 

It bas Two View=Finders 

in the usual position, protected by a Hinged Metal Hood. 

A Drop Door 

is fitted in the bottom of Camera, to enable any exposed plate to be withdi'awn 
without moving the unexposed plates. 

It is fitted with a tlioroughly good fixed Focus Single Landscape Lens, 

having an Iris Uiapliragui. By siniply turning a button, time or inst;int'aneous 
ex]iosurPs can be made at the will of the operator. 

It is Morocco Bound, 

and measures S by 7 by 4 in., and weighs 3 lbs. 
Black Leather Cases to Jiold Camera, and sling on Shoulders, fis. extra. 



" Practical Photography for Amateurs" 

Is the title of a neat little book which is written in simple and intelligible 
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in tlie art require. Price Is. 



ALL OR EITHER OF THE ABOVE WILL BE SENT POST FREE, ON 
RECEIPT OF POSTAL ORDER, BY 

Barclay & Sons, Ld., 95, Farringdon St., London. 

Face Half Title.'] S 



THE 

Yeae-Book of Theatment 

For 1898 



y 



THE 



YEAR-BOOK OF 
TREATMENT 



1898 



A CRITICAL REVIEW FOR PRACTITIONERS OF 
MEDICINE AND SURGERY 



€ontr 
Francis D. Boyd, M.D. 
Dudley W. Buxtox, M.D. 
Albert Carless, M.S.Loxd. 
Alfred Cooper, F.R.C.S. 
George P. Field, M.E.C.S. 
Archibald E. Garrod, M.D. 
G. A. GiBSOx, M.D. 
M. Haxdfield-Jones, M.D. 
Reginald Harrison, F.R.C.S. 
Herbert P. Hawkins, M.D. 
G. Ernest Herman, M.B. 
J. Ernest Lane, F.R.C.S. 
A. P. Luff, M.D. 



ibutors 

1 Patrick Manson, M.D. 

j M.1LC0LM Morris, F.R.C.S. Ed. 

ED.MUND Owen, F.R.C.S. 
I Sidney Phillips, M.D. 
' Henry Power, F.R.C.S. 
I E. S. Reynolds, M.D. 

"William Rose, F.R.C.S. 
I GusTATE Schorstein, M.B. 

StClair Thomson, M.D. 

Nestor Tirard, M.D. 

W. J. Walsham, F.R.C.S. 

E. F. Willoughby, M.D. 

Dawson Williams, IM.D. 




CASSELL AND COMPANY, Limited 

LONDON, PARIS d: MELBOURNE 



ALL RIGHTS RESERVED 



PREFACE. 

In this the fourteenth annual issue of the " Year-Book of 
Treatment " the aim has been, as heretofore, to present the 
busy practitioner with a readable digest of the progress made 
in the domain of therapeutics during the past year. The only 
changes in the staff of contributors are that Dr. G. A, Gibson, 
Lecturer in the Edinburgh School of Medicine, lias supplied 
a review of the advances in the treatment of Diseases of the 
Heart and Circulation ; and Dr. Herbert P. Hawkins, Physician 
to St. Thomas's Hospital, has dealt with Diseases of the Stomach, 
Intestines, and Liver. 

It is hoped that the present issue will be found not less 
useful to the medical profession than its predecessors. 

THE EDITOR. 

Jamtary, 1S9S. 



ADVF'^RTISKMENTS. 



"The Prototype of all Bitter Waters."- Z.a/7cef 0896). 

©unpJji Bnm^ 

Over 1,000 Testimonials from Medical Authorities. 

7'I/E LANCET. 

" Himyadi Janos." — " ]iaron Liebig affirms that its richness in 
aperient salts surpasses that of all other known waters." (,1873.) 

BRITISH MEDICAL JOURNAL. 

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l)hysicians and therapeutists of every country, whose testimonies 
bear witness to its action as a speedy, sure, and gentle aperient 
for ordinary use ; it is remarkably and exceptionally uniform in 
its composition." (August 30, 1884.) 

" Hunyadi JAnos sprang rapidly into great and widespread 
reputation owing to its speedy, sure, and gentle action. It ap- 
parently continues to hold the ground which it so (piickly and 
effectually secured." (August 23, 1890.) 

Annual Sale exceeds 6,000,000 Bottles. 

HUNYADI JANOS 
25 Years' Success in the United Kingdom. 

THE PRACTITIONER. 

" This product of nature's pharmacy has for many years held 
a place in the very front rank of natural saline waters." 

"We have found that in the treatment of constipation, from 
whatever cause arising, Hunyadi Jdnos fulfils the requirements of an 
efficient remedy, in that it acts cito, tuto et jucunde." (May, 1896.) 

MEDICAL PRESS AND CIRCULAR. 

" Hunyadi Janos is certainly the best known, and, in our ex- 
perience, the most trustworthy of the Hungarian laxative mineral 
waters. Taken in the morning, either pure or diluted with hot or 
cold water, it produces a copious evacuation without leaving behind 
it any intestinal discomfort or exhaustion." (February 5, 1896.) 

CAUTION. — Every Bottle bears the Signature of the Proprietor, 

Andreas Saxlehner. 



CONTENTS. 



PAGE 

Diseases of the Heart and Circulation. By G. A. Gibson, M.D., 

D.Sc, F.E.C.P. Edin 1 

Diseases of the Lungs and Organs of Eespiration. By Gustave 

ScHORSTEiN, M.A., MB. OxoN., F.R.C.P., D.P.H. . . . 19 

The Treatment of Nervous and Mental Diseases. By Ernest 

Septimus Reynolds, M.D. Lond., F.R.C.P 59 

Diseases of the Stomach, Intestines, and Liver. By Herbert P. 

Hawkins, M.D., F.R.C.P 86 

Diseases of the Kidneys, Diabetes, etc. By Francis D. Boyd, 

M.D., F.R.C.P. Edin 106 

Gout, Rheumatism, and Rheumatoid Arthritis. By Archibald E. 

Garrod, M.A., M.D., F.R.C.P 129 

Infectious Fevers. By Sidney Phillip.s, M.D. Lond., F.R.C.P. . lay 

Medical Diseases of Children. By Dawson Williams, M.D. 

Lond., F.R.C.P 148 

Anesthetics. By Dudley W. Buxton, IM.D., B.S., M.R.C.P. . . 1.56 

General Surgery. By William Rose, M.B., B.S., F.K.C.S., and 

Albert Carless, M.S. Lond., F.R.C.S Kjg 

Orthopedic Surgery. By W, J. Walsham, F.R.C.S. . . 21'j 



Mil THK YEAR-BOOK OF TKKATMP:NT. 

PAGE 
TlllC SUKOICAI, iJiSKASF.S OT CuiLDRKN. By EuMUND Owe.N, ^!.lj., 

F.R.C.S. . 229 

Diseases of the Genito-Ukinakv System. By Reginalij Uaurison, 

F.R.C.S 249 

Diseases of the Rectum. J>y Alfred Cooper, F.R.O.S. . . . 258 

Venereal Diseases. By J. Ernest Lane, F.R.C.S. . . . 264 

The Diseases of- Women. By G. Ernest Herman, M.B. Lond., 

F.R.C.P 276 

Midwifery. By M. Handfield-Jones, M.D. Lond. . . , 313 

Diseases of the Skin. By Malcolm Morris, F.R.C.S. Ed. . . 352 

Diseases of the Eye. By Henry Power, M.B., F.R.C.S. . . 368 

Diseases of the Ear. By George P. Field, M.R.C.S. . . . 384 

Diseases of the Nose and Throat. By StClair Thomson, M.D. , 

M.R.C.P. Lond., F.R.C.S . .401 

Tropical Diseases. By Patrick Manson, M.D., F.R.C.P., LL.D. . 421 

Public Health and Hygiene. By Edward F. Willoughby, 

M.D. Lond., D.P.H 430 

Medical Jurisprudence. By Arthur P. Luff, M.D., B.Sc. Lond., 

F.R.C.P 440 

Summary of the Theuapeutics of the Year 189G-97, Chiefly in 
Reference to New Remedies. By Nestor Tirard, M.D. 
Lond., F.R.C.P 448 

Index to Authors Quoted ........ 471 

Index to Subjects - 475 



THE 

Yearbook of Treatment 

For 189S. 

DISEASES OF THE HEAET AND 
CIRCULATION. 

By G. a. Gibson, M.D., D.Sc, F.R.C.P., Edin., 

Senior Assistant Physician to the Royal Infirmary, Consulting Physician to the Deaconess 
Hospital; Lecturer on Medicine in the School of Medicine, Edinhurgh. 



During the year which has elapsed since the appearance of the 
last volume of the "Year-Book," one most important advance 
has been made in cardiac therapeutics, through the application 
of the serum treatment to endocardial disease. Beyond a doubt 
the employment of this method has been in the minds of many 
physicians as a possible means of averting the sei'ious consequences 
of infective endocarditis, and the matter has now passed into the 
realm of achievement. In the following pages the subject is 
somewhat fully reported. 

Echoes of the discussions held in preceding years on the 
mechanical treatment of circulatory diseases have still been 
heard, and some of the inevitable contributions on this subject 
have accordingly appeared. It cannot be said that any new 
facts have been brought out, but some of the criticisms which will 
be referred to in the sequel are not only of interest but of use. 

The year has been distinguished by the appearance of 
Dr. Lauder Brunton's lectures on the action of medicines, in 
which there are some excellent directions in regard to cardiac 
therapeutics. The book is not mei'ely of great value in discussing 
the effects of drugs, but it is most suggestive in many hints on 
practical therapeutics. Some of the subjects which are discussed 
will be referred to in the following pages. 

The year has also been marked by the appearance of Sir 
William Broadbent's work on the heart, in which prognosis and 



2 THE YEAR-BOOK OF TUEATMENT. 

treatment occupy a very important place. It gives the results of 
wide experience and deep thought; Lis well-weighed opinions, 
therefore, are certain to be carefully considered. Several points 
on which he expresses strong views will, in the following pages, 
be referred to. 

ACUTE CARDIAC DISEASES. 

1. Scriiin tlioi-apeutics in acute oiidocaidifis. 

Harrington Sainsbury (^Lancet, vol. ii., 189G, p. 1079) reports 
the case of a patient, aged tliirteen, who was admitted to the 
Royal Free Hospital June 22, 1896, on account of cardiac pain. 
The boy had been ill for a fortnight before admission, the promi- 
nent symptoms being weakness, pyrexia, cough, and sleeplessness. 
There was no history of rheumatism or chorea. On admission 
the patient was obviously ill, of dusky complexion, with a dry 
skin, and a temperature of 103*2. The cardiac dulness was 
found as high as the first left intercostal space. The apex beat 
was in the fifth left space, 4 inches to the left of the mid-sternal 
line, at which point there was a well-marked thrill and double 
murmur. There was some evidence of pulmonary implication at 
both bases posteriorly. The liver and spleen were not palpable, and 
the renal secretion contained no albumin. The patient was treated 
by means of salicylate of sodium. Two days after admission he 
was quite delirious, and on the following day, although there had 
been no rigor, there was dulness over the left lung behind, with 
increase of vocal resonance and rusty sputum. These symptoms 
were followed by a symmetrical erythematous rash, spreading over 
the body, which lasted for five days. On July 1, streptococci 
were found in the blood. During the month which followed 
there were considerable fluctuations in the patient's condition, 
and by the beginning of August he appeared to be in a serious 
state, the temperature rising to 104-4, witli vomiting and cough, 
attended with expectoration of blood-clot; there was also 
abdominal tenderness, and the spleen appeared to be ])alpable. 
During this period the patient was treated with perchloride of 
mercury. On August 17 the use of anti-streptococcic serum was 
begun, 20 c.c. being injected. The following day 10 c c. were 
again injected, and two days later this latter dose was repeated. 
The temperature at this time was 99-8. The injections produced 
no local or general reaction. There was nevertheless a great 
improvement in the condition of the patient, so much so that, 
after two more doses of the same size as the last, he was up 
and walking about in the ward. The blood examined at this 
time was found to contain no streptococci. On September 1 



DISEASES OF THE HEART AND CIRCULATION, 3 

a further injection of 10 c.c. of serum was administered, and was 
followed by slight local and general reaction, the temperature 
rising to 102, and the patient feeling ill and complaining of pain 
at the puncture. The temperature after this last injection 
remained normal. The condition continued satisfactory, and on 
the l-lth the patient left the hospital. 

In his remarks upon this most interesting case, Sainsliury 
contrasts it with another similar case under his care in the 
Victoria Park Hospital for Chest Diseases, about the same time, 
in which the anti-streptococcic serum absolutely failed to arrest 
the disease. The two cases cannot be regarded as in any sense 
parallel, as the one treated in the Victoria Park Hospital was at 
once more virulent and more advanced, while it was also compli- 
cated with grave kidney disease. 

A. E. W. Fox {Lancet, vol. i , 1897, p. 520) reports the case of 
a man, aged thirty-six, who entered the Royal United Hospital, 
Bath, November 17, 1896, on account of pains in the back and 
limbs, attended by sensations of shivering. No morbid tendencies 
could be found in the family history, and he had previously 
suffered from no affection which could bear upon that for 
which he was admitted. Seventeen days before admission, 
after a rigor, he complained of pains, esi)ecially in the back, 
which, after the application of embrocations, disappeared. On 
admission he was found to have a pallid and muddy aspect, with 
traces of jaundice in the conjunctivje. The temperatui'e was 
101 "S, the pulse 100, the respirations 20. The tongue was 
slightly coated, white, and moist. The right radial artery did 
not pulsate, and a clot was made out in the middle third of the 
brachial artery, which was not tender. The anterior and posterior 
tibial arteries on both sides pulsated freely. The cardiac dulness 
began at the third left rib, and the apex beat was in its normal 
position. At the apex the first sound was douljle, and its second 
portion ended in a faint murmur. The second sound was clear 
and distinct. At the base a faint, soft, systolic murmur was 
audible. The spleen extended from the upper border of the 
eighth rib to the costal margin. The liver was slightly enlarged. 
No albumin was present in the renal secretion. On the 18th 
the temperature rose to 104-6, and there was profuse perspiration 
without rheumatic odour. On the 19th, 10 c.c. of anti-strepto- 
coccic serum were administered. The injection was not followed 
by any rash or other discomfort, but there M^as profuse perspira 
tion. On the 23rd, two injections of 10 c.c. of the sernm were 
administered, and similar injections were made every day there- 
9,fter. By the 24th, it was noted he was not quite so well, and 
B 2 



4 THE YEAK-HOOK OF TREATMENT. 

that the murmur at the apox of the heart was becoming louder 
and rougher. On the 25th, tiiere was no pulsation in either of 
tlie tiljial arteries, or in th(! popliteal artery of the left leg. Two 
days later he felt a little better. The systolic murmur at the 
base of the heart was on that day deternuned to be loudest in the 
aortic area, the second sound being short and sharp. Jilood taken 
from the left arm was examined microscopically, as well as by cul- 
tivation, at the British Institute of Preventive Medicine, but no 
micro-organism was discovered. The injections were discontinued 
on the 29th, seeing that they appeared to have so little effect. 
As the tempei'ature ran up to 103 '6, and the patient became 
obviously worse, with delirium and sleeplessness, attended V^y 
diarrhoea, the injections were resumed on December 1. Cardiac 
failure ensued, with cyanosis and dyspnfea, and the patient 
died on the 2nd. 

At the 2^ost-77iortem examination, there was evidence of 
slight recent pericarditis. The heart weighed 14 oz. The 
right auricle and the right ventricle were dilated, but the 
valves were normal. The left ventricle was hypertrophied and 
dilated, but the mitral orihce was healthy. The aortic valve 
was invaded by a vegetation which almost entirely blocked up 
the orifice. The vegetation Avas about the size of a walnut, 
measuring 1 inch in length, and | inch in breadth. It appeared 
to rise from the left posterior aortic cusp ; but extended on to 
the surface of the anterior cusp. There was some atheroma of 
the aorta, but the coronary arteries were not blocked. The 
spleen and liver were much enlarged, weighing respectively 20 
and 71 oz. The kidneys contained infarcts and were much 
congested. The vegetation contained numerous streptococci. 

The j)ost-r7W)iem examination showed good reason for the 
want of success which attended the treatment of this patient, 
since the almost complete closure of the aortic orifice must 
have diminished the chances of i-ecovery. Notwithstanding the 
want of success which attended the treatment in this particular 
instance, Fox states that he, from his own past experience of 
the futility of all other treatment, will certainly give a further 
trial to serum therapeutics. 

Margaret Pearse (Lancet, vol. ii., 1897, ]). 92) has also 
employed anti-stieptococcic serum in a somewhat similar case. 
The patient had been suffering from dyspnoea, with acceleration 
of the pulse, and elevation of the temperature, before admission. 
After admission it was found tliat she had a fluctuating temper- 
ature, sometimes rising to 105. The pulse-rate was much 
accelerated. The area of cardiac dulness was increased to the 



DISEASES OF THE HEART AND CIRCULATION. 

light. The aortic soiimls were feeble, and there were mitral 
systolic and aortic diastolic murmurs, along with some peri- 
cardial friction. There was also some dulness of the right 
pulmonary base, and diminution of the breath sounds, probably 
from efl'usion. Under treatment during the first week after 
admission, the patient somewhat improved, the temperature 
falling from 103 to 100-4 in the evening and being normal in 
the morning. The puLse-rate fell from 114 to 84, and the respi- 
rations from 2G to 24. During this time the patient was treated 
by means of salicylate of sodium. The physical signs appeared 
to indicate that the disease was progressing, and during the 
second week an erythematous rash appeared over the face and 
limbs. During the week which succeeded, the temperature 
became higher, and the pulse was more accelerated. As the 
salicylate treatment appeared to be useless, it was decided to 
try the effect of treatment by serum. All other drugs were, 
thei'efore, discontinued, and 2*5 c.c. of anti-streptococcic serum 
were injected. There was no local or general discomfort. The 
following day a dose of 5 c.c. was administered, and on the third 
day the amount was doubled. Two days later 20 c.c. were 
injected, and the following day a dose of 10 c.c. was also 
administered. A considerable amount of erythema was present 
after this, and the administration was sus{)ended for two days, 
after which 20 c.c. were injected. Considerable imjirovement in 
the condition of the patient followed, and two or three more 
administrations of the serum were had recourse to, the result of 
which was that the patient was discharged perfectly well. Un- 
fortunately, no bacteriological examination of the blood w'as made 
until more than a fortnight after the use of the serum ; yet 
there can be no reason for doubting the diagnosis of ulcerative 
endocarditis. 

J. W. Washbourn [Lancet, vol. ii., 1897, p. 107) also records an 
instance of malignant endocarditis successfully treated with the 
serum, in the case of a girl aged 20, who was admitted to Guy's 
Hospital on account of headache, and of pains in the joints, 
where, however, there was no swelling or other disease. The 
affection ran a prolonged course, with an exti^emely variable 
temperature, reaching even as high as 105, and attended by 
frequent rigor and perspiration. Thei-e was some leucocytosis 
and diminished hpemoglobin. Treatment by means of quinine 
and salicylates produced no beneficial eftects ; the patient, in fact, 
became gradually worse. A pulmonary diastolic murmur was 
ultimately developed, which led to the diagnosis of ulcerative 
endocarditis. A few days thereafter injections of anti-strepto- 



D TIIK YKAU-BOOK OF TREATMENT. 

coccic serum were coimnencod, and were given daily, with tin- 
exception of three days, for two months. The doses were 20 c.c. 
until the last two weeks of treatment, when the amount was 
diminished. The ti-eatment lasted, as \Va.slibourn says, altogether 
nine weeks, duiing which time 1,030 c.c. of serum were injected in 
59 doses. The general condition of the patient began to improve 
five or six days after the commencement of the injections, and 
three weeks later she was to all appearance cjuite well. When 
she left the hospital, almost six months after her entrance, she 
still presented the diastolic pulmonary murmur. In this case, 
unfortunately, as in the last, no bacteriological examination of 
the blood appears to have been carried out, and the anti-strepto- 
coccic serum was used simply because it was thought that the 
case was one of streptococcic infection. 

The result of treatment of these four cases is certainly 
encouraging. Three of the patients made a perfect recovery, and 
the result is therefore to be regarded as one which will lead to 
the employment of the serum in those hitherto hopeless cases of 
disease. 

2. Siir^^ieal ti-catmciit of |>yopei'icnr<litis. 

H. Bohm (Dent. med. Woch., Bd. xxii., 8. 7G9), after describing 
a case of sup})urative pericarditis, taking its origin in pneumonia 
following influenza, in which, after the failure of internal remedies 
to produce any benefit, recovery occurred upon free opening of the 
p ricaixlial sac, pleads for the treatment of this aSection by 
incision. He points out that of fifteen instances on record eight 
recovered and seven were fatal. 

THE TREATMENT OF CHRONIC HEART DISEASE. 

1. Cardiac failure. 

In an important paper on the treatment of chronic cardiac 
inadequacy, F. Neumann (B&rl. klin.Woch., 1897, S. 376 and S. 405) 
calls attention to instances in which chronic disease of the heart 
had existed for even forty years, and emphasises the importance of 
a simple mode of life, with which such patients may live long with- 
out diminishing their activity. He is of opinion that digitalis is 
the most important remedy, and the method of administration is 
to employ large amounts in brief })eriods. When there is any 
sclerosis of the vessels and cardiac degenei-ation, he combines 
iodide of potassium with digitalis in the form of infusion, 
and finds that it has a very beneficial action on the heart, the 
pulse, and the secretions. In cases where there is cai'diac 
degeneration, with little or no arterial sclerosis, he finds the 
iodides sometimes worse than useless. The effects found from the 



DISEASES OF THE HEART AND CIRCULATION. 7 

use of stropliaiitlnis have not been equal to those obtained with 
digitalis ; but he admits that since obtaining a better preparation 
of the former he has had more successful results. Most other 
so-called cardiac tonics are in his view useless. Of these he 
signalises cafteine as an example. The paper goes on to refer to 
the importance of nitro-glycerine in chronic cardiac disease, as 
well as of iron wdien the condition of the digestion will permit 
of it. 

"I. Tiio iniportancc of diet. 

Shortly before his death M. J. Oertel puljlished (Zeitsch. f. 
Krankenpf., xviii., S. 1 and 25) an important paper upon diet 
in chronic diseases of the heart, in which he emphasises the 
overwhelming- impoi-tance of suitable food in the treatment of 
such affections. He urges the selection of articles of food, and 
the regulation of the size and number of meals, in order to obtain 
the highest nutrition with the least possil^le disturbance, so that 
the cardiac energy and the vascular relations ma}'' l;e, as far as 
possible, improved. He says, somewhat sarcastically, that the 
cai'eful supervision of such matters is of far higlier importance 
than the administration of a few drops of digitalis or strophanthus, 
or the employment of a few carbonic acid baths. 

!{. The methods of Schott and Oertel. 

H. N. Heinemann {Deutsche med. Woch., xxii., S. 525) strongly 
urges the importance of the Schott methods of treatment, from 
observations made in Nauheim upon seventy-six cases, as the 
result of which he believes that there is not merely temporary 
relief but permanent improvement. He is of opinion that neither 
the baths nor the exercises by themselves are of so much value as 
the combination of botli methods. 

W. H. Broadbent's views ("Heart Disease," p. 92 and p. 325) 
as regards the Oertel and 8chott methods of treatment are well 
worthy of cai-eful consideration. With reference to the former, 
he holds that in cases of valvular disease, in which compensation 
has completely given way, the treatment is certainly not advisable, 
and in many cases would be impossible. When, however, com- 
pensation has been established or restored, gentle climbing exercise 
in fresh, rarefied air will certainly do more to develop further 
compensatory hypertrophy of the heart then mere walking on 
the level. It is more especially in cases of fatty accumulation, 
without fatty degeneration of the cardiac muscle, that the treat- 
ment by dieting and systematic muscular exercise may be of real 
service. 

After stating the theory of Schott, that the heart is stimulated 
by a reilex process so that its contraction becomes more complete 



o THE YKAR-BOOK OP TREATMENT. 

and furciljld, as Ji result of wliicli the heart muscle undergoes 
hyp('rtro2)hy, and . so becomes competent to cope with the extra 
woi'k thrown on it l>y the valvular lesion, Broadbcnt expresses 
the view that it is more probable that the baths and movements 
give rise to a physiological dilatation of the capillaries in the skin 
and muscles respectively, so that the resistance to the onward flow 
of bloud is lessened, and the left ventricle, thus relieved, is able to 
complete its systole. He admits, however, that the cliief objec- 
tion to this theory is the slowing of the pulse which occurs in the 
bath or during the exercise, as diminished peripheral resistance 
would tend to accelerate the pulse. He allows the possibility 
that slowing of the pulse may be attributable to reflex stimulation 
of the vagus. 

In summing up the i-esults of treatment by baths and exei'cise, 
Broadbent allows that the method may give relief and greatly 
modify the symptoms in suitable cases of valvular disease; but 
that it is not to be regarded as applicable to, and infallible 
in, all varieties and conditions of morbus cordis, or as a sub- 
stitute for all other forms of treatment. In cases of cardiac 
dilatation from loss of tone of the heart muscle, after influenza, or 
some other depressing disease, it may be of great service and an 
effective remedy where drugs and other treatment fail. In many 
cases of functional and neurotic heart disease, it may also give satis- 
factory results. In valvular disease it is unnecessary when com- 
pensation is established and no symptoms are pi-esent. When 
compensation has completely broken down, it is not advisable, as 
rest in bed and suitable treatment by other means will be more 
eflScacious. In cases of mitral disease, more especially of obstruc- 
tion, when compensation is maintained with difficulty, it may be 
of great service. In aortic disease it is not advisable, owing to 
the risk of syncopal attacks, though when con)pensation is break- 
ing down, and the mitral type of symptoms is present, it may 
sometimes bring about good results. 

In an appendix dealing with the methods employed in the 
Schott treatment of heart disease, Broadbent states further that 
the mere fact of a patient having heart disease should not be a 
signal for its immediate employment. When compensation is 
perfect no special treatment is required, and in a large proportion 
of cases of valvular and muscular disease the value and efficacy 
of this treatment are doubtful, equally good or even better results 
being obtainable by other means. The best results of this treat- 
ment are to be seen in cases of functional or imaginary heart 
disease in neurotic individuals. It is impossible not to agree 
with Broadbent in the final sentence of his work : " The practice 



DISEASES OF THE HEART AND CIRCULATION. 3 

of placing in the liamls of the patient elaborate diagrams to 
illustrate the supposed diminution in the size of the heart after 
a bath is to be deprecated." 

Lauder Brunton's views (" The Action of Medicines," pp. 353 
and 3G8) as regards the treatment of heart disease ))y baths 
and exercises ai'e by no means similar to those of Broadbent, 
inasmuch as he writes almost enthusiastically of these methods in 
the treatment of certain cases. He has appended to his lectures 
dealing with this subject, just as is done by Broadbent, a descrip- 
tion of the various resistance exercises which are employed. It 
is impossible, however, to regard the diagram which he gives, 
showing the reduction of the cardiac dulness after a bath, as being 
vei'v true to nature. 

A. Bum (Wien. mecl. Presse, xxxvii., S. 281 and S. 320), in an 
important contribution to the treatment of circulatory disorders 
by mechanical means, points out that as the result of increased 
muscular action there is an elevation of the blood pressure, after 
which it falls to a lower level than previously, and finally comes 
to the normal. He agrees with Hasebroek that the initial rise 
of pressure must have its origin in increased activity of the heart. 
The performance of increased work in resisted movements is only 
possible for the heart in systole if the work of the heart in 
propelling the blood can be permitted by a lowering of the 
peripheral resistance. Methodical movements of the muscles are 
able to lower the resistance in the systemic circulation in a reflex 
manner, as well as to increase the activity of the heart and 
favour the return of venous blood. The author is, therefore, 
strongly of opinion that in massage and gymnastics there are 
means of powerfully increasing the retuini of venous blood. 
These opinions lead him to advocate the employment of such 
therapeutic methods, with careful attention to the general con- 
dition of the patient, as well as to the character of the circulatory 
disturbance. 

4. The uses of massage. 

J. Zabludowski (^Berlin, klin. Woch., 1896, S. 435) emphasises 
the usefulness of massage in chronic affections of the heart. After 
pointing out that patients with feeble hearts not infrequently 
collapse under the effects of active and resisted exercises, he 
shows that the various passive movements included under the 
term massage are of benefit. Massage often within a few days 
renders a previously frequent and small pulse larger and less 
frequent, while palpitation and oppression are reduced, and the 
improvement is accompanied by better sleep and spirits. The 
author has also observed excellent results from massage in 



10 THK YKAR-ROOK OP TURATMENT. 

circulatory neuroses ; in .sclerosis of the corouaiy arteries, the 
diagnosis of which, by the way, he does not specify; in hypertrophy 
from over-eating and drinking, weakness of the heart after 
influenza, and in cases of Graves's disease. He holds that along 
with digitalis it constitutes an active means by which, often in a 
very short time, the heart may be quieted and steadied ; while, at 
the same time, the peripheral resistance is diminished. The 
process must be begun gently, and the cardiac region must at 
first not be disturl)ed. After the circulation has been stimulated 
it is not necessary to restrict the method to any particular part of 
the body, but general massage may be adopted. Stimulation of 
the nerves of the back, of the neck, and of the intercostal spaces, 
as well as of the vagus through percussion, constitutes an im- 
portant part of this general massage, and considerably increases 
its action. 

RECENT PHARMACOLOGICAL ADVANCES. 

1. The effects of baths. 

The influence of cool baths upon the circulation in health has 
been carefully investigated by A. Breitenstein {Arcli.f. exp. Path. u. 
Pharm., Bd. xxxvii., S. 253), who has carried out a very large 
number of observations on this sul)ject. Although his work does 
not bear directly upon the treatment of circulatory aflections, yet 
it is of importance to notice that he observes an increase in the 
force of the heart, and a diminution of blood pressure in the 
veins, so that the rapidity of the circulation is increased, and 
any tendency to stasis lessened. He is of opinion that the cold 
bath exerts an immediate reflex effect on the heart and the blood 
vessels, while, at the same time, the deeper respirations antagonise 
stasis in the great veins. 

2. Tlie actions of dis^italis. 

Arthur Cushnie (Journ. Exp. Med., 1897, vol. ii., p. 233) has 
investigated the action of substances belonging to the digitalis 
group. Strophanthin, digitalin, antiarin, erythrophlcein, and con- 
vallamarin were the drugs more particularly investigated. Some 
of the observations were carried out simply by watching the 
movements of the heart, but more accurate observations were 
made with the myocardiograph and the cardiometer. By means 
of these methods he has been able to test the work of previous 
observers, and to criticise the opinions which they have expressed. 

He has been led to the conclusion that in producing their 
effects on the cardiac muscle all these drugs have an action which 
is identical, but that they differ considerably in their relative 
strength ; on the other hand, their effects upon the blood vessels 



DISEASES OF THE HEART AND CIRCULATION. 11 

are niucli more vai-ial)le. Tliey also differ very widely in their 
relative action on the cardiac muscle and the nervous apparatus. 
According to the author, the action of digitalis may be divided 
into two stages, of which the first is marked more by nerve 
inhil)itoi-y action than by changes in the cardiac muscle ; while 
the second shows less inhibitory action and more muscular effectf--. 
The inhibitory effects are brought about by direct stimulation of 
the vagus nerve, both in its central apparatus in the medulla, 
and in its peripheral distribution to the heart ; while the cardiac 
muscular efTects are manifested by increased extent of systole, 
and in some cases diminished diastolic relaxation. When larger 
doses are administered, the irritability of the muscle is consider- 
ably increased, and there may be a development of the spon- 
taneous rhythm of the ventricles. The result in the first stage 
is to give diminished frequency of cardiac action, with more 
complete ventricular contraction, and, as a rule, increased diastolic 
relaxation — this latter phase may, however, be unchanged or 
even diminished. The auricles sometimes do not contract with 
so much force and perfection, but the opposite condition was 
sometimes observed, and they usually undergo a more complete 
relaxation than is normal. There is increase of systolic pres- 
sure and augmentation of the amount of blood ejected from 
the heart. These effects, added to the contraction of the 
arterioles, produce inci'eased pressure and acceleration of the 
systemic circulation, perhaps a rise of pressure in the great 
veins, which is only transient, if it occurs at all, and possibly also 
augmented pressure of a temporary kind in the cardiac cavities 
during diastole. Cushnie found that the pressure in the pulmonary 
artery is scarcely affected by some drugs belonging to the group, 
while it is increased by others, and he concludes that these effects 
are due to the action of the poisons on the peripheial arteries, not 
on the heart. When the action of the vagus is very strong, 
there may be more slowing of the heart, while the ventricles beat 
spontaneously, and lose their relationship to the auricles. A 
diminution in the amount of blood ejected may be produced by 
the retardation of the heart, and the blood pressure even may 
fall to a considerable degree. The ventricles, however, do not 
lose their associated activity, although they become irregular from 
variations in the length of the pause. 

The second stage is marked by acceleration of the action of 
the heart from increased irritability of the muscle fibres, and the 
ventricles have frequently a spontaneous contraction. Occasion- 
ally the auricular and ventricular movements interfere with each 
other, and, by the passage of impulses i:n either direction, give 



12 THE YEAR-BOOK OP TREATMENT. 

rise to iiTOgularity. It is of iiittsrcst to olwcrvc that IIk; two 
ventricles maintain their common rliytlim tliroughout, although 
the auricles may contract at quite a different rate. The inhilji- 
tory nerves lose their power of retardation, the output of blood 
undergoes extreme variations, and the blood pressure falls to a 
great degree. The auricles, as a rule, cease to contract before 
the ventricles fail, but this is not an invariable experience. The 
heart comes to a standstill in the diastolic phase. 

The author, finally, seeks in these effects for an explanation 
of the results obtained by the use of digitalis in the treatment of 
disease, and is led to the conclusion that the beneficial effect must 
be attributed for the most part to its direct cardiac action. The 
early part of the first stage alone can be held as of use in thera- 
peutics. In dilatation of the ventricle, there is a much less com- 
plete systole than there should be, and some residual blood remains 
behind. An increase of the systole leading to expulsion of all 
the blood, such as is produced by digitalis, is of the greatest value 
in such conditions. It is possible that the diastole in such cases is 
not so great, but this cannot be regarded as certain. If there 
should be any incompetence, an increase in the contraction of the 
ventricle during systole will have a tendency to diminish the 
irritation, and thus lessen the regurgitation. The jiapillary 
muscles at the same time act more powerfully and diminish the 
incom2)etence of the valve. The auricles do not seem to be 
affected by digitalis to such an extent as to produce any effects 
upon the cii-culation ; but Cushnie frankly admits that he is not 
quite certain about this point. The increased contraction of the 
ventricle has the same compensatory effects in dilatation and in- 
competence on the right side of the heart, just as in the case 
of the left, and this is the case whether the right side sutlers from 
affections of the left side of the heart, or from affections of the 
lungs. It appears to be established that digitalis has much more 
tendency to increase the resistance of the flow of the blood through 
the lungs than is the case with strophanthus. Possibly the latter 
drug may therefore be more useful in dilatation of the right 
ventricle as a consequence of pulmonary conditions than the 
former. In pneumonia the effect of digitalis may be due to its 
acting as an antagonist to the toxins of the disease. 

Brunton and Tunnicliffe (Journ. of Physiol., 1896, vol. xx., 
p. 351) have made some investigations upon the vexed questions 
connected with the action of digitalis on the vessels. Their 
method consists in («) inhibiting the heart for an equal period of 
time under ordinary conditions, and after injecting digitalis ; and 
{b) comparing the rate and extent of the ensuing fall of blood 



DISEASES OF THE HEART AND CIRCULATION. 13 

pressure in the carotid in these two cases. It is obvious that if 
the heart is arrested for the same length of time in both cases, 
the extent of the f;\U of blood pressure as well as its rate will 
depend on the pressure at the time of arrest — i.e. on the state 
of contraction of the peripheral arterial system." The results 
obtained were strongly in favoui* of a distinct effect on the arterial 
system. Without previous administration of digitalin, the pres- 
sure of a rabbit, on inhibition, fell from .50 to 13 mm. Hg., thus 
showing a fall of 37 mm. After the administration of digitalin, 
the blood pressure in the s ime animal fell from 58 to 32 mm., or 
26 mui. The lessened rate of fall, under inci'eased pressure, can, 
in the opinion of the observers, be produced only by stimulation 
of the peripheral vessels. 

3. T'lie eflfccts of dii^italis. 

Upon the use of digitalis Broadbent, in his recent work (op. cit., 
p. 112), expresses sound opinions. "It is too commonly taken 
for granted," he say.s, " that the existence of valvular disease con- 
stitutes an immediate indication for the administration of digitalis ; 
but to make the discovery of a murmur the signal for giving 
digitalis is fatal to anything like precision in treatment, and may 
deprive the sufferer of the advantage to be derived from this 
remedy when it is really needed. The special indications for its 
use are frequency, weakness and irregularity of pulse, and oedema 
of the extremities, with scanty, turbid, concentrated urine. 
When these are absent, it is rarely of service, but even when the 
symptoms begin to show themselves gradually, or occasionally on 
slight provocation, it will be well to combat them at first with 
strychnine, iron, quinine, and general tonics, i-ather than resort at 
once to digitalis, the salts of potash and any suitable diuretic 
being employed to promote secretion. When the use of digitalis 
is called for, the most trustworthy evidence of its beneficial effects 
will be increase in the secretion of urine, with an improvement in 
the tone and vigour of the pulse, as well as more regular and less 
hurried action of the heart. W^lien there is no response in the 
form of diuresis, the pulse and general symptoms must be carefully 
watched lest harmful effects should occur." 

In connection with this subject it may be noted that the 
author speaks very strongly in favour of the combination of 
digitalis with nux vomica, as well as of the almost classical union 
with mercury and squills ; and he further advises the use of 
a mercurial aperient before the exhibition of digitalis, to be re- 
peated from time to time. Broadbent is of opinion that con- 
vallaria is not of great service ; he holds that strophanthus may 
be most useful when digitalis produces sickness, and may even 



14 THE YEAR-BOOK OF TllEATMKNT. 

succeed where digitalis lias failed. In his ojuiiion calleino lias 
been a most useful accessory to digitalis, but Ik; has not found 
that it is an efhcient substitute for it. 

T>roadl)cnt in discussing the physiological action of the grouj) 
of cardiac stimulants, maintains that thuir eflect is a stimulation 
of the muscular fil>res of the cardiac and vascular system, giving 
rise, on the one hand, to more deliberate action of the heart, and 
on the other, to tonic contraction of the arterioles and capillaries. 
This he believes to be produced Ijy a direct action upon tlie mus- 
cular structures, and not, therefore, by an indirect influence upon 
nerves. Arguing from these physiological effects, he thereupon 
discusses their therapeutic action. He lays particular stress 
upon the more complete expulsion of the contents of the heart by 
the energetic contraction of the ventricles, which thereby fills the 
arterial side of the circulatory system ; and upon the important 
suction action during diastole which will lead to withdrawal from 
the veins of the blood stagnating in them. He further empha- 
sises not only the efiectiveness of the systole, but the renewed 
vigour of the heart through the increased physiological rest from 
prolongation of the diastole. The primary effect, no doubt, of the 
tonic contraction of the arterioles is to increase the resistance in 
the peripheral circulation, and it is therefore conceivable that 
under certain conditions, such as serious cardiac degeneration, the 
contraction may more than neutralise the increased force of the 
systole. As, however, there is in most cases some considerable 
hypertrophy of the muscular walls of the heart without any 
corresponding hypertrophy of those of the vessels, the balance of 
advantage is largely on the side of the heart. Replying to a 
feasible argument that the contraction of the arterioles might 
diminish the force of the current passed on to the veins, he 
submits that the contraction affects also the capillaries, and that 
the narrowing of their channels will increase the rapidity of the 
current of blood within them, so that more propulsive force will 
be communicated than through a network of flaccid, dilated, 
and bulging capillaries. This increased flow will also favour the 
absorption of fluid from the intercellular spaces. 

Broadbent thereafter seeks to exjjlain why the drug is not, 
as might be expected, of equal service in all forms of heart 
disease, excepting structural degeneration. It is universally 
agreed that, in mitral incompetence, digitalis is of the greatest 
service, and there is almost equal concurrence of opinion that it 
is not of so much use in mitral obstruction ; while in aortic 
diseases there is a conflict of views as to the effects obtained 
from cardiac tonics. Broadbent points out that the discussion of 



DISEASES OF THE HEART AND CIRCULATION. 15 

digitalis is often carried oi;t on theoretical grounds, and he 
calls attention to the fact that it is upon experience that the 
conclusions which have just been referred to are Vjased. The 
differences in the eflects of digitalis were known long before its 
physiological action was ascertained. He points out that when 
mitral obstruction was not distinguished from incompetence, the 
varying effects of digitalis must have been very perplexing. He 
further suggests that, in aortic regurgitation, failure of compen- 
sation may occur in two different ways : in the one, from 
defective propulsion of blood into the arteries, in which death 
occux's by syncope; in the other, from backward pressure upon 
the lungs and right heart. There are, as he puts it, " aortic 
physical signs with mitral symptoms." In the former of these 
cases he regards digitalis as of uncertain and sometimes, indeed, 
of grave effects ; in the other, digitalis frequently acts as well as 
in mitral incompetence. In the same way, as regards aortic 
obstruction, he regards digitalis as useful when there are pul- 
monary symptoms ; while if there be a limited supply of arterial 
blood, he considers that moi-e relief may be obtained from the 
use of nitro-glycerine. Broadbent is of opinion tliat the favour- 
able results of cardiac tonics in mitral regurgitation are due 
almost entirely to a reinforcement of the right ventricle. He 
states that among the conspicuous favourable results of digitalis 
is diminished irregularity of the pulse, which beneficial effect is 
entirely due to the higher blood pressure in the left auricle. He 
holds that mitral incompetence is the one among valvular 
affections which is specially liable to irregularity of the pulse, 
and that this is brought about by the vaiying conditions of 
pressure within the thin walls of the left auricle. The effect of 
digitalis, therefore, in dinjinishing variations of pressure within 
the auricle is to steady the heart and render the pulse more 
regular. 

As regards the effects of digitalis in mitral obstruction, 
Broadbent is of opinion that as the left ventricle in uncompli- 
cated cases is neither dilated nor hypertrophied, while the arteries 
generally are small and contracted, there can be no advantage in 
further constriction of the arterioles ; the symptoms rather are 
removed by producing dilatation. Moreover, no great increase 
in the output of blood is to be gained by more vigorous contraction 
of the walls of the left ventricle ; while, further, an increased 
stimulation of the right ventricle may sim})ly lead to embarrass- 
ment. Seeing that the blood cannot be forced through the orifice 
in mitral stenosis beyond a certain rate of speed, the usefulness 
of the drug is restricted. 



16 THE YKAU-I500K OF TUEATMKNT. 

4. I>i;;it:iliiiiiiii \'ei-iiiii. 

P. Deucher {^iJent. Arch. klin. Med., Ivii., S. 1), in order to have 
a means whereby it might be possible to obviate some of the dis- 
agreeable effeets of digitalis, has pursued some carefid investiga- 
tions on digitalinum verum. The theoretical l>enelit which might 
be expected from the subcutaneous use of this remedy has not 
been realised in practice. The preparation is greatly inferior to 
such a substance as infusion of digitalis, and it even produces 
serious local effects. Deucher, therefore, concludes that digitali- 
num verum is only indicated in such cases as have been found to 
be unsuitable for the use of the ordinary preparations of digitalis. 

5. Aiitag:oiiistic action between <lig:italis and 
nitrites. 

C. R. Marshall i^.Tonrn. Phys., 1897, vol. xxii., p. 1) has in- 
vestigated the antagonistic effects of digitalis and some of the 
vaso-dilators. The employment of digitalis combined with nitrites 
was, several yeai-s ago, suggested by Huchard, and although no 
experimental light has been thrown upon the matter, the com- 
bination has been largely employed by practical physicians. 
The author is of opinion that the action of digitalis is a chemical 
one on the myoplasm of the cardiac cell itself. The effects of 
stimulation of the inhibitory and accelerator nerves may be 
produced in the early stages, but whether these result from 
changes brought about in the contractile substances, or whether 
they are due to a true stimulation of the inhibitory and accelera- 
tor nerves, apart from the muscle cells, is a debatable point. As 
all observers are agreed that an effect on the muscular substances 
exists in all phases of digitalis action, and as this is almost the 
only effect desired in practice, this influence for the present must 
be regarded as predominant. On the blood vessels digitalis 
exerts a powerful constricting influence, prol^ably a direct one on 
the muscular tissue in their walls. He regards the nitrites, on 
the other hand, as being also muscle poisons, with effects entirely 
different from those of digitalis ; they dilate the vessels by acting 
directly on their walls, in consequence of which the heart beats 
more rapidly. The nitrites also have a depressing effect on the 
cardiac muscle, and they are therefore in every way antagonistic 
to digitalis. From the careful investigation of the combined action 
of the two classes of drugs, which were carried out l^y means of 
kvmographic, perfusion, and sphygmographic experiments, as well 
as by examination of the renal secretion, Marshall has come 
to some interesting conclusions. Digitalis and the nitrites are 
antagonistic as regards effects on blood pressure, each drug partly 
counteracting the effects of the other. The nitrites are believed 



DISEASES OP THE HEART AND CIRCULATION. 17 

under all conclitious, to protluee a reduction of blood pressure ; 
and digitalis employed during the action of the nitrites can 
always to some extent, at any rate, raise the pressure of the 
blood. If the two drugs are administered at the same time, the 
vasodilator action is principally seen probably from the more 
rapid action of the nitrites. The pulse is not by any means 
so much retarded as w'hen digitiilis is given by itself. Even 
after the production of irregularity of the heart l)y means of 
digitalis, the nitrites will often remove the symptoms for a 
time. The conclusion from observations on the vessels and the 
heart are that the drugs are mutually antagonistic, the result- 
ing effects depending on the excess of either substance. 

The observations on the renal secretion were carried out on 
rabbits, and the result of the experiments was to prove the gener- 
ally accepted view that digitalis produces in health a diminu- 
tion rather than an augmentation of the secretion. Marshall, 
however, finds that nitro-glycerine acts as a diuretic after a 
return of blood pressure to normal, and he concludes that the 
combination of the two substances is more powerful in this 
direction than nitro-glycerine alone. When the blood pressure 
is reduced by nitro-glycerine, the secretion is greatly diminished, 
but when digitalis has been administered before so as to lessen 
the fall of pressure, the diminution was extremely small. It is 
to be remarked that sodium nitrite does not produce so much 
effect as nitroglycerine. 

The human pulse observed by means of the sphygmograph 
showed that the nitrites were more powerful in antagonising 
digitalis than the converse. Digitalis has undoubtedly some 
effect on the action of the nitrites, but in the main it does not 
greatly influence their action ; wdiile, even after large doses of 
digitalis, the action of the nitrites is easily produced. Marshall 
regards the antagonism as being produced through the muscle 
cells by chemical action, and the toxic effects of either drug 
are not lessened by their antagonistic action, as seen in the 
heart of the frog. 

ARTERIAL DISEASES. 

1. Ai'terio-solei'osis. 

Groedel (Wieu. ))ied.Wock.,lS9G,8.6C)5 and S. 727) considers that 
apprehensions with regard to the treatment of arterial sclerosis 
by means of baths are destitute of foundation, and expresses the 
opinion that their effect, by stimulating metabolic processes, is 
beneficial. He holds that hot brine baths containing carbonic 
acid act as tonics upon the heart after it has undergone weakening 
c 



18 THE YEAR-ROOK OF TREATMKNT. 

in (•()ii.S('(|\icnc<" oF ailciial sclcnjsis. Ifc, admits, liowuvc;)-, that 
tliero an; certain, contra-iiulications, such as aj)(>plcxy and other 
brain aiiections. There is some unconscious liumour about this 
paper which renders it most amusing. 

2. TroatiiK'iit nf aneurysm by means of wire 
and elocti'icily. 

A successful case of treatment of an aneurysm of the innomi- 
nate artery lias been reported Vjy Hershey (^Tkerap. Gazette, vol. 
XX., p. 51)0). The method of treatment was the puncture of the 
aneurysm by means of a needle, and the introduction of gold wire 
of 14 carats. It had been intended to insert sufficient wire to 
fill the cavity, but after '1^ feet had been employed the wire 
became bent and no more could be introduced. It was, there- 
fore, cut short and attached to the positive pole of a battery, 
while the negative rheophore was applied to the back of the neck. 
A current of 70 milliamperes was in this way conducted thi'ough 
the s ic. For three-quarters of an hour the aneurysm underwent 
no change, and the needle showed free pulsations, but after this 
the appearances changed, and the galvanometer showed only a 
current of 60 m.a. The movements of the needle gradually 
became less, and the current fell to 40 m.a., while the mass 
began to feel hard to the touch. The patient made an excellent 
recovery, and has been able for his work ever since. 

CIRCULATORY NEUROSES. 

Exoplitlialinic g^oitre. 

F. Berndt (Arch. klin. Chir., 52, S. 709), in reporting two cases 
of Graves's disease, both of which made a complete recovery after 
removal of part of the thyroid gland, makes some reflections upon 
the rationale of the treatment without coming to any detinite 
conclusions. He is inclined to regard the affection as a primary 
central neurosis caused by the mechanical effects produced by the 
pressure of the enlarged thyroid gland upon the sympathetic! 



DISEASES OF THE LUNGS AND ORGANS 
OF RESPIRATION. 

By GrsTAVE Schorsteix, M.A., M.B. Oxon., F.K.C.P., D.P.H., 

Assistmt Physician to the London Hospital, and to the Hospital for Consumplion, 
Broinpton. 



A. — Pulmonary Tuberculosis. 

I. — Preventive measures. 
II. — The diagnostic value of Koch's original tuberculin. 
III. — The new tuberculin. 
IV. — Serotherapy. 
V. — Special drugs and methods. 

(1) Guaiacolate of piperidine. 

(2) Oxy toxins. 

(3) Camphoric acid. 

(4) Eucalyptus oil and oil of cinnamon. 
(.5) Eosote. 

(6) Peronin. 

(7) Rontgen Rays. 

B. — Pneumonia. 

I. — Serotherapy. 
II. — Large doses of digitalis. 
III. — Formate of sodium. 
IV. — Creasote. 

C. — Whooping Cough. 
1. — Ozone. 
2. — Exalgin. 
3. — Resorcin. 

D. — Chronic Bronchitis. 

A.— PULMONARY TUBERCULOSIS. 

L PREVENTIVE MEASURES, 

There has been a very healthy activity during tlie past year in 
regard to the development of preventive measures against tubercle. 
The knowledge that tuberculosis is very largely a preventible 



20 THE YKAR-BOOK OP THKATMENT, 

disease, not liopelessly due t(j lieredity, is slowly becoming 
difl'used. Ijut we are a long way yet from the general recognition 
of the fact. The most interesting report of what can be done is 
contained in Hermann Biggs's address on Pulilic Medicine at the 
Montreal meeting of tl)e British Medical Association. It is of 
such general importance that it is worth quoting in extenso. 

"The Health Board of New Yoi'k City first began an educational 
campaign in relation to the causation and prevention of pulmonary 
tuberculosis in 1889. In that year a communication on this suljject 
presented by the writer and the associated Consulting Pathologists 
of the Department was widely published, and leaflets based on it, 
giving the essential facts as to the nature of this disease, were 
freely distributed. No further action was taken at that time, 
as investigation showed that the medical profession and the public 
were not then prepared for more extended measures. In December, 
1893, the attention of the Department was again called to the 
subject by the writer, and it was determined at once to institute 
more comprehensive measures for the prevention of this disease. 
The measures then adopted required the notification of all cases 
of pulmonary tuberculosis occui-ring in public institutions, and 
requested reports of cases occurring in the practice of private 
physicians. They also included arrangements for the bacteriological 
examination of sputum, to assist in the early diagnosis of this 
disease ; the inspection of all reported cases in tenement houses, 
lodging-houses, hotels, and boardingdiouses, and the instruction of 
the patients and their families as to the nature of the disease and the 
means to be taken for its pi-evention; the inspection of the premises 
in all instances Nvhere deaths were reported as due to tuberculosis, 
and the issuing of orders, when it was deemed necessary, upon the 
owners of apartments which had been occupied by consumptives 
and vacated by death or removal, requiring that such apartments 
be thoroughly renovated, by cleansing and by painting, papering 
or kalsomining, before they were again occupied by other persons ; 
and, finally, the education of the public by wider and more com- 
prehensive methods as to the nature of this disease. 

" Placards wei'e attached to the doors to prevent the reoccupa- 
tion of apartments which had been vacated by death or removal 
before the orders requiring renovation had been complied with. 

" Under the resolutions by virtue of which these measures were 
enfoi'ced, 4,166 cases of tuberculosis were reported in 1894, 5,818 
in 1895, and 8,334 in 1896. So far as was possible, all of these cases, 
except those in private houses, were visited or the premises where 
they had lived were inspected, and, in addition, the premises 
occupied by persons dying from tuberculosis (numbering each 



DISEASES OP THE LUNGS AND ORGANS OP RESPIRATION. 21 

year 6,000) were inspected, and such action taken as was con- 
sidered possible and desirable. Altogether the premises and cases 
thus coming under observation during these three years numbered 
more than 35,000. 

" These facts convey some idea of the enormous sanitar}- import- 
ance of the subject. It is conservatively estimated that there are 
at least 20,000 cases of well-developed and recognised pulmonary 
tuberculosis now in New Yoi'k City, and an additional large 
number of obscure and incipient forms of disease. A very large 
proportion of the former cases constitute more or less dangerous 
centres of infection, the degree of danger depending in each 
instance upon tlie intelligence and care which are exercised in 
the destruction of the expectoration. All the suffering and death 
consequent upon the prevalence of this disease, in view of modern 
scientific knowledge, are largely pi"eventible by the careful ol)serv- 
ation of simple, well-understood, and easily ap|)lied measures of 
cleanliness, disinfection, and isolation. 

"In the beginning of 1897 the Health Board further adopted 
some recommendations made jointly by Dr. T. Mitchell Prudden, 
Consulting Bacteriologist to the Health Department, and the 
writer, which advised that pulmonary tuberculosis be declared to 
be an ' infectious and communicable disease, dangerous to the public 
health, and which required the notification of all cases occurring 
in the city,' in the same way as is required with regard to typhoid 
fever, diphtheria, and other similar diseases. Tuberculosis, how- 
ever, in accordance with the special section of the Sanitary Code 
enacted to provide for these measures, is distinctly separated from 
the eruptive diseases, is not classed with them as a contagious 
disease, but is referred to as an ' infectious and communicable 
disease.' It has always ajyjjeared to the Health Board exceedingly 
desirable that a hroad distinction should exist in the pioblic mind 
between this disease and the diseases which are more projjerly 
classed as contagious. 

" In the treatment of apartments which have been occupied 
by tuberculous patients, and vacated by death or removal, renova- 
tion has been, and is, ordered rather than disinfection attempted, 
because the Health Board has always felt that disinfection for 
tuberculosis in the poorest tenement houses was too difticult to 
be performed satisfactorily, and has considered renovation as 
certainly efiicient. In the thousands of orders requiring the 
renovation of premises which have been issued under the reso- 
lution referred to upon the owners of real property during the 
last four 3'ears, little or no difficulty has been experienced in 
enforcing compliance, and rarely has there been serious objection. 



22 TIIK YEAR-liOOK OK TKKA'I'MKNT. 

" PuUlio institutions, hospitals, asyliiins, lioiiics, etc., are now 
not only rccjuired to report the narnc!, last adtlress, sex, age, and 
occupation of every case of tul^erculosis coming imder observa- 
tion, within one week of sucli time, but they are further i-erjuii-ed 
to notify the Department of the discharge or transfer of such 
patients. The purpose of this procedure is to keep under more 
or less constant supervision those cases of pulmonary tuberculosis 
which occur among the poorest classes of the population ; in 
other words, those which are most likely to be dangerous sources 
of infection to others. Unfortunately, at the present time there 
are no hospitals directly under the control of the Health Depart- 
ment for the care or isolation of cases of pulmonary tuberculosis ; 
but it is hoped that such hospitals may be soon provided. 

" The best medical opinion forbids that persons suffering frinn 
pulmonary tuberculosis be treated in association with other 
classes of cases in the general medical wards of general hospitals. 
This opinion is based on the daily observation of the dangers 
incident thereto, and it has very properly resulted in the exclusion, 
to a large extent, of persons suffering from this disease from 
many of the general hospitals to which they were formei'ly 
admitted. 

" A large experience has also shown that in institutions devoted 
solely to the care of consumptives the general welfare of the 
patients is more easily fostered, the risks of fresh infection are 
more certainly diminislied, and the chances for recovery are more 
surely enhanced than in general hospitals, in which all classes of 
cases are received. 

" From the beginning of this work, the officials of the Health 
Department of New York City have encountered, in the lack 
of proper facilities for the care of consumptives, a great obstacle 
to practical success, and I am convinced that the grave responsi- 
bilities which rest upon sanitary authorities generally in this 
matter cannot be properly discharged without the establishment, 
under their direct control, of additional special hospitals for the 
care and treatment of this disease. No week passes in which the 
officers detailed to this work in New York do not encounter many 
instances in which the members of many households, numer- 
ous inmates of crowded tenement houses, employees in dusty 
and unventilated workshops, and many others, are dangerously 
exposed to infection from victims of this disease, who cannot 
gain admittance to the overcrowded i^ublic institutions, or who 
reject all proffered assistance and instruction, and, from ignorance, 
indifference, or inability tlirough weakness due to the disease, 
scatter infectious material broadcast, thus diminishing their own 



DISEASES OF THE LUNGS AND ORGANS OF RESPIRATION. 1^3 

chances for recovery and imperilling the health and safety of 
others. In such cases sanitary suggestions are futile, and 
removal to a hospital constitutes the only elective action. I 
am convinced that no factor is so potent to day in perpetuating 
the ominous death list from pulmonary tuberculosis as the lack 
of proper facilities for the adequate care of the poor stricken 
with this malady : — 

" The measures designed for the prevention of tuberculosis 
properly include not only those which relate to the transmission 
of the disease from human beings to each other but also those 
which relate to the transmission of the disease from affected 
animals, especially the bovine species, to human beings, through 
the meat and milk used as food. The Health Department of 
New York City, wliile feeling strongly that the most important 
source of infection is through the sputum of consumptives, lias 
yet elaborated with great care methods for protecting the public, 
so far as lies within its power, from infection by the meat and 
milk of tuberculous animals. In order that a more effective 
control of the milk siapply should be possible, an ordinance was 
passed in 1895 forbidding the sale of milk within the city without 
a permit from the Health Department, and requiring that all 
waggons used for transportation or delivery of milk should like- 
wise have waggon permits. Before these permits are issued, the 
holder of the permit must furnish information as to the source 
from which the milk is obtained, the number of animals, the 
character of the food supply, and the sanitary conditions sur- 
rounding the dairy. Special regulations have been established 
with regai'd to the sale of milk, and pei-mits may be revoked 
at any time by the Healtli Board, where evidence exists that 
the i-egulations have not been strictly complied with. All milch 
cows in New York City (about 3,000 in number) are now being- 
subjected to the tuberculin test, under the supervision of the 
Health Department, and animals found to be diseased are killed. 
It is proposed, as soon as this work is completed in New York 
City, to require similar tests to be applied to all cows whose 
milk is sent to New York City. There also exists a careful 
inspection of animals slaughtered for food, and of all meat sent 
into the city, and the carcases of those found to l^e tuberculous 
are destroyed. 

"Most l)eneticial effects have already resulted from the various 
measures instituted for the prevention of this terrible disease. 
Not only has there been a very material decline in the inunber 
of deaths occurring from it l)ut there has been a most gratifying 
increase of knowledge and intelligence as to its nature araonii; the 



24 TlIK VKAR-UOOK OF THKATMKNT. 

poorest class of the population, 'i'lu; inspectors fletailed foi- this 
work report that. on their first inspection, in nearly one-half of 
the cases occurring in many parts of the tenement-house districts 
of the city, it is found that more or less eHicient precautions are 
being taken for its prevention. Such precautions are the use of 
rags to receive the sputum, which are later burned, instead of 
handkerchiefs, the use of cups containing water or a disinfecting 
solution, the separation of the clothing of the patient from that 
belonging to others, and similar measures. 

" This increase of intelligence, and the precautions resulting 
from it, afford the greatest promise for the future of a persistent 
and still more rapid decline in the frightful morbidity and 
mortality caused by the tuberculous diseases. 

"Investigations made by the Department, showing that the 
dust in the street cars and various public places is often infec- 
tious, led to the enactment of an amendment to the Sanitary 
Code, prohibiting spitting on the floors of street cars, ferry l)oats, 
and other public conveyances, and requiring that all compani(;s 
should post in their cars, boats, etc., printed notices forliidding 
this. This regulation is very difficult of enforcement ; but while 
the results have been by no means entirely satisfactory, there has 
yet been a definite improvement in the existing conditions." — 
Brit. Med. Journ., Sept. 11, 1897. 

Of the five great methods available for checking the disease, 
viz. : — 

1. General sanitation of towns, including drainage of subsoil 

and abundant air space and ventilation ; 

2. Supervision of trades tending to development of tuliercle; 

3. Proper isolation of the sick ; 

4. Disinfection of rooms and destruction of sputa ; 

5. Control of tuberculous food supply, milk and meat ; 

the first two only have received anything approaching adequate 
attention in Great Britain. 

The isolation of tuberculous patients (except under conditions 
where they can be most carefully supervised at home) is an urgent 
necessity. There is not a shadow of a doubt that many hundreds 
of people develop tuberculosis of lungs yearly who need not have 
done so if proper precautions had been taken. It is impossible 
in poor homes for such means to be available. The only solution 
is the tackling of the question on a large scale, and the foun- 
dation of sanatoria for the ti-eatment of both early and late 
stages of the disease away from the towns. No greater service 
could be done to the community at present than that this fact 
should be vividly brought home to the general public by medical 



DISEASES OP THE LUNGS AND ORGANS OF RESPIRATION. 25 

men. The very problematical discomfort to the patient would be 
far outweighed by the greater chance of cure in well-organised 
special hospitals, and it is unpardonable to allow friends and 
relations to be exposed to risks which they do not and cannot 
thoroughly understand. The incubation and development of 
tubercle are so slow that the danger does not strike the layman 
with so much force as in the case of scarlet fever or measles. 

In Glasgow, the wise Health Committee has arranged that 
every single ratepayer shall receive the following leaflet describing 
fully the nature of tuberculosis and the precautions to be taken : — 

" HINTS ABOUT THE PREVENTION OP CONSUMPTION. 

The Committee on Health of Glasgoio hope that all clthens will 
read this Paper carefully, and observe the instrioctions ivhich 
it contains, and any others given by the Medical Attendant 
having the same end in view. 

Consumption is an acquired, not a hereditary, disease. 

What a child may inherit is not the seed but the 'good 
ground ' in which the seed will grow readily. 

This is known as a 'hereditary predisposition to consumption.' 
Special care ought to be taken to protect persons possessing it 
from any chance of catching the disease. 

Colds, sore thi'oats, infectious diseases (especially measles, 
whooping-cough, scarlet and enteric fevers), intemperance, over- 
crowding, darkness, dampness, stale air — in short, whatever 
lowers health produces a predisposition to consumption altogether 
apart from pedigree. 

Consumption of the lungs is only one of many forms of 
disease caused by a minute living creature (germ or microbe) — 
the bacillus of tubercle. Every case of consumption has received 
this bacillus, either from man or beast (milk, flesh), and may 
pass it on to man or beast. 

Good health, local and genei"al, is like a coat of mail against 
the attacks of the bacillus of tubercle. 

Every person suflTering from consumption suffers from a 
disease which may be communicated to other persons. This 
takes place through the spit, which contains bacilli. 

So long as the spit is moist it can do no harm unless under 
such circumstances as are dealt with in Rules 6 and 7. 

The spit is gravely dangerous only when allowed to dry, 
become dust, and so infect the air we breathe. 

The surest way to form infectious dust is to spit in a hand- 
kerchief and put it in the pocket or beneath the pillow, or to spit 
upon the floor. 



26 THK YKAK-IJOOK OF TltKATMKNT. 

Tho saiiiu r(!sult foll<nv.s if .s})it is .smoarcd ov<;r bcd-clotlies, 
i:i^dit-(lrosses, etc.^ or, in tlie case of men, over moustache or 
l)(;ard. 

Practically, then, a case of consumption may be made per- 
fectly harmless by preventing tlie spit from becoming dust. 

1. Indoors. — The greatest care is necessary. Dust in closed 
places is the dust which infects. Use a spittoon containing a 
little water (not sand or sawdust), or spit into a rag or piece of 
paper, to be burned at once or thrown into the w.c. 

2. Out of doors. — Dust is not so readily formed in our damp 
climate, and it is disinfected by sunshine and fresh air. It is 
therefore better -to spit on the ground than into a handkerchief 
or into anything which is to be put into one's pocket, except a 
special spit-bottle, such as may be had for a small sum. Failing 
this, spit over a street gulley or into the gutter, never on the 
pavement, and never in a tramcar, 'bus, cab, or railway carriage. 
Never swallow the spit ; it may infect the bowels. 

3. If a handkerchief or other article is soiled with tuberculous 
spit, keep it wet until it can be boiled and washed. 

4. Empty the contents of the spittoon down the AV.c, and clean 
the spittoon with boiling water. A little carbolic acid will keep 
the flies away : these carry off infective matter. 

5. In cleaning rooms occupied by consumptives, capture the 
dust with damp dusters and tea leaves or damp sawdust used in 
sweeping. Do not chase it about or stir it up. Boil the dusters ; 
burn the sawdust and tea leaves. 

6. No spoon, cup, or other article which has been applied 
to the mouth of a consumjjtive ought to be used by a healthy 
person until it has been carefully washed. The remains of food 
left by a consumptive ought not to be used by the healthy. 

7. No consumptive ought to kiss or be kissed, except on the 
cheek or brow. 

8. No consumptive mother should give suck. 

9. Consumptive persons ought to have a bed to themselves. 

10. Sunlight and fresh air are nevei'-failing disinfectants. 
Use them freely. 

N.B. — Consum))tion is not communicable by the breath or 
perspiration. If these precautions are attended to, there is no 
danger to the healthy in the ordinary intercourse of the family or 
society. 

DISINFECTION. 

It is necessary that washing and disinfection should .be 
effectively carried out after every death from consumption. 



DISEASES OF THE LUNGS AND ORGANS OF HESPIRATION. 27 

The sei'vices of the Sanitary Departineut are at the dis- 
posal of the ratepayers for this purpose. Immediate notice 
of such an event ought to be sent to the INIedical Officers of 
Health. 

During the currency of cases of tuberculous disease in which 
there is a discharge, the JNIedical Officers will give any assistance 
in the way of washing and disinfection which may seem expedient 
in the public interest. J. B. R." 

Sanitary Chambers, 

Montrose Street, Glasgow, 
October, 1896. 

The admirable example of Glasgow might well be widely 
followed by other towns. 

The disinfection of rooms occupied by tuberculous patients 
must also become, as it has done in New York, part of the 
ordinary routine of sanitation. Now that it has been con- 
clusively [)roved that masses of cases of tuberculosis in special 
hospitals ofler no real risks to their surroundings, whih; with 
any carelessness the disease may spread through dust, etc., the 
least the laymen can ask of us is to see that the best possible 
means of disinfecting rooms be taken, with as little delay as 
can be. Those who are familiar with the lives of the tuber- 
culous poor know how bad the conditions really are. There 
is no sufficient reason why this work should not at once be 
taken up by sanitary authorities, so far as the public will 
allow. 

For the prevention of food tuberculosis, many influences are 
at work. The Royal Commission on Tuberculosis has been at 
great pains during the year to amass all available information 
on the subject, and has visited many places abroad to this end. 
Their report will be awaited with much eagerness. 

Both in Liverpool and in Manchester great attention has 
beeii paid to tlie question. Niven summed up his conclusions as 
follows {Brit. Med. Jouru., ii., 1896, p. 331) : — 

" Preventive action should take something like the following 
shape : — 

" 1. Information as to the precautions needing to be taken 
should be distributed to every home from time to time, until a 
sufficient body of opinion is created on the subject. 

" 2. Tuberculosis attended with discharge should be made a 
notifiable disease. This would entail additions to the sanitary 
staff, including probably a qualified medical assistant. The 
objects of notification would be : (1) To gather precise clinical 



28 'IIIE YEAK-BOOK OF TREATMENT. 

knowledge as to the various conditions un<lei- wliicli iiiili\ i<lua]s 
contract tuherculosis. During such an inquiry in Oldliaui in 
1889 I found that al)Out lialf tlie deaths from tuberculosis 
investigated were of people who had ])reviously been in inti- 
mate and prolonged intercourse with previous cases. (2) To 
ascertain and remove insanitary conditions about the house as 
speedily as possible, so as to give a chance to the patient of 
recovery, and so as to diminish the risk to the other members of 
the household. (3) To distiibute printed information on the 
preventive measures required, and to bring about an under- 
standing with medical practitioners as to their giving systematic 
personal instruction to the patient and attendant. (4) To bring 
about the disinfection of rooms and clothing when needed. 

".3. Hospitals for consumptives are at present foci, whence a 
practical knowledge of preventive measures radiates. 

" It may be doubted whether the time is ripe for the establish- 
ment of such hospitals at the public expense. If this becomes 
possible, such hospitals will greatly aid in reducing the amount 
of infective material in circulation. 

" 4. To prevent the milk from tuberculous cows remaining 
the source of danger which it now is, we require a systematic 
examination of cows in all cowsheds by competent veterinary 
inspectors. Two assistant veterinary surgeons have recently 
been appointed in Manchester for this purpose,* and already five 
cows have been slaughtered as tuberculous, and found to be so. 
This appointment is one which I have had much at heart. The 
milk of suspected cows will also be examined bacteriologically 
where the grounds for condemnation are otherwise not perfectly 
clear. The veterinary surgeon is now authorised by the coi'- 
poration to examine suspicious cows with tuberculin. 

" Under new regulations an effort will be made to bring the 
cowsheds into a tolerably sanitary condition — at least those which 
can be so amended. If the cowsheds are cleansed with water 
twice a day, and the cows kept clean, and if, in addition, the 
cowsheds are kept well lighted and well ventilated, then thei'e 
will not be much risk of infection between cows and human 
beings, or from cow to cow. 

"5. All meat and pork should be thoroughly examined ; hence 
no meat should be taken direct from a private slaughterhouse for 
sale. The presence of tuberculous glands in meat or pork 
should suffice to condemn it. In the case of animals killed 
at the public abattoir, this criterion is not required. It is 
the more necessary that it should 1)e rigoi'ously applied in other 
cases. 



DISEASES OF THE LUNGS AND ORGANS OP RESPIRATION. 29 

" 6. Cats certainly, and fowls possibly, are a serious source ol' 
danger. More attention should be given to tlie diseases of 
which cats have died- — and, indeed, the causes of death of all 
our domestic animals should be more fully investigated." 

The results of systematic investigation of milk supply at 
Liverpool are given in a report of tlie Medical Officer of Health 
to the Health Committee. 

" After describing the conditions which are recognised as the 
causes of tuberculosis, it is pointed out that the effect of improved 
sanitation in Liverpool has been to produce a notable decrease in 
the death-rate from this cause. Thus the annual average death- 
rate per 100,000 of the population from all forms of tuberculosis 
in the decade 1866-75 was 430-8, while in the year 1896 it 
was only 292 5. Investigations into the condition of the milk 
supplied to the city were made by Professors Boyce, Delepine, 
Hamilton, and Woodhead. A total of 168 samples were taken 
from diiierent soui'ces, so as fairly to represent the city supply. 
The examinations were made both by means of the microscope 
and by the method of inoculation, but for obvious reasons the 
results arrived at by the latter method wei-e much more valuable. 
The conclusions drawn as to the infective properties of the milk 
are on the whole fairly satisfactory, though indicating the need 
for further vigilance on the part of the authorities. Contrary to 
what might have been anticipated, the samples of milk derived 
from sources within the city were much freer from the germs of 
tuberculosis than those obtained from the country supply. Thus, 
out of 122 samples of city milk only 2-8 per cent, gave evidence 
of infection ; while of 24 specimens obtained at the railway 
stations 29 '1 per cent, were capable of producing the disease. 
The comparative freedom of the milk obtained from town cows is 
no doubt due to the excellent supervision exercised by the health 
authorities over the dairies and shippons within their jurisdiction. 
The report points out that the risk of infection from drinking the 
milk of tuberculous cows can be entirely avoided by boiling it 
for a few seconds, and that the common prejudice against this 
proceeding is entirely groundless. Dr. Hope concludes his 
report by stating that there is need for additional powers to 
prevent the erection of town shippons without adequate yard 
space, and without adequate open spaces around them ; also, 
that more direct powers are required to enable the compulsory 
removal of diseased animals from ship])ons, and that measures 
are called for to prevent the importation into cities of the diseased 
products of insanitary country shippons." — (Jh'if. Med. Jotcrn., 
Jan. 12, 1897.) 



30 TIIK YKAH-noOK OF TREATMENT. 

II. — TIII'J l)I.\(i.\0,S)'I(; VALUK UK TllK OLD TUHKRCULIN. 

Evidence accumulates steadily of the use of Koch's older pre- 
paration in the diagnosis of tul)erculosis in cattle. The great 
danger in its use in human ))oings was thiit in so many cases it 
appeared, beyond all doubt, that a tuberculous lesion, quiescent 
before injection, became active and spread after. This objection, 
which practically stops its employment for diagnosis in man, is 
not of importance in cattle, where the object is to discover the 
tuberculous animals, and then immediately destroy them. Mr. 
Jams; Wilson, the Fordyce Lecturer in Agriculture at the 
University of Aberdeen, has publislied a very interesting little 
pamphlet on the "Results of the Use of Tuberculin." By 
separating oft" all animals that reacted to the injection of tuber- 
culin, a steady diminutio.i of reacting animals from year to year 
has been observed. Similar results have been obtained by 
Professor Bang, of Copenhagen, and others. 

Kasparek ( ^K^e?i. kliti Woch., 1897, No. 26, Brit.Med. Journ. Epit., 
Aug. 14, 1897) records the results of an important series of investi- 
gations into the action of tuberculin on healthy and tuberculous 
animals. His first object was t) determine in some measure the 
relation between the reactions produced by different varieties of 
tuberculin. Preparations were made from human and avian tuber- 
culosis by concentrating six- to eight-weeks-old cultures to one- 
eighth or one-tenth their bulk. It was found that eight times the 
quantity of bird tuberculin was required to pro luce the same effect 
in the experimental animals (guinea-pigs) as a given dose of the 
human product ; a good deal depended on the body weight of the 
animal, and guinea-pigs of as nearly as possible the same weight 
were selected in consequence. These precautions having been taken, 
the author was al>le to demonstrate that the tuberculin reaction 
was constant in diseased as distinguished from non-tuljerculous 
animals. He next investigated the length of time which elapsed 
after infection with tubercle bacilli before the i-eaction was obtain- 
able. When infection was accomplished by the injection of 
bacilli into the abdominal muscles the reaction appeared in thirty- 
six to forty-eight liours, at a time when no macroscopic lesion 
could be detected, though the bacilli were multiplying at the seat 
of injection. The fact that no reaction takes place at first shows 
that it is an actual tissue change in the animal and not the mere 
presence of 1 acilli which renders it so susceptible to the influence 
of tuberculin. This is confirmed by the fact that the substitution 
of an equal amount of living tubercle bacilli for the tuberculin 
gives no reaction whatsoever. When the tuberculous infection 



DISEASES OF THE LUNGS AND ORGANS OF RESPIRATION. 31 

was t'ftected by means of iu'ialatiou no reaction was obtained till 
after six daily exposures of an hour each ; wlienever it was ob- 
tained the animal eventually succumbed to tuberculosis. This 
shows the extraordinary diagnostic value of tuberculin. The last 
series of experiments consisted in the injection of tuberculin into 
animals which had been weakened previously by diphtheria toxin. 
Fever resulted in these cases, but was not of the same type as that 
constituting the tubercle reaction, than which it lasted at least 
five or six hours longer. Kasparek's conclusions are as follows : 
(1) The tuberculin reaction occurs very early (thirty-six to thirty- 
eight hours) in animals infected with tubercle — as soon, in fact, a^ 
the slightest amount of tissue change has taken place ; (2) the 
activity of a tuberculin preparation varies with the source from 
which it is obtained ; (3) the fever evoked by tuberculin in 
animals weakened, for example, by diphtheria toxin is distinguish- 
able from the typical reaction by its greater duration. 

Loesch (^Archives des Sci. Biolog. de VInstitut Iiuj^er. de Med. 
Experiment, a St. Fetershourg, Tome iv., No. 5, 189G ; £rit. Med. 
Journ. Efit., Sept. 4, 1897), as a result of numerous experiments 
on healthy and tuberculous animals, finds that after injection of 
tuberculin for diagnostic purposes what he terms the blood re- 
action is a much more constant and reliable sign of tuberculosis 
than the usually accepted elevation of temperature. This blood 
reaction consists in a diminution of the number of white cor- 
puscles in the blood of tuberculous animals, which is most marked 
two to four houi's after the injection of tuberculin. The reaction 
is never met with in healthy animals. Another difference is that 
leucocytosis is at its maximum the day after the injection in 
healthy animals, but on the second day in tuberculous ones. 
From other experime.its, which were, however, too few for posi- 
tive conclusions to be drawn, he believes that mallein in glanders 
has the same effect on the white corpuscles as tuberculin in tuber- 
culosis. 

III. THE NEW TUBERCULIN. 

Undoubtedly the most interesting announcement of the year 
was Koch's account in the Deutsch. med. Wocli., of April 1st, of 
the steps that had led to the production of his new tuberculin. 

In "Treatment," p. 187, Edward Squire gives an admirable 
summary of the article. 

" In publishing his further researches with tubercular cultures 
and the elaboration of a preparation which possesses the anti- 
tubercular properties of tuberculin, without its unsatisfactory 
effects, Koch ('Ueber neue Tuberkidin-prjiparate,' Deutsch. med. 



32 TIIK YKAU-nOOK OF TREATMENT. 

Worlnischr., No. 11, 1S'.J7) points out tluit in coiiiplote iimiiiinity 
tlicrc arc two factors — iiiinuiiiity as rcj^ards the l)actcria, and 
immunity as regards the toxin. ]>ehring and Kitasato liave 
shown that animals can be immunised against tetanus. After a 
time, however, the immunity passes off, and the animals may tlien 
suffer from tetanus without any n(;w infection of I.)acilll The 
immunity here is against the efects of the bacilli — the toxin ; 
the bacilli themselves may remain active, and when the protection 
against their products passes off they are able to produce the 
disease. The other innnunity — that against the bacteria — is seen 
in cholera and typhoid. In these .diseases Pfeiffer lias shown 
that immunised animals are protected against the living bacteria 
but not against the products of these, since injection of the toxin 
is followed by the disease. 

" ' The ideal of immunisation will always be to protect the 
animal or the human body not only against one of the dangers 
which the pathogenic micro-organisms bring in their train but 
against all.' 

"It seems as though no immunity is possible against tuber- 
culosis, since in man it may exist for years without appreciable 
loss of virulence. Even when cure is effected the individual is 
not protected against a new invasion of the tubercle bacillus. 
Koch, however, in spite of this fact, sees indications which suggest 
that, under certain cix-curnstances, a kind of immunisation is 
evidenced. This he finds in the fact which may be observed in 
miliary tuberculosis in man, and in the experimental tuberculosis 
of guinea-pigs, that there is, as a rule, a stage during which the 
bacilli, which were at first in large numbers, again disappear. It 
can be seen that the tubercle bacilli are extremely slowly absorbed, 
and the immunity appears to be purely bacterial. 

" All Koch's attempts to produce rapid resorption of thetubercle 
bacilli from the tissues were unfortunate. Dead tubercle bacilli 
injected into the blood-stream produce in the lungs exactly the 
same tubercular nodules as the living bacilli ; and in these nodules 
one can find, a long time afterwards, the unaltered tubercle bacilli. 

" Chemical investigation showed that thetubercle bacillus con- 
tains two fatty acids of different solubility in alcohol. It is one 
of these which fixes the colour of fuchsin, and so gives to the 
bacillus its characteristic staining reaction. It is apparently this 
substance also which renders resorption of the bacillus so difficult. 

"The problem then resolved itself into the endeavour to free 
the bacilli from this substance. 

" The attempt was therefore made to render the bacilli capable 
of resor[)tion l)y chemical means. 



DISEASES OF THE LUNGS AND ORGANS OP RESPIRATION. 33 

" A preparjitioii was made by extractin<^ tubercle bacilli with 
ileci-normal soda solution. The fluid was hltered and neutralised, 
forming a clear pale yellow liquid, which was not free from (dead) 
tubercle bacilli. This licjuid was designated T.A. (alkaline tuber- 
culin). 

'" This T.A. produced in animals, even in very small doses, a 
similar reaction to that of tuberculin ; Uie reaction lasted longei', 
and the tendency of the animal to react to the fluid also remained 
longer than in the case of tuberculin. One great disadvantage of 
this preparation was that it invariably produced abscesses at the 
seat of injection. 

" Resort was next made to mechanical means. Taking a well- 
dried culture, this was well pounded with agate pestle and moi'tar 
for a long time, till few bacilli remained. The material was then 
diluted with distilled water and ceutrifugalised. A clear, whitish, 
opalescent and transparent fluid was thus separated from a solid 
residue. The residue was dried, again pounded in the mortar, 
and again ceutrifugalised, giving again a clear liquid and a solid 
residue. The process can be again repeated until practically no 
solid matter remains. Injections with tlie fluid obtained in this 
manner never produced abscesses so long as the preparation had 
been well ceutrifugalised, and no bacilli remained. The fluid by 
the first centrifugalisation differed somewhat from the rest, and 
was designated T.O. ; the results of the further centrifugalisations, 
which could not be distinguished from each other, were called 
T.R. 

"Tested on animals, the T.O. produced almost identical results 
with the alkaline extract (T.A.), except that no abscesses were 
produced. It has, however, very small immunising effect. The 
T.R., on the contrai'y, produces decided immunisation. It also 
may produce ' reaction ' if given in too large doses, but its 
effect is not at all dependent on this reaction ; whereas with the 
original tuberculin, as well as with the T.A. or the T.O., 'reac- 
tion' must be obtained in order to get the curative eflfects. When 
an individual is immunised against the T.R., even when during 
the immunisation reactions are almost entirely avoided, he no 
longer reacts to even large doses of tuberculin or of the T.O. 
This Koch has confirmed in so large a number of cases that 
there can be no doubt of the fact. 

"The preparation by hand of this immunising material is not 
free from danger of infection ; it can, however, be perfectly well 
prepared by machinery, and is manufactured according to Koch's 
directions by the firm of Meister, Lucius and Bruning, of Hochst 
on Main. 



34 TIIK YKAR-BOOK OF TREATMENT. 

"Tlie iiso and dosage of the preparation is simple. The injec- 
tions are made with a sterilised syringe in the l)ack. The lluid 
contains 10 nigr. solid in a culnc centimetre, and is to be diluted 
for use with physiological salt solution (not with carbolic solution) 
to bring it to the required dose. One corameVices with -;.',(, mgr. 
If a reaction occur the dose must be further diminished. In- 
jections are made every other day with slightly increasing doses, 
so that there is never a rise of temperature over |° C. (nearly 
1° F.). Any rise of temperature must be allowed entirely to 
subside before a fresh injection is made. Koch has, as a rule, 
gone U2> to a dose of 20 mgr., and if no reaction follows this dose, 
he stops the injections, or only resumes them after a long interval. 
In lupus cases Koch has found improvement in excess of that 
obtained by tuberculin, and satisfactory results have also 
followed the employment of the remedy in tuberculosis of the 
lung." 

The method of dilution has recently been slightly modified. 
The directions are now as/ollows : — 

" It must be kept in a cool, dark, and dry place. The solu- 
tion contains 10 mgr. solid substance in each cubic centimetre. 

" The treatment is generally commenced with -^^-^ ™gi'- oi 
solid substance. If a reaction appears, the dose must be still 
further reduced. 

" For dilution of the liquid, a 20 per cent, glycerine solution 
should be employed. The dilutions are preferably made in the 
following manner : — 

" 1. With a 1 c.cm. pipette calibrated to -j-V) ^'S c.cm. is with- 
drawn from the bottle and mixed with 2'7 c.cm. 20 per cent, 
glycerine solution, making in all 3 c.cm. This 10 per cent, solu- 
tion contains 3 mgr. solid substance. 

" From this 10 per cent, dilution 0*1 c.cm. is taken and made 
up to 10 c.cm. with glycerine solution. Thus a 1 per mille dilution 
of the original fluid is obtained. Two divisions, or y-^j c.cm. 
of a Koch or Pravaz syringe of this dilution therefore contains 
-g-i^ mgr. of solid substance. 

" Instruments and pipettes must, before use, be sterilised with 
absolute alcohol and ether, and then rinsed out with sterilised 
glycerine solution, in order to remove every trace of alcohol and 
ether. 

"N.B. — The 20 per cent, glycei'ine solution is prepared by 
boiling 20 c.cm. pure glycerine with 80 c.cm. distilled water for 
afteen minutes, and then cooling thoroughly before use. 

" Dilutions which present a turbid appearance, or show a 
deposit which does not dissolve upon shaking, must not be 



DISEASES OF THE LUNGS AND ORGANS OP RESPIRATION. 35 

employed. Generally, the dilutions keej) well for a fortnight 
in cool and dai'k j)Iaces. 

" The injections are made subcutaneously every second day, 
the dose being raised so gradually that a rise in temperature 
of more than half a degree is as far as possible avoided. Any 
febrile symptoms caused by the injection must have entirely 
disappeared before a fresh injection is made. With doses of 
mgr. solid substance and upwards it is not advisable to 
make more than two injections within the week, and with still 
larger doses not more than one. The individuality of the patient 
has generally to be taken into account. 

"As a rule, the dose is increased to 20 mgr. solid sub- 
stance, and if no reaction follows the injection of this dose, the 
treatment is discontinued, or only repeated at long intervals. 

" For injection, such parts of the body should be selected where 
large folds of skin may be raised. The local reactioii that not 
infrequently appears in the locality of the injection generally 
disappears within twenty-four hours, and must be taken into 
account in increasing the dose." 

The few months that have intervened make it impossible 
to draw any definite conclusions as to the value of the remedy. 
It is being used by many investigators in many places. 

Most of the early criticisms of the new remedy that have 
appeared so far are not convincing. In the Anales Medicos 
Gaditanos, July 15, 1897 {Brit. Med. Journ. Ejnt, Aug. 21, 1897), 
Prof. Juan L. Hohr, of Cadiz, reports on four cases of varied forms 
of tuberculosis, treated with the new tuberculin. 

" (1) Boy, aged seven years, suffering from Pott's disease and 
tuberculous osteitis of the femur. There was a fistula with 
scanty discharge, with pain in the limb so severe as to prevent 
sleep, and great weakness. On April 21st 1 c.cui. of the ^^jf 
solution, and on the 23rd 2 c.cm. were injected. The immediate 
result was increase of suppuration and cessation of tlie pain. 
Further injections were followed by rise of temperature, sleepless- 
ness, and loss of appetite, and they were discontinued for two or 
three weeks. The treatment was then resumed, but the febrile 
symptoms produced were so marked, and showed such persistence, 
that it was again abandoned. The sole benefit observed in this 
case was the total cessation of pain. (2) A man, aged twenty- 
three, with pulmonary tuberculosis at both apices. Injections of 
the ~Q solution caused increase of cough and diminution of 
appetite ; the febrile reaction caused by the tuberculin continued 
for some days after the injection. (3) A man, aged thirty-one, 
with tuberculous adenitis of the cervical glands and ulcers on the 
D 2 



30 TIIK YEAU-nOOK OP TUKATMKNT. 

neck iiiul slioiildcis ; no clicstr syiii])loiiis. In jcctioiis of 1 iiii<l 
■J (•(•III. of I lie .,',,, solution W(!rc f(jllo\vc'd ity tlio devclopiiieiit of 
sliai'i) catuirli, with abundant discliarge and cough. The effect 
of the tuljerculiu on the diseased parts in the neck was to set up 
inHamniation in the scars of old ulcers, which quickly broke 
down, exposing caseous miterial, which was eliminated in a fev;^ 
days. 13ut new points of ulceration appeared in the neck, and at 
tlie same time chest symptoms deveh)ped to such an extent that 
it appeared that the disease had been kindled in several foci. 
On the injections being discontinued, the patient regained his 
strength, and the ulcers healed under surgical treatment. (4) 
A woman, aged thirty-six, suffering from superficial lupus of the 
nose and upper lip, which were the seat of scars ; the disease 
was of eight years' standing. There was a fresh patch on tlie 
chin, and another along the jaw. Injections (1 and 2 c.cm.) of 
the yiy solution caused disappearance of the redness around tlie 
patches, but the patient complained of great weakness and pain 
in the limbs, and of feeling ' ill all over.' The treatment was 
therefore discontinued. The author's experience leads him to 
conclude that the new tuberculin, even in the highest degree of 
dilution, always causes reaction, though the intensity may vary. 
Koch's statements cannot, he thinks, be reconciled with clinical 
facts, and he considers the new tuberculin 'impossible' as a 
therapeutic agent" 

Bussenius {Deut. med. Woc/i., July 8, 1897 ; Brit. Med. Journ. 
Epif., Jn\y 31, 1897), has used the T.R. tuberculin in nineteen cases, 
comprising four cases of lupus, twelve of laryngeal tuberculosis, 
two of uncomplicated pulmonary phthisis, and one of asthma. 
In fifteen of the nineteen cases the treatment was completed, 
with a total of three hundred and fourteen injections ; in the 
four remaining cases twenty injections were given. The largest 
number of injections given in a single case was twenty-five ; the 
o-reatest total amount used was 15 ■276 c.cm., and the largest 
sino-le injection of the fluid 4 c.cm. The longest duration of 
treatment was sixty-five, and the shortest twenty-nine days. 
A short time after the completion of the cure, the reaction was 
tested with the old tuberculin, but in all the nineteen cases with 
a neo'ative result. Any reaction after T.R. is to be avoided ; 
the body temperature should not rise above 1^" C. Tlie object in 
view is, by a gradual increase of the dose, without any consider- 
able local or any general reaction, to make the patient rapidly 
immune against the larger doses. This was only completely 
effected in four cases. The age of the injection fluid is of great 
importance in connection with the rise of temperature. Curves 



DISEASES OF THE LUNGS AND ORGANS OF RESPIRATION. 37 

obtained showed that any increase in tlie pulse and breathing 
depended ahnost always on the rise of temperature, and that 
other symptoms also stood in direct relation to it. As regards 
weight, seven patients increased in body weight, but iive lost in 
weight up to ten pounds, the remaining ones ke ping stationary. 
The author says that it may be open to question whether it is 
desirable to continue the system of doubling the dose when the 
larger quantities are being given. There was never any blood 
or albumin in the urine. No abscess occurred. The fluid was 
proved bacteriological ly to contain no pyogenic microbes. The 
syi'inge was boiled for ten to fifteen minutes before use. In ten 
of the nineteen cases there was a slight infiltration at the 
site of the injection. No decrease in the area of dulness was 
made out in the cases of ])ulmonary phthisis, whether uncom- 
plicated or not. In tuberculosis of the larynx, etc., no considei'- 
able i-edness or swelling was observed in the infiltrated parts. 
Occasionally a tendency to cicatrisation of ulcers was seen. The 
author is unable to say, however, that the new tuberculin gave 
better results than other treatment applied to the laryngeal 
disease. He gives details of three lupus cases, in which the 
treatment was completed. The results were such as to encourage 
a further trial of the treatment. 

Schultze {Deut. med. Woch., July 8, 1897) says that the time 
is as yet too short to give any conclusions as to the value of T.R. 
He has used it in nine cases. There was no deterioration in the 
condition of the patient, such as was noted even after small doses 
of the old tuberculin. In one case an apparently tuberculous 
lai-yngitis appeared during the treatment, and the genei'al con- 
dition of the patient's nutrition made it necessary to discontinue 
the treatment. Intestinal disturbance occurred in another case, 
so that the treatment could not be continued. In four other 
cases no noteworthy change was observed. In yet another case 
a dry pleurisy improved, as well as the patient's general condition. 
In the remaining two cases, treated as out-patients, there was an 
improvement, and in one of them a laryngeal perichondritis 
cleared up. 

In La Fresse Medical e, June 5, 1897, L. de Nencki, L. de Mac- 
zewski, and A. de Logucki sharply criticise the new drug. They 
base their attack on three points : — 

1. The whole method of preparation is extremely dangerous 
to the workers. Koch himself had called attention to this. 

2. The tuberculin sent out is not always absolutely stci'ile. 
A glass or rubber cork instead of tlu^ ordinary cork wouM be f:ii- 
better. (This has been done.) 



38 THK YKAR-liOOK OF TKKATMENT. 

3. Tlic dilutions tliat liavo to bo made, and the small (juantities 
employed, make its use very difficult for the l)usy practitioner. 
There is much force in this objection. Unle.ss the whole of tlie 
instruments and materials used are .strictly sterilised, it is easy 
in the process of dilution thoroughly to contaminate the prepara- 
tion, and so get unfavourable results. In the earlier bottles sent 
out (April '1 and April -G), they found, on making cultures, that 
there were pneumococci and streptococci and staphylococci pi-esent 
in the tuberculin. 

A careful microscopic examination of the tuberculin, and 
I^referalily a bacteriological examination also, should be made of 
each bottle before use. This has been found necessaiy in the 
case of serums also. 

Kocli points out, and it is needful to he perfectly clear as to 
this, that only early cases and pure tuberculous cases can he 
influenced for good by the treatment. Many of the cases used for 
criticism do not properly belong to this class. 

In the Mi'mch. med. Woch., July 20, 1897, Schroder, of Hohen- 
honnef, who has tried the remedy in three cases, is severe and 
brief. All three patients became worse, and he confirms Nencki's 
observation that the fluid is not invariably sterile. The results 
are of some importance, as the patients seem to have been 
precisely at the stage when some benefit might have been 
expected. 

lY. — SEROTHERAPY. 

Full accounts of the Maragliano serum were given in the 
"Year-Books" for 1896 and 1897. Investigatious as to its 
value continue to be made, though the reports are not so 
numerous this year as last. 

Raimondi and Mascucci {Rif. Med., May 5, 1897) report the 
effect of this serum in five men and ten women. Five are 
described as phthisis with lesion circumscribed in one or both 
lungs, slowly jn'ogressing disease with little or no fever ; ten had 
more or less extensive tuberculous bi'oncho-pneumonia, with 
cavities, fever, and night sweats. In the latter group 5 to 
10 c.cm. of serum were given every five to eight days until 
some eflect was produced (for example, lowered temperature), 
and then 1 c.cm. every day or alternate days. In the former 
group 1 c.cm. was given on alternate days. A generous 
diet was ordered, and phosphates of iron or calcium were 
administered. The total quantity of serum given varied from 
20 to 100 c.cm. No deleterious results of any importance 
followed the injections. As to the effect on the disease, no 



DISEASES OF THE LUNGS AND ORGANS OP RESPIRATION. 39 

absolute cure was effected. Apparent cure or noteworthy and 
persistent improvement was observed in four cases, transitory- 
benefit in six cases, no useful result in three cases. The good 
effects observed were diminution or cessation of the fever and 
night sweats, rapid impi'ovement in strength, nutrition and body 
weight, and disappearance or lessening of the physical signs. — 
{Brit. Med. Jonrn. Epit., June 5, 1897.) 

Hager, in a preliminary communication (Munch, ined, Woch., 
August 3, 1897) relates his clinical experience of this serum 
in the treatment of tuberculosis. A great advantage of the 
serum treatment over tuberculin is that it does no harm even in 
advanced cases of tuberculosis. The reports on tlie value of this 
serum have been generally favourable. The author would con- 
firm the statement of Maragliano that the serum may have a 
favourable action on all the specific symptoms of tuberculosis. 
The serum does not appear to exercise any effect on the tubercle 
bacillus itself, but neutralises the products of this micro-organism. 
Among cases of advanced phthisis treated within a yeai", and 
mostly confined to bed, only one had succumbed to the disease. 
The author then discusses the action of the serum on the lupus 
lesion. It can be painted on the patch, and yet produce its 
beneficial results. It produces a swelling of the lupus tissues, and 
in a few days retrogressive changes are present. The neighbour- 
ing lymphatic glands become swollen. Three or four paintings 
usually suflice if the lesion is not too extensive. The cicatricial 
changes develop themselves speedily under this treatment. A 
simultaneous injection of the serum hastens the recovery. It is 
quite possible that Maragliano's method of obtaining the serum 
may be improved upon, and thus a more efficient serum be pro- 
duced. The author concludes by stating that those trying the 
preparation as obtained from Merck will not fail to find that this 
treatment constitutes an advance. — (Brit. Mf.d. Jowm. Epit.., 
Sept. 9, 1897.) 

V. SPECIAL DRUGS AND METHODS. 

1. Ouaiacolnte of pipcridiiie. 

Arnold Chaplin and F. W. Tunnicliffe, in the Brit. Med. Journ., 
Jan 16, 1897, give an account of foui-teen cases in which this 
drug was used. 

The pharmacology of the guaiacolate of piperidine resolves 
itself into the pharmacology of guaiacol and piperidine, for it is 
into these substances that the salt is decomposed, probably not in 
the acid medium of the stomach but in the alkaline one of the 
duodenum. The reason for this assumption is that large doses — 
5J — can be given without the slightest eructation of guaiacol. 



40 TUE YEAR-HOOK OF TREATMENT. 

The action of guaiacol is too well kiiosvn ((» lie discussed Ihtc. 
It acts in the intestine as an antiseptic ; in tiie structures througli 
whicli it is excreted^ — for example, the respiratory mucous 
membrane — it acts also as an antiseptic. The authors only 
give a brief sunmiary of the pharmacology of piperidine, as 
this subject forms part of a research to be published elsewhere 
by Tunnicliffe in conjunction with Dr. Lauder Brunton. 
When hydrochlorate of piperidine, suitably diluted, is injected 
into the circulation in doses of 0-05 gr. pro kilo body weight, the 
heart is slowed and the vessels are contracted, a considerable rise 
of blood pressure tnking place. When injected under the skin in 
doses of from 1 to 2 cgr. pro kilo, an increase in reflex excitability 
occurs, so that if the drug is pushed convulsions may develop. 
Thus in suitable doses piperidine must lie regarded as a cardio- 
vascular tonic and spinal stimulant. 

During the last three months an inquiry as to the value of 
piperidine guaiacolate in the treatment of pulmonary tuberculosis 
has been carried out at the City of London Hospital for Diseases 
of the Chest. The j^atients to whom the drug was given were 
subjected to close observation, and the effects of the medicine were 
from time to time noted. In all, fourteen cases were placed under 
observation, of which eight were out-patients and six in-patients. 
The duration of the observations varied, but as a general state- 
ment it may be said that six weeks was the average. In order 
to test efficiently the value of the drug, cases were chosen more 
or less haphazard, some being early cases in which improvement 
might be expected under appropriate treatment, others being 
more advanced, wdiile yet others were in such a stage as to make 
it improbable that much good would accrue from any form of 
treatment. In all cases the dose to begin with was fixed at 5 gr. 
three times a day, and this was gradually increased luitil 20, and 
in one case 25 gr., were given for a dose. So far as could be 
gathered from questioning patients and personal observation, no 
unpleasant effects were noticed. All of them stated that the 
medicine had agreed with them. Pains were taken to ascertain 
if the drugs produced any gastric or intestinal irritation, but in 
no case could it be determined that the processes of digestion 
were in any way interfered with by the medicine. We think 
this worthy of special stress, because experience has to often 
taught us that when other derivatives of creasote, such as crude 
guaiacol, are given over a lengthened period, their use has to 
be discontinued from time to time, owing to the gastric and 
intestinal disturbances caused l)y them. But in these cases jio 
such untoward event happened. 



DISEASES OF THE LUNGS AND ORGANS OF KESPIIIATION 41 

With regard to the varied symptoms of ])lithisis, it is difficult 
to say with certainty that the guaiacohite of ])iperidine had any 
distinct etf'ect upon them. For in all cases of phthisis it is so 
frequently found that improved hygienic conditions (good food, 
rest, and attention), such as residence in a hospital affords, play a 
large part in the restoration of the patient's health. This much 
may, however, be said, that in many instances the cough appre- 
ciably improved while the treatment was in progress. The tem- 
perature was in no case affected adversely by the drug ; in mo.st 
cases it receded to normal. The appetite, for the most part, was 
maintained, and very often patients expressed the belief that the 
medicine improved it ; indeed, in some cases it seemed that it had 
a markedly good effect upon the appetite. Some patients gained 
in weight while the treatment was going on, and in two instances 
it was thought that more flesh was put on than would have been 
the case had ordinary remedies been tried. The expectoration in 
most cases decreased while the drug was being taken. Among 
the out-patients especially there was a general improvement in 
strength and vitality. In the case of out-patients it must be 
I'emembei'ed that improved hygienic conditions do not come into 
operation to the advantage of the patient as they do in in-patient 
practice. 

Coming now to speak of the changes noted in the j)hysical 
signs, it must be admitted that discussion of this subject is full 
of difficulty, for it so often happens that, although considerable 
improvement takes place in the general condition of the patient, 
yet no marked change occurs in the physical signs. Some of the 
cases (out-patients) whose condition was found to be improving 
were examined week by week to see if any change could be found 
in the physical signs. Consolidation and excavation were of 
course unaffected, but in not a few instances the lungs were 
noticed to become drier, with less moist crepitant rales. This 
change was attril>uted to the fact that the area of simple inflam 
mation around the tuberculous infiltration itself had passed from 
an active to a more quiescent condition. It must be admitted, 
however, that the same improvement in physical signs could not 
be seen in most of the cases under treatment as in-patients. Two 
out-patients considered that the medicine relieved their dyspna3a, 
and, to judge from the lung signs, which were under the treatment 
improving rapidly, it might very well be the case. 

In stating the effects of any new drug upon a given disease, 
the physician must always guard himself against " over-enthu- 
siasm " ; so often it happens that a new medicine has been reputeil 
to be successful in some affection, and upon fuller trial its effects 



42 THK YKAH-HOOK OF TREATMENT. 

are found to 1k', triOiiig, or oven nil. Oi i>iperidiiie guaiacolate it 
may bo generally stated : — 

1. That experience has shown that it is a perfectly safe drug 
ill doses of from 5 to 30 gr. three times a day. 

2. That it causes no unpleasant effects. 

3. That it is exceedingly well borne by the stomach, and in 
this respect it is equal to any other derivative of creasote. 

4. That patients while under its influence improved in ajjpe- 
tite and general strength. 

2. Oxytoxins. 

Hirschfelder, of San Francisco [Bi'it. Med. Journ. Epit., 
April 17, 1S97) has published a "provisional report" of a new 
treatment of tuberculosis and other infectious diseases. Having 
regard to the well-known objections to the administration of anti- 
toxins in solution in the serum of animals, he has sought a 
method of preparing them directly from the toxins in the culture 
fluids, without the intervention of the animal body. He believes 
that the spontaneous cure of tuberculous peritonitis after simple 
laparotomy is due to the oxidation of the tuberculin in the peri- 
toneal cavity. He therefore concludes that the oxidation of 
toxins produces antitoxins, and has investigated the action of the 
oxytuberculin manufactured by lengthened treatment of tuber- 
culin with peroxide of hydrogen. At the same time, as tubercu- 
losis is usually a mixed infection, he prepared an oxysepsin in a 
similar manner from the sputa of cases showing high fever. The 
quantities of these oxytoxins which could be injected without 
causing a local disturbance wei'e enormous, reaching 60 c.cm. ; 
the ordinary daily dose was, howevei', 5 c.cm. of oxytuberculin 
and 10 c.cm. of oxysepsin. The author adduces eight cases in 
support of his treatment, for which he claims the following re- 
markable properties : Within a few days the cough and expecto- 
ration diminish, the appearance of the patient reverts to that of 
health, and the appetite returns ; the temperature rapidly sinks 
to normal, the infiltration of the lungs disappears, and the tubercle 
bacilli in the sputum rapidly diminish, and eventually disappear. 
A year's use of this ti-eatment by the author has been singularly 
satisfactory, particularly in early cases. He has also obtained 
promising results with similar oxvtoxins in pneumonia, empyema, 
and streptococcus infection. 

This report is amplified by a further contribution in the Xetv 
York }Miml Npws, July 3, 1897 ("Treatment," vol. i., p. 282). 
Formerly Hirschfelder used Koch's tuberculin for the preparation 
of oxytuberculin. He now prepares his own by the cultivation 
of the tubercle bacillus upon veal bouillon containing 4 per cent. 



DISEASES OF THE LUNGS AND ORGANS OF RESPIRATION. 43 

of glycerine, 1 per cent, of peptone, and 0-5 per cent, of chloride of 
sodium, to every litre of which, when neutralised, 3 c.cni. of a 
normal solution of carbonate of sodium are added. After the germ 
has fully grown, so that the tuberculous scum which Hoats on the 
surface begins to sink, the flask is sterilised by heat for two hours, 
and the contents are filtered. A measured quantity of this 
tuberculin is put into a stone jug, and one-tenth the quantity of a 
ten-volume solution of peroxide of hydrogen is added, and the jug 
is stoppered with cotton-wool and put into a steriliser at 100° C. 
Every twelve hours the same quantity of peroxide of hydrogen 
is added, until at last the quantity of peroxide solution equals 
the qiu\ntity of tuberculin used. This is then heated to 100" C. 
for twelve hours longer, and at the end of this time (120 hours in 
all) it is found still to contain free peroxide of hydrogen, is highly 
acid, and has become darker. It is made alkaline with caustic 
soda, and reheated to drive off the excess of peroxide of hydrogen. 
Five per cent, of boric acid is added to keep it from decomposing. 
It is then filtered into sterile vessels, and is ready for use. Expe- 
riments are detailed which show that this oxy tuberculin directly 
prevents the gi'owth of the bacillus of tuberculosis ; that its 
action is specific upon that germ, and that it is not due to a 
genei'al antiseptic effect. Though the bacillus of tubercle will 
grow- on a veal bouillon Avhich has been mixed with an equal 
quantity of the original tuberculin, no growth will take place if 
oxytubercidin he similarly used instead of tuberculin. Other 
germs — such as those of typhoid and diphtheria, and the staphylo- 
coccus — develop, however, in this latter liquid. 

Injected under the skin of patients with the usual antiseptic 
precautions, no abscesses are formed and there is no reaction, but 
marked improvement is quickly noted. 

It is used in lai^ge doses, as much as 40 c.cm. being given. 

The author believes that consumption may be cured by the 
use of oxytuberculin if the remedy is administered during the 
early stages of the disease, and that the cure is effected by a direct 
action upon the causative germ. 

Reports by others than the inventor of this method are at 
present very few. 

3. Camphoric :i€i«l in phthisical sweating:. 

('amphoric acid is suggested by Ralph Stockman and Prof. 
Hare as valuable in the treatment of tuberculosis. Hector Mac- 
kenzie gi\es a summary of their paper in the Fractiiio7ier, April, 
181.17, p. 408. The dose is 20 gr. in cachets, or dissolved in whisky 
or Ijrandy, or in dry powder placed on the tongue and washed 
down with a little water or milk. It is only slowly absoi'bed, and 



44 THE YKAR-liOOK OF TKKATMKVT. 

sliould be given an hour or (wo lurfore th(^ sweats couk^ on. Tt 
is not poisonous, even in large dosfis, and its only unjileasant 
effect is occasional slight irritation of the stomach. 8onic renal 
irritation and a skin eruption have also been caused l)y it. 

4. V.-n*'i\lyptns oil and «»il of rinnaiiBon. 

(1) Fiira/i//)/ns oil. — Arthur Douglas, of I'^ort Peddie, Cape 
Colony, describes a very thorough method of em}iloyiiig this drug 
in " Treatment," vol. i., p. 175 : — 

" In carrying out the antiseptic treatment of phthisis the drug 
I piefer to employ is the oil obtained from the leaves of the 
eucalyptus glo))ulus, for the following I'easons : — 

1. It is three times as powerful an antiseptic as carbolic acid 
in arresting the development of Ijacteria. 

2. It is volatile at ordinary temperatures. 

3. Its vapour ozonises the oxygen of the air. 

4. Its smell is not unpleasant. 

5. It is readily absorbed into the system either — 

a. By the air breathed ; or 

b. By the stomach ; or 

c. By the skin. 

6. After absorption it exercises no in-itant or other deleterious 
effect on the body. 

7. It is excreted in considerable amount by the breath. 

8. It is a powerful ' febrifuge.' 

9. It reduces the foi'ce and frequency of the heart. 

10. It increases elimination of urea. 

11. It lessens mucous secretion, improving its quality and 
pi'omoting its expectoration. 

"I have frequently administered it in 5- to 30-minim do.ses for 
weeks at a time without the manifestation of any symptoms. 

"It can be conveyed into the system either (1) by the mouth, 
or (2) by inhalation, or (3) by inunction. 

'• Internally it is conveniently included in the following 
formula : — 



I^ 01. Eucalypti 
Sp. Chloroformi 
Sp. ^^]theris . . 
Mucilage Acacia 
Glycerine 
Aq. ad. 



«l.v. 
)ivx. 
inx. 
5J- 

5SS. 

5.1 ■ 
T. T). .^ 



"The dose of the oil is gradually increased to 10 minims 
thrice daily. 



DISEASES OF THE LUNGS AXD ORGANS OP RESPIRATION. 45 

" For • iiilialatioii ' I prefer not to use any steam vai)()riser, 
atomiser, or respirator. The object I have in view is to induce 
the patient to breathe a '■ sahirated atmosphere' without any 
efibrt or inconvenience on his part, and witliout interfering in 
many cases with his daily avocation. 

" To do tliis etiectually we proceed to saturate the atmosphere 
in the patient's bedroom by vapour volatilised from the eucalyptus 
oil. It is necessary that a large extent of surl'ace should be ex- 
posed. This is effected by saturating a long piece of cotton or 
linen fabric with the oil and stretching it out in several layers, 
one above another, over a double series of horizontal rails placed 
parallel to each other. By this means a large area is exposed 
without occupying too much space. The size of the cotton 
should 1)6 about ten feet long by one foot broad, divided into 
eight layers or folds. The dry cloth is dipped into a basin con- 
taining about 6 or 8 oz. of the oil, being gently squeezed 
to prevent dripping, and hung in the manner indicated at a 
temperature of 65' F. Over four-iifths will be found to have 
evaporated in six hours. 

" The cloth should be placed in the patient's room one hour 
before he retires to rest, the windows and door being closed. 

" On entering the room the patient should be directed sys- 
tematically to practise full and deep breathing for five or ten 
minutes in a standing position. An attendant then rubs into the 
chest 3 or 4 dr. of an ointment of lanoline and eucalyptus oil 
3 dr. to the ounce. This should be completely absorbed. 

" It is desirable, too, that the patient should go through a gentle 
exercise for ten minutes with light dumb-bells or Indian clubs to 
promote expansion of chest and muscles. This exercise must 
always be suspended short of fatigue ; there must be no shortness 
of breath and no dilatation of alfe nasi. The patient then retires 
to bed, the windows and door remaining closed. This treatment 
should be persistently carried out for weeks and months, and 
should not be in any way relaxed on improvement taking place. 
Obviously the cases most benefited are those taken at an early 
stage; but even in advanced cases no little improvement may be 
looked for, especially in the amount and freedom of the expecto- 
ration, diminished waste and fever." 

To those who do not quite appreciate the charm of eucalyptus 
oil the treatment must be somewhat severe. 

(2) Oil of cinnamon. — Hilton Thompson, in the Brit. Med. Journ., 
Nov. 7, 1896, revives again, with some good cases, the use of oil 
of cinnamon in tuberculosis. He says : " I take it tliat a drug to be 
perfect for inhalation should possess the following qualities : 1. It 



4G TIIK YKAIl-IiOOK OF TKKATMKNT. 

should ))(' strongly antiseptic. 2. It .slioukl not be injurious to tlie 
tissue cells of the lung or the organism. 3. It should possess a 
pleasant taste and smell or an absciiice of both. 4. It must not 
produce nausea or loss of appetite; if used for a considerable time. 
None of the antiger'micidal drugs that liave been used in the 
treatment of plithisis appear to possess all these (jualities. 
Although most have their good jjoints, and are no doubt useful 
in certain c;ises, none of them ajjpears to be thoroughly 
satisfactory. 

I first used the drug as an inhalation in cases of tuberculous 
phthisis in 1892. I found the patients liked the smell and taste 
of the oil ; it caused no irritation of the air-passages, and did 
not interfere with the appetite ; the progress of the disease was 
influenced favourably. My interest was further aroused in 1S93 
by a pa[)er by Dr. Lucas-Championniere, and since then 1 have 
regularly prescribed inhalation of the oleum cinnamomi ver. in 
cases of consumption. 

That oil of cinnamon, when used as an inhalation in cei-tain 
stages of consumption, affects injuriously tubercle bacilli is, I 
think, rendered probable by the very remarkable way in which, 
in the above cases, the organism diminished in numbers or dis- 
appeared from the sputum in a comparatively short time after 
commencing treatment. Also by the tendency for the disease to 
relapse when inhalation was discontinued. It appears probable 
that the oil of cinnamon tends to cure consumption in two ways : 
first, in the very early cases of catarrhal phthisis, by so directly 
affecting the bacilli as to stop their growth ; and secondly, in 
cases that are rather further advanced, by only allowing organ- 
isms incapable of growth to pass along the bronchi, thus prevent- 
ing the infection of fresh lobules. In this way the disease may 
be limited to a small area, where it caa\ be dealt with by the vital 
processes of the body, and cut off from the system by the form- 
ation of fibrous tissue, and so cease to be an immediate source 
of danger. Besides the five cases abstracted, the drug was tried 
in the more advanced stages of the disease, but, as might be 
expected, without any benefit. 

An interesting feature of the above cases was the order in 
which the symptoms subsided. The expectoration and the 
cough were the first to improve, then the tempei'ature tended 
to the normal, and finally the weight began to increase. These 
favourable changes in tlie symptoms were accompanied by a 
gradual diminution in the number of tubercle bacilli in the 
sputum. 

With regard to the form of inhaler used, I found that those 



DISEASES OP THE LUNGS AND ORGANS OP RESPIRATION. 4< 

in ordiiuiiy use served the purpose very well. If the jiatient 
were in an early stage of the disease, I endeavoured to persuade 
him to use an inhaler that would cover botli the nose and the 
mouth, but in the later stages, when there was shortness of 
breath, an inhaler covering the mouth only was used. I found 
that in the early stages of the disease particularly the patients 
liked the smell and taste of the cinnamon ; they could use it 
most of the day and also at night with very little discomfort. 
It was also interesting to note that the continued inhalation of 
the vapour caused no irritation of the buccal cavity or of the 
air-passages, and that no constitutional effects were produced. 

Of course, ray experience with the oil is comparatively limited, 
but so far as it goes I have found the oil of cinnamon to have 
more points in its favour, when used as an inhalation in the early 
stages of consumption, than the drugs that hitherto have been ad- 
ministered in this way and for similar objects." 

That oil of cinnamon is an exceedingly pleasant substance to 
inhale, and in many cases lessens cough is certain. It can do no 
harm. Whether it is of any real permanent value is doubtful. 

5*. £osotc. 

Grawitz [Therap. Monatshefte, July, 1896; Brit. Med. Journ. 
Epit., Oct. 10, 1896) has employed this new compound (the 
valerianic acid ester of creasote) for several months in Gerhardt's 
clinic. It is a labile fluid distilling at 240° C, and is free 
from irritant or poisonous pi'operties. It is put up in gelatine 
capsules, and is taken by patients without the repugnance which 
they usually exhibit towards creasote compounds. Each capsule 
contains 3 gr., and the dose commences with one three times a 
day, increasing to six or nine, so that nearly 30 gr. of creasote can 
be taken daily in this form. Grawitz's experience of eosote 
extends to thirty-tive cases of tuberculosis and many others of 
gastro-intestinal afiections in which it was used as an intestinal 
disinfectant. Its employment was nearly always attended with 
complete success, and only in the rarest cases was it necessary, 
after many weeks, to suspend or cease the use of the drug on 
account of. digestive disturbances. No toxic indications were 
observed, and the author strongly recommends the new substance 
on account of its palatability, its cheapness, and the ease with 
which large doses are tolerated. 

6. Pci'oiiiii. 

Schroder, of the Hohenhonnef Sanatorium [Tlierap. Monats- 
hefte, 1897, No. 4), advocates the employment of this drug in some 
of the useless irritating coughs of tuberculosis of lungs. It is the •> 
hydrochlorate of the benzylic ether of morphine. Compared with 



48 THE YKAR-nOOK OP TKRATMENT. 

codcia it JipjM'urs to li;iv(; tlic ;ul vantage in causing less sickness 
and constipation.- The close is from .', to ^ gr., given either in 
watery solution or in pill form. So far as T havt; used it at 
present, it seems of some value. 

it is aliuiulantly proved that the X rays are of value in 
demonstrating certain conditions of lungs. The more intei'csting 
problem, whether they have any effect on organisms, is still quite 
unanswerable. The question was raised very early by Glover 
Lyon. Attempts to diminish the virulence of bacteria in the 
laboratory by exposing them to the rays have ended so far in 
failure or very doubtful positive results. Here and there we read 
in clinical records of patients who have V)een exposed to the 
X rays for curative purposes in pulmonary tuberculosis, but the 
complexity of possible influences is so great that the results ai'e 
not convincing. One such is a})stracted in the Brit. Med. Journ. 
Eint., 1897. 

Chapteloube, Descomps, and 'Roullies (^Archives d'Electricite Jle'cli- 
cale, May 5, 1897) describe the effects of treatment by means 
of Rontgen i-ays upon a woman aged twenty-two, the subject of 
acute and rapidly-spreading pulmonary tuberculosis. " There 
was a cavity at tlie right apex, the whole right lung 
Avas infiltrated, and there was generalised extension to the 
left lung ; the sputum was crammed with tubercle bacilli. 
Medical treatment had no effect upon the symptoms ; hectic 
supervened, and the patient rapidly lost ground. All medicines 
were accordingly left oft', and the influence of the X rays was 
substituted. During the first fortnight of their employ- 
ment, which was much resented by the patient, the general 
condition became worse. At the eighth application a kind of 
crisis occurred, with a fall of temperature, which had, however, 
risen again to 103 "2° by the end of the fortnight. At this time 
there could be noticed some improvement in the right infra- 
clavicular fossa. During the next month the rays were used 
from behind twice a day ; this resulted in a marked drying up 
(fibrosis) of both lungs, diminution in cough and expectoration, and 
almost complete disappearance of tubercle bacilli. At the same time 
the general condition remained grave, and ulcers appeared on the 
exposed parts. The use of the rays was discontinued, and during 
the next three weeks great impi'ovement took place. The patient, 
who had hitherto refused food, regained her appetite, the healing 
of the pulmonary lesions continued, together with the diminution 
of the cough and the bacilli, and the greater ease and depth of 
respiration. The diarrhoea disappeared and the strength returned ; 



DISEASES OF THE LUNGS AND ORGANS OF RESPIRATION. 



49 



the temperature alone kept up (101"' in the evening), wliich the 
authors explain as being probably due to bacillary infection of 
some other part than the lungs. The authors conclude that, 
without discussing the question of a permanent cure, in thirty 
sittings the X rays have favouraljly affected and almost healed 
lungs atiected with acute tuberculosis, no other medicinal agent 
being employed at the time." But we have all seen similar im- 
])rovement without the use of the rays, given rest in bed and good 
food. And the major part of the improvement seems to have 
followed the disuse of the rays. 



B.— PNEUMONIA. 
1. Serotherapy. 

The most important contribution to our knowlege of serum 
ti'eatment in pneumonia has been made this year by Washbourn. 
In the Brit. Med. Journ. of Februaiy 27, 1S'J7, he gives a 
full account of the method of inoculation of the pony usf;d to 
obtain the serum, and the means by which the serum was 
standardised : — 

'• Before using the serum for the treatment of pneumonia in 
the human subject, it was necessary to ascertain, first, whether 
it would protect animals when injected after infection, and, 
secondly, wliether large quantities produced any ill eftects. 

" In the following experiments the serum was injected into 
the peritoneal cavity of rabbits at different periods after inocula- 
tion. The tables show that a single dose of 66 units' serum 
protects when injected five or six hours after inoculation, but 
that the same quantity injected as late as eight or twelve hours 
only retards the fatal event. It Mdll be observed that the 
controls died in twenty-four to twenty-six hours, and therefore 
recovery ensued when the treatment was begun in the first 
quarter of the disease. 

"TABLE VIII. 



Rabbit S 


1,500 g. 


0-0000001 loop 


Died in 24 hours. 


„ T 


1,500 g. 


000001 loop 


Died in 24 hours. 


„ u 


1,600 g. 


0-000001 loop. Six hours later, 


Alive 6 weeks 






2 c.cm. serum (66 units) 


later. 


» V 


1,600 g. 


0-000001 loop. Eight hours later, 
2 c.cm. serum (66 units) 


Died in 4 days. 


"TABLE IX. 


Eabbit \V 


2.750 g. 


0-000001 loop 


Died in 24 hours. 


„ X 


2,400 g. 


0000001 loop. Twelve hours 


Died in 48 hours. 






later, 2 c.cm. serum (66 units) 





50 



TlIK YKAK-IiOOK OF TUKATMKNT. 
"TAl'.LK X. 



l{al)bit Y 
.. / 



2,350 g. 
2,500 - 



000001 loop 

0000001 l<x)p. Five hours later, 
2 com. serum (GC units) 



Died in 2G hours. 
Alive 2 uioTiths 
Liter. 



" The following ex])eriments show that large closes of the 
serum produce no ill effects on rabbits : — 

" llabbit 1 : 5 c.cni. serum injected into the peritoneal cavity. 
No rise of temperature ensued, and the animal lost neither weight 
nor a])])etite. 

" llabbit 2 : 10 c.cm. serum injected into the peritoneal cavity. 
No rise of temperature ensued, and tlie animal lost neither weight 
nor appetite. 

" From the foregoing expei'iments it will be seen that the 
serum possesses the power of protecting animals against infection 
when injected either at the same time or subsequent to inoculation. 
It is impossible to say whether it possesses antitoxic powers, 
because hitherto no satisfactory toxin has been obtained from 
cultivations of the pneumococcus. 

"The serum should be injected into the subcutaneous tissue, 
and strict aseptic precautions should be taken. The skin should 
be well washed with an antiseptic, and the syringe should be 
boiled immediately before use. As to the dose, 20 c.cm. (660 units) 
should be injected. I would suggest that the injections be made 
twice a day until the patient is convalescent. It is important to 
commence the treatment as early in the disease as possible."' 

The number of cases in which this treatment has been used is 
rapidly growing. Some of the reports give good reason for 
hoping that valuable results will be obtained. Among the cases 
published, one of the best is Dr. Washbourn's ow'n. 

A. H., 25, law writer ; admitted December 10, 1896, into 
Guy's Hospital under care of Dr. Washboui-n. 

Previous history. — Was in the army, and was stationed i"n 
India for live years. Returned to England last month. Has 
been a heavy drinker. 

History of present illness. — Was seized with a rigor at \ p.m. 
on day before admission. Was very sick during the night. 

December 10. Condition oii admission. — Tempei'ature 
101-4°, respirations 44, pulse 140; tongue furred; skin hot and 
dry ; rapid shallow breathing ; pain in right side of chest : 
harsh vesicular murmur at right base, but no other physical 
signs in lungs ; first cardiac sound rather blurred, and impulse 
to be felt in line with nipple and half an inch extex'nal ; urine 



DISEASES OF THE LUNGS AND ORGANS OF RESPIRATION. 



51 



contains trace of albumin. A mixture containing acetate of 
annnonia ordered every six hours. At 10 p.m. temperature 103-8°; 
patient delirious, attempting to get out of bed ; ^ gr. morphine 
injected. 

December 11. Coughing up a little rusty sputum. On right 



DAY Of MO NTH 


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Chart Illustrating Treatment by Serotherapy : Washbourn's case. 



side of chest behind there is dulness at the base, extending up to 
angle of scapula. Tubular breathing, bronchophony, r6les, and a 
pleuritic rub audible over dull area. On the left side behind 
there is diminished resonance at the base extending up to angle 
of scapula. Small area of tubular breathing, and bronchophony 
E 2 



52 THE YEAR-BOOK OF TItKATMENT. 

just below angle of scapula. The apex beat still displaced 
outwards. Strychnine added to mixture, and 2 oz. of brandy 
ordered daily. At 1 p.m. very restless and delirious, ,1 gr. 
morphine injected. .At 4 p.m. the dulness on the right side had 
increased upwards for two inches. At 5 p.m. GGO units anti- 
pneumococcic serum injected (20 c.cm.). 

December 12. Has passed a quiet night. This morning 
better; the physical signs are unaltered. Teiiiperature 102-G, 
pulse 112, respirations 60. At 11.30 a.m., GGO units serum 
injected. During the day patient was restless, and J gr. 
morphine was injected. At G p.m. the temperature rose to 
104 •5°. At 11 p.m. patient was delirious; ^ grain morphine 
again injected ; brandy increased to 3 iv. 

December 13. Temperature 100"4°, respirations 33, pulse 
104. On the right side the dulness has decreased by 2 inches ; 
tubular breathing faint. On the left side the tubulai- breathing 
replaced by fine ?'rt^es. At 10.15 p.m. GGO units serum injected. 
Brandy omitted. 

December 14. Passed a quiet night, and is much better 
this morning. Temperature 99', pulse 92, respirations 36. On 
right side dulness replaced by impaired resonance, and tidmlar 
breathing by rales. Left side has completely cleared. 

December 15. There was a rise of temperature to 102-8° 
during night, but it has fallen to 99 "4° this morning. Patient is 
now convalescent. 

From this time he rapidly recovered. On December 17 the 
heart sounds were normal, and the apex beat had returned to 
normal position. 

On December IS the physical signs in the chest had com- 
pletely cleared. An urticarial rash appeared on the chest and 
limbs, and lasted two days. 

Remcn-ks. — The patient, though young, was a bad subject for 
pneumonia, on account of his intemperate habits. The attack 
was a severe one, and both lungs were affected. There was a 
good deal of delirium; the pulse was 140, and the heart showed 
signs of dilatation on the second day of the disease. The serum 
appears to have exerted a beneficial effect upon the disease. On 
the day after the first injection the pulse-rate had fallen from 132 
to 112. The process in the left lower lobe never advanced after 
the treatment was begun. It will be observed that the serum 
was injected at an early stage — namely, on the third day of the 
disease. In both cases an urticarial rash was observed during 
convalescence similar to the rashes occurring after injection with 
antitoxic and antistreptococci sera. 



DISKASES OF THE LUNGS AND ORGANS OF RESPIRATION. 53 

Renzi, using a serum prepared in a siniikir manner, reports 
equally well. 

2. Troatinoiit by large doses of di^^italis. 

Earth (^Sem. Med., Dec. 25, 1896 ; Brit. Med. Journ. Epit., 
Jan. 23, 1897) discusses the treatment of pneumonia by 
the administration of large doses of digitalis continued with- 
out interruption until defervescence occurs. He instances two 
patients who were successfully treated in this way, one an elderly 
man worn out with hard work and strong drink ; the other a 
feeble, neurotic patient, deformed by spinal curvature, and sutfer- 
ing from malaria, influenza, and general bronchitis. Large doses 
were given. Two grammes of the powdered leaves of digitalis 
were infused in 100 gr. of watei-, 25 gr. of rum and of infusion 
of orange peel added, and a tablespoonful of the mixture 
given every two hours. Hirtz, of Strassburg, demonstrated 
that the average duration of fever was markedly shortened, and 
never met with a case of poisoning or serious ill effects in the 
course of treatment by digitalis. Petrescu (Bucharest) gave to 
young robust soldiers sufiering from pneumonia 6 to 8 gr. 
daily for several days. He observed no malaise or toxic efiects. 
The temperature fell 1° to 3° in one day, 5" to 6' in two 
days. Out of 825 cases he had only 17 deaths. Finkl reduced 
his mortality from 17 per cent, to nil. He gave small doses — 2 
to 3 gr. Under the combined influence of the mechanical 
obstruction of the pulmonary arterial area and the paralysing 
action of the pueumococcic toxins the heart is liable to failure : 
this is the chief, if not the only, danger, and is the one met by 
the administration of digitalis. Large doses may cause complete 
fall of temperature, but this artificial defervescence twenty-four 
to forty -eight hours earlier than the normal is not proved to be 
advantageous. It is frequently followed by a rise, and the course 
of the disease is not [)erceptibly shortened. As regards symptoms 
following the administration of digitalis, hypothermia, slowing of 
the pulse, vertigo, and cerebral depression are without gravity in 
the young and robust ; but with old, alcoholic, or weak patients 
it is better to employ it in doses calculated to increase the action 
of the heart, to diminish the congestion of the lung, and to facili- 
tate the diuresis necessary for the elimination of pneumonial toxins. 
All grave cases of pneumonia in which treatment by baths is 
contrci-indicated or impracticable should be treated by tlie adminis- 
tration of digitalis. 

3. The treatment of piieniiioiiia by formate ol 
sodium. 

" An interesting paper on this subject by M. Rochon appears in 



54 THE YKAR-IIOOK OP TREATMENT. 

a recent munlxM- of Medecine Moderns (No. 10-^, p. 80.'), 180Gj. 
It is known tliut cultures of tlie pneurnococcus, on almost any 
niediuni, cease growiiiff after a few days, and that this cessation 
of growth is associated with the formation of formic acid. It 
was found ako that formic acid added to a young culture at onco 
stopped its growth. On these grounds Iiochon was led to try tJie 
effect of its salts in several cases of pneumonia, tliree of them 
being children. These were all suffering from typical acute 
pneumonia, and formate of soda was administered to them in 
doses of 4 to 8 gr. In all the temperature fell on the ihird 
or fourth day, the physical signs persisting for a few days longer. 
At the same time, large doses of brandy were given, so that it is 
not quite clear to which drug the result was due. Rochon believes 
that the alcohol becomes converted into aldehyde, and that this 
may aid in the conversion of formic acid into formic aldehyde, 
which is an extremely pov\'erful antiseptic. In support of this 
theory he states that the pi'esence of aldehyde in the urine can 
be demonstrated by its reducing an ammoniacal solution of silver 
nitrate. In future he intends to employ the formic aldehyde 
itself, which, he says, is easily taken. He also speaks favourably 
of the value of formate of soda, in a 4 per cent, solution, as a 
gargle in a case of tonsillitis occurring during the course of 
pneumonia." ("Treatment," vol. i., p. 1.) 

4. Creasote. 

Casati (Gazz. degh Osped. e delle Clin., April 11, 1897 : Brit. 
Med. Journ. Ejnt., Aug. 8, 1897), with the idea that creasote is 
a cardiac and nervine stimulant, was led to try it in twenty-six 
cases of pneumonia, forming part of a somewhat serious epidemic 
of that disease. The only case recorded in detail by the author 
is that of a man, aged seventy, who was given creasote on the 
third day of the disease, and recovered. Some of the cases were 
treated with creasote (in tincture of gentian) alone ; in others 
this was supplemented by digitalis or caffeine in small doses. 
The author believes that the ca.ses treated with creasote recovered 
more rapidly and more thoroughly than those treated in other 
ways. He pushed the drug freely, but never saw any un- 
pleasant symptoms follow its use. 

C— WHOOPIXG COUGH. 
I. Ozone. 

The possibilities of ozone in whooping cough have again been 
receiving attention. In the Brit. Med. Journ. Epit., April 3 
and 10, 1897, are records of several observations. 



DISEASES OF TEIE LUXGS AND ORGANS OF RESPIRATION. 55 

Labbe und Oudin (Archives d'Electricite Medicale, December 
15, 1896) report excellent results from the use of ozone in the 
treatQient of whooping cough. Two, three, or four inhalations 
are given daily, each lasting from ten to fifteen minutes. Owing 
to the great irritability of the throat in these cases, the authors 
connnence by using the ozone produced by the silent discharge 
from an induction coil giving an inch spark, and by holding the 
child some distance away i'rom the tube. Later the patient is 
brought nearer to the tube, the capacity of which is increased, 
the power of the coil being at the same time doubled. The 
efiects are rapid diminution in the paroxysms, improvement in 
the general condition, gain in weight, and increase in oxjdia'mo- 
globin. 

Doumer [Nord Medical, No. 50, 1896) reports his experience 
of this method. He treated five cases — brothers and sisters and 
mother, all sutFering from whooping cough of a fortnight's to a 
month's duration, with paroxysms of medium severity, varying 
in number from twenty to sixty a day. The ages of the patients 
ranged from three to thirty-five years. The treatment consisted 
in the inhalation of ozone for ten to fifteen minutes twice a day. 
The results were as follows : In four cases in which sleep at 
night was much broken, there was impiovement after four 
inhalations. In one case in which vomiting was severe, it was 
speedily checked. In all the cases there was diminution both in 
the frequency and in the severity of the paroxysms from the« 
second day ; discontinuance of, the inhalations, however, being 
always followed by relapse. A cure was effected after twelve to 
twenty-seven inhalations — that is, in nine to fifteen days. 
There was no relapse in any of the cases two months and a half 
later. 

2. Exalgin. 

Green, of Sandown, records the very satisfactory results he 
has had with a combination of exalgin and amonium bromide 
during the last four years. For a child of four years his routine 
treatment is to gi\e a single dose in the morning, and a double 
dose in the evening of the following mixture : Ammon. Brom. 
gr. ij, Exalgin gr. j, Syr. Tolut. y\\ xxx, Aq. ad. 5J. If there 
is much bronchitis, Ammon. Carb. gr. j and Vin. Ipecac. ^^\ j are 
given every hour in sweetened water. This mixture also counter- 
acts any depressing effect which the exalgine may have. As the 
spasms become less frequent the dose of the exalgin may be 
diminished. Green insists that "it is necessary for rapid 
recovery that the patients should be kept in one atmosphere, and 
should not be allowed out of doors until quite cured." Otheiwise 



50 I'lll'; YKAIMiOOK OF TKKATMKNT. 

Ji .sIku')) ifliipsc, with severe iiuliiioiiary c()iii|ili<-;it ions, is u])t (<» 
occur. ('' 'rrciitiiiciil," i., 5.) 

li. K4'SO|-4-ill. 

Roskam (Aiiv.. de la Hoc. Med. Chir. de JAaje, Felj., 1H97 ; Brit. 
Med. Jonrn. EplL, March 27, 1897) since 1800 has treated 290 
children suH'eriiiif from whoopim^ cougli l)y the metiiod introduced 
by Moucorvo, namely, by applications of a 2 to 3 per ceiit. solu- 
tion of resorciu to the glottis with a tine sponge. i>efore the date 
mentioned he had used Moncorvo's method in its entirety— that is 
to say, before applying the resorcin he ana'sthetised the glottis by 
the application of a 10 per cent, solution of cocaine. Finding, 
however, that this was apt to cause severe spasm, he used the 
resorcin without previous cocainisation. In this way eighteen 
out of twenty-five children were cured in ten days. In three 
others in whom a relapse occurred, a definitive cure was effected 
in three weeks. Two cases proved refractory to the treatment, 
and in two others death occurred from weakness, although the 
severity of the paroxysms was mitigated. In the 290 cases 
treated since 1890 no other therapeutic measure of any kind was 
employed, in order that the effects of the resorcin might be tested 
as fairly as possible. The treatment was generally begun within 
the first fortnight of the illness, but in many of the cases it had 
existed for three weeks, and was of a very severe type. In 200 
cases cure was complete within a fortnight ; in seventy before the 
twenty-fifth day of the illness ; in eighteen before the thirtieth day. 
In two cases (brother and sister) in which relapse occurred, a 
further course of applications of resorcin brought about a cure. 
Children under two years of age seemed to get well more easily 
than older ones. Infants under one year were, "in the immense 
majority of cases," cured in about a week from the first applica- 
tion of the resorcin. Roskam thinks it important to wait till 
the initial congestive stage is past and the " whoop " is fairly 
established before commencing the applications, as in that period 
they are apt to cause irritation. In children under one year a 

2 per cent, solution should be used ; in those between one and two, 
a 2 per cent, and then a 3 per cent. ; from two years upwards, a 

3 per cent, solution. The a})plications should be made every four 
hours, beginning at 6 a.m., and once or twice in the night. Im- 
provement in the general condition shows itself within two or 
three days ; in five or six days the paroxysms become shorter in 
duration and less severe. When the applications have been con- 
tinued for ten or twelve days they should be suspended. Very 
often recovery takes place without further treatment ; if not, 
after an interval of five or six days the applications may be 



niSRASliS OF THE LUNUS AND ORGANS OF RESPIRATION. 01 

resumed for some days. It may be added that after a few appli- 
cations by the practitioner the treatment is carried out by tliose 
in charge of the patient. 

D.— THE TREATMENT OF BRONCHITIS. 

In a discussion of the Hunterian Society, Nov. 2^y, 189G 
(Trans. 1896-7) Arthur Davies brought forward a number of cases 
demonstrating the value of some of the less-used methods in the 
treatment of chronic bronchitis. The spray of ipecacuanha ivine 
advocated by Sidney Ringer and Murrell very often proves of 
service. *'The manner of employment consists in spraying by 
means of an ordinary hand-ball spray apparatus, or the steam 
atomiser of Siegle or Richardson, the ipecacuanha wine, either 
alone or diluted in a proportion of 1 to 3 of water. The patient 
is directed to inhale as deeply as possible, at the same time closing 
his nose witli his lingers. The amount spraye.l at a single sitting 
consists of 1 to 4 dr. — 100 squeezes of the hand-ball are equi- 
valent to 1 dr. of the si)ray used. The patient must also 
be directed not to swallow any of the spray which may accu- 
mulate in uhe mouth, but to spit it out. ... It tends at once 
markedly to relieve the dyspnoea and so promote sleep, and to 
shorten the duration of the case. Each patient spontaneously 
remarked that the breathing was easier, and the oppressive tight- 
ness across the chest relieved, and that the deeper the inhaled 
spray seemed to penetrate into the lungs the more relief they 
obtained. What are the disadvantages 1 In hospital practice it is, 
of course, an easy matter to carry out the treatment systematic- 
ally, but it is not so in private practice. The amount of the 
spray must be carefully regulated, as at first it is sometimes not 
well borne, and tends to induce vomiting, and sometimes severe 
paroxysmal dyspncea. The strength of the spray requires careful 
adjustment. ' 

Another spray tried is a 1 per cent, solution of potassium 
iodide. This also will relieve some cases of dyspnuea, and is 
especially useful in asthma and in persons of a gouty tendency. 

Sanger, in the C entralblatt filr inn. Med.^ 1897, No. 17, records 
results from the use of hydrastis Canadensis. He has used the 
drug for a considerable time in chronic bronchitis, and thoroughly 
satisfied himself of its value before reporting. The dose is 20 to 
30 drops of the liquid extract four times a day. In many cases 
of chronic bronchitis he has found that it eases cough, diminishes 
quantity of sputa, aiid renders it thin and easy to bring up. The 
results last also for some timi'. The drug is useless in acute 
bronchitis. 



58 TIIK VEAU-noOK OF Tl'.KATMKNT. 

Kector Ma.ckenzie, in thii /'ractilioiicr, A|>ril, iSlj?. j). Ill,al) 
sLracts two inlci-csting papers on the Inicteriology of broncliitis. 

S. Dessy lias made some bacteriological researches upon cases 
of acute bronchitis occurring in the Military Hospital of Florence; 
(Lo Sperunentah. l89G, p. 325). He isolated a coccus which in 
some respects resembled a diplococcus and in others a stre])to- 
coccus. The bacterium rapidly lost its virulence, so that the 
author was unable to make researches as to specific immunity 
after the method of PfeifFer. It had many of the characters 
attributed by various authors to tlie streptococci of the mucous 
membranes normally occurring in the mouth, vagina, etc., and 
ordinarily little or not at all pathogenic. The author thinks it 
probable that these strejitococci ordinarily present in the mouth 
in some way acquire virulence in tlie bronchial mucous membrane. 

G. Carriere has published a detailed account of a case of 
streptococcic chronic bronchitis treated with great benefit by anti- 
streptococcic serum (Presse Med., Paris, June 5, 1897, ]>. 258). 
In this case there were febrile temperature, profuse sweats, and 
abundant expectoration in the morning. There were the general 
signs of bronchitis with emphysema, together with some evidence 
of a cavity at the left apex. The sputum was repeatedly ex- 
amined, and while it contained neither bacilli nor elastic fibres, 
streptococci were constantly found to be present. After an 
injection of 10 c.cm. of antistreptococcic serum, the temperature 
first rose, but soon fell to normal, and improvement set in. A 
fortnight later the expectoration had greatly diminished in 
amount, not exceeding 5 or 6 oz., and was more mucous and less 
purulent. There was genej-al improvement, although the physical 
sig]is were unaltered. A second injection of the same amount 
was made. Three weeks after the second injection the patient 
left the hospital greatly in^proved. The cough was slight, and the 
expectoration only amounted to between 1 and 2 oz. The cavity 
signs disappeared. In a month the patient was quite well. 



THK TREATMENT OF NERVOUS AND 
MENTAL DISEASES. 

By Euxest Septimus Reynolds, M.D. Loxd., F.R.C.P., 

Senior Phyitician to the Ancoais Hosjntai, Manchester; Physician to the Mdm-.hcUer 
I^o^/.■hol^^•^' Injlmarij anl Limaci/ Tr«r.!s. 



This article includes the following subjects : — 
I. — Lumbar Puncture. 
II.— The Treatment of Epilepsy. 
III. — The -i5^tiology and Treatment of Tabes Dorsalis. 
IV. — The Treatment of Pain, including Local Anaesthetics. 

V. — The Treatment of Insomnia. 
VI.— The Treatment of Tetanus. 
VII.^Thyroid Extract and Serum in Insanity. 
VIII. — Miscellaneous Articles. 

Special attention has been directed to further observations on 
lumbar puncture, to the treatment of epilepsy by opium and 
bromides, the results obtained at epileptic colonies, the relation- 
ship of syphilis to tabes, and the treatment of ataxia by systematic 
exercises. 

I.— LUMBAR PUNCTURE. 

In " The Year-Book of Treatment" for 1897 will be found 
a full account of what is known as Lumbar Puncture. This 
method of ascertaining the pressui'e of the cerebro-spinal fluid, 
together with its chemical, microscopic, and bacteriological con- 
stituents, was there shown to be of some distinct service in the 
differential diagnosis of various forms of meningitis and of brain 
tumour. It was shown, however, by many observers that even 
for diagnostic purposes the proceeding did not yield infallible 
results, that as a means of treatment its use was almost nil, and 
that it occasionally hastened, even if it did not cause, death. 

In medical literatui-e during the past twelve months further 
observations have been made, which only confirm the general 
conclusions just mentioned. Full use does not, however, seem to 
have been made of the operation, as in most of the cases reported 



60 THE YKAR-I500K 01-' TRKATMENT. 

the pressure; of Uie lliiid lias not hcfoi ascertainrd, and tliis, uccord- 
iui; to (^Hiineke, is one of tlie most important diagnostic points. 

Mya {LiiticU'iHuina Aled., Jan. 23, 1<S'J7) points out tliat, even 
in cases in wliicli the removal of some iicjuid may l)e palliative, it 
occasionally hajjpens that the sudden diminution of pressure leads 
to death. In the acute non-tuberculous affections of the meninges 
lumbar puncture can have little curative effect, though it may be 
of use in hydrocephalus following a chronic meningitis. When 
operating on children chloroform was not given, and in some cases 
the patients walked home immediately after the operation. He 
alludes to thirty-three cases, fifteen of which suffered from tuber- 
culous meningitis, two from serous meningitis accompanied by the 
staphylococcus, one from syphilitic lobar sclerosis, three from 
cerebral tumour, eleven from chronic hydrocephalus, and one from 
sinus thrombosis after otitis. Mya speaks highly of the diagnostic 
value of the method in tuberculous meningitis, and points out how 
in this disease the liquid flows at a quicker rate ; for example, 
20 to 40 c.cm. in a few minutes, compared with 5 to 10 c.crn. in 
the same time in other cases. The fluid is slightly turbid, and 
coagulates if left to stand. Microscopically, fragments of epen- 
dyma and leucocytes in small quantities were found. Glucose is 
usually less than normal, and may be absent. Tubercule bacilli 
were found only in two cases, and cultivations were not successful. 
The author relates one case of tuberculous meningitis diagnosed 
by puncture and by injection of tuberculin, which recovered. The 
other fourteen cases of tuberculous meningitis ultimately died. 

Thiele [Deut. ined. Wochen., 1897, No. 24) has used the method 
in twenty- four cases, and concludes that it is a valuable addition 
to our methods of diagnosis, and may be of use therapeutically 
in serous and sero-purulent meningitis and in the cerebral dis- 
turbances of chlorosis. 

Wentworth (^Arch. of Pediatrics, Aug., 1896) summarises as 
follows : — The normal cerebrospinal fluid contains neither cells 
nor fibrin, and is perfectly clear, whereas in meningitis the fluid 
withdrawn is invariably cloudy in proportion to the character of 
the meningeal exudation ; the cloudiness is caused by cells, which 
differ according to the form of the meningitis, and the presence 
of the cells and appearance of fibrin after withdrawal is patho- 
gnomonic of meningeal inflammation. The diffei'ential diagnosis 
between the various forms of meningitis can be made by micro- 
scopic examination of the sediment, by cultures, and by inocula- 
tion experiments. In normal fluid a faint trace (J^ per cent.) of 
albumen is found, but in meningitis this is increased, and may 
vary from Jg- to yi,j per cent. In one of his cases a diagnosis of 



THK TKKATMENT OF NERVOUS AND MENTAL DISEASES. 61 

general infection by the staphylococcus pyogenes aureus was made 
from cultures of the cerebro-spinal fluid. 

Wilms (Miinch. med. Wochen., 1897, No. 3) has operated 
thirty times on twenty-three patients. In four cases of epidemic 
cerebro-spinal meningitis he found Weichselbaum's meningococcus 
twice ; in a third patient sudden death took place two hours after 
the puncture, and in the fourth case no bacteria were Ibund, but 
after the removal of 100 c.cm. of clear fluid complete recovery 
occurred ; five eases of tuberculous meningitis ended fatally, and 
in only one of these were the tubercle bacilli found. In several 
cases there was a remission of the symptoms for a short time 
after the punctui-e. Of three cases of pseudo-meningitis with 
infectious disease, one ended fatally, and no bacilli were found. 
In a case of chronic nephritis and uraemia no increased pressui-e 
of the fluid was present. In syphilitic meningitis no therapeutic 
eflect was noticed ; in a case of chronic hydrocephalus with enor- 
mous cranial distension, but with no brain pi-essure symptoms, 
no increased pressure was found, but in the serum were traces of 
albumen and a little sugar. He found no increased pressure in 
chlorosis. In a case of cerebral tumour the pressure was increased 
to 66 mm. of mercury (normal pressure about 5 mm. of mercury), 
whilst in a case of cerebellar tumour with pressure symptoms no 
increased pressure of fluid was found, probably due to the tumour 
shutting otr the spinal canal from the cerebral meningeal spaces 
and ventricles. In epidemic meningitis, with one exception, the 
fluid was turbid and purulent, but in tuberculous meningitis it was 
nearly always clear ; and also in pseudo-meningitis with infectious 
fevers and syphilis, in uremia, embolism and tumours, the fluid 
was always clear. 

Habel (^Deufscli. med. Woch., October 15, 1896) mentions that in 
Eichorst's cliniqu^e, lumbar puncture has been performed twelve 
times. In eight cases the disease was tuberculous meningitis, and 
yet the bacillus was found only once. Of the remaining cases 
two were purulent meningitis (in which the fluid drawn off" M^as 
purulent), one was a serous meningitis which ended in recovery, 
and one was a syphilitic meningitis. In all the tuberculous cases 
clotting of the fluid occurred after a few hours, whereas clotting 
was not noticed in the other cases. 

1. I.<tinibar piiiicttii'e in the coiiiplicatioiis of car 
disease. 

Leutert (Milnch. med. Wochen., Februaiy 23 and March 2, 
1897) discusses the diagnostic value of lumbar puncture in the 
intracranial complications of ear disease, such as meningitis, sinus 
thrombosis, and combined sinus thrombosis, and cerebral abscess. 



62 TIIK YKAIMiOOK OF TKKA I'M KNT. 

The diagnosis between sinus tliroiiibosis and meningitis is not 
always easy, and yet is very important in the early stage as 
an indication for operation. Details of twelve cases are given, 
including two of suppurative meningitis ; two of suppurative 
meningitis and sinus thrombosis ; one of sinus thrombosis with 
intra-dural and cerebral abscess; one of sinus thrombosis with 
maltiplo cerebral abscesses ; one of suppurative meningitis with 
cerebral abscess ; one of perisinuous abscess : and one of sinus 
thrombosis. Details are also given of one case of ccrebro-spinal, 
another of tuberculous meningitis, and a third of serous menin- 
fitis. All the cases except the perisinuous abscess, and one of 
epidemic meningitis, ended fatally. In tlio author's first case 
death occurred fifteen minutes after the puncture, but the patient 
was already almost moribund. In these cases negative evidence 
is often of value. Tlie presence of a large quantity of fluid shows 
that the communication between the brain and cord cavities is 
open. In purulent meningitis the fluid contains more or less 
inflammatory products, so if these are absent in cases diagnosed 
as sinus thrombosis or cerebral abscess, then meningitis may be 
excluded. Uncomplicated sinus thrombcsis may undoubtedly 
produce an excess of cerebro spinal fluid. In cases of sinus 
thrombosis with cerebral abscess the exclusion of meningitis (by 
lumbar puncture) would lead to a successful operation on the 
sinus, and then the symptoms of pressure due only to the abscess 
may be apparent. Cultivation experiments were negative in five 
out of seven cases examined. A considerable number of leucocytes 
present in the fluid makes the diagnosis of meningitis very 
probable. In one case mentioned a subperiosteal abscess behind 
the ear was opened, and two or three weeks later cerebral symp- 
toms appeared. Lumbar puncture was performed, but no tubercle 
bacilli were found, although the autopsy revealed a general 
tuberculosis. 

3. faiinbar piiiictiire in g^eiicral paralysis and iiic- 
laiirliolia. 

Babcock (State Hosjyitals Bidletin, 1896) has used the method 
in twelve cases of general paralysis of the insane. The skin was 
first injected with cocaine. No bad results were seen. It is 
o-enerally accepted that the increased cerebro-spinal fluid is at first 
inflammatory in nature, but afterwards merely compensatory ; 
but in all cases albumin was present in it. There was some 
excitement after the operation ; the expression was less vacant, but 
the pupils were" unchanged ; the ataxia was slightly improved, but 
the hesitation of speech scarcely changed. If there was a very 
deep stupor, the operation should be performed. The fluid 



TIIK TRKATMKNT OF NERVOUS AND MENTAL DISEASES. 63 

generally returned, demanding renewed interference ; the albumin 
was increased, but the specitic gravity was lowered. In more 
than 50 per cent, of the cases the operation produced good but 
transitory results; and, as repeated puncture would be necessary, 
the use of the treatment in general ^laralysis is probably of 
no service. Babcock found the method useless in melancholia 
with j^ressure symptoms. 

:$. LiiiiiR>nr puiictiirc in lead cnceplinlopatliy. 

Seegelken (Miiuc/i. wed. fVoch., 1896, No. 47) describes a case 
of lead encephalopathy in a painter's assistant in which right- 
sided convulsions were followed by right hemiplegia and deep 
coma, with absent knee-jerks, but a normal urine. By lumbar 
puncture 60 c.cm. of cerebro-spinal fluid were withdrawn, the 
pressure of the fluid at the beginning registering 310 mm. of 
water, and at the end 80 mm. Soon after the operation there 
was a return of consciousness and lasting improvement. The 
fluid was at first almost clear (probably from the spinal sub- 
arachnoid space), but the latter portions (probal:)ly from the l)rain) 
were turbid. 

II.— THE TREATMENT OF EPILEPSY. 

During the past year no new treatment of epilepsy has been 
published except that by extract of pituitary body by Mairet and 
Bosc (Arch, de PJiysiolog. norm, et 'pathol.., July, 1896), who found 
that repeated feeding with the pituitary glands of oxen produced 
no effects in dogs, and subcutaneous injection of the gland in 
water only gave rise to slight transitory fever and a little wasting; 
intravenous injection of the fluid produced death by coagulating 
the blood. In healthy man the gland, taken by the mouth, was 
not followed l)y any change, but injection caused slight general 
malaise and fever lasting for twenty-four hours. The gland was 
given by the mouth or subcutaneous injection to twenty-one 
epileptics. It was found to increase, rather than diminish, the 
number of fits, and in addition it produced a state of mental 
exaltation which, in some cases, was quite different from any pre- 
vious mental aberration from which the patients had suffered. 

Cividali and Gianelli {Lancet, Jan. 30, 1897) report that 
duboisin sulphate diminishes the number and intensity of epileptic 
attacks ; the dose given was y^^ grain, increased to ^\^ grain, 
and the most favourable results were obtained in cases of epilepsy 
associated with psychical disorders. 

The majority of the articles on the treatment of epilepsy 
relate to the treatment by large and increasing doses of opium 
followed by large doses of bromides, as proposed about two years 



G4 TIIK VKAll-HOOK OF TltKATM KNT. 

ago l)y Flechzig. The method has received much adverse criticism, 
and l)ut few ot" the many trials have had encouraging results. 
BOhme {Zeitsch. f: PsycMalrie, vol. liii., p. 30) treated ten cases 
in this way, and of these five showed an ahscnce of fits for some 
months, and three others were slightly improved. With some 
patients the tits incn^ased during the opium treatment, and several 
patients showed symptoms of poisoning. Bohme doubts the u.se 
of the opium administration. Bratz [Neuroloy. CerttralbL, 1-S!J7, 
p. 47) says that many think the method, not only useless, but 
even hartnful, as during the time when the large doses of opium 
are being given, severe delirium and (;ven death may occur. He 
reports his results in forty-three cases. Of these, twenty-four 
showed no good etiect, and there were three cases of death ; with 
only a few cases was the result good. During the opium period 
of treatment the majority of the cases were miseraV)le, the skin 
was cold, and the body-weight decreased, but when the bromide 
was given the body-weight increased. Some of the cases suffered 
from slight delirium, and there was often a feeling of giddiness. 
Jastrowitz (ibid.) had never seen any good from the method, but 
Oestreicher (^ibid.) mentioned a severe case which had received 
benefit. 

PoUitz (AUrjemein. Zeitsch. f. Paycli., vol. liii., p. 37) 
tried the treatment in seventeen cases, but with no specially 
good results. He warns others against using the method, because 
of the symptoms of poisoning, the loss of weight, the increase in 
number of attacks during the 0])iuni treatment, and the numerous 
deaths which have occurred. He thinks that the theoretical 
basis of the cure is very assailable, and the practical results, if 
one excepts those produced by the bromides, doubtful. 

Van Gehuchten [Polyclinique, 1896, No. 3) used Flechzig's 
treatment in a weak-minded epileptic, twenty-three years of age, 
who had suffered for two years, and had latterly five to eight 
attacks daily, which were not relieved by any of the usual 
methods of treatment. The intensity of the attacks diminished 
early in the stage of opium treatment, whilst the number lessened 
as soon as the bromides were given. The improvement was so 
great that for twenty days there was no attack. The opium was 
well Ijorne, on the whole, with the exception of some vomiting, 
loss of sleep, and constipation, which occurred towards the end of 
the opium-administration period. 

Flechzig (Neurol. Centralbl., Jan. 15, 1897) criticises the 
unfavourable results of his treatment which have been recorded 
by others, and utters a note of warning that it is only suitable 
for inveterate cases of epilepsy which have withstood all other 



THE TREATMENT OF NERVOUS AND MENTAL DISEASES. 65 

treatment, and that the greatest care is requisite during the course 
of the cure. He considers that in the fatal cases recorded no causal 
relation to the treatment has been shown, and points out that a 
fatiil result is common enough in status epilepticus without any 
opium administration. A careful watch should be ke[)t by the 
physician for any untoward symptoms which woidd indicate 
withdrawal of the drug ; indeed, Flechzig is more inclined to 
blame the physician than the drug for the fatal result. His own 
experience of the treatment by opium nnd bromides has been 
most satisfactory ; six cases out of fifty so treated have had no 
recurrence of the tits for two and a quarter years, and all the 
cases treated were severe and of many years' duration, and had 
resisted all previous treatment. He does not use the opium 
method until he has first ascertained that the bromides alone are 
of no service. If the opium is given, then the patient must be 
treated as if he were seriously ill ; he must be kept in bed, and 
must have constant skilled nursing and medical attention. 
1. The behaviour of bronii<le» in tlie bo<ly. 
Laundenheimer [JVeurol. Centralbl., 1897, p. 538) found in a 
series of experiments that, contrary to the usual opinion, the 
bi-omides do not leave the body within tw^elve to thirty-six hours 
after they are taken, but are only excreted by degrees, and 
increase the excretion of chlorine, taking its place in the body to 
a large extent. After a certain time, in a period of bromide 
administration, a kind of bromide equilibrium is established, the 
bromide taken in and that excreted being about the same. The 
author thinks that possibly bromism is due to the increased 
excretion of the chlorides, and suggests that sodium chloride 
should be given as a remedy for the bromism. In some cases 
there was noticed a lessening of the urine before an epileptic 
seizure came on, whereas during the period of opium adminis- 
tration of Flechzig's treatment there was a considerable in- 
crease in the flow, and, in fact, this was the cause of the loss 
of weight, as the urine was greater in amount than the fluid 
ingested. It was also noticed that after the opium administra- 
tion the lessening of the i;riue before an attack was no longer 
present, which may have some connection with the success of 
Flechzig's method in some cases. 

2. The treatment of epileptics in " colonies." 
No annual review of the treatment of epilej)sy would be com- 
plete without a reference to the good work which is being carried 
on in so-called epileptic colonies. An interesting review of this 
subject, together with the results obtained at the colony estab- 
lished at Chalfont St. Peter, has been published by Aldren Turner 
p 



66 THE YEAR-COOK OF TREATMENT. 

{Lancet, June 2G, 1897), and deserves more than a passing notice. 
The autlior points out that a return of the Ix)cal Government 
Board in 1893 stated that in the Poor Law institutions of London 
there were 31,889 inmates, of whom 004 were sane epileptics, or 
about one-fiftli of the probable number of sane epileptics in the 
Metropolitan area. This large numljer at once suggests the ques- 
tion as to whether it is not possible for these individuals to 
support themselves by work under proper care and supervision. 
In Germany colonies for this purpose have for long Ijeen estab- 
blished, and at Bielefeld 1,100 epileptics are employed in various 
forms of field and garden work. Other sinular institutions are 
to be found at Zurich, Potsdam, and Stettin ; and in America at 
the Craig Colony in New York State there are 145 patients em- 
ployed and 23 epileptic children in the schools. In England until 
two years ago there were only two small homes for epileptics, one 
at Maghull, near Liverpool, founded in 1889, for both male and 
female patients, and Lady Meath's Home for Epileptic Girls. 

In 1894 the National Society for the Employment of Epi- 
leptics opened the first house at the epileptic colony at Chalfont 
St. Peter, Buckinghamshire. The principles upon which this 
colony is worked are :^(«) Removal of the epileptic from the 
town to the country ; (b) the regular employment in the garden, 
fields, orchard, workshops, etc. ; (c) the maintenance of a well- 
ordered and regular mode of life, with the avoidance of excite- 
ment and abstinence from alcoholic liquors; (d) abundance of good 
nourishment of a simple nature. Living under such conditions, 
it has been found that the epileptic requires only a minimum 
amount of medicinal treatment, and it is the custom to give each 
patient 30 grains of potassium bromide at bedtime. There are 
at present two houses, each containing eighteen males, and one 
for twenty-four females. Another building for men is being 
erected, and it is proposed to build two houses and a school for 
male and female childx-en. Payment has been made either by the 
friends of the patients or by Boai'ds of Guardians. Since 
August, 1894, sixty-two male epileptics have been under ob- 
servation. 

As regards the results obtained. Turner summarises as 
follows :—(l) Frequency of Jits. In the majority of cases a 
marked diminution in the number of attacks has been observed 
after admission, probably due directly to the removal from bad 
hygienic surroundings in a town to a pure country air. In a 
minority there was a temporary increase in the number of fits, 
which may have been due to the fact that previous to admission 
large doses of bromide had been taken, which ai'e stopped on 



THE TREATMENT OF NERVOUS AND MENTAL DISEASES. 67 

admission, except for the single nightly dose. After a time the 
average number of fits is struck, which, of course, varies in 
diflerent cases. The greater number of fits occurred during the 
day, and by far the commonest time is during the first hour after 
rising in the morning. Fits are rare on going to bed, and, as a 
rule, the patients are much better and brighter during the evening. 
More fits occurred in the house than outside, and probably more 
during warm and close weather than during cold. (2) Severity of 
the attacks. In the majoi'ity an amelioration in the severity of 
the attacks occurred, in a minority no alteration was noticed, and 
in a few the attacks were more severe. In some, severe fits gave 
place to attacks of ^jeii^ mal, in others attacks of an average 
nature became more severe. (3) General mental state. In quite 
a minority there has been a progressive tendency towai'ds de- 
mentia. In some it appeared to be the natural course of the 
disease, and in others it was owing to the frequency and severity 
of the fits. In the majority, however, no such mental deterio- 
ration was observed. Some are able to do work reqiiiring in- 
dividual alertness and tact, while most are able to do work under 
supervision. But the greatest benefit of the treatment consists 
in the good general moral eflfect upon the patients, for here they 
are not regarded as "family lepers," but each patient finds that 
he can be of use, and interest is taken in the work and amuse- 
ments, and there is a feeling of higher self-respect. (4) General 
physical state. It is here that the greatest improvement has 
been noticed. All the patients put on weight, notwithstanding 
the frequency or severity of any fits which may have occurred. 

It has been found that all fonns of work in field and garden 
are most beneficial, but good work has also been done in the car- 
penter's shop by picked men. The farm of 135 acres is worked 
by the colonists, with the addition of a few farm labourers, a 
bailifl^, and a gardener. In the summer months cricket matclies 
are played, but football is forbidden. The granting of holidays at 
intervals has been found of benefit. 

The patients for admission are carefully selected, the special 
points to which attention is directed being : — Has the epileptic 
been unable to obtain employment I Or, has he been discharged 
from situations by reason of his fits 1 Is he capable of work 
under supervision? Is he absolutely free from attacks of 
violence, mania, or every symptom indicating insanity 1 



F 2 



68 TIIK YEAR-BOOK OF TREATMENT. 

Ill Till': .KTloLOCV AND TREATMENT OK TABES 
IJOIISALIS. 

A. — THE TETIOLOfJY OF TABES DORSALIS. 

At the Intematioiiiil Congress at Moscow there was a dis- 
cussion on the M'tiology of tabes dorsalis {Neur(jl. Centralbl., 
Iy97, X). 873). Borgherini thought that tlie causes of tabes .sliould 
be divided into the general and the spoicial ; in his experience 
there was a history of syphilis in 30 per cent, of the cases. 
Leyden did not think that it was proved satisfactoi-ily that 
syphilis was the great cause of tabes, and was not content with 
the statistical method in this connection ; he thought it might be 
just as easy to prove that gonorrhoea or cold was the great cause. 
The syphilitic theory did not explain why tabes was so un- 
common in women ; and he thinks that in men many previous 
diseases are put down to syphilis, althougli they have been 
nothing of the kind. Virchow had further noticed that in 
autopsies on tabetic cases other signs of syphilis were very rarely 
seen. Leyden does not believe that the disease begins in the 
spinal cord, but that it is a parenchymatous change which begins 
in the sensory and motor nerves. 

Erb said that for the last twenty years he had carefully 
collected his own cases, and found that in 6,000 patients 
sutferino- from other forms of nervous disease, there was a 
history of syphilis in only 20 per cent ; whereas, in 1,000 
cases of tabes, there was a previous history of syphilis in 90 
per cent. He said that it was notorious that tabes did not 
appear in married people unless there was a previous history of 
syphilis, so that the condition could not be due to sexual excess. 
He believed that heredity played only a small part in the 
aitioloo^y, and then only if syphilis had been present. Heuschen 
mentioned that in his clinique there were but few cases of 
svphilis, and but few of tabes. 

Hermanider (^Virchow' s Archiv, Bd. cxlviii.) discusses this sub- 
iect on the basis of hitherto published statistics. He points out 
that the percentage of cases of tabes put down as due to syphilis 
varies from 92-5 (Erb) to 30-6 (Leyden), and thinks the personal 
equation must be considered in these statements. In most of the 
statements — except those of Erb — there is no comparison with 
healthy or non-tabetic individuals as regards previous syphilitic 
historv and it is only by such a comparison that a reliable 
estimate can be made. Hermanider suggests that sexual excess 
is also a potent cause; but here, of course, there is more 



THE TREATMENT OF NERVOUS AND MENTAL DISEASES. 69 

chance of syphilis. He mentions the proximity of the genital 
centre in the lumbar region to the part fii'st affected in tabes. 
He further brings forward the possible connection between 
gonorrho-a and tabes, although proof is still wanting, in spite of 
many researches. In conclusion, Hermanider thinks the con- 
nection between syphilis and tabes is very probable, but by no 
means certain, and lie decidedly combats the view that syphilis is 
"the only cause of tabes, whether as a predis])osing or as an essential 
cause. 

Trennan (Alienist, Oct., 1896) states his opinion that syphilis 
is only put down as a cause of tabes because it is so common in 
the white races. He remarks that in Japan, where syphilis is so 
frequent, tabes is very rare ; and that in x\rkansas, where 
syphilis is very common among the negroes, he has not seen a 
single case of tabes among the black races in twelve years. He 
calls attention to the possibility that the long and uninterx'upted 
use of iodide of potassium in large doses may damage the blood- 
cells, and indirectly the intima of the vessels, producing thereby 
an arteriosclerosis, and so possibly setting up tabes. [This seems 
to us to be rather a gratuitous hypothesis. — E. S. R.] 

Collins (The Post-Graduate, July, 1896), after a study of the 
nervous diseases supposed to be due to syphilis, says : (1) That 
exudative and degenerative diseases of the nei-A^ous system due to 
syphilis are most liable to show themselves at the end of the 
third and the beginning of the fourth decade of life. (2) 
Thorough and prolonged administration of anti-syphilitic remedies 
during the activity of the virus does not seem materially to pro- 
long this time limit. (3) Active and prolonged anti-syphilitic 
treatment does not seem to prevent the development of such 
diseases as tabes dorsalis or genei'al paralysis ; and further, that 
the cases in which syphilis is acknowledged, and in which treat- 
ment has been most desultory and incomplete, are not more 
liable to the earlier development of, or to severe manifestations 
of, these diseases than those cases are in which the treatment 
has been all it should have been. (4) The administration of anti- 
syphilitic remedies in the most approved way does not fulfil 
the requirements of cure, and thus syphilis is often an incurable 
disease. 

L.oa<l-)»«)>i<i«oiiing: as a cause of tabes. 

Redlich (Wieiie)' med. Wochen., 1897, Nos. 18 and 19) says 
that, although most of the cases of tabes are proljably due to 
syphilis, yet a certain number are ])robably due to other ])oisons. 
He has investigated the influence of lead as a cause, autl could 
tind only four cases out of one hundred of tabes in whicli this 



70 TIIK YKAIl-BOOK OF TUEATMENT. 

connection probably existed. One of these cases he relates, in 
whicli, after death, there were found changes in tlie posterior 
columns, and also a poliomyelitis in the anterior horns of the 
upper cervical region. 

C. THE TREATMENT OF TABES DORSALIS. 

I. R\oi'ci«c trcatiiiciit of tabos. 

Frenkel {Deritsch. med. Wochen., Dec. 17, 189G) has during the 
last six years treated a number of ataxics by regulated exercises, 
a method first introduced by himself. Improvement in the ataxia 
was almost always obtained, and much more may be expected 
from this method than is usually believed. The author divides 
co-ordinated movements into : (a) Those which maintain the 
body or part of the body in a given position (static co-ordination) ; 
(J>) those which regulate the change of position of the whole body, 
as in walking, etc. ; (c) those which effect co-ordinated movement 
of one or more parts of the body when the centre of gravity is 
left out of consideration, as in movements of the arms, legs, itc, 
in the sitting or lying position. Inco-ordination may affect one 
or more of these groups ; (a) represents the lightest, and (c) the 
most serious forms of ataxia. The object of treatment is to 
convert the simplest ataxic movement into a normal one, and this 
can be effected by the exercises. These consist of exercises for 
the hands and arms, and exercises for the body and lower limbs. 
Examples of the former are : — Sit in front of a table, place the 
hand upon it, then elevate each finger as far as possible ; then, 
raising the hand slightly, extend and then flex each finger and 
thuml> as far as possible ; do this with the right and then with the 
left hand. Touch with the end of the thumb each finger tip 
separately and accurately ; then touch the middle of each phalanx 
of each finger with the tip of the thuml:). Sit at the table with a 
large sheet of paper and a pencil ; make a dot at each corner of 
the paper and one in the centre, and draw lines from the corner 
dots to the centre dot, first with the right and then with the left 
hand. Put ten pennies on the paper, pick them up and place 
them in a single pile, first with the right, then with the left hand. 
For the body and lower limbs sample exercises are: — Sit in a 
chair, rise slowly to erect position without help of cane or handles 
of chair ; then sit down slowdy. Stand with cane, feet together, 
advance left foot and return it ; then same with right. Walk 
slowly ten steps forward and five back with help of cane. Stand 
without cane, but with the feet a little apart, and the hands on 
hips • in this position stoop down by flexing the knees, and rise 



THE TREATMENT OP NERVOUS AND MENTAL DISEASES. 71 

slowly. Stand without cane, with the feet separated, i-aise the 
hands from sides to above the head, carry them downwards and 
forwards, and try to touch the toes. Walk along a fixed line on 
the floor by help of a cane, placing each foot in turn on the line ; 
then repeat without using cane. Most of these exercises should 
be repeated several times. Other similar exercises can be invented 
from time to time, if necessary. 

Insufficient duration of the treatment or an unsuitable selection 
of exercises may give rise to an insufficient result. Frenkel draws 
attention to the absence of the feeling of fatigue in locomotor 
ataxia. In these cases great care is needed to find out the suitable 
form of exercise required. The treatment is not without benefit 
even in cases in which there is marked disturbance of sensation. 
The movements should be made with the eyes both closed and 
open. Possibly in the earliest cases these exercises may be a 
means of warding off the ataxia. The improvement may last for 
years, if the disease is stationary or only slowly progressive. 
With the intelligent patient it is possible to adapt the exercises to 
the actual state of the disease, even if slowly advancing. Frenkel 
says the treatment is absolutely contra-indicated in cases of acute 
or sub-acute ataxia, and relatively contra-indicated in cardiac 
valvular disease and marked arthropathy. No good results can 
be expected when other diseases of the nervous system are present. 
Attention is drawn to the harm that may be done by passive 
movements and injudicious active movements, including those 
against resistance ; instances are given in which fracture, blood 
effusions, weakness in the legs, etc., have been known to follow 
such efforts. Prudence should be used in recommending walking 
exercise, as, the feeling of fatigue being absent, over-exertion may 
lead to increased ataxia ; and the least fatigue felt should lead to 
great caution. Sport of all kinds should be forbidden, and 
especially cycling, even in the earliest stages, for any advantages 
gained by the improved co-ordination is lost by the baneful effects 
of over-exertion. 

At the Moscow Congress Fi'enkel {Neurol. Centralbl., 1897, 
p. 879) further stated that the worst cases could only be satis- 
factorily treated by those who had an exact knowledge of the 
methods, but in light cases good results could easily be obtained. 
The ataxia of the unburdened lower extremities (as in lying), of 
the burdened lower extremities (as in standing), and that of the 
trunk, must all be considered specially. Exhaustion by the 
exercises must be carefully avoided. For the treatment of the 
lower extremities complicated apparatus is unnecessary, but the 
treatment of the upper extremities requires special apparatus. In 



/ J 'JUK YEAR-BOOK OF TRKATMKNT. 

a regular course of treatment the exercises must Vje performed 
two or tliree times a day, and tdways under tlie direction of the 
])hysician. It is probable that if used in the pre-ataxic stage the 
threatening ataxia might be combated. The results are lasting. 
Troatm(!nt by Ijaths should be forbidden while the exercise treat- 
ment is being used. 

Kalinin (Vraich, No. 7, 1897) has used Frenkel's method in 
five cases of tabes with great improvement in the condition of the 
patients. He arrives at the following conclusions: — (1) By this 
treatment the loss of motion can be restored to a satisfactory 
degi^ee, the gait and locomotion gradually becoming safer and 
firmer. (2) The sense of locality and that of movement, and the 
skin sensibility, are but little improved. (3) Rombei'g's symptom 
(swaying on standing with the eyes closed and the feet together) 
very soon becomes less pronounced. (4) The duration of the 
treatment should entirely depend upon the prognosis and degree 
of the motor disturbances present, but in any case it should not 
amount to less than a month. (5) No ill-effects were observed if 
the treatment was interrupted at shoit intervals of two to three 
weeks, but not longer. 

Raichline [Neiirol. Centralbl., 1897, p. 473) has applied this 
method in twelve cases — with complete success in eight, relative 
success in three, and with no good etiect in one case. He thinks 
the method is applicable even in very advanced cases, and the 
effects are lasting ; not only the ataxia, but also the sensibility and 
the bladder troubles were improved. The conditions of success 
are a long, as opposed to a short, coui-se of treatment, a well- 
nourished condition, good sight necessary for watching the 
movements accurately, a certain amount of energy and in- 
telligence, not complete loss of sensibility, a.nd the absence of 
arthropathies or fresh fractures. 

2. Oeiioral ti'oatineiit of tabe!!*. 

A most interesting and valuable paper on the ti'eatment of 
tabes was given by Erb at the International Medical Congress at 
Moscow {Neurol. CentralbL, 1897, p. 875). He deals with the 
subject under several heads: (1) Ueview of former treaiinent. 
Romberg declared that in no disease was there so little hope of 
cure. After this time derivatives, baths, and drugs were employed ; 
then the faradic cuiTent was recommended by Duchenne, and the 
galvanic by Remak ; nitrate of silver being given internally by 
Wunderlich, and such drugs as ergot, arsenic, iodine and bromine 
preparations, strychnine and tonics by others. Besides these, 
animal extracts, such as testicular juice, spermin, spinal cord and 
brain substance were given. Massage, gymnastics, systematic 



THE TREATMENT OF NERVOUS AND MENTAL DISEASES. 73 

movements, suspension, and nei've-st retelling (with or without 
operation) have all been reeoaunended. 

(2) ^Etiology and nature of the disease. There is no doubt 
that syphilis is i-esponsible for most of the cases of tabes, although 
some doubt this. It is certainl}' a point for discussion as to how 
syphilis gives rise to the disease : whether it is a true tertiary 
symptom, or whether it is a post-syphilitic or metastatic syphilitic 
affection (from a toxin), or whether it should be considered as a 
disease due to some agent acting on a cord weakened by syphilis. 
Besides syphilis, cold, fatigue, sexual excesses, trauma, excess in 
alcohol or tobacco, overstrain and emotion, may be occasional 
causes, perhaps acting more as immediate causes. 

(3) Residt of the modern therapeutics of tabes. It has been 
determined without doubt that the early and thorough treatment 
of syphilis will lessen tlie appearance of tertiary manifestations, 
but even the most thorough early treatment will not absolutely 
prevent the appearance of tabes. It is, however, necessary to 
treat the early stages of syphilis as thoi'oughly as possible. Anti- 
syphilitic treatment should also be used in the early stages of 
tabes, when the infection by syphilis is not very remote or where 
there has not been a thorough early treatment of the syphilis. 
Erb considers that the systematised movements proposed by 
Frenkel are of real service in lessening the ataxia. 

Grasset (ibid.) at the same Congress considered that in tabes 
we have only one part of a general disease which may be- 
characterised as a multiple disseminated sclerosis ; for we find 
scattered, discontinuous lesions of the nervous system, often also 
other clinical signs, such as polyneuritis, lateral sclerosis, etc., and 
often sclerosis of other organs, such as the heart and arteries, and 
often diabetes. The pi'incipal cause of tabes is syphilis, but in 
addition we must consider as factors arthritis, different in- 
toxications, and hereditary or acquired predispositions ; and thus 
he thinks that syphilis is merely a co-agent. From this stand- 
point, tabes may be considered a curable disease. In treating 
these cases, one must try to cure the disease and improve the 
anatomical condition of the spinal cord, to improve the destroyed 
functions of the spinal cord, and to lessen the pain and other 
symptoms. We must, therefore, use : (a) Agents to modify the 
cause of the disease, such as anti-syphilitic or anti-rheumatic 
remedies, (b) Agents to modify the lesions, such as iodine pre- 
parations or, if these cannot be borne, silver, and, in acute or 
subacute attacks, ergot. For the spinal cord itself, local 
derivatives, electrotherapy, and stretching of the nerves or cord 
itself may be employed. Suspension is chiefly useful in chronic 



74 THE YEAR-BOOK OF TREATMENT, 

cases, and it must be long-continued. (c) Agents for lessening 
pain, such as opium, antipyrin, chloroform, warm water, elec- 
tricity, (fee. For the muscular weakness and asthenia massage 
and hydrotherapy may be used. Frenkel's method is useful for 
the ataxia, and suggestion for the neurasthenia. 

Raichline (ibid.) agrees that, except in the early stages, anti- 
syphilitic treatment is of no use in tabes, nor is anti-syphilitic 
serum of any value, and the organic extracts can have no other 
influence than that of mere tonics. On the contrary, hydro- 
therapeutics, electrotherapeutics, massage and gymnastics, are of 
great service, together with fresh air and good nourishment. 

Brower (ibid.) thinks that a warm, dry, and equable climate is 
necessary for tabetics, together with great ease and quiet, daily 
massage, electricity, and methodical exercises ; he also recommends 
the use of gold chloride and zinc phosphate. 

IV.— THE TREATMENT OF PAIN, INCLUDING 
LOCAL ANESTHETICS. 

A. — THE TREATMENT OF PAIN. 

1. Tic douloureux, facial ncuralg'ia, and inig^rainc. 

Gilles de la Tovirette (^Sem. Med., June 24, 1896) says that, 
from a therapeutic point of view, it is most important to dis- 
tinguish two classes of facial neuralgia. The first is transitory, 
and usually due to cold and peripheral irritation ; but the second is 
refractory, and perhaps incurable. In the first form the pain during 
the attacks is not very intense, but is not entirely absent between 
the attacks ; the onset is sudden, then there is an acme and a 
decline. The second form, or tic douloureux proper, is completely 
paroxysmal, the pain being entirely absent between the attacks ; 
its maximum intensity is reached quickly, and it ceases as suddenly 
as it came on, the whole time of attack being of short duration. 
There may be ten to a hundred attacks in the day, which are 
often brought on by physiological acts, such as blowing the nose, 
laughing, mastication, or they may come on spontaneously. The 
patients compress the painful spot, and the face is contracted. 
Secondary vasomotor symptoms are infection of the eye, oedema 
of the eyelids, and discharge from one nostril. If the lingual 
nerve is affected, the mouth tills with a copious secretion ; herpes 
along the course of the nerve is common. Most often the 
neuralgia lasts some time, even weeks or months, and then 
vanishes completely for a period. However, as age advances 
these intervals tend to become shorter, and the painful pei-iods 



THE TREATMENT OF NERVOUS AND MENTAL DISEASES. 75 

longer, until tlie disease is permanent. A hysterical variety can 
be distinguishecl from the true by the in-egular occurrence of the 
attacks (perhaps one a day, and then no more for some time), by 
the actual duration being longer, by the usual presence of aune, 
and by the frequent termination in hysterical convulsions, which 
are never provoked by true neuralgia, though hysteria and tic 
may co-exist. 

The first form of facial neuralgia is always benefited by 
analgesics, such as antipyrin, phenacetin, or hydrobromate or 
valerianate of quinine. The second form, or true tic, is quite 
uninfluenced by these drugs, and the only drug which can be 
relied on is opium in large doses. The author gives it in fx'eshly- 
made pills, containing | grain of the thebaic extract of the French 
pharmacopoeia ; three pills a day are given at first, and, the effect 
being carefully watched, one pill is added every other day until 
the desired effect is' produced. The maximum dose is continued 
for a few days, then gradually diminished by one pill every 
alternate day. The attacks, cured for a time, almost always 
return, and intolerance of opium is usually more marked during 
the second than during the fii'st course. It is, however, the best 
treatment, unless syphilis is present, when ordinary anti-sypliilitic 
treatment should be tried. 

Migraine differs entirely from trigeminal neuralgia, though the 
two may co-exist in the same person and be quite distinct. The 
author considers that the best treatment in obstinate cases is to 
give bromides, starting with 30 grains a day for a week, and then 
i-aising the daily dose by 15 grains every week, and after a time 
reducing progressively by the same amount, when it is again 
increased. One hundred grains a day may be tolerated. By 
this means migraine of years' standing may be completely cured, 
but the treatment must be absolutely continuous, and may have 
to be persevered with for more than a year. Thus the metliod is 
unsuited for slight cases, owing to the inconvenience attending 
upon the long course of bromides ; the treatment also is useless 
during the attacks ; alcohol is forbidden. This treatment will be 
seen to be the same as for epilepsy, the disease being looked on as 
a neurosis allied to that afiection. 

Dana {Chicago Med. Rexord, 1896) treats tic douloureux by 
hypodermic injections of increasing doses of strychnine, then by 
iodide of potassium, and tonics, such as large doses of tincture of 
iron, rest in bed with low diet and diuretics. The patient must 
take the full course, and sometimes even a second or third course. 
The strychnine is given hypodermically in simple daily doses, 
beginning w'ith ^^ gi'ain, very slowly increased until by the 



76 THE YEAR-BOOK OF TREATMENT. 

fifteenth or twentieth day a dose of from | to | grain is given, Ijut 
most patients cannot take more tlian * grain. These large doses 
have an anodyne effect like morphia. After reaching the maximum 
dose, the drug should be continued ior a week or ten days, and 
then gradually reduced so that l)y the end of five or six weeks the 
initial dose is reached. The drug is tlien stopped, and 5 grains 
of iodide of potassium (increased to 20 grains), together with 5 
minims of tincture of iron (increased, if possible, to 20 minims), are 
given twice daily. In some cases salicylate of potassium is given 
instead of the iodide or nitroglycerine is added. Rest in bed 
is essential. At the end of* four weeks the patient is allowed 
to go out for two hours daily, and at the end of six weeks he can 
go about his work. Out of six cases of very old-standing 
neuralgia, relief was obtained in all but two, and in one of 
these the method was not fully tried. 

2. Osiiiic acid injections in ncnrni|;:ia. 

Franck (Fortschr. cler Med., August, 1896) records some 
results of the treatment of neuralgia by injections of osmic acid. 
In three cases, varying in duration from two to nine years, where 
other modes of treatment had failed, this drug caused a rapid 
cessation of pain. In the one case the patient was a woman, aged 
twenty-seven, who. had suffered for four years from neuralgia so 
severe that she lost her hair. Partial relief was given by division of 
the infra-orbital nerve, but the pain still persisted in the supra- 
oi'bital region. This was completely cured by injections of osmic 
acid, and the hair grew again. The solution used was a 1 per cent, 
solution, and 1 to 5 minims were injected on each occasion. The 
best results are obtained by injecting the acid directly into the 
nerve affected, and so the treatment is more effectual where the 
nerve is superficial. The pain at the moment of injection is 
intense. 

3. DotEclies in sciatica. 

Borischpolski (N'eurol. Centralbl.,Dec. 1, 1806), adopting the 
view that sciatica is due to disturbances of the circulation followed 
by the accumulation of the products of metal^olism in the affected 
nerve, has used the Scottish douche (hot water followed by cold) 
in 32 cases of sciatica. Of these cases 23 were cured, 7 wei-e 
impi'oved, and 2 were unimprbved. Bechterew (ibid.) agreed that 
these douches were of great service, especially in long-standing 
cases of sciatica. 

4. Compression in traninatic nenritis. 
Occasionally one meets with extremely difficult and obstinate 

cases whei'e intense pain is caused on touching a cicatrix. 
Delorme (Journ. de Med., June 25, 1896) puts forward a new 



THE TREATMENT OP NERVOUS AND MENTAL DISEASES. 77 

method of treatment for these, and rehites ten cases. One was 
after a bullet wound in the neck, with neuralgia for twenty-three 
years, although the cicatrix was removed several times by opera- 
tion ; the least touch or draught on the cicatrix caused pain. In 
a second case a soldier injured the last phalanx of the index- 
finger, and for several months complained of severe pain shooting 
up the rest of the hand and up the arm. In all his cases 
Delorme first defines the exact extent of the painful area ; then 
the patient, either sitting or lying, is supported by assistants, 
and the operator compresses the painful part, such as the finger, 
between his own finger and thumb with all his sti-ength. This is 
done successively over the whole extent of the hypera^sthetic area 
over and round the cicatrix, beginning at the most painful part. 
If, after the first application, which lasts only a few seconds, any 
hyperfesthesia remains, the operati6n is repeated after a few 
minutes' rest, and this may even be done a second or third time 
after a few days' interval. After the operation the compressed 
part is wrapped up for eight or ten days in wool. After this 
treatment the part may be touched without pain, sensation is 
unaltered, and even trophic changes may disappear. The author 
does not employ a general anaesthetic for fear of syncope, nor a 
local one, as this would hide the extent of the painful area. 

5. Comparative study ofaiialg'esics. 

Kuttey (Therap. Wochemch., July 5, 1896) gives a comparative 
study of the value of ten reputed analgesics in nine cases of pain 
from nervous disease, including tabes, chronic and compression 
myelitis, disseminated sclerosis, and intracranial sarcoma. The 
drugs employed were phenacetin, antifebrin, lactophenin, neu- 
rodin, migrainin, agatbin, euphorin, exalgin, anti-nervin and 
malakin, and in all about 700 observations were made. Of all 
these drugs plienacetin and malakin were considerably better and 
safer than the others. Neurodin was also of much value, followed 
in order by antifebrin, exalgin, migrainin and lactophenin. 
Euphorin and anti-nervin were but of slight use, and agathin was 
of less value than any. The most marked diaphoretic action was 
produced by malakin, the least by exalgin and antifebrin. 
Idiosyncrasy plays an important part in determining the efiicacy 
of analgesics. In compression myelitis the severe pain was only 
relieved ninety-one times out of a hundred, the pain being only 
subdued by morphia. 

6. Pyraiiiidoii. 

This is a new antipyi'etic and analgesic derived from anti- 
pyrin, and has been experimented with and used therapeutically 
by Lepine (^Lyon Med., June 13, 1897).. He says it is about two 



78 THE YEAR-BOOK OF TREATMENT. 

or three times stronger than antipyrin. In dogs "2 grauune per 
kilo, of body weiglit is fatal in a few hours, lie gave it to twenty 
patients without bad results, and, in most of the cases, with 
benefit. In a case of tabes with lightning pains which antipyrin 
and morphia had not lelieved, dozes of 10 giaiiis of pyramidon 
three or four times a day were successful, and (piite removed the 
pains for several weeks. This dose is, however, a large one, and 
he usually only gave 4 grains three or four times daily. The 
drug was useless in a severe case of neurasthenia. 



B. LOCAL ANESTHETICS. 

]. Siicaiiie. 

Spencer i^Univ. Med. Magazine, Nov., 1896) has used eucaine 
hydrochlorate (a complicated synthetical compound : see " Year- 
Book of Treatment," 1897, p. 461) in twenty cases as a local 
anpesthetic in minor surgery, and found it most serviceaVjle. 
When the solution is to be injected, as in the case of punctured 
wounds, tumours, etc., 5J-ij of a 5 per cent, solution will be 
generally sufficient to cause complete antesthesia. When the 
drug is to be applied to a raw surface or to a mucous membrane, 
if the surface is large it is best to apply 5j of a 5 per cent, 
solution to the part, then saturate a piece of cotton with a similar 
amount of the same solution, and allow this to remain in contact 
with the surface for five minutes. At the end of this time the 
area can be lightly curetted without pain. After this, two more 
drachms of the solution should be applied in the same manner. In 
eleven of the cases ansestliesia was complete within five minutes 
after the application, and in seven cases it was complete in three 
minutes after. No systemic efiects of the drug were observed in 
any of the cases. Eucaine is rapid in action, safe and efficient, 
and its solutions can be sterilised by boiling. Leguen (Me'd. Mod., 
Oct., 28, 1896) points out that the toxicity of eucaine is less than 
that of cocaine — 6 cgrm. of cocaine killing a guinea-pig in three- 
quarters of an hour, whereas 8 cgrm. of eucaine only killed one 
of the same weight in one hour and a half. He used 8-10 ccm. 
of a 1 per cent, solution for injection under the skin, and 100-200 
ccm. of a 1 in 500 solution for injection into the bladder. 
He considers that the only drawback to the drug is that it causes 
congestion of the part to which it is applied. Somers (^Therap Gaz., 
Jan. 15, 1897) has used eucaine (4 per cent, solution in water) 
in nasal operations. He found that cocaine usually produced 
anaesthesia in three to five minutes, the condition lasting twenty 
to thirty minutes, but eucaine only caused anaesthesia in eight to 
ten minutes, lasting twenty minutes. In active infiammatory 



THE TREATMENT OF NERVOUS AND MENTAL DISEASES. 

conditions it is best to use a mixture of cocaine and eucaine, as 
their opposite actions on the blood vessels neutralised one another. 
Eucaine may be kept indefinitely in a sterilised watery solution. 
These conclusions have been generally confirmed by Gibb [Philad. 
rolyclimc, Jan. 23, 1897), who used it in throat and nose condi- 
tions ; by Charteris and MacLennan (Proc. Roy. Soc. Edin., 1895-96), 
and by Hobday {Journ. Comp. Path, and I'herap., March 29, 1897), 
who says that it is quite as good as cocaine for operations on the 
cornea, but not so good as cocaine when injected subcutaneously 
in horses, dogs and cats ; he says, however, that a mixture of 
cocaine and eucaine is equal to cocaine alone and can be tolerated 
in larger doses. 

Pouchet {Sem. Med., Feb. 3, 1897) thinks that the toxic 
equivalent of eucaine is almost equal to that of cocaine, and acts 
on the heart with an intensity equal to if not greater than that of 
cocaine. 

2. Holocaiiie. 

This is another new substitute for cocaine, and is a crystalline 
substance which may be looked upon as a combination of a mole- 
cule of phenacetin with a molecule of phenetidin, a molecule 
of water being set free. A review of its properties is given bv 
Prof. Leech (^Medic. Chron., June, 1897). It forms crystalline salts 
soluble with difficulty in cold, but easily in hot water ; the watery 
solutions are neutral and not decomposed by long boiling. The 
hydrochlorate of holocaine is the preparation employed, and cold 
saturated solutions contain about 2*5 per cent, of the salt. So 
far it has been chiefly used for eye surgery, two or three drops of 
a 1 per cent, solution causing antesthesia of the cornea in half to 
one minute, lasting ten minutes. It is a poisonous drug, so injec- 
tions into the su.bcutaneous tissue should not be used. It has no 
effect on the tension of the eye, on the size of the pupil, nor 
on accommodation. No bad effects have been seen from its 
application to the cornea. An abstract of the various publislied 
papers on holocaine is given in Prof. Leech's review. 

v.— THE TREATIVIENT OF INSOMNIA. 

1. Pellotiii. 

Pilcz {^Wien. Ixlin. Wochens., 1896, No. 48) records the results 
of his investigation with this new hypnotic, prepared by Hefiher 
from anhalonium unlliamsii, and so strongly recommended by 
Jolly, according to whom two grains of the hydrochloride of the 
alkaloid can be injected subcutaneously without causing any effect 
beyond that of refreshing sleep. Pilcz used the drug in fifty-eight 



80 THE YEAR-BOOK OF TREATMENT. 

cases of insomnia, giving one-third of a grain as a ininiinuni dose. 
The patients were inmates of hmatic asylums. In twenty nine 
cases a perfect result was obtained, the patient falling asleep 
within one hour and a half, and remaining so all night ; a 
moderate effect was seen in seventeen cases, while in the remaining 
twelve tlu! remedy was ineffectual, though of these latter Pilcz 
considers that four were not fair tests. Of the successful cases, 
nineteen reacted to the minimum dose, and none of the others 
required more than one grain. Curiously enough, the author 
himself was refractory, one-third of a grain only giving him half 
an hour's sleep. The beneficial effects were sometimes very 
marked in cases where other hypnotics had failed. Thus one- 
third of a grain of pellotin produced sleep in one patient who had 
resisted sixty minims of paraldehyde, and another who was 
unaffected by seventy-five minims. Pilcz did not observe the 
slowing of the pulse noted by Jolly, or the collapse seen in one 
case by Langstein. He did not try to obtain any anodyne effects. 
In two cases only was there giddiness, and one of these cases- was 
a paranoic with sensory hallucinations. The drug appeared to be 
particularly valuable because it can l^e given subcutaneously 
without trouble. As regards dosage, he recommends one-third to 
two-thirds of a grain repeated two or three times if necessary. 

2. Trional. 

Drews (]Vien. vied. Presse, 1896, Nos. 13 and 14) thinks that 
trional is an ideal hypnotic in doses of fifteen to thirty grains in 
adults and three to fifteen grains in children, producing sleep in a 
quarter to half an hour. It has no accumulative effect, and causes 
no habituation and no gastro-intestinal disturbances. There is 
but little risk of poisoning even after very large doses. It is also 
an analgesic, and, in sufiicient doses, may produce sleep even in 
painful conditions. It acts more rapidly than sulphonal, and its 
hypnotic effect lasts for six to eight hours. To prevent hiemato- 
porphyrinuria (only one case of wliich has been seen after trional) 
the dose should never exceed thirty grains. It should not be 
taken dry or followed by cold water, but only with a cupful of 
some fluid, such as soup, tea, or milk, taken as warm as possible. 
It is to be occasionally discontinued, and some carbonated mineral 
water should be taken with some vegetable acid to keep the 
blood alkaline, and the bowels should not be allowed to be 
constipated. 

[We think this author rather under-estimates the possible 
dangers of trional. Although it has appeared to us to be safer 
and to have fewer after-effects than sulphonal, yet acute poisonous 
symptoms have resulted from sixty grains taken in twenty -four 



THE TREATMENT OF KERVOUS AND MENTAL DISEASES. 81 

hours, and at least two cases of litT'niatoporphyrinuria have Ijeen 
recorded. See "Year Book of Treatment," 1897.— E. S. R] 

Koster (T/ierap. Jfonafs/i., 1896) has used trional in all forms 
of sleeplessness, in doses of fifteen to tliirty grains, given in warm 
milk shortly before bedtime. Generally the result was very good, 
sleep coming on within an hour, and he noticed no bad symptoms 
or after-effects. In alcoholic delirium, the attempt to substitute 
trional for chloral failed, and he found the drug of little use 
in painful affections, although it was of much service in severe 
asthmatic cases. 

YI.— THE TREAT:\IENT OF TETANUS. 

1. Tetanus antitoxin. 

Hbfiling (DpAitsch. med. Wochen., April 1, 1897) relates the case 
of a boy in whom symptoms of tetanus appeared one week after 
an injury to the hand. Five days after the onset there were 
very marked spasms ; on the eighth day 5 grammes of dry 
antitoxin from the Hochst factory, dissolved in 45 c.cm. of 
sterilised water below -40° C, were injected, and slight improve- 
ment occurred. Two days later there was great difficulty of 
l)reathing from spasm of the diajjhragm. The next day a second 
injection was given, and this was followed by considerable im- 
provement and ultimate recovery, 

2. Carbolic acid. 

Poll (Gazz. clegli Osped., ]\Iarch 14, 1897) had a case of a 
boy who had been kicked on the foot by a horse, and five days 
later tetanus set in. He was admitted into hospital on 
September 28, the part was excised and cleansed with carbolic 
acid and iodoform. Potassium bromide and chloral were given 
internally, together with injections of 1 per cent, carbolic acid 
every two hours. Nicolaier's bacillus was found in the excised 
portion. On September 30 the spasm was less, but on October 2 
the trismus and opisthotonos were still well marked ; on October 4 
the carbolic acid injections were given every hour, and on 
October 16 the boy was perfectly well, Nearly five hundred 
injections were given in all, but no bad symptoms were noticed, 

3. ITlercnry percliloride. 

Hendley (Brit. Med. Journ., 1897, vol. i., p. 138) at first ad- 
ministered chloi-al hydrate in a case of tetanus the cause of which 
w^as unknown, but no great effect followed. It was, however, con- 
tinued, and in addition y\7 grain corrosive sublimate was injected into 
the buttocks twice daily. After the first two injections the spasms 
decreased markedly, and after eleven injections ceased entirely. 



82 THE YEAR-BOOK OF TKKATMKNT. 

4. V4'r:ifi-iiiii vii'idc aiicl K^elst'iiiiiiiii. 

Fordyce Grinnell (Med. Nnvs, July, 180G) gives the case of a 
boy six years old in whom tetanus came on nine days after injury. 
Three days after the onset tr. veratr. virid. was given, at first 
in 1 minim doses every hour and then 2 minims every hour ; 
and from time to time the fluid extract of gelsemium was given 
in doses of from 1 to 3 minims hourly. The tr. veratr. was in- 
creased to 3 minims hourly. These drugs were continued for 
forty-eight hours until the spasms ceased and then gradually re- 
duced. Daring the whole time 4 grains of ammonium bromide 
were given every two hours. Recovery occurred in sixteen days. 

VII.— THYROID EXTRACT AND SERUM IN 
INSANITY. 

1. Soi'iiiii therapy in mental and nervous diseases. 

Mairet and Vires [Nouv. Montpellier Medical, No. 8, 1897, p. 
14) conclude from a series of observations of the action of 
various serums upon mental and nervous diseases, as follows : — 
1. Pure artificial serum given by hypodermic injection has no ap- 
preciable therapevitic effect in e])ilepsy nor in mental disease. 2. 
Artificial serums with medicinal substances in solution only act 
as carrying the drugs more rapidly into the circulation. Such 
drugs as bromide of potassium, ergotine and phosphoric acid 
given in this way seemed to have no effect whatever, but ure- 
thane controlled maniacal excitement more rapidly, given hypo- 
dermically with artificial serum, than when simply by the mouth. 
3. The blood serums of the rabbit and dog gave some positive 
results, that of the latter being more potent. 4. While serum 
therapy Avould appear to be useless in hysteria, in epilepsy and in 
those forms of mental disease associated with exaltation, it is 
useful in cases where depression is present ; in such cases tem- 
porary stimulation is obtained which may be made to continue 
under repeated injections ; permanent cures were not, however, ob- 
tained. The bodily functions were stimulated and this might 
account for the relief of the mental condition. 

The same authors [Sem. Med., Aug. 19, 1896) report that 
they had injected serum taken from a patient cured of acute 
mania into two women suffering from acute mania. In one of 
them each injection was followed by the onset of marked drowsi- 
ness, but afterwards the agitation was as great as before. In the 
other case twenty similar injections were given, the dose being 
5 c.cm., and here each injection was followed by a feeling 
of drowsiness, buzzing in the ears, and then heavy deep sleep. 



THE TREATMENT OF NERVOUS AND MENTAL DISEASES. 83 

Definite improvement was at first noticed, but a relapse occurred 
and the agitation became as bad as ev'er. A second series of 
injections of doses of 20 ccm. in the twenty-four hours was 
given ; similar symptoms followed the injections as those occur- 
ring before, but the improvement which followed was persistent 
and finally the patient was cured. [Surely this recovery cannot 
be considered as a cure by serum ! Cases of acute mania have 
been known to recover long before the serum treatment was heard 
of.— E.S.R.] 

2. Tliyroidiii in insanity. 

Shulansky {Vratch, No. 33, 189C) has tried Merck's thyreoidi- 
num siccatum in fifteen cases of chronic mental disease prin- 
cipally suftering from secondary dementia, and found that the 
frequency of the pulse was increased and became softer but fairly 
strong. In some patients there was a rise of temperature. The 
body-weight at first decreased, then remained at a minimum, 
and after discontinuing the drug increased markedly. The in- 
fluence of the drug on the mental condition was nil and in some 
cases fibiillary muscular twitchings and increased perspiration 
occui'red. Prolonged administration produced gastro-intestinal 
disturbance. 

VITI.— MISCELLANEOUS. 
1. The aetiolog^y of diisseniinated sclerosis. 

Strumpfell (Neurol. Gentrcdbl., Nov., 1896), while admitting the 
occasional occurrence of disseminated sclerosis after the acute 
specific fevers, does not agree with Marie that these are usually 
the cause of the disease ; nor does he consider that a toxic origin 
is common, for out of twenty-four of his own cases only one 
seemed possibly due to a poison (in this case, lead). A primary 
affection of the blood vessels seems equally improbable, as the 
changes in the nervous system are quite unlike those seen in 
arteriosclerosis or syphilis, nor are they such as would be caused 
by ischfemia from narrowing of the lumen of the vessels. 
Strumpfell would rather consider the affection to be of congenital 
origin and to be endogenous, not exogenous. He was led to this 
conclusion by a case in which hydromyelia with a central glioma- 
tosis of the cord was combined with well-marked disseminated 
sclerosis. This combination, which can hardly be accidental as 
he has recorded another similar case, suggests the true pathology 
of the disease. The theory of congenital origin is also sup- 
ported by the early commencement of the disease, which almost 
always begins in youth and occasionally in childhood. Further, 
almost all the exogenous diseases of the nervous system soon 
G 2 



84 TIIK YEAR-BOOK OF TREATMENT. 

affect the axis-cylinders, or even the nerve cells themselves, 
whereas disseminated sclerosis spares them until very late. The 
irrej,ailar distribution of the sclerosis suggests that the change 
starts in the neuroglia as a multiple gliomatosis of congenital 
origin ; and this would explain the early affection of the nerve 
sheaths rather than of the axis-cylinders. Acute illnesses, 
ti-aumata, etc., are not excluded from the aetiology of the 
disease l)y this theory, for they may act as exciting causes, as 
the}^ undoubtedly do in hereditary ataxia, the endogenous origin 
of which is generally accepted. 

2. Percussion of tlic spine in diag^iiosis. 

Bechterew (^Neurol. Centralbl., Dec, 1896) points out the diag- 
nostic value of percussion of the lower part of the spine. In 
the sacral region over a triangular area with its base at the upper 
part of the sacrum, and its apex at the top of the coccyx, there is 
normally a slightly tympanitic note. In cases where there is some 
morbid change, as in a case where the cauda equina was com- 
pressed by a fungoid tumour, the pei'cussion note was definitely 
altered. Localisation of a lesion may thus be facilitated ; in the case 
mentioned the localisation was proved to be correct by an autopsy. 

3. The pi'Og^nosis and treatment of aphasia. 

Karl Bok (Festsch. des Stuttgart, drtzlich. Verein, 1897) says 
that the prognosis of aphasia depends on the site and nature of 
the lesion. Incurable lesions may preclude improvement even in 
the slighter cases of aphasia. Extensive progressive lesions are, of 
course, worse than circumscribed ones. Haemorrhage, embolism, 
and thrombosis include the bulk of the causes of aphasia. If 
death does not occur, even the worst disturbances of speech may 
be recovered from, wdiilst on the other hand slight affections of 
speech may remain for life. Age is an important factor in 
prognosis : children may learn to speak again even after extensive 
damage to the speech-centres, while small lesions in old people 
may produce a lasting aphasia. The individual power of learning 
undoubtedly plays a part in the result. The longer the aphasia 
lias lasted without any tendency to improvement the worse the 
prognosis, and this is also the case where the intelligence steadily 
fails. In the didactic treatment of aphasia it must be taken into 
account wdiether the lesion is capable of recovery ; whether it has 
progressed slovvdy or quickly ; and whether the intelligence is 
involved. It is well to let some time elapse before commencing 
the treatment, in order to ascertain more accurately whether the 
result is due to the treatment or not. The kind of aphasia, whether 
motor, sensory or amnesic, must also be taken into account. 

The object of treatment is to restore the conduction of impulses 



THE TREATMENT OP NERVOUS AND MENTAL DISEASES. 85 

along the usual paths, or to open up new paths. The treatmeut 
of amnesic aphasia lies in strengthcnini:; the defective recollection 
of woi'ds. The words must be learned by heart, and then short 
reading exercises adopted. The exercises should be performed in 
front of a mirror, in order to recall the necessary movement to the 
recollection. In motor aphasia other parts of the brain may take 
on the function of the part destroyed. Single sounds, then 
syllables, and lastly words are taught, and writing exercises with 
the left hand should be performed with the articulation exercises. 
The patient should be taught to form words from printed letters. 
The treatment of sensory aphasia is more difficult. The first 
attempts are made by means of wi-itten language. Lip reading 
should be developed, and reading, writing, and other exercises 
combined with it. The case may be much complicated by the 
combination of different forms of aphasia. In the absence of 
complete recovery a considerable improvement may be obtained in 
th.ese cases by patient teaching. 

4. A symptom oi clironic cocaiiiism. 

Rybakoff [Neurol. Centralbl., Aug , 1896) points out the diag- 
nostic value of Magnan's symptom in chronic cocaine poisoning. 
This consists of a hallucination of common sensation ; the patient 
complains of feeling some foreign body under the skin. In some 
cases the foreign bodies felt are said to be like grains of sands, in 
others they feel larger than this and more or less rounded, and 
again are sometimes described as being microbes, crystals, worms, 
etc., situated just under the skin. 

5. Kolaiiiii. 

D ornbliltli (Berl. klin. Wochens., June 21, 1897) draws atten- 
tion to the stimulating effects of the kola nut. The investigations 
of Knebel and Hilger have shown that the nut does not contain 
any alkaloids, but a glucoside to which the name of " kolanin " 
has been given. In the ripe or dried fruit this may be split up 
into glucose and caffein, which necessitates a very careful prepara- 
tion of the nut if the glucoside is to be retained. Kolanin is 
decomposed either by the saliva or the gastric juice. Dornbliith 
has used it in tabloid form in many patients. He found that it 
rapidly restores the strength after exhausting work without any 
ill effects. It is considerably superior to caffeine. In one case, how- 
ever, that of a hystero-neurasthenic woman, 3 grains of kolanin 
produced a feeling of uncertainty and trembling in the hands. In 
neurasthenics the good effects produced were only temporary. In 
neurasthenic cardiac depression the drug was of temporary benefit. 
In migraine a beneficial effect was obtained, as well as in head- 
aches following upon, mental over-dxertion or alcoholic excess. 



DISEASES OF THE STOMACH, INTES- 
TINES, AND LIVEK. 

By Heeisert P. Hawkins, M.I)., F.K.C.P., 

I'hysician to St. Thomas's Hospital. 



The past year cannot lay claim to any marked advance in the 
treatment of abdominal disease by drugs or medical means. It 
shows, however, a steady widening of the sphere of abdominal 
surgery. Physicians are placing more reliance on surgical aid. 
The surgeon appears on the scene at an earlier point of the illness, 
and the successes gained are proportionately greater. 

1. Surgical treatment of iioii-perforated gastric 
ulcer. 

The necessity of operation in a case of perforation of a gastric 
ulcer at the earliest possible moment is, of course, now generally 
recognised, and some instances will be given illustrating the com- 
plications that may arise. But there is a movement in favour of 
the surgical treatment under certain conditions of a simple gastric 
ulcer which has not perforated. These conditions must be care- 
fully considered. 

Leube detailed the results of his practice at the German 
Surgical Association {Centralbl. f. Chirurgie, No, 28, 1897). His 
treatment consists of rest in bed, poultices, Priessnitz douches, 
Karlsbad water, and a carefully regulated diet. Drugs are 
scarcely used, comprising only occasionally sod. bicai'b., and for 
constipation rhubarb with sulphate and bicarbonate of soda. Of 
556 cases so treated, 74 per cent, were cured and 22 per cent, 
improved, while 1-6 per cent, remained uncured, and rather more 
than 2 per cent. died. There is clearly not much opportunity for 
surgery here, but Leube reckons that in a small proportion 
(4 per cent.) surgical intervention is indicated. He would confi- 
dently recommend operation in cases of " small but frequently 
repeated haemorrhages " from the stomach. On the other hand, a 
"single profuse haemorrhage," such as arises from the sudden 
opening of a large artery, he does not regard as necessarily 
requiring surgical intervention ; but if such large hajuiorrhages 



DISEASES OF THE STOMACH, EJC. 87 

should be repeated, then iu liis opinion the question of operation 
comes up at once, each case being consitlei-ed on its own merits, 
due regard being paid to the strength of the patient and the con- 
dition of the pulse. In considering such a case, it must be remem- 
bered that deaths from hsemorrhage are rare and, further, that for 
successful interference a previous diagnosis of the exact position 
of the ulcer is of great importance ; and such a diagnosis he admits 
is not possible. In the next place, indication for operation 
(especially gastro-enterostoniy) is sometimes afforded by the 
" intense pain and ui'gent vomiting," which point to spasmodic 
closure of the pylorus. Such a condition is dangerous by pro- 
ducing inanition, but it usually' yields to rest and medical treat- 
ment. Further, he would employ surgical aid in cases of 
perigastritis, adhesion of the stomach to neighbouring parts, and 
peritoneal abscess, but only when the diagnosis approuches to 
certainty, and when the inflammatory adhesions form a palpable 
mass in the abdomen. Finally, it is his opinion that immediate 
operation is necessary in all cases of perforation of an ulcer into 
the peritoneal cavity, but he considers that the prospects of 
success are slight if ten hours have elapsed before it can be under- 
taken. 

At the same Congress the views of a surgeon on the question 
were expressed in an admirable paper by Mikulicz. As might 
be expected, he goes much further than Leube in recommending 
operative interference. He believes that operation is indicated 
in the first place, whenever it can be said that the patient's life is 
directly or indirectly threatened, as, for example, by repeated 
hivmorrhages, increasing emaciation, commencing suppuration 
around the stomach, or where there is a susjjicion of carcinoma ; 
and, in the second place, wherever a tliorough course of medical 
treatment has been found to give little or no result and, in conse- 
quence of the continued pain, vomiting, and dyspe^^sia, the 
patient's capacity for work and enjoyment of life is seriously 
impaired. 

Mikulicz was himself the first man to attempt ojjeration in a 
case of severe haamori-hage from a gastric ulcer, which was of 
frequent occurrence. The ulcer was situated at the pylorus. It 
was cauterised with the thermo-cautery, and the pylorus which 
was narrowed was subjected to pyloroplasty. The patient died 
three days later with some local peritonitis around the stomach. 
A successful case of cautery of a gastric ulcer, with the perform- 
ance of gastro-enterostoniy for stenosis of the pylorus, was recordetl 
some years ago by Kuster (^Deutsche med. Woch., No. 24, 1894). 
Cutler and Elliot (Boston Med. and Surg. ,Joiirn., July 15, 



OO Tin-: VKAK-I500K OF TKKATMKNT. 

1897) record a case of reiK-atef] lia-moi rlKi''e from a <;liioiiic irastric 
ulcer. Ihc patient was a man aged forty-seven, wlio had had 
symptoms of the disease for two years. Elliot operated. There 
was found to be extensive cicatrisation at the pyloric end of the 
stomacli, and on incising the pylorus it was found to be nearly 
completely obstructed. The cicatricial tissue in the stomach on 
the inner surface was rough and frial)ie, and in a very degenerate 
condition . So large an area was thus affected that it was thought 
necessary to excise the pylorus and all the diseased tissues, and to 
take out about one-tifth of the stomach, including the whole of 
the lesser curvature on the anterior and posterior sides. The 
patient stood the operation without any shock, and seemed to be 
doing very well for two days, but he died on the fourth day with- 
out any peritonitis and without any definite cause. Cutler, in 
reviewing the case, regrets that the operation was not attempted 
at an earlier period, before the patient became so much reduced. 
He quotes four cases of excision of a gastiic ulcer when life was 
threatened by haemorrhage, of which three were successful. 

Hirsch (quoted in 2fedical JVetos, February 27, 1897) is in- 
clined to favour operation in all cases of haimorrhage from the 
stomach, even during the actual bleeding. The difficulty, how- 
ever, of such a measure must be very great and perhaps insuper- 
able. The seat of an ulcer cannot be indicated before exploration 
with any certainty, and sometimes even a guess is impossible. 
But he is hopeful of the results to be obtained from an endoscopic 
examination of the interior of the stomach through an incision. 

There are two points of view from which the operative treat- 
ment of a simple non-perforated gastric ulcer may be regarded. 
Surgical intervention may be considered (1) as a precautionary 
measure to save life in the kind of case which experience shows 
is likely to be fatal ; (2) as a quicker means of cure than the 
usual medical method of rest and dieting. As regards the first 
point of view — that of saving life — it must be remembered that 
the mortality rate in cases of gastric ulcer under ordinary medical 
treatment is extremely small, probably not more than 6 or 7 per 
cent. ; Leube's figures, indeed, show a mortality of but little more 
than 2 per cent. Now in the majority of fatal cases the cause of 
death is peritonitis from perforation, and it is well known that 
the cases which perfoi'ate are just those in which the symptoms 
of the ulcer before perforation are of the slightest. Of 276 cases 
of gastric ulcer consecutively admitted into St. Thomas's Hospital 
(many other cases being doubtless under treatment as out-patients 
during the same period of time) twenty-six died. In eighteen, of 
these the cause of death was peritonitis from perforation ; in five 



DISEASES OP THE STOMACH, ETC. 89 

others a large sudden fatal hfemorrliage occurred. So that the 
conolusion is forced on us that the future of the proposed surgical 
treatment of gastric ulcer as a means of saving life umst depend 
largely on the possibility of accurately recognising beforehand 
those cases in which a fatal event from perforation or haemorrhage 
is likely to occur ; and our means of diagnosis hardly extend so 
far as this at the present time. But tliere is obviously much to 
be said in favour of immediate surgical intervention in the class 
of case indicated by Leube — viz. that in which small and repeated 
luiemorrhages occur, for this occurrence points strongly both to 
the depth of the ulcer and to its proximity to a large artery. 

In favour of the second point of view, more especially urged 
by Mikulicz, from which the operative treatment of a gastric 
ulcer is looked on as a time-saving measure, there is much to be 
said. The medical treatment is a long atfair, often spread over 
several months. Sometimes after apparent cure only a few 
months elapse before the patient comes back again with a return 
of all the symptoms. In such cases, especially those which are 
resistant to treatment and liable to speedy relapse, it may be by 
some considered reasonable to fall back on surgical help. And 
this procedure will have the further advantage that secondary 
conditions, such as narrowing of the pylorus and interference 
with the gastric movements by adhesions, may thereby be recog- 
nised and relieved by gastro-enterostomy or other means. 

*i. Surgical treatment of gastric ulcer after per- 
foration. 

Numerous cases of successful suturing of a perforated gastric 
ulcer have recently been recorded. Although it is an undoubted 
fact that such cases have been known to recover without surgical 
intervention, so rare an occurrence should not be allowed to 
influence the decision. Kirkpatrick, of Montreal (Practitioner, 
August, 1897) describes a successful case under his care, in which 
the operation was begun four hours after the onset of symptoms. 
He notes sixteen other cases taken from various sources, of which 
nine recovered after operation. The prospect of recovery after 
operation (apart from the question of the skill of individual 
surgeons) depends on the time elapsing between perforation and 
operation, and on the nature and amount of the stomach contents, 
especially as regards the bacteria present. In Kirkpatrick's case 
the fluid in the peritoneal cavity was apparently sterile. The 
result probably depends largely on the varieties of bacteria 
present. In a case under my care only six hours elapsed between 
perforation and operation ; the ulcer was found on the front wall 
of the stomach immediately under the line of the abdominal 



90 THE YEAR-BOOK OF TREATMENT. 

incision, ami the peritoneum was carefully cleansed. Thus evory- 
thinj^ was favourable for recovery. Yet the patient died two 
days later of general peritonitis. On the other hand, two suc- 
cessful cases of oper;ition after pcrfcnation are recorded by 
Hawkins and Wallace, and Makins and Toller (^Jirit. Mi'A. Journ., 
April 10, 1897), which show that an operation should always be 
attempted even at a late period, provided that the general condi- 
tion of the patient permits a reasonable hope of success. In one 
of these cases sixty hours, and in the other twenty-four, elapsed 
before operation. These two cases are further interesting as 
showing the severity and varieties of the complications which 
may ensue after the more immediate danger of death from peri- 
tonitis has been removed. The first case developed a large pai-otid 
swelling on both sides, a pelvic abscess which discharged into the 
rectum on the eighteenth day after the operation, and thrombosis 
of the deep veins of the left leg on the twentieth day. The other 
patient was seized a week after the operation with sudden dyspnoea 
suggestive of pulmonary embolism, and this was followed by con- 
solidation of the lower lobe of the left lung. Two successful cases 
of operation for this condition are related by Littlewood (^Lancet, 
Nov. 21, 1896). In the first case the operation was performed 
seven hours after the onset of severe symptoms, but for forty- 
eight hours previously the patient had suffered from intense pain 
in the upper part of the abdomen and a feeling of faintness, which 
probably indicated the beginning of leakage from the ulcer. In 
this case, as in one previously mentioned, thrombosis of the femoral 
and popliteal veins, with fever, set in about seventeen days after 
tlie operation. In the second case six hours elapsed Ijetween 
perforation and operation. Convalescence was uninterruj^ted 
except by the occurrence of severe pain in the left shoulder, 
which lasted several days, and necessitated the use of morp>hia. 
Seven cases are recorded by Barker [Lancet, Dec. 5, 189G), of 
which three recovered. They afibrd good illustrations of the 
complications which may be looked for, such as subphrenic 
abscess, pleurisy, and a possible localised basal empyema. 

3. Sut'i^ical treatment of perforated typhoid ulcer. 

Mention was made of this question in " The Year-Book of 
Treatment" for 1897, and it was then pointed out that in 
advanced stages of typhoid fever it is by no means easy to recog- 
nise the occurrence of perforation with the degree of certainty 
which the surgeon would desire. It may often be suspected in 
cases in which subsequent recovery will prove the suspicion to 
have been unfounded ; and, on the other iiand, it may be added, 
cases occur where a patient who has had a distended abdomen for 



DISEASES OF THE STOMACH, ETC. 



01 



some tiaie dies without any of the classical signs of peritonitis, 
and witliout any sudden alteration of his symptoms, and yet 
peritonitis from perforation is found at the jjost-inortem examina- 
tion. Admitting, however, that the diagnosis is not always easy, 
it may yet be allowed that in many cases the occurrence of per- 
foration can be recognised quickly, and the position of the surgeon 
in such cases has to be determined. A very useful paper on the 
subject has been written by Finney (Annals of Surgery, March, 
1897). 

It may be taken as fairly certain that nearly all cases of 
perforation in typhoid fever die, and instances to the contrary 
ax^e open to doubt. Cases of sudden perforation of the vei-miform 
appendix, and consequent general peritonitis, die with great regu- 
larity, unless saved by an early operation. Here the patient has 
been usually in perfect health up to the onset of peritonitis ; but 
in the case of typhoid fever the patient is commonly already 
extremely ill, and his very small chance of recoveiy is thereby 
greatly diminished. Finney has reported and collected forty-five 
instances of operation in this condition, which he has carefully 
examined and considers genuine. These show no less than eleven 
recoveries, a percentage of 26-22. He notes, as an important 
fact, that in nearly all the cases which proved fatal after opera- 
tion there was no e^ddence of any defect in the healing process. 
From his own experience, he is inclined to place most reliance in 
the diagnosis of perforation upon the development of an attack of 
severe continued abdominal pain, coupled with nausea and vomit- 
ing, and at the same time a marked increase in the number of 
white blood corpuscles ; and he considers that the rational treat- 
ment is by immediate operation, save in patients who are actually 
moribund. A successful case has been put on record by Lauder 
Brunton and Bowlby [Trans. Med. Chir. Soc, 1897). The operation 
was begun some fifteen hours after perforation. About half a 
pint of dirty yellow ftecal fluid was evacuated from the lower part 
of the abdomen. On passing the hand into the cavity amongst 
the intestines, from which this fluid had escaped, a very indurated 
coil of bowel could be felt, and after a little trouble this was 
separated from its adhesions and drawn out of the abdomen. In 
this section was found a perforation the size of a pea ; it was 
sutured without excision, the sutures being carried clear of the 
whole Peyer's patch, and extending over a line an inch and a half 
in length. The operation lasted about forty minutes ; there was 
no collapse at its conclusion, and recovery was uninterrupted. 
4. Idiopathic dilatation of the colon. 
This form of disease has recently been attracting attention. 



02 TIlR YEAR-BOOK OP TREATMKNT. 

Much interest attaches to its causation, l)ut apart from that the 
couditioii is one that requires prompt recognition and treatment ; 
aiid it can hardly be doubted that relief can be best afforded Vjy 
the surgeon. Under this name are included all cases of extreme 
dilatation cjf any ])art of the colon, where no mechanical ob- 
struction can be foun<l at the poni-nioriem examination. 

Hale White (Al!l)utt's "System of Medicine," vol. iii., 1897) 
gives a very complete account of the condition, with mention of 
some twelve cases. He is inclined to exclude from the term 
"idiopathic dilatation," or '^' dilatation of unknown origin," those 
cases of long-standing constipation which end in f;ecal impaction, 
inasmuch as in such cases the mechanism of production of dilata- 
tion of the colon is readily intelligible, and he is inclined to 
limit the use of the term to those cases in which the sigmoid 
flexure only is dilated. Of this group of pure idiopathic dilata- 
tion of the sigmoid flexure he has found six recorded cases. In a 
man over seventy years of age the sigmoid flexure was found to 
resemble a dilated stomach, while the rest of the bowel was 
normal. In a man of fifty the sigmoid flexure was 2 feet in 
circumference and bent on itself, so as to fill the abdomen. In 
another man, aged fifty-eiglit, its circumference was 14 inches. 
In another it consisted of two large sacs even larger than an 
ordinary dilated stomach. In a boy. aged four and a half the 
sigmoid formed two huge sacs lying vertically side by side, one 
in the right half of the abdomen, the other in the left. 
Taking this vsigmoid group alone. Hale White with RoUeston 
and Haward consider that the condition may be comparable 
with the dilatation of the stomach that occurs without obstruc- 
tion of the pylorus. In another group he places cases which 
are probably of similar origin, where, as well as the sigmoid 
flexure, the colon as a whole or in parts is dilated. This 
condition of the large bowel is one of which the nature and 
causation will probably only be determined by the observation 
and comparison of a large number of instances, and the time has 
not arrived for an attempt at generalisation. But it may well be, 
tliat all these cases, including the cases of long-standing constipa- 
tion ending in faical impaction, may eventually be proved to have 
a simple mechanical cause, and to depend upon some congenital 
abnormality in the length or arrangement or attachments of the 
part. 

Enemata and purgatives seem from the quoted cases (Hale 
White) to have no eflect. The pas.sage of a long rectal tube and 
puncture of the bowel are alike ineffectual. Aiid there can be 
little doubt that such cases should be transferred to the sursfeon. 



DISEASES OF THE STOMACH, ETC. 93 

and relief afforded either by an artificial anus or by a lateral 
anastomosis between the ileum and some point low down in the 
colon. 

Martin (^Montreal Med. Jonrn., March, 1897) describes and 
discusses such a case. The patient was a boy aged three and a half 
years. After his birth the bowels did not mo^•e for five days, but 
this constipation was overcome by a purgative. During the first 
])art of his life the child was constantly constipated, sometimes for 
as long a period as eleven days. At the end of the first year 
gradual and progressive enlargement of the abdomen began, and 
continued till the end of his life. From time to time the abdo- 
minal distension lessened and fiatus passed freely, but the bowels 
were inactive unless purgatives or injections were persisted in. 
When he came under Martin's observation he was in fairly good 
condition, but the abdomen was enormously distended, having a 
girth of 68 cm., with visible peristaltic movements. Tlie abdomen 
was opened for examination in the median line, and the distended 
bowel was found to consist of sigmoid flexure, whose diameter 
was 9 to 10 cm. A second operation was performed a fortnight 
later, and an incision made in the left inguinal region. But im- 
pacted ffeces in the colon gave rise to difficulty, and semi-solid 
faeces were pushed out of the dilated sigmoid flexure. He died 
six days later from perforative peritonitis. Osier had a similar 
case in a boy aged ten, and here life was prolonged for two years 
by an opening in the colon. The condition is clearly one of those 
in Avhich a successful operation will dejoend largely on its earliness. 
And it may be noted in this connection that parents are apt to 
think little of it in their children until the time has arrived at 
which purgatives and enemata fail. On the other hand, it must 
be recognised that, as pointed out by Martin, death may be sudden 
and unexpected. Martin's paper is illustrated by a photograph of 
his patient, and Rolleston and Haward {Trans. Clin. Soc, vol. xxix) 
give a drawing of the appearances seen on opening the abdomen 
in a case under their care. 

At the Clinical Society Glutton (Trcms. Clin. Soc, vol. xxx.) re- 
ported a case of resection of a dilated sigmoid flexure for chronic 
obstruction. The patient, a woman aged fifty, had suffei'ed as long 
as she could remember from chronic constipation, and occasionally 
from sudden attacks of distension of the abdomen accomj>anied by 
pain. These symptoms had been much more severe in the last 
five years, and enemata had lost their efiiciency. At the opera- 
tion a very large dilated sigmoid flexure was found. This was 
removed, and the two ends of the divided bowel were united by 
Murphy's button. The operation was perfectly successful, excejjt 



94 TIIK YEAR-BOOK OF TREATMENT. 

for the fact that the button remained in situ. Nearly a year 
later, however, symptoms of obstruction appeared, due, as was 
sliown at a second operation, to a stricture developed at the line of 
union. 

a. Kiiptiirc of the liver. 

An iut(M'esting case is recorded Ijy Martin (Lancet, May 8, 
1897) in which life was apparently saved after rujjture of the 
liver by abdominal section. The patient was caught between two 
sets of trucks, and received a severe "rolling crush." The 
operation was performed about six hours later. At that time 
temperature was 103°, pulse 130, l)reathing short and distressed, 
abdomen hard, tense, and distended, tympanitic in front, dull at 
the flanks, and evidently containing nmch free fluid. There 
was no obliteration of hepatic dulness, and a correct diagnosis 
was made. The operation was performed in a miner's cottage 
by the uncertain light of a paraflin lamp. A large quantity of 
black blood, fluid and clotted, was removed from the abdominal 
cavity, containing detached portions of liver tissue. A rent, 
from 1 to 2 inches deep, was found to run from before back- 
wards on the under surface of the right lobe from the portal fissure 
as far up the pi)sterior surface as could be reached. Hot water 
was used to arrest the haemorrhage. The peritoneal cavity was 
thoroughly cleansed, and a second incision was made above the 
symphysis, in which a glass tube was placed. He made satisfactory- 
progress, but seven days afterwards developed symptoms of 
pneumonia, with fever, semi-purulent bloodstained sputum, and 
distressed rapid respiration. Nine days later this subsided, and 
the patient made a good recovery. 

In some cases of Glenard's disease with displacement of the 
liver, the condition has been rectified by operation. Now that 
attention has been generally called to this affection, it is astonish- 
ing how frequently some degree of it is met with. Ferrari 
[Sujjplem. al Policlinico, Dec. 26, 1896) has freed the liver from 
adhesions, replaced the organ, and fixed it in position by catgut 
sutures passing through its substance and through the abdominal 
wall. In this case the liver was rotated on its transverse axis, so 
that the upper surface had come to the front ; and the patient, a 
young woman, was in constant pain. Other similar cases have 
been recorded. I have recently had under my care a woman who 
had borne eight children. Her stomach, as mapped oiit by dis- 
tending it with gas, was somewhat dilated, and the greater part 
of it lay below the umbilicus. The liver had become displaced 
downwards, so that it nearly reached the right iliac fossa and at 
the same time it had been rotated, so that its anterior edge was 



DISEASES OF THE STOMACH, ETC. 95 

now in a nearly vertical position, running from the costal margin 
towards the pelvis. With all this, her symptoms were slight, and 
refei-red merely to the stomach. They were relieved by dieting 
and diminution in the amount of fluid taken. She was a placid 
individual ; and it is probable that in these cases, as with those of 
floating kidney, the possession ^)f a neurotic, sensitive tempera- 
ment plays an important part in the production of severe 
symptoms. 

6. Poi-itoiieal tiiboi'ciilosis is an affection of which the 
percentage rate of mortality has greatly diminished in recent 
yeans, either through an increased power of resistance in the 
patients or through an improvement in the method of treatment. 
The experience of Bristowe after long service in the wards and in 
the post-mortem room was to the effect that "it tends, as a rule, to 
a fatal result : at the same time, there are good grounds for the 
belief that i-ecovery occasionally ensues." Fagge also said that he 
had seen " several instances in which there was I'eason to believe 
that recovery took place, and in one case the diagnosis was after- 
wards proved to be correct by a post-mortem examination." Such 
pronouncements as these must be considered far too gloomy at the 
present time. Statistics show that in all probability 50 per cent, 
recover ; and the diagnosis in these cases cannot ]je questioned, 
inasmuch as the abdomen is commonly opened as a routine 
treatment, and the condition of the peritoneum is thus verified. 
Probably the I'ecognised treatment at the present time in Great 
Britain may be thus summed up. The patient is placed at 
complete rest and he is given a generous diet, limited only when 
there is evidence of much intestinal affection. As regards drugs, 
in simple cases either tonics are used with or without cod-liver 
oil, or guaiacol or creasote is administered. Guaiacol carbonate 
can be given with the syrup of phosphate of iron. If there is 
much diarrhoea, intestinal disinfectants are used. (Cf. " Year-Book 
of Treatment " for 1897, p. 85.) When fluid in any amount can 
be detected with certainty above the symphysis or in the flanks, 
the abdomen is opened by an incision 1| or 2 inches long below 
the umbilicus. ai;d the fluid is removed and expressed. No 
bactericidal substance is introduced into the abdomen, but if there 
is much lymph observed, or the fluid is turbid, the peritoneal cavity 
may be irrigated (so far as that is ever possible) with sterilised water 
or sterilised normal salt solution. The incision is immediately 
sutured, and gives rise to no subsequent trouble. I have recently 
-had six cases of tuljerculous peritonitis under my care, all of 
whom left the hospital apparently in perfect health. Five of 
these were drained dry through a small incision. It has often 



96 TlIK YEAU-HOOK OK TREATMENT. 

been recommended also tliat the abdomen should Ije opened and 
the peritoneum exposed to the air, even when no fluid eliusion can 
be detected. But tliis practice is probably not very general in 
Great Britain, so far as can be judged from recorded cases. 

Thoma [Lancet, Jan. 16, 1897) is a strong advocate of the use 
of creasote in this condition. " Laparotomy is no douV>t the best 
and quickest of all methods for dealing with those cases in which 
the peritoneum is covered with miliary tubercles ; but it is always 
a serious operation, and one also which not every medical 
practitioner is competent to perform. Moreover, the parents of 
the little patients are usually averse from surgical intei'ference, and 
anxious for the employment of some other mean.s." These draw- 
backs to the surgical method of treatment fortunately cannot be 
said to exist in Great Britain. But if they ever should aiise, 
Thoraa's alternative plan of creasote enemata may be remembered. 
At first each enema contains 1.50 grm. (about 4 oz.) of emulsified 
cod-liver oil and 0'5 grm. (8 gr.) of creasote, but after eight or ten 
days the amount of creasote used may be increased to 1 grm. 
(15^ gr.). The enema is given daily. After the treatment has 
been continued for some weeks, he recommends that it should be 
suspended for an interval of five or six days. He has not noticed 
that the taste of the creasote is perceived by the children. The 
appetite is somewliat impaired at first, but it is not lost, and it 
subsequently improves. He relates two cases which made a good 
recovery under this treatment. 

The apparent benefit which results from opening the peritoneal 
cavity in tuberculous peritonitis has led Peterson [Med. JS^etrs, Aug. 
28, 1897) to try its effect on tuberculous mesenteric glands. The 
benefit derived in tuberculous peritonitis he ascribes to the 
development of an " increased resistance " of the tissues to the 
specific bacilli. The explanation that he adopts is that coeliotomy 
excites an inflammatory reaction of the peritoneum accompanied 
by an increase in its " resorbing power." Whether this is 
the true explanation or not, he set himself to determine if 
this increase in resorbing power would have a favourable effect on 
underlying tuberculous glands. He has three suich cases to record, 
and for two of them he claims a cure. In one of these successful 
cases he enucleated four glands fi'om the mesentery, and in the 
other he merely opened the abdomen and examined the glands. 
He is of opinion that primary tuberculosis of the mesenteric 
glands is by no means uncommon, independent of disease of the 
bowel, and that under favourable conditions beginning tuber- 
culous disease of the glands can be diagnosed, without the 
presence of palpable tumours, by means of such symptoms' as 



DISEASES OF THE STOMAOII, ETC. 97 

indefinite abdoiiiiual pain and tenderness, nausea, and creneral 
malaise. 

7. 'I'lie <'ol(l-l»:itii troatiiient of typlioid fever. 

It is still the general practice in British hospitals, and in 
private practice in England, to reserve the bath treatment in 
typhoid fever for cases which are attended with a dangerously 
high temperature. For most cases occasional sponging, with the 
use of various antipyretic drugs, is the routine treatment. The 
teaching of Brand, however, has taken root in America, and it is 
probable that England will follow suit. A very clear statement 
of the results of the routine cold-bath treatment at the Brisbane 
Hospital for ten years is given by Hare {^Med. Record, May 8, 1897). 
For tive years of the old-fashioned treatment, without the routine 
use of the bath, the mortality in 1,828 cases was found to be 
li'vS per cent. For ten years under the bath treatment the 
mortality in 1,902 cases was 7*5 per cent. All the fallacies 
which are inherent in a bare statistical record such as this are 
fully recognised by the author. He discusses the chances of error 
from paucity of data, variations in the iise of the term typhoid 
fever, mistakes in diagnosis, differences dependent on age and sex, 
and variations in the severity of the disease in different places 
and at different times. His conclusions are probably perfectly 
fair and just. He adds a table, which distinctly confirms the 
conclusion that it is this bath treatment, and no other factor, 
which has so largely altered the rate of mortality. This table 
shows by analysis that the reduction of the general mortality is 
owing to reduction in the deaths due to the febrile state and its 
consequences, while the mortality from perforation and haemorrhage 
is but little altered. Thus Murchison's mortality rate from per- 
foration was 3 per cent., from haemorrhage \'\ per cent., and from 
other causes — i.e. fever and its results on the various tissues and 
organs — 12-8 per cent., while Hare's figures after the bath treat- 
ment are, under the same classification, 2-9, 1-2, and 3-4: per cent, 
respectively. This, by the way, shows a very striking drop from 
a total general mortality of 17 "2 per cent, to one of 7 "5 per cent. 
A paper was read by Thomley, at the Medical Society of the 
County of New York {2Ied. Record, Dec. 28, 1896), in which 
a series of 250 cases of typhoid fever under the bath treatment, 
administered in various ways, shows a mortality of 8 per cent. It 
is not, of course, a strictly scientific comparison, but it may be 
added that of the last 317 cases treated in St. Thomas's Hospital 
on the usual plan, without the routine use of baths, the mortality 
is 17 per cent. The drawbacks to the method, both in private 
and in hospital practice, are the increased expense due to the 

H 



98 TiiR vKAn-nooK of treatment. 

greater iiuinbcr of attciuliUits required and (he alaim which its 
use is apt to excite both in patient and relations. Osier (./o/r/is 
Hopkins llosjntal Reports, vol. v.), testifies to the value of this 
method of treatment, and X'eckons that at least G per cent, more 
lives are saved by it ; but he would welcome the discovery of some 
method which, while to an equal extent life-saving, wouhl be less 
disagreeable. The easiest plan is to use a bath which can be 
wheeled to the l)edside, tlie water being at a temperature of 
70° F. In this the patient shoi^ld be placed for fifteen to twenty 
minutes whenever the rectal temperature reaches 102-5°, and this 
may be repeated six or eight times in the twenty-four hours if 
necessary. On removal from the bath the patient is dried gently, 
no rubbing, of course, being employed over the abdomen ; and 
some stimulant should be given. If there is any collapse, the 
extremities and thorax should be well rubbed, and hot-water 
bottles may be applied to the feet. From the wide expei-ience 
which is now on record, it is clear that there is no danger 
attaching to the method if it is carried out intelligently. It 
should, however, be used with caution when, from the inter- 
mittence of the pulse, there is evidence of great changes in the 
muscular substance of the heai-t, and it should, of course, not 
be used when htemorrhage has occurred, or when there is any 
suspicion of peritonitis. 

8. Salol calculi. 

The formation of these calculi is the subject of a communica- 
tion by Marshall I^BTit. Med. Journ., July 10, 1897), which is 
important as well as interesting in view of the large use of this 
drug. The calculus which he had the opportunity of examining 
was sent to him by Professor Bradbury. The patient, a young 
lady, had taken a cachet containing 10 gr. of salol once or 
twice daily for nearly six months. Then attacks of severe colic 
began, accompanied by vomiting. In one of these attacks the 
calculus was vomited, and tlie patient declared that similar bodies 
had been frequently passed by the bowel. A similar case is 
quoted from Brossard. Here fi'om 4 to 5 grm. (62 to 77 gr.) 
were given daily, and at the end of ten days the patient, who 
was habitually constipated, developed severe symptoms of intestinal 
obstruction. After thirty-six hours of treatment a motion was 
passed and this, on being searched for a biliary calculus, was 
found to contain ten crystals of pure salol, weighing altogether 
4 grm., the largest weighing 1'8 grm. 

In another quoted case (Girode) two masses of salol weighing 
3 grm. were found in the stomach of a patient who had died from 
cholera. A correct explanation of this phenomenon of the aggrega- 



DISEASES OF THE STOMACH, ETC. 99 

tion iif siiuiU quantities of salol into a large calculus is of great im- 
portance, and it may be that the usual method of administering the 
drug by means of cacliets will have to be discontinued or modified. 
Brossard's explanation is that a dose of salol comes in contact 
with the decomposition products (salicylic acid and phenol) of a 
previous dose, that under the influence of the phenol the salol 
becomes liquid, and that when the jjhenol is replaced by water 
the salol is converted into a crystalline mass. Marshall's experi- 
ments throw doubt on the truth of this explanation. He himself 
attributes the calculus formation to the varying tempei^ature 
which is met with in stomach and bowel. The melting-point of 
salol is a little above the normal temperature of the body (42" C), 
and after meals the interior of the stomach may be above this 
point, so that salol will melt. As the temperature falls reci-ystalli- 
sation occurs. But the result is found to be no longer in the 
form of minute individual crystals, but solid lumps of coherent 
ciystals are produced, which resist the decomposition on which 
the beneficial action of the drug depends. His practical recom- 
mendcxtion is, therefore, that salol should be given rubbed up with 
some innocuous powder, or in the form of an emulsion. 

9. Trfatineiit of dysentery. 

A new drug and the results of its use in dysentery are 
described by Maberly {^Lancet, Feb. 6, 1897). From his account 
it appears that this drug has long been known by the old 
colonists in South Africa as a spirituous vegetable tincture. With 
ditficulty he discovered specimens of the plant, and it was identi- 
fied as Monsonia ovata of the order Geraniacese. With this he 
made a tincture by maceration in spirit, 2\ oz. to the pint of 
rectified spirit, which he used in over one hundred consecutive 
cases of dysentery. He claims a specific action for it. He 
used it in doses of 3 or 4 dr. at intervals of four hours. 
Ninety of his cases may be called acute. In none of these acute 
cases was ipecacuanha used, the treatment consisting of tincture 
of monsonia in doses of 2 to 4 dr. every four or six hours. 
In a few instances this was supplemented by a lead and opium 
pill. The average number of days during which a patient in this 
class was under treatment was 2 "3, which is far below the 
average given by the statistics of other countries. Ten of his 
cases were chronic, and of these nine made complete recoveries 
and were under treatment for 8'1 days on the average. In the 
remaining case the dysentery was cured, but the constitution was 
so exhausted by the long illness previous to treatment that 
the child succumbed to cancrum oris. .Seven of the chronic cases 
recox'ded as being cured were under observation for periods vary- 
H 2 



100 TIIK YRAK-BOOK OF TREATMENT. 

iiig tVuiii oiKi 1,(» four years, no relapses ()ceurl•in•,^ In one case 
only, so far as tlie autlioi''s knowlcdjj;*', went, did a relapse oceui'. 
Tlie plant appears to be common in Houth Africa. Several 
species are known to have astringent properties due to their 
tannic acid. l>ut from the facts that the drug has very little 
ed'ect in ordinaiy diarrluea, and that good results followed tlie 
use of only the dried lloweiing plant (the tannic acid heing chicifly 
in the i-oot), he concludes that it has a specific effect not dependent 
on its asti'ingent quality. Considering our ignoi'ance of the exact 
cause of dysentery, and the probability that several forms of the 
disease exist, it is by no means improbable that a plant having 
specific qualities may flourish in the tlysenteric regions of South 
Africa ; and on the evidence here afforded a more extended trial 
of the drug is to be desired. 

to. Troiitnieiit of the siiiniiior (liariiio'a of yoiiii^: 
rliiltlrcii. 

Solis-Cohen (^MpcI. JVeirs, No. 8, vol. Ixix., 1896) em|)hasises the 
l)elief that is now generally held, that " in the majority of cases 
in which infants or children present symptoms of disturbance of 
the alimentai'y canal the local i)henomena are those of ii-ritation 
rather than of structural change, and the systemic phenomena 
those of intoxication chiefly." In other words, there is little or 
no true inflammation of the intestinal mucous membrane, and the 
alarming symptoms, at any rate, are dependent on bacterial action 
and toxin-formation. He gives the following outline of his 
mode of treatment. The appearance of vomiting and diarrhoea is 
by itself a proof that the food is from some cau.se unfit for the 
child, and this must be taken to be true, even if the source or 
nature of the unfitness cannot be discovered. The diet must be 
changed. The alimentary canal should at once be cleansed of 
irritating and toxic matters. If this can be accomplished by the 
adnunistration of a mild laxative, calomel in small doses, or castor 
oil and aromatic syrup of rhubarb without lavage, it is better to 
avoid the passage of a stomach tube. If, however, the vomiting 
is urgent, it is useless to attempt to give an aperient. The 
stomach should in that case be washed out with a warm (100° F.) 
solution of sodium borate or sodium bicarbonate, 1 dr. to the 
pint. At the same time a high enema of warm normal salt 
solution should be given. The next step is the administration of 
a powder, in which the author has great faith, consisting of benzo- 
naphthol and bismuth salicylate, usually in equal parts with or 
without the addition of Dover's powder. A child of six months 
can usually swallow 3 gr. of such a powder, and some can 
take much more. The dose of the first two ingredients is 



DISEASES OF THE STOMACH, ETC. 101 

regulated mainly by the ability of the child to swallow it, but the 
Dover's powder must, of course, be added in accordance with the 
rules which govern the use of opium for young children. Jn 
some cases it may be necessary to make up a powder contain- 
ing 5 gr. of the benzo-naphthol and 5 gr. of the bismuth 
salt, and administer this (perhaps with the addition of a little 
lactose) in small quantities at frequent intervals, say of ten 
minutes. The dose for an adult is a powder containing 5 gr. 
of each of the three ingredients. He insists that it is the com- 
bination and not any one constituent that is effective. The 
intervals between the doses should vary from two to four hours 
at first, and may be lengthened as the symptoms abate. As 
regards diet during the treatment, it should consist of barley 
water in small quantities for two or three days, and all milk 
should be forbidden. Then freshly prepared meat juice, Pasteur- 
ised milk, or even boiled milk may be used, with scrupulous care 
as to cleanliness. The author is emphatic in declainng against 
the use of any astringent, such as logwood, kino, or tannic acid, 
before the alimentary tract has been as far as possible cleansed of 
irritating poisonous materials. It is no doubt far too common a 
custom to have recouri-e to astringents on the first appeai'ance of 
diari-hcea. In very severe cases with collapse, hot. bathing, the 
external application of heat, and the use of strychnia and alcohol 
may be necessary. In its broad outlines this plan of Solis Cohen 
may be taken as presenting the best line of treatment that we 
have before us at the present time. 

In this connection may be mentioned a paper by Marfan 
{La Med. Moderne, June 15, 1897). In the very severe form of 
choleraic diarrhoea of infants, he is disinclined to wash out the 
stomach and intestines owing to the possible production of convul- 
sions or collapse. In such cases he confines his attention for the 
moment to combating the collapse consequent upon the vast drain 
of fluid from the body. He gives no food or drugs at the 
extremity of the illness, but administers boiled water at the 
ordinary temperature, 100 grm. every hour for at least twenty- 
four hours. He also injects slowly under the skin every tive 
hours from 5 to 20 grm. (according to the age of the child) 
of a solution consisting of 300 grm. of sterilised (not distilled) 
water, 2 5 grm. of common salt, and 75 grm. of citrate or 
benzoate of caflein. In addition warm Imths at 35° C. from 
two to four times in the twenty-four hours may be given, each 
lasting five or ten minutes. 

The use of tannigen in various forms of diarrluea was 
mentioned in the "Year-Book of Treatment" for 1897. This 



102 THK YEAH-IJOOK OF TREATMENT. 

substance is diacetylic tannin, and it appears to have a decidedly 
l)eneticial effect in catarrhal states of the bowel arising from 
any cause. The dose is from 3 to 8 gr , and as much as .35 gr. 
may he given in a day to an adult. It does not begin to show 
its astringent effect until it is in an alkaline medium such as is 
met with low down in tlie intestine. Vandenberghe {Bd(j. Med., 
Dec. 24, 1896) gives a report on its use, and chiinis for it a great 
value in many cases of enteritis from ^■aricus causes. Comby (^La 
Med. Moderne, July 28, 1897) has used it with .success in the 
simple diarrhrea of children, and it may be combined in infantile 
cholera with calomel or .some other intestinal antiseptic. Tn this 
respect the warning of Solis-Cohen against the hasty use of 
astringents in this condition, which has been mentioned above, 
may be recalled with advantage. 

11. Ai'ti(it!ial food preparations. 

The rational use of artificially prepared food forms the subject 
of a most suggestive paper by Klemperer [Berliner klin. Woch., 
June 28, 1897). This subject, as he says, is a small but important 
dej)artraent of practical medicine, As regards albuminous pre- 
parations, he points out how the old belief in tlieir great ^•alue, 
as compared with carbohydrate and fatty foods, has altered since 
the time of Liebig and Voit. When attention was first turned 
to the possibility of ])roviding invalids with albuminous food, 
which should be I'eady for absorption as soon as it was taken into 
the stomach, the idea was to give it in the form of peptones. 
Now pure peptone is bitter to the taste, it irritates the stomach 
and produces vomiting, and it may in large quantities produce 
diarrhciea. It cannot be used. Then it was recognised that 
peptone is not necessarily the sole result of gastric digestion, but 
that a stop is made during the process at the stage of the forma- 
tion of albumose. So came on the market a number of preparations 
containing much albumose and little peptone. By the adminis- 
tration of these artificial foods the stomach is no doubt spared 
much of the work of digestion, but Klemperer questions whether 
this is- often necessary, and whether we do not too often have 
recourse to them. He thinks that even in conditions of great 
feebleness there is sufficient hydrochloric acid to ensure conversion 
of small quantities of albumin. Even when hydrochloric acid is 
entirely absent, it has been shown by experiment that a sufficient 
destruction of albumin, with the formation of albumose and 
peptone, takes place. What the stomach cannot perform is 
effected in the intestine by the pancreatic secretion and the action 
of intestinal bacteria. Albumose preparations, then, he allows 
have nutritive value, but he maintains that they are not necessary. 



DISEASES OF THE STOMACH, ETC. 103 

On the other hand, his point is that every finely divided all^umin 
and every soluble native albumin is just as valuable as the same 
amount of albumose, and he recommends a soluble albumin or an 
albumin in the form of a powder as being desirable in all cases 
with very few exceptions. Such soluble albumin is now to be 
obtained under the name of " nutrose " and " eucasin," substances 
which are prepared from the casein of milk. They are found to 
be well taken by invalids. As regards an albumin in the form 
of powder, he details how both meat and egg albumin can be 
completely dried and reduced to this state. Such a powder is 
easily taken in water or milk, it is easily swallowed, it creates no 
irritation, and it is quite as valuable as the artificial albumose 
preparations. Such a preparation will be especially useful in 
cases of gout, Bright's disease, and a tendency to the excessive 
foi'mation of uric acid, when the extractives from meat have such 
a prejudicial influence. " Back to nature " is, in fact, his recom- 
mendation. Oppler also (Therap. Monatshe/te, April, 1897) writes 
of eucasin and nutrose, and he is convinced of their value from 
his own experience. 

I'i. Acid dyspepsia. 

It is important to recognise the very common condition of 
hyperacidity of the stomach contents, and to treat it on rational 
lines. Jaworski (Therap. Monatshe/te, September, 1897) gives us 
a paper with a clear outline of the leading features of the disorder 
and a recommendation of its treatment with an alkaline eflfer- 
vescing water. In a mild degree the symptoms comprise a feeling 
of thirst, heartburn, and acid eructations. In moi'e advanced 
cases there is a feeling of burning about the stomach, which 
is often intense, with pains radiating into the back, ^nd with 
vomiting, so that a differential diagnosis from gastric ulcer may 
be difficult. Often, of coui-se, an ulcer is co-existent with 
this hyperacidity. There is pathological evidence sufficient to 
indicate the pyloric region as the seat of the disease. The causes 
are various. It may be due (i) to organic change in the acid- 
secreting apparatus, or (2) to fermentative acid-forming processes. 
As regards the first head, the trouble may make its appearance 
during the height of digestion, or it may occur with an empty 
stomach, or it may be continuous. And in the author's opinion 
all these forms should be regarded as different stages of one 
continuous anatomical })i'ocess, of one continuous over-secretion of 
hydrochloric acid, probably dependent on liyperaMuia of the secret- 
ing surface. As Sir William Roberts puts it, acid dyspepsia 
may to a certain extent be regarded as an ill-directed vigour of 
digestive action. And it is certainly very common in strong and 



104 



TIIK YEAR-BOOK OF TREATMENT. 



otherwise liealtliy individuals. On the other liand, tlie fermen- 
tative variety of hyperacidity depends on the production of acetic 
and lactic acids. Acetic acid is accompanied by more intense 
pain than is lactic acid. Now a rational treatment of all such 
cases comprises attempts to hinder the formation of the excess of 
acid and to remove the anatomical changes in the mucous mem- 
brane of the stomach. Obviously the tirst jjoint is the neutralising 
of the acid, on which the subjective symptoms of discomfort 
apparently depend. Althotigh the exact effect of alkalies on the 
gastric secretion is still a matter of dispute, the broad clinical fact 
remains that, by neutralising the stomach contents, not only are 
the subjective symptoms for the time thereby removed but, by 
a long continued course of such treatment, an apparently normal 
process of digestion can be induced. Jaworski, after long expe- 
rience, is convinced that the best method of attaining the necessary 
neutralisation is by tlie administration of an alkaline water. For 
simple neutralisation he uses bicarbonate of soda, and in order to 
check fermentation he makes the addition of the sodium salts of 
salicylic and boric acids. He uses his alkaline water in two 
strengths, both being impregnated with carbonic acid gas. The 
fir.st contains 8 grm. of bicarbonate of soda, 2-5 of sodium sali- 
cylate, and 2-0 of sodium biborate, in a litre of water. The 
second contains 5, 2, and 1 grm. of the same salts respec- 
tively, in the same amount of water. Of the stronger water 
he gives half a tumbler on an empty stomach, early in the morn- 
ing ; of the weaker a third or half a tumbler after every meal. 
When fermentative processes are predominant, the stronger water 
may be given more frequently. He notices that the thirst which 
these patients experience is relieved with smaller quantities of 
this solution than of ordinary water. The heartburn and gastric 
oppression and pain are i-elieved. In cases where the hyperacidity 
reaches its maximum during digestion, and in pure cases of con- 
tinuous hypersecretion (hyperchlorhydia) the subjective symp- 
toms markedly diminish when the water is taken in doses of 
half or a whole tumbler half an hour or one hour after a meal. 

Bergmann has suggested a plan with the same view of neutral- 
ising an excess of hydrochloric acid, which is simple and may be 
efficacious in the milder forms of the condition. He bases his 
suggestion on the fact that the saliva which is swallowed naturally 
tends to neutralise the gastric acid without irritating the gastric 
mucous membrane. In this condition of hyperacidity, however, 
the saliva loses much of its alkalinity, or even itself becomes 
acid. He recommends, therefore, that such patients should chew 
during the process of digestion tabloids composed of ammonio- 



DISEASES OF THE STOMACH, ETC. 105 

])liosphate of magnesia and calcined magnesia. The saliva is 
thereby rendered strongly alkaline and exerts a considerable 
neutralising effect in the stomach. By this plan there is avoided 
the risk of exciting the stomach to a still greater secretion of 
acid, which he considers may be the case when alkaline drugs are 
dii-ectly introduced into the stomach. His plan is, in fact, an 
attempt to imitate and increase a natural pi-ocess ; inasmuch, 
however, as the mouth is often unriaturally dry in this condition, 
he adds to the tabloids small doses of ginger and of calamus-root, 
an extract of which finds a place in the pharmacopoiia of the 
United States. A large secretion of alkaline saliva is thus pro- 
duced. Wagner [Theraj:). Monatshefte, May, 1897) has tried this 
plan, and records several cases in which it was apparently liighly 
beneficial. 

The thought must often occur to us as to the possible danger 
of eventually doing harm by the long continued use of antacids as 
neutralising agents in this condition of acid dyspepsia. Many a 
patient having experienced relief from a dose of bicarbonate of 
soda, continues to use it indefinitely at his own free will. The 
experience of Sir William Roberts is comforting on this point. He 
is satisfied [Diyestion and Diet, 1897) that with due precautions 
the practice is harmless. Of all drugs he prefers the bismuth 
lozenge of the British pharmacopteia, and he regulates the use of 
it in this way. They are not to be used at or near meal times, in 
fact, not sooner than three-quarters of an hour, or an hour, after 
breakfast, nor sooner than an hour or an hour and a half after 
dinner. The}' are not to be used regularly and systematically, 
but only when the discomfort arising from hyperacidity is more 
than a man can be reasonably expected to bear when he has an 
easy means of relief ready to his hands. The bismuth lozenge 
(preferably without the bismuth) he considers a valuable remedy ; 
its value lies in the carbonates of magnesium and calcium. He 
also, like Bergmann, is in favour of lowering the acidity of the 
stomach contents by exciting a copious flow of saliva ; and he 
recommends, as a valuable addition to the resources of the 
dyspeptic, the sucking or chewing of a gum lozenge, a glycerine 
jujube (if the sugar contained is no bar to its use), or even a 
"tear" of gum arable. He has obtained good results from this 
simple treatment, and he thinks that tlie gummy solution as it 
arrives in the stomach has a local soothing effect. Of course, in 
severe cases some form of alkali must also be administei'ed. 



DISEASES OF THE KIDNEYS, DIAJJETES, 

ETC. 

Bv Francis D. Boyu, M.D., F. R.C.I'. Euin., 

Physician to the Deaconess Hospital, ICdinbiirgh, etc. 



I.— SYNOPSIS. 

During the year that is past a considerable number of papers 
has been contributed to the literature of urinary and renal 
therapeutics, and some brilliant results have been got by difterent 
observers in the treatment of toxaemias by lavage of the blood. 
The method promises well in the treatment of ursemia, and is 
worthy of a wider trial. There is not much that is new in the 
literature of nephritis. Band contrilnites an interesting paper on 
the value of tube casts in prognosis in nephritis, and further 
experiences are given of lactate of strontium. In the section 
of diabetes is a paper by Lepine on his further experience of 
alkaline injections in the treatment of diabetic coma, and several 
papers are contributed on the question of diet in diabetes, amongst 
which will be found a timely protest on the too rigorous dieting 
of the diabetic. Several articles of interest have been published 
during the year on renal ])ain, its varieties and treatment. The 
serum treatment of disease has been applied to urinary infection 
through the bacillus coli communis, and seems to promise well in 
some cases. The use of urea as a diuretic is advised by Klemperer, 
but the results of other observers do not support his contention. 
The usual elaboration of urinary tests will be found. 

IL— NEPHRITIS, ETC. 

1. Tlie iiii|»oit:iiicc of tube casts in prognosis in 
nephritis. 

Band [Lyon Medical, No. 41, Oct. 11, 1896) lays special stress 
on the importance of tube casts in cases of albuminuria, enabling 
the observer to distinguish between an epithelial nephritis and 
other renal lesions, interstitial, arterial, and cardiac, etc. The 
simple presence or absence of casts is alone of little imi)ortahce 



DISEASES OF THE KIDNEYS, DIABETES, ETC. 107 

from a prognostic point of view, but the study of casts has a 
special significance, which nothing else supplies, in the diagnosis 
of epithelial nephritis, and the appreciation of the inliamniatory 
process in the atfection. 

The presence of granular casts shows an active inliamniatory 
process going on in the epithelial cells. Granular casts show 
many varieties, their appearance varying with the intensity of 
the inflammation. When the inflammatory process is very active, 
the proliferation and destruction of epithelial cells are very rapid, 
and granular debris is abundant ; the resulting casts are then 
consistent and opaque. Wlien the inflammation diminishes, the 
granules are clearer and less numerous, lose their confluent 
appearance, and are scattered in an amorphous hyaline debris. 
The casts are clear and more or less ti'ansparent. In both cases, 
but especially in the second, detached cells are present in the 
cast — cells not yet completely destroyed. The diameter of the 
casts varies with the diameter of the tubes from which they 
are derived, and is the larger the more intense, and especially 
the more long-standing, the inflammation. 

Epithelial casts, })roperly so called, are those which consist of 
a mosaic of epithelial cells, and are not so frequently found in 
epithelial nephritis. They belong more to the degenerative 
lesions. Their significance is not so precise as that of the granular 
casts, but, as a rule, they indicate a more simple inflammation. 
When albuminuria persists after an epithelial nephritis, the 
absence of casts on several consecutive examinations shows that 
all epithelial inflammation is gone, and that the albuminuria is 
cicatricial. On the conti'ary, the abundance, opacity, consistence, 
and size of the casts show that the inflannnation is active, and 
that the diminution of the clinical symptoms is deceptive. The 
presence of granular casts, clear, tiansparent, and of small diameter, 
points to a less active })rocess, non-progressive, but not completely 
abolished. Repeated and regular examination of the urine is 
necessary, as giving a just appreciation of the progress of the 
case. 

*i. The use of iiicrciiry in iiopliritis. 

Campbell Black (^Scottish Medical and Surgical Journ., vol. i., 
No. 5), in a paper on the pathology and treatment of nephritis, 
advises the use of perchloride of mercury. He considers mercury 
an antiphlogistic agent of supreme eflScacy. The mercury should 
be combined with iodide of potassium, so as to form a biniodide, 
and thus keep the drug in solution. In aildition to the ad- 
ministration of mercury, the author advises that diluents be 
reduced to a minimum, and that solid food be given. Fourteen 



108 THK YKAK-BOOK OF TUEATMENT. 

cases of nephritis are quoted to illustrate the advantage of the 
treatment. 

[With the restriction of diluents in cases of nephritis few 
physicians will agree, and the recent success of the treatment of 
uraemia by "washing the blood" would support the view tliat 
diluents, far from being noxious, are of advantage in cases of 
nephritis, especially if any tendency to uraemia be ])resent. 
The use of mercury in nephritis must still be considered a 
vexed question. Pepper [Medical Neivs, No. 24) advocates the 
use of calomel as a diuretic in some cases of renal disease. 
Welander [Archiu filr Dermatologie unci Syphilis, vol. xxxvii., 
No. 3) has published an exhaustive study of the effects of 
mercury on the kidney in syphilis. He finds that mercury, 
especially when it is pushed, causes cylindruria, and at times 
albuminuria, more or less severe according to the idiosyncrasy 
of the patient. In nephritis of syphilitic origin, mercury must 
be given cautiously, as the drug is at times eliminated abundantly 
through the kidneys, and toxic effects may easily be produced 
where the kidneys are damaged.] 

3. Sti'oiitiiiiii lactate in nephritis. 

Pick [Prayer niecl. Wochemchr., No. 39, 1896) records over 
forty cases of different forms of nephritis treated with strontium 
lactate. The remedy was well borne, in only one case was there 
vomiting, and the strontium lactate was not retained. There 
were no unpleasant secondary effects noticeable from the drug, 
with the exception of a peculiar skin affection which was noted 
in one case. As far as the therapeutic effect was concerned, in 
interstitial ne^jhritis and in conditions where a large amount of 
urine with a small proportion of solids was being excreted, no 
beneficial effect was noticeable from the drug. In acute nephritis 
it was difficult to estimate any benefit obtained, for such cases 
undergo improvement by rest in bed, equable temperature, and 
bland diet, so that the influence of the drug could not be properly 
appreciated. It must be admitted, however, the author considers, 
that where the remedy was administered over a prolonged time, 
there was a decided diminution not only in the percentage amount 
of albumin, but also in the total. 

An increased diuresis was noticeable in a certain number of 
cases, and in many a decided increase of appetite and subjective 
betterment. The drug, the author concludes, is one with decided 
diuretic and hygienic usefulness, and in certain cases of parenchy- 
matous nephritis diminishes the albumin, relieves the tedema, 
and produces a subjective feeling of betterment. 

[There is now considerable evidence in favour of the use of 



DISEASES OP THE KIDNEYS, DIABETES, ETC. 109 

stioutium lactate in nephritis where a diuretic effect is desired 
(see " Year- Book," 1897, p. 102). The drug is best given in 
watery solution.] 

4. To tost the activity of tlio ki«liioys. 

Achard and Castaigne I^Gazettr Hehdoinadaire, No. 37, 1897) 
advise the use of subcutaneous injections of a solution of methyl 
bhie to test the activity of the kidneys. The methyl blue being 
excreted by the kidneys gives to the urine a blue or greenish-blue 
colour, the length of time required for the colour to appear in the 
urine gives an indication of the rapidity and efficiency of the 
kidney excretion. By introducing the colouring matter under 
the skin, any error through the differing rate of absorption by the 
stomach is eliminated. The methyl bhie is used in a 1 in 20 
solution, and 1 c.cm. of tliis is injected. The substance is 
innocuous. After the injection the patient should urinate every 
quarter of an hour. It is only in cases of extreme polyuria that 
the dikition of the blue is so gi-eat as to vitiate results. In healthy 
persons the colour appears in the urine a quarter of an hour 
after injection, and reaches its height during the third or fourth 
hour. All colour is gone from the urine in from thirty-five to 
tifty hours. In individuals where the kidneys are diseased, the 
appearance of the colour is retai-ded. It is absent during the 
first hour, and does not apjjear for three hours or longer, and in 
some cases is excreted so slowly as never to give an appreciable 
colour to the urine. Thus in interstitial nephritis the colour 
appeared very slowly, and persisted for six days after the injec- 
tion. The authors find from their observations that when elimina- 
tion of the pigment begins within the hour, tlie kidneys may be 
considered as possessing normal permeability, even though, as in 
some cases quoted, albumin is present in the urine. 

•?. Tiie use of artifirial seriiiii in kidney ciiseaso. 

Bovet and Huchard {Bulletin General de The'rap., vol. cxxxii., 
Jan. 30, 1897), in an interesting paper, I'eview the literature of 
the employment of subcutaneous injections in toxaemia, and quote 
an illustrative case of septic pyo-nephritis. The condition had 
lasted for some months, and the patient showed all the symptoms 
of general toxpemia. The urine was scanty and contained pus, 
albumin, and tube casts. There was nightly fever. The pulse 
was rapid and the tongue dry. Exhaustion and delirium set in, 
and the gravity of the condition was increasing when the injec- 
tions were ])egvin. Under treatment by injections, amelioration 
of the symptoms took jjlace, when the injections were |)uslied to 
1,700 to 2,000 grammes daily during nearly a week. Tiie amount 
of urine excreted rose in [troportion to the amount of the injection. 



HO TIIK YKAR-BOOK OF TUEATMKNT. 

Tlio ;iiiioiiiit of ;ill)uiiiiii in tlic uiiiic fell under the treatment from 
3 <^raiiimes to Ui gramme. The clinical phenomena showed a 
continuous improvement after the injections. From being in an 
apparently ho[)eless condition the patient became quite con- 
valescent. In the course of the treatment the patient received 
IG litres of lluifl subcutaneously and 14 litres by enema. The 
lluid used contained sodium chloride in the proportion of seven 
parts per thousand. The absorption of 2,000 c.cm. of this fluid was 
completed in about an hour. TJie authors conclude that the 
injection of 2,000 c.c. of saline fluid into the cellular tissue 
is accompanied by no danger, while the same cannot be said if it 
be injected directly into a vein. As the result of the injections 
marked diuresis occurs. Usually, as the injection is given, the 
patient shows signs of improvement, but witliin half an hour 
a rigor sets in with rapid pulse, followed in half an hour with great 
flushing of the skin, then profuse sweating and increased urinary 
excretion. There may be marked febrile movement. 

Sole (Za Fresse Medicate Beige, Jan. 24, 1897) contributes a 
paper on the use of subcutaneous injections in eclampsia, and 
advises the treatment in all cases of toxsemia. The case of a 
married woman is recounted who when pregnant was attacked 
with pains, nausea, vomiting and headache. She was semi- 
comatose. The urine was scanty, contained blood and an 
enormous amount of albumin. The coma deepened and convul- 
sions supervened. Artificial delivery was carried out, but two 
days afterwards, the coma still persisting and the general condition 
deteriorating, normal saline solution was injected into the subcu- 
taneous tissue of the axilla on each side. This was immediately 
followed by increased seci'etion of urine. The injections were 
repeated in different parts every four hours, and at the end of 
twenty-four hours the patient's condition was very much improved 
and recoveiy took place. Hare (TlLerap. Gazette, No. 4, April 1/5, 
1897) records two cases of toxaemia treated by injection. The first, 
an old man, developed acute toxaemia with high fever and coma 
as the result of spreading gangrene of the leg. The result of the 
injection was to rouse him out of his coma ; but he ultimately died. 
The second was a patient with chronic parenchymatous nephritis 
who developed uremia. As the patient was too ill to be bled, 
or purged, or to receive pilocarpine, the injection of hot saline 
solution was tried. The following day his ursemic symptoms had 
disappeared, and the dropsy had not increased. Ten days later, 
as the ursemic condition seemed to be returning, the injection was 
repeated with good effect. These results are in line with a case 
of eclampsia formerly reported by Proben, where recovery took 



DISEASES OF THE KIDNEYS, DIABETES, ETC. Ill 

place under saline injections when the patient seemed in a 
liopeless condition. Richardi^re {Union J/edicale, Dec. 6, 1895) 
has also used injections of artiiicial serum in ursemia. In his cases 
the patient was bled preparatory to injecting the fluid. Both 
the cases made a good recovery. Michard [Le Progres Aledieal, 
No. 2, 1896) used injections in fifteen cases of septic peritonitis 
along with the usual surgical means of treatment. Of the fifteen 
cases five recovered. 

[The best fluid for injection seems to be a modification of 
Ringer's fluid as advised by Edes {Boston Medical and Surgical 
Joiirn., March 4, 1897). It consists of — 

Calcium Chloride 0-1 gramme. 

Potassium Chloride ... ... ... ... 0"7o ,, 

Normal Salt Solution 1-000 com. 

("75 per cent, solution.) 

The fluid should be injected slowly into the cellular tissue, not 
into a vein. 

Absorption from the cellular tissues is very rapid, and the 
injection is not accompanied with the same danger as in direct 
injection into a vein. Preliminary bleeding, as advised by 
Richardiere, is quite unnecessary. The method is worthy of a 
wide trial in toxaemia and especially in urajmia, and seems to ofl"er 
a chance of recovery to many almost inevitably fatal cases.] 

6. Ether in itrseniic tlyspiiflea. 

Gallois {TJiese de Lille, 1897) discusses the treatment of urfemic 
dyspncea and advocates the use of ether, which, being rapidly 
eliminated, can be given in fairly large doses without danger of 
intoxication. In urtemia with dyspncea, ether may be given hypo- 
dermically in ^-drachm doses night and day as well as by the 
mouth in dessertspoonful doses. Under large doses of ethei- 
improvement in the respiration takes place, and the feeling of 
suffocation disappears. A diuretic effect was also noted. The 
treatment should be continued for several days, the dose of the 
drug being gradually diminished, and the interval between the 
doses increased. The author emphasises the point that the drug 
must be pushed, two to three ounces being given in twenty-four 
hours before good results can be expected. Though subcutaneous 
injection is painful, the rapidity of absorption is a point of 
importance : the injections must be given deeply into the muscles 
to avoid irritation of the skin. The drug exerts no injurious effects 
upon the kidneys, nor does it aggravate any existing lesion. 

7. Aljineiitary albuiiio*^iiria. 

Chvostek and Stromayer ( Wiener kiln. Wochenschr., 1896, No. 47), 



112 TIIK YEAR-BOOK OF TREATMENT, 

discuss tho question of alimentary iilljumosufia first described 
by Maixner in ulcerating carcinoma of the alimentary canal. 
When an ulcerating surface is present in the alimentary canal 
albumose may bo absorbed directly into the circulation without 
being reconverted into all)umin in the intestinal wall. The 
aUniniose is then found in the urine. The authors record six 
cases of tuberculosis, where the symptoms pointed to an implication 
of the alim(!ntary canal, but in which ulceration of the bowel 
could not b(! diagnosed with certainty. Peptone, or somatose in 
solution or in the form of a thin soup, was administered, and in a 
few hours albumose could be demonstrated in the urine. In every 
case ulceration of the bowel was found poft mortem. A series 
of twenty cases without any intestinal affection were given peptone 
as a control experiment, and no albumosuria occurred. In the 
case of three patients where ulceration of the bowel was found 
post mortem, albumosuria could not be produced. The authois 
conclude that while the production of alimentary albumosuria is 
proof of intestinal ulceration, a negative result does not exclude 
the presence of ulceration. 

III.— DIABETES. 

8. The initial stag^cs of diabetes ineilitiis. 

Loeb {Gentr. filr iunere 3Iedicin, No. 5, 1897) in a previous 
paper {Centr. fur innere Medicin, Nov., 1896) advanced the 
view that, in many cases of diabetes, long before the disease 
definitely manifested itself by marked glycosuria or other 
symptoms, the excretion of sugar could be demonstrated in the 
urine. He now brings forward an additional case in support of 
his contention. The patient, a man 55 years of age, sought 
advice on account of loss of smell, which had existed for two years. 
In other respects he seemed in perfect health. Nothing local 
could be found to account for the loss of smell, but a decided 
sugar reaction was obtained in the urine. With a specific gravity 
of 1,018 the urine contained 25 per cent, sugar. There was no 
complaint of thirst or exhaustion, nor of emaciation, the patient 
being well nourished. A year afterwards, the patient, though 
still in good health, complained of cramps in the legs, most severe 
in the early morning. He drank more fluid and passed more 
water than formerly, having to rise twice, as a rule, during the 
night. The urine contained 3-5 per cent, sugar. Had the patient 
not consulted a medical man while still apparently in perfect 
health, the early occurrence of sugar in the urine could not have 
been noticed. 



DISEASES OF THK KIDNEYS, DIABETES, ETC. 113 

Tlie occurrence of cramps in the legs in the case quoted is of 
interest. Cramp in the legs as an eai-ly symptom of diabetes 
seems first to have been noted by Unschuld of Neuenahr. 

f>. The troatineiit of diabetic roina. 

Lepine in 1S87 recorded cases of diabetic coma treated by the 
intravenous injection of lai'ge quantities of saline solution. 
Returning to the question (Xa Semaine Jledicale, xvii., 1897), he 
gives his further observations, and records the case of a patient 
treated in this way. A young man, 2-1 )^ears old, had suffered 
from diabetes, subsequent to a fall. When admitted to hospital, 
it was found that on a diabetic diet he was excreting 9 to 10 
litres of non-albuminous urine, with an average of 48 to 55 grm. 
of sugar. The patient was not much emaciated, but was very 
weak from nightly i'ever consequent upon a tuberculous affection of 
the lung. The urine gave a marked red I'eaction with iron per- 
chloride. On December 30, 1896, unusual amplitude of the respira- 
tory movements was noted — a symptom which Lepine regards as 
of very grave significance ; 25 grm. of bicarbonate of soda was 
ordered during the day. By ten o'clock next day tlie patient had 
become completely comatose, the breath smelt of acetone, and the 
pulse was veiy weak. A solution containing 7 grm. sodium chloride 
and 10 grm. sodium bicarbonate per litre was prepared, and two 
litres at a temperature of 1004' F. were injected into a vein, 
the whole bulk of fluid being introduced in less than a quarter of 
an hour. During the injection the pulse became stronger, and 
the respirations less exaggerated, and by the time it was com- 
pleted the patient had regained consciousness. Though the patient 
rallied considerably, he passed but little urine, which had a strongly 
acid reaction. At night the patient became comatose again, and 
died. The author ascribes the benefit obtained to the fluid 
neutralising organic acids in the blood, and expresses great 
hopes of the treatment in more favourable cases, and when used 
before coma has been completely established. In the L)/07i 
Medical, No. 15, 1897, Lepine records two cases. The first 
patient seemed in imminent danger of passing into coma. A 
subcutaneous injection of two litres of the saline tiuid was given, 
but without marked amelioration. The patient was removed from 
hospital, so the further history of the case could not be obtained. 
The second case, a man of thirty-seven, was passing in twenty- 
four hours ten to twelve litres of urine, containing about 
700 grm. of sugar. Under treatment he improved, but on being 
allowed some liberty in diet, the disease grew worse, and the 
respirations became laboured. Two litres of saline fluid were 
injected into a vein. After injection there was decided diuresis, 
J 



114 TUK YKAIl-nOOK OF TREATMENT. 

and the amount of acetone and oxyl)utytic acid was trebled, 
showing an increased excretion of tlie toxic substances constantly 
present in diaVjetic coma. Tlie patient made a good recovery. 

[Lepine's results are encouraging, and agree with those of 
Ilogue, Devie, and Hugounenq. Ldpine considers that the fluid 
should be injected directly into a vein instead of into the cellulai- 
tissue, when phlegmonous iuHammation may supervene. Intra- 
venous injection he considers entirely free from danger, a con- 
clusion with which few observers will entirely agree. Indeed, 
Mourette (These de Paris, No. 40, I89G-7) records two fatal cases 
after intravenous injection, while no fatality has been noted after 
subcutaneous injection. Injections into the cellular tissue are 
more easily carried out, are entirely free from immediate danger, 
the fluid is very rapidly absorbed, and if the injection be per- 
formed with the care which should, at the present day, be 
accorded to every surgical operation, however trivial, there should 
be but little or no danger of phlegmonous inflammation.] 

10. Diet in diabetes. 

Pfaff (^Boston Medical and Surgical Jour., 1896, p. 234) 
advocates the treatment of diabetes by rest and exercise of the 
diseased cells of the organism. He points out that Cantani Avas 
the first to recognise the importance not only of a qualitative, but 
also of a quantitative restriction of the diet— a qualitative restric- 
tion in the way of carbohydrates and a quantitative restriction as 
reo-ards proteids. These views have been elaborated by Naunyn 
with the view of strengthening the diseased cells by giving them 
rest by withholding carbohydrates and permitting but a limited 
use of pi'oteids for a period, after which, according to the indi- 
vidual necessities of the case, the amount of food is increased 
and the quality varied. 

The treatment begins with a course of " severe diet." Five 
hundred grammes of lean meat of any description, except liver, is 
o-iven per diem. The meat is weighed after boiling. In the pre- 
paration of the meat only oil, butter, vinegar, or lemon are used. 
As well as the meat three litres of liquid are permitted — water, 
meat In-oth, soda water, etc., along with a little brandy. This 
diet is kept up for 14 days, and according to the results obtained 
by this treatment and the subsequent alteration in the diet by the 
addition of carbohydrates, cases of diabetes are divided into three 
classes — severe, moderate, and slight. If after the trial treatment 
sugar remain present in the urine in quantities exceeding 1 per 
cent, the case is severe. If the sugar disappear, three ounces of 
bread are added to the diet, and if the ui-ine remain sugar-free the 
case is considered slight. If sugar appears after the addition of 



DISEASES OF THE KIDNEYS, DIABETES, ETC. 115 

bread to tlie diet, the case is put in the second class — the class of 
moderate severity. The ultimate treatment consists in the cai'eful 
regulation of the diet, so that the strength is kept up and the 
body- weight not diminished and the sugar excise tion kept down. 
In the first week of the treatment the patients (as might be 
expected) lose a few pounds in weight. In increasing the diet 
proteids must at lirst be used, unless dyspeptic symptoms be set 
n\) from excessive meat diet ; afterwards vegetables, bi-ead, and 
milk in small quantities are added. In severe and moderate cases 
it is impossible to keep the urine sugar-free, but it can be done in 
slight cases. Fat should be added to the proteid as early as 
possible. It is best given in tlie form of cream, which is better 
borne than fat meat, lard, or butter. If the cream be diluted with 
weak tea or coffee, a pint a day can easily be taken. Moderate 
exercise and baths are beneficial, for, as has been shown, exercise 
increases the power of the diabetic in the consumption of sugar. 
During the period of " severe diet " codeia will be found useful in 
soothing tlie patient and rendering the diet more easily V)orne. 

II. Itliik <liet and diabetes. 

Oettinger (Za Setncdne Mediccde, No. 8, 1897) discusses the 
question of the use of milk diet in diabetes. If milk is to be 
avoided, it is on account of its containing lactose, cow's milk con- 
taining 50 grammes per litre. JMilk sugar in the alimentary 
canal under the influence of the invertive ferment is not broken 
up like glucose into inverted sugar, but its ultimate transforma- 
tion into glucose does not appear to be a matter of doubt. 
Bouchard, indeed, found that if a diabetic on a fixed diet be given a 
litre of milk in addition to his diet in twenty-four hours an in- 
creased excretion of 50 grammes of sugar takes place. Donkin, on the 
other hand, disagrees with this observation and advises milk in the 
treatment of diabetes. Oettinger tried milk in a series of cases of 
diabetes. The first was a man 55 years of age, who had pre- 
viously suffered from nephritis with cedema and ursemic symptoms. 
In 1896 he began to suffer from polyui'ia and polydipsia, and 
the urine was found to contain a lai'ge amount of sugai'. On 
account of the former attack of nephritis, the low proportion of 
urea in the urine, and the presence of marked oedema, he was 
put upon an exclusively milk diet. No other medication was 
given. Five days afterwards all trace of sugar had disappeared 
from the urine, and the quantity of urine fell from five litres per 
diem to two. At the same time the oedema disappeared. The 
sugar continued absent from the urine for eight days, then the 
patient, disgusted with milk, and complaining much of lassitude, 
returned to an ordinary diet. The sugar immediately returned 
i2 



116 TIIK YEAR-HOOK OF TRI^ATMENT. 

and increased in quantity, and the amount of the urine rose. A 
diet was then tried consisting of 1,500 grammes' milk with eggs, 
meat, and legnmesj and the sugar rapidly diminished again, and 
the general health improved. A second ca.se was that of a gouty 
patient with diabetes and albuminuria who was put on milk diet 
on account of dyspepsia. A remarkable diminution in the sugar 
excreticm took place. A third patient suffered from diabetes and 
nephritis with (edema. An exclusively milk diet in )io way in- 
creased the sugar excretion, and the general symptoms were con- 
siderably ameliorated. From purely clinical eviflence the author 
concludes that milk is by no means hurtful in diabete.s, and that 
milk sugar is not in cdl diabetics a generator of glucose. 

[The views of Oettinger are supported by Chan-in. and (Tuille- 
ment {La Semaine Medicale, 1896), who found that the adminis- 
tration of milk along with a diabetic diet rendered the diabetic 
food more easily supported, and did not increase the sugar excre- 
tion to any appreciable extent. Klemperer {Therap. Monatsltefte, 
vol. X.) considers that in severe cases of diabetes milk is a 
necessary and staple article of diet, and may be given in quantities 
up to two liti'es per diem.] 

J 2. Trcatniciit of cliaboto*^ iiiellitiis. 

Munson {Jonrn. of the Amer. Med. Assoc, Chicago, May 15, 
1897) advocates the necessity of permitting the use of a certain 
amount of carl^ohydrate food in diabetes. He considei's that 
the diabetic should be under the same diet conditions as the 
healthy individual, and that the rigid exclusion of carbohydrates 
is productive of abnormal metabolic changes, which result in pro- 
gressive emaciation and weakness, and in the production of 
various toxic bodies to which the severe cei'ebral symptoms of the 
disease are attributable. He argues that sugar is always present 
in the blood and cannot be made to disappear by exclusion of 
carbohydrates as the systemic and ingested albumins are capable 
of furnishing sugar by their decomposition. The increased decom- 
position of albumin resulting from a purely nitrogenous diet 
causes increased metabolism and consequent loss of body-weight. 
The administration of carbohydrates retards metabolism. The 
diabetic has not lost the power of oxidising sugar, which must be 
given even more than in health, to prevent loss of weight and 
muscular weakness. The abnormal metabolism of albumin, which 
is especially produced by a rigid proteid diet, results in the pro- 
duction of toxic bodies, while the administration of carbohydrate 
prevents or retards the production of these bodies. 

The accepted treatment of diabetes has essentially consisted 
in placing the patient on a diet from which all carbohydrates are 



DISEASES OF THE KIDNEYS, DIABETES, ETC. 117 

excluded, with tlio sole object of causing ilie disappearance of 
tiie sugar from the urine. This treatment, Munsou considers, is 
based upon the false hypothesis that the presence of sugar in the 
urine constitutes the disease and if it can be made to disappear 
the affection is cured. But the glycosuria is merely a symptom 
resulting from intricate morbid processes. To treat the sugar 
cannot cure the diabetes, and is merely symptomatic treatment. 
A healthy individual cannot maintain health on a purely proteid 
diet, much less a diabetic. The dangerous cerebral symptoms, 
the great bod}' waste, and consequent emaciation resulting from a 
purely proteid diet, are of more importance than the excretion of 
unoxidised sugar, which in the author's opinion has little patho- 
logical and no prognostic significance. The diabetic should live 
upon a diet which keeps his body metabolism at its lowest, and 
for this carbohydrates are necessary. There is no cure for 
diabetes, and treatment must be directed to prolong life, which a 
rigid proteid diet is not calculated to do. 

[INIunson's paper is interesting, and is a timely protest against 
the too rigorous proteid diet which may result in an attack of 
coma. The views advanced seem to be somewhat extreme, and 
the right path will probably be found in a middle course which 
permits the diabetic sufficient carbohydrate to satisfy the neces- 
sary calls of the organism and keep the body-weight up, but 
eliminates all unnecessary carbohydrates from the food.] 

13. irraniiiiu nitrate in diaboteft. 

Burton (^Brit. Med. Journ., i., 1894, p. 847) reports a case of 
diabetes ti'eated by uranium nitrate. The patient, a lad aged 
seventeen, had suffered for a year from thirst and polyuria, with 
emaciation and weakness. He had cramp-like pains in his lower 
limbs, both knee-jeiks were absent, and there was some tender- 
ness on pressure in the legs. When first seen he was passing 10 
pints of urine per diem, of a specific gravity of 1040, containing 
acetone, a trace of albumin, and 38 gr. of sugar per oz., the 
average daily excretion amounting to 7,600 gr. Rigorous dia- 
betic diet was ordered, and by the end of a week the sugar had 
but slightly diminished. Uranium nitrate was then ordered in 
gr. doses, thrice daily. The dose was gradually increased till 
after three weeks the patient was taking 6 gr. thrice daily. Some 
improvement was noticeable, the average daily excretion of sugar 
having fallen to 2,400 gr., the aaiount of urine to 5 pints, while 
the patient's weight had increased. The dosage of the drvig was 
pushed up to 12 gr. thrice daily, gradual improvement taking 
place. There was passing disturbance of digestion, but the body- 
weight increased and the sugar excretion remained at an average 



118 THE YEAR-BOOK OF TREATMENT. 

of 2,000 gi', per diem. Tlie drug seemed to have no effect on the 
amount of albumin and acetone in the urine. Wliile under 
treatment tlie jjationt gained 7 lb., and the daily (ixcretion of 
sugar and urine was reduced from 10 pints and 7,600 gr. to 
3i pints and 2,170 gr. i-espectively. 

Duncan [Brit. Med. Journ., Oct., 1897) considers that the 
treatment of diabetes by uranium nitrate merits further trial. 
He records live cases in wliicli the drug was employed, and formed 
the opinion that the diminution in the amount of urine and 
sugar and the improvement in the weight and in the general health 
and stren<{th were due to the stimulatinjf eliect of the uranium 
salt upon the sugar-consuming cells of the organism. 

[Since the publication of West's paper in 1893 a number of 
careful observers have used uranium nitrate in diabetes. Some, 
such as Duncan and Burton above quoted, have got good results, 
but in the hands of others, such as Saundby and Tyson, little or 
no benefit has resulted from its use. The drug cannot ha 
regarded as by any means a specific, but in a certain number of 
cases it seems to do good.] 

14. Aiitipyi'iii ill (iiiibetcs. 

Jobin (^Monats. ueher die Ham- und Sexual- AjJparatus, vol. ii., 
No. 1, 1897) advocates the use of antipyrin in diabetes mellitus. 
Mousse {^Semaine Medicale, 1896), however, finds that the drug 
causes merely a fleeting diminution in the amount of sugar, uric 
acid, and urea, and concludes that it should not be prescribed in 
diabetes. As Coolet has shown, antipyrin exerts an undoubted 
influence on phlorizin glycosuria, but little or no conclusion can 
be di'awn from such experimental results, as many drugs which 
have an undoubted influence on the sugar excretion in diabetes 
have no influence upon phlorizin glycosuria. Former observers 
have found antij^yrin of benefit in diabetes by diminishing the 
polyuria. Thus a dose of antipyrin at bedtime may enable the 
patient to sleep without having to rise so frequently during the 
night. 

15. Sparkling: Aviiie in diabetes mellitus. 
Teschemacher [Muncliener med. Woch., No. 10, 1897) discusses 

the question of the use of sparkling wine in diabetes. In his 
observations half a bottle or more of dry champagne was added 
to the daily diet and no increase in the sugar excretion was 
noticeable. From the results he concludes that good sparkling 
wine (best, he thinks, "made in Germany"), even in large 
quantities, has no deleterious effect on the sugar excretion in 
diabetes. 

The results agree with an observation of Ebstein, who notes 



DISEASES OF THE KIDNEYS, DIABETES, ETC. 119 

the caso of a tliaUetic who daily cousumed kirge quantities of 
ohamjtayiu' without any evil results. 

16. " BroiiKe diabetes." 

Jeanselme {Societe Med. des Hdpitaux, February 5, 1897) 
describes two cases of the so-called " bronze diabetes." In the 
" first case the diabetes was ascribed to intoxication, in the second 
to trauma. In the blood of neither could pigment be demon- 
strated, but it was present in all the secreting organs in both 
cases, and there was marked increase of interstitial tissue in the 
liver and pancreas. The disease, he considers, begins with a de- 
struction of red blood corpuscles. Pigment is thus set free, and is 
deposited in tlie various organs, and a consequent sclerosis takes 
place. The diabetes he considers to be secondary to this sclerosis 
in the liver and pancreas. 

[Jeanselme's views agree with those of Moose and other 
observers in considering that the pigment results from altered 
hfemoglobin. Hanot and Chautf'ard, who originally described 
the condition, considered the cirrhosis to be tlie result of the 
diabetes and not the cause.] 

17. Pentosuria and xanthoma diabeticorum. 
Colombini {Monatshefte fur praktisclie Dermal., No. 3, 1897) 

describes an interesting case of xanthoma witli the occurrence of 
pentose in the urine. The patient, a peasant fifty years old, con- 
sulted the author on account of an eruption which had appeared 
on the legs, buttocks, loins, and ai-ms. The eruption had been 
pi-esent for about 160 days, and since its ajDpearance the patient 
who had formerly been in perfect health, found that his strength 
had deteriorated, and that he was unable to work. On examina- 
tion^ the eruption showed the characteristic appearance of 
xanthoma diabeticorum, but when the urine was examined, 
to the author's surprise, it did not give the ordinary sugar 
reactions. It was found that the patient was passing between 
6.50 and 920 c.cm. urine in the twenty-four hours with a specific 
gravity of 1023 to 1025, of a reddish golden colour, slightly acid 
in reaction, and containing neither albumin, propeptone, nor 
peptone. There was a doubtful reduction of Fehling's solution 
which appeared on cooling, and grew stronger on standing, and 
there was an equally doubtful reduction of Nylander's and 
Bottger's reagents. The urine was examined for milk sugai-, 
inosite, and levulose, with negative results. The author then 
examined for pentose with phenylhydrazin, and found tliat an 
osazon formed in characteristic crystals, which had a melting- 
point of 159° C. On quantitative examination, the carbohydi-ate 
was found present to the amount of 0"352 per cent. The urine 



120 TIIK YKAU-BOOK OF TIUUTMKN'T. 

giiw ;i marked reaction with Tolliii's phloroi^'lueiu iiieLli(j<l. Ki(jiii 
its reaction and the iiieltiii^-p(jiiit of the osazoii there could l)e no 
doubt that the carbohydrate present in the urine was pentose. 
On testin<^ the urine by Tronuner's method, and using a rehi- 
tively small amount of copper and heating for some time, na 
change appeared at first, but after a considerable time the reaction 
appeared slightly, with a precipitate of yellow oxyhydrate of 
coppei". When the urine was treated with excess of Felding's 
solution, it gave first a green and then a yellowish colour, but 
there was no precipitation of copper oxide. The patient was put 
upon a milk and flesh diet, and given arsenic. In the course 
of four months the eruption and the pentosuria had entirely 
disappeared. 

1§. Aiiiyl liy<1i-;ite in diabetc!^ iii«>>i|>i«lii<!». 

Bra.ckma.n (^T/ierap. Monahhffte, 189G) gives his experience of 
amyl hydrate in diabetes insipidus. The patient, whose grand- 
mother died of dial)etes mellitus, had suffered since childhood 
fi'om diabetes insipidus to a greater or less degree, and had fre- 
quently been under treatment. In July, 1894, when twenty-one 
years of age, he was attacked with acute mental symptoms. The 
daily quantity of urine passed averaged 7,000 c.cm. It was pale, 
clear, without pathological constituents, and had a specific gravity 
of 1005. Till March, 1895, the diabetic condition remained un- 
changed. As he was sufiering from sleeplessness, amyl hydrate 
was prescribed nightly in half-drachm doses. In the course of 
six days it was noted that the thirst had diminished, and the 
quantity of urine had fallen to 3,000 c.cm., with a specific 
gravity of 1011. On continuing the amyl hydrate, the quantity 
of urine varied between 2,800 and 2,000 c.cm. When the drug 
was discontinued, the urine secretion rapidly rose to 8,000 c.cm. 
When the drug was again exhibited, the polyuria diminished, 
while it recurred again whenever it was discontinued. The 
author considers an interrupted course of the drug should give 
good results in diabetes insipidus. 

19. DinbctO!!> insipidus. 

Burgess (Dublin Medical and Surgical Journal, 1897) records 
a case of diabetes insipidus in which all the usual remedies were 
tried with little or no residt. The only form of treatment which 
gave any benefit was an occasional purgative dose of calomel, a 
form of treatment first recommended by Golding Bird. 

20. Leviilosiiria. 

May (Deutsch. Archiv fiir klin. Med., vol. Ivii.) describes 
a case of levulosuria. The patient suffered from tra.nsverse 
myelitis. The urine answered to Trommer's test, gave an 



i 



DISEASES OP THE KIDNEYS, DIABETES, ETC. 121 

')saz(iu with plienylhydraziii, the crystals having a melting- 
point of 204-205°. On examination with the polarimeter, the 
urine was found to be levo-rotatory. On separating the carbo- 
h3xlrate from a large quantity of urine, it was found to answer 
to all the reactions of levulose. 

IV.— DIURETICS. 

"il. Urea as a diuretic. 

Klemperer {Berlin, klin. Wocliensckr., 1896) has strongly recom- 
mended the internal administration of urea as a diuretic on the 
ground that it is the natural diuretic. Thus in recent ascites, 
whei'e he prefers the use of the diuretic agents to tapping, the ad- 
nunistration of urea gave satisfactory results, the diuresis being 
marked. Urea he also considers indicated in the uric acid 
diathesis, as first recommended by Rosenfeld (Centralbl. fur klin. 
Med., 1895). Urea is a good solvent of uric acid, and Klemperer 
obtained better results with it in uric acid gravel, stone in the 
kidney, etc., than with piperazine or lysidin. Klemperer now re- 
cords further residts (Deutsch. med. Wochenschr., 1896, No. 47), and 
still claims that in ascites and dropsy irhere tlie kidneys are sound 
urea has a valuable and marked diuretic action. Kohn (Zeitschr. 
fiir IJeilk., 189 o), however, did not obtain such good results, though 
in his series of cases the kidneys were sound. The drug was tried 
in four cases of hepatic cirrhosis with ascites, two cases of pleurisy 
with effusion, one case of pericarditis with effusion, one case of 
tuberculous ascites, one case of ascites from carcinoma, and 
one case of ascites from cardiac disease. The urine passed in 
twenty-four hours was carefully measured, and the specific gravity 
taken. The eftects of urea on the kidney excretion were 
compared with the effects of other recognised diuretics, such as 
diuretin, digitalis, calomel, and salicylate of soda. From his ob- 
servations Kohn concludes that the action of urea is uncertain. 
Any action produced seemed to be through stimulating tlie 
secreting mechanism of the kidney. 

Bettman [Berliner klin. Wochenschr., 1896, No. 49) discusses 
Klem[)erer's results, and gives his own experience in the Heidel- 
berg cliin'c, where the remedy was tried in twelve cases (three 
cases of liver cirrhosis with marked ascites, four cases of one- 
sided pleurisy w^ith effusion, and five cases of dropsy). The remedy 
was given in doses of 150 gr. per diem in a watery solution, and 
was gradually increased to 300 gr. per diem after three to five 
days. The patients took on an average 900 gr. during the first five 
days. An increased diuresis during the prolonged consumption of 



122 TIIK YEAU-1500K OF TREATMKNT. 

ui'ea was only iiotia^iLle in three cases, and in three cases it could 
be accounted for without r(;ference to the urea. Tin; drug proved 
itself neither a rapidly acting nor an etHcient diuretic. 

v.— MISCELLANEOUS. 

H'i. Keiial pniii. 

Ralph i^Transactioiis of the Medical Society, London, vol- 
xix.), discussing nephralgia where distinctive symptoms are absent) 
divides the condition into four varieties : — 

(1) Reflex nei've disturbance, giving rise to kidney pains. As 
examples, the author quotes three cases of aortic disease where, as 
first described by Ilabershon, the pain, severe and colicky in 
character, radiated down into the right hypochondriac region 
The urine was, as in the other instances, normal in character and 
cpiantity. A like condition may be seen in aneurysm of the thoracic 
or abdominal aorta, all the symptom? of renal colic being present, 
without any of the recognised signs. The same condition ot 
simulated renal colic may be seen in some delicate women as the 
result of scybala in the colon. 

(2) The second variety is described as the ''aching kidney." 
It is generally associated with movable or floating kidney. This, 
however, is not always the case, for an aching kidney may be met 
in young ladies where no mobility of the organ can be detected. 
There are severe pain and tenderness over the right kidney, the 
organ at times being enlarged and palpable. The cause of the 
condition is to be found in tight corsets pressing down the liver. 
On active exercise a certain amount of perinephritis is set up, with 
acute symptoms. The condition is difficult to ti'eat. If the 
patient consent to remain at rest for a month, all may go well ; but 
if not, on lising from the recumbent posture, aching pains occur 
daily in the aftected organ. A slight purulent deposit may 
appear in the urine, and an increased proportional amount of urea 
and the deposit of oxalate of lime crystals. 

(3) Gouty paroxysm of the kidney, a true paroxysmal gout 
affecting the kidney, and difficult to distinguish from nephritis on 
the one hand and renal colic on the other. The attacks are of 
sudden onset, the pain and tenderness being, as a rule, confined to 
one side. There is pain on micturition, the urine is loaded with 
uric acid crystals, and some blood corpuscles and leucocytes are 
present. Between the attacks the urine is normal. The condition 
yields to gouty treatment. 

(4) Diseases of the kidney. Under this heading the autlior 
includes cases of doubtful diagnosis on the border-line between 



DISEASES OF THE KIDXEYS, DIABETES, ETC. 123 

medicine and surgery, but not giving rise to determinate symptoms 
in the ui'ine or to a tumour in the Hank, so that no more tlian 
suspicion is ai'oused. Illustrative cases ai'e quoted of obscure 
cases of suppression of urine with pain and other conditions wliere 
the diagnosis was doubtful. 

Hurry Fenwick [Trans, ^fed. Soc, London, vol. xix.) divides 
renal pain from non-suppurative renal stone into two classes : 
(1) where the stone produces irritation of the cortex; (2) where 
the stone produces irritation of the pelvic mucous membrane. 
In the first class of case the stone is lodged in a cavity in the 
cortex of the kidney almost under the cap.sule. The pain is then 
felt at the angle which the last rib forms with the erector spinte. 
It is strictly localised, and can be elicited by percussion, sucous- 
sion, or exercise It is liable to exacerbations, but never radiates 
downwai'ds towards the testis. Tliere are no colics ; the urine is 
normal, and blood may never be noticed. The pain is relieved by 
the recumbent posture. The position daring sleep may be typical 
— the patient sleeps on the affected side. If he should turn 
during sleep on to the sound side, he is awakened by the 
pain. 

In the second class of case, where the stone is loose, and pelvic 
irritation and ureter obstruction are produced, the pain is colicky, 
and radiates to the neck of the bladder, the groin, the testicle, 
and the thigh. The urine varies in quantity, and bladder irrita- 
tion occurs. When asleep, the patient lies upon the sound 
side, so that the affected kidney may be exposed to no 
pressure. 

The author admits that there are some cases which do not fall 
under these two gx'oups, the symptoms partaking partly of both 
primary classes. The symptoms of one or other class may pre- 
dominate in proportion as the stone is situated the nearer to the 
cortex or the pelvis. 

mwitz (^Therap. Gazette, No. 4, 1897) records four cases where 
all the symptoms of renal calculus were present, but on operation 
no stone was discovered. Recovery was complete after operation, 
the pain entirely disappearing. He conjectures that in these 
cases there must have been a mobility of the kidney too slight 
to be detected by palpation. 

23. The treatment of nephritic colic. 

Mantoux [Lyon Mkl, Nos. 12, 13, and 14, 1897), discussing 
the treatment of renal colic during the crisis, remarks that the 
object to be aimed at is the arrival of the stone in the bladder. 
This object may be aided in two ways : (1) by urging the stone 
downwards ; (2) by making a way before it. 



124 THK YKAH-liOOK OF TURATMENT. 

Propulsion lowai'ds the hiaddci- may hi: (employed citliiM* liy 
produciiiL,' ris a (^'rt/o, or ])y augmenting the secretion of urine, or 
l)y exercising direct pressure. Diuresis may bo procured by 
administering large quantities of diuretic infusions and decoc- 
tions ; but it must always be reniemljered that the method is only 
applicabl(> within certain limits, and there is always the risk of 
increasing the tension within the kidney and thus favouring the 
dilatation of the ureter. The method should be used only in the 
slighter forms of colic. The method of exercising direct pressure 
by massage of tlie abdomen the author considers impracticable in 
most cases, on account of the anatomical relations of the ureter 
and the tenderness of the parts. When practicable, it must be 
regarded as by no means free from danger. 

The second method of -obtaining the passage of the stone by 
preparing a way for it consists in inhilnting the contractions of 
the ureter which prevent the stone from passing downwards. 
Different means may be used for this end. 

Poultices, sinapisms, frictions, etc., have been tried, and have 
fallen into disuse. The best that can be said for them is that 
they are inofiensive, please the patient, calm liis impatience, 
and gain time. Cupping, dry or wet, is useful and rapid in 
action, but the patient is apt to dread the procedure. Heat is 
a powerful agent for relief of the pain, but should not be applied 
in the form of a damp stupe, which may become displaced by the 
patient in his movements necessitated by the pain, and is objec- 
tionable on account of its weight. Much to be preferred is a 
bag filled with heated bran, or, more simply, a cataplasm of wool 
in layers heated before the tire or in the oven, applied to the 
region of the pain, and fixed in position with a bandage. The 
heat is kept in, the skin is not irritated, and the elastic pres- 
sure aids the action of the heat. The rubber hot bottle is too 
heavy to be used with advantage. Prolonged hot baths are of 
great value in aiding the expulsion of the stone, and also aiding 
the diuresis produced by the decoctions. The temperature of the 
Ijath should not V)e below 93° F., and, indeed, unless contra- 
indicated by extraneous circumstances, can with benefit be raised 
to 100°-104° F. Careful supervision must, however, be exercised. 
A patient with nephritic colic, while in the bath, must be con- 
tinuously under observation. Antispasmodic decoctions, such as 
henbane, added to the bath, are not to be des})ised, owing to 
their soothing efiect on the genei'al condition of the patient. 
The application of sedative liniments and ointments has but 
little efiect. Sedatives should be employed internally — opium 
in its various preparations, belladonna, henbane, ether, chloral. 



DISEASES OF THE KIDNEYS, DIABETES, ETC. 125 

If liquids are not retained, powders in small volume may be 
tried, thus : — 

I^'' Morphina^ riydi'ochloratis ... ... ... gr. tis 

Pulv. Belladonna) ... ... ... ... gr. 5 

Sig. One to be taken evei-y quarter of an hoar. 

Antipjn'iu lias proved unsatisfactory on account of the difficulty 
which the stomach has in I'etaining it. When the stomach will 
not tolei'ate draughts, powders, or pills, the rectiim should be 
used. Suppositories of belladoinia and morphia can be adminis- 
tered. The tolerance for belladonna during the crisis is very 
great, the author stating that he has seen 12 grammes (18.5 grains) 
taken in twelve hours without any inconvenience. Enemata are 
superior to suppositories, as they are more easily prepared and 
more rapid in their action. The bowel is first cleared out by a 
simple enema, with the sedative enema to follow. 
The following formula has proved very useful : — 

^ Chloral Hydrate ... ... ... ... gr. xxx-lx 

Antipyrin ... ... ... ... ... gr. xxx 

The yolk of one egg- 
Milk ... .". jiijss. 

Fiat enema. 

The effect is rapid and complete. In ten to fifteen minutes the 
pain diminishes, and the patient falls asleep. The unpleasant 
effects which follow the administration of mor])hia are not notice- 
able. In very extreme cases the inhalation of chloroform or ether 
may be made use of. 

The hypodermic injection of morphia occupies the first place 
in the treatment of renal colic, on account of its rapidity of action 
and the certainty of its effects. The initial dose should not exceed 
yo of a grain, and may be repeated in a quarter of an hour. The 
author advises the combination of atropine with the morphia, to 
minimise the after-sickness. No other remedy given hypodermic- 
ally can compare with morphia. Antipyrin and cocaine have 
given good results in some cases, but the hypodermic injection of 
antipyrin is accompanied with considerable pain. 

34. Incoiitiiieiice of iiriiic in rliildroii. 

Coutts {2'reatment, No. 13, Sept. 9, 1897) speaks highly of 
lycopodium in the treatment of nocturnal enuresis in chikh'en. 
While belladonna acts by paralysing the detrusor muscle of the 
bladder, lycopodium seems to exert a selective sedative action on 
the vesical mucous membrane. The drug is best exhibited in the 
form of the tincture, commencing with a dose of twenty drops 



12G 



THE YKAK-liOOK OF TliKATMKNT. 



tlirec times daily, and gnidually increasing the dose up to a 
dniclnii twice daily. 

Betschinski (,S7. Patter sbitry. mod. Wochenschr., 1890) advises 
inassagci pci-foruied per rectum in the treatment of nocturnal 
enuresis. The treatment need only be menti(m(!d to he con- 
demned. 

'1^. <^iiiiiitit:itiv4> c'«»tiiii:ifioii of albiiiiiiii. 

Wassiliew (^bY. Peter dmrycr med. Worheuschr., No. 37, liSOG) 
compares the different methods for the estimation of albumin in 
the urine, and describes a titration method for which he claims 
great accuracy. A known quantity of urine was taken and 
titrated with a 25 per cent, solution of salicyl sulphonilic acid. 
As an indicator to show when all albumin had Ijecome pre- 
cipitated and free salicyl sulphonilic acid was present, " Echt- 
gelb " was used. "Echt-gelb" is one of the aniline dyes, a 
weak solution of which is straw-coloured, but in the presence of 
free salicyl sulphonilic acid assumes a brick-red tint. It was 
found that 1 c.cm. of a 2.5 per cent, solution of salicyl sulphonilic 
acid precipitated 0-0 1006 gramme albumin. In carrying out the 
estimation 10 or 20 c.cm. of urine are taken, and, if dark- 
coloured, diluted with distilled water, 2 drops of a 1 per cent, 
solution of " Echtgelb " are added, and the mixture is titrated with 
a 25 per cent solution of salicyl sulphonilic acid till a brick-red 
colour is obtained. The number of c.cm. of the acid solution 
used gives the amount of albumin, which can easily be calculated 
in percentage. In carrying out tlie process, the urine, if alkaline, 
must be first treated with acetic acid. 

[The test is by no means as accurate as Wassiliew claims. If 
bile be present as well as albumin, the colour reaction is difficult 
or impossible to obtain. At other times, probably from the 
presence of varying amounts of acid salts in the urine, the results 
ol)tained by this test are quite at variance with results got by the 
gravimetric and other reliable methods of estimating albumin in 
the urine.] 

30. Peptone in urine. 

Bogomolow and Wassiliefif (Centralb. filr med. Wissensch., No. 3, 
Jan. 16, 1897) discuss the different methods for estimation of 
peptone in the urine. They find that the preliminary use of 
saturation with ammonium sulphate to precipitate other proteids 
interferes with the peptone reaction in the filtrate. They advise 
that any albuminous bodies present in the urine be first pre- 
cipitated with trichloracetic acid, and the filtrate then tested with 
the biuret reaction, when, if peptone be present, a beautiful rose- 
pink reaction is obtained. 



DISEASES OF THE KIDNEYS, DIABETES, ETC. 127 

'J7. iYl4>tlio<1 4»r «listill^'lliKllill;;' albiiiiiigi and |»r|»- 
toiK' \\ lion |>i'<><i«4'iit lo^^otlior in tlio iiriiK'. 

Jaworski (Z« Medecine Jloderne, 1897, No. 18) advises tins 
following- procedure : The urine is saturated with bicarbonate of 
soda and then filtered, evaporated to a third of its volume, shaken 
with amy lie alcohol, and then neutralised with citric acid. To 
4 c.cra. of this mixture a drop of ammonium molybdate solution 
is added. If the urine contains albumin or peptone, a precipitate 
forms. The fluid is then warmed and filtered ; while warm any 
peptone will pass through into the filtrate to reprecipitate on 
cooling, while the albumin remains undissolved. 

3§. Test for tlio bile 3>ig^nient$ in nrine. 

Jolles I^ZeitscJir. filr pliysiol. Gliemie, N^'ol xx., No. 5) describes 
a modification of his test for bile pigment for which he claims great 
delicacy. 50 c.cm. urine are mixed with 5 c.cm. of a 10 per 
cent, barium chloride solution and chloroform in a separation 
funnel. The chloroform and the precipitate which forms are then 
easily separated, and the chloroform can be removed by evaporat- 
ing over a water bath. If, then, a di-op or two of strong sulphuric 
acid be allowed to fall upon the residue a characteristic green and 
blue ring forms if bile pigment be present. 

29. ^>iv test for blood in the tirine. 

Zakarias Donogany [Virchow's ArcJdv, Vol. 148) describes a 
new method for the recognition of blood pigment in the urine. 
Ten cubic centimetres of mine ai-e taken in a test-tube and 
1 grannne of ammonium sulphate, and an equal quantity of 
pyridin are added. Instead of the addition of ammonium sulphate, 
the urine may be rendered strongly alkaline with caustic soda 
solution. On mixing the fluid, reduction occurs immediately, and 
if blood be present the mixture assumes a more or less intense 
orange-red colour, which is characteristic. If the urine contain 
only a little blood, it is advisable to examine the fluid in the test- 
tube by looking through it vertically against a white gi'ound, the 
fluid first having stood to allow the coloured precipitate to fall. 
The fluid reduces blood-colouring matter to hpemochromogen, 
Avhich can be submitted to spectroscopic examination if the colour 
be so faint as to be unappreciable to the eye. The author claims 
that the method is very simple and extremely sensitive. 

30. Serum treatment of urinary infeetion. 
Albarran and Mosney (Annales des Maladies des On/anes Genito- 

Urinaires, No. X., Oct., 1896) discuss the treatment of genito- 
urinary infection by the injection of the serum of animals rendered 
immune against the bacillus coli communis. In preparing the serum 
three methods were used : (1) The inoculation of living cultures. 



128 THE YEAK-liOOK OK TKKATMENT. 

This method, it was found, did not produce :i total and persisting 
immunity, and there was risk to the life of the animal injected, 
and, as secondary suppurations were frefjuently set up, the serum 
obtained could not be used. (2) The second method consisted in 
the inoculation of the filtrate of the macerated organs of animals 
which had died from the infection of the bacillus coli. These 
filtrates produced constant but very variable toxic phenomena. 
(3) The third and best method consisted in a combination of the 
first two, the alternate use of filtrate and virulent culture 
inoculations. By this method a serum was got which liad a 
strong protective action against the bacillus coli infection. 

The toxins of the bacillus coli produced in animals a ccmstant 
rise of temperature, varying with the dose of the toxin Mdminis- 
tered. Clinically there may be no fever present in those affections 
of the urinaiy tract where bacillus coli is present, but, given a 
breach of continuity of the mucous surface, and elevation of 
temperature will follow absorption of the toxin. 

The authors used the serum in infection of the urinary tract 
in man, and obtained good results. In addition to subcutaneous 
injection they advise the injection of diluted serum into the 
bladder in septic conditions, and anticipate good results from the 
method. 

[The method may hold out good prospect of success in cases 
whei'e the infection is due to the bacillus coli communis, but other 
organisms are found in urinary infection. Thus Richta, in 22 
cases of cystitis found the bacillus coli 11 times, and in three of 
these cases other bacilli were present. In five cases proteus 
vulgaris was present in pure culture. Again, Van Graf (Deiitsch. 
vied. Wochenschr., 1896, No. 38) records two cases of pyonephritis. 
In one, examination showed a small number of bacilli coli in pure 
culture, but the second gave an organism which has not hitherto 
been described, which, however, belongs to the same class as 
bacillus coli. The organism was highly pathogenic in the case of 
guinea-pigs and mice.] 



GOUT, RHEUMATISM, AND EHEUMATOID 
ARTHRITIS. 

By Aechibald E. Garrod, M.A., M.D., F.E.C.P., 

Assistant Physician to the Hospital for Sick Children, Great Ormond Street; Medical 
Registrar and Demonstrator of Morbid Anatomy at St. Bartholomew's Ilospital. 



1. Oont. 

The chemical pathology of gout was selected by A. P. Luflf 
as the subject of his Gulstonian lectures for 1897 {Lancet, 1897, 
vol. i., pp. 857, 942, and 1069). After discussing the various 
theories which have been from time to time adv^anced in ex- 
planation of the phenomena of the disease, he proceeded to give 
an account of certain experimental investigations which he had 
carried out with the view of thi'owing further light upon some 
of the dark places of its pathology. 

The fir.st series of observations related to the occurrence of 
uric acid in the blood of men, mammalian animals, and birds. 
The blood to be examined was allowed to flow directly into its 
own volume of rectified spirit, to which 2 per cent, of formalin 
had been added. The mixture was thoroughly shaken and after- 
wards evaporated upon a water bath. The powdered residue was 
then extracted by boiling for half an hour with distilled water. 
After evaporation to a small bulk and filtration the Gowland 
Hopkins method for the estimation of uric acid was applied to 
the extract. It was found that when uric acid in known quantity 
was added to blood in which previously no uric acid was found, 
from 80 to 87 per cent, of the quantity added could be recovered 
by this means. Luflf was unable to detect uric acid under normal 
conditions either in the blood of birds or mammals, and, seeing 
that birds excrete large quantities of ammonium urate, he holds 
that it can hardly be objected that in them the quantity present 
may be too small for detection by the method employed. He 
further confirms Sir A. Garrod's observation that the blood of 
birds, although free from uric acid, contains urea. 

Lufl" thei'efore concludes that under normal conditions uric 
acid is formed in the kidneys alone, probably by the conjugation 
of urea and glycocin, but he holds that in such diseases as 



l-'''^' TIIR YKAR-nOOK OF TRKATMENT, 

leucocythseniia part of the excess of uiic acid excreted has a 
ditierent oi'igin, being formed from nuclein. 

The accumulation of urate in the l^lood in gout he ascribes 
to deficient excretion by the kidneys and consequent al.-sorption 
from these organs, and he accepts the view that uric acid circu- 
lating in the blood as a soluble quadriurate has no toxic action, 
the morbid phenomena of gout being due to its deposition as 
sodium biurate in the tissues. 

A further series of experiments showed that the solu})i]ity of 
uric acid in the blood is not affected Ijy diminished alkalinity due 
to the addition of an organic acid ; that diminished alkalinity of 
the blood does not hasten the deposition of sodium biurate or 
diminish its solubility. 

Of special interest from the point of view of treatment are 
certain experiments which show that the mineral constituents of 
meat, milk, and vegetables respectively, differ remarkably in their 
influence upon the solubility of sodium biurate and upon the 
decomposition of the quadriurates. Whereas distilled water took 
up 1-10 per 1,000 of sodium biurate, and water with 1 per cent, 
of meat ash in solution 0-93 per 1,000, water containing 1 per 
cent, of vegetable ash (from potatoes, spinach, and beans) dis- 
solved no less than 2- 15 parts per 1,000. Again, whereas a 
solution of quadriurate in distilled water began to deposit 
crystals of uric acid at the end of half a minute, and a O'l per 
cent, solution of meat ash in one minute, the deposition of crystals 
from a 0. 1 per cent, solution of vegetable ash only began at the 
end of two hours. 

Luff further suggests that the gout-producing properties of 
certain wines are not due to their acidity, but more probably to 
their effect upon hepatic metabolism. The etherial salts to which 
old wines owe their bouquet did not, when extracted, hasten the 
decomposition of the quadriurate or diminish the solubility of the 
biurate. 

In three interesting but long papers, of which lack of space 
forbids lengthy abstract here, C. Mordhorst discusses the deposition 
of urates in the tissues of gouty patients. (Zeitschr. f. klin., 
Med., 1897, vol. xxxii., p. 65 ; Virchoid's Archiv, 1897, vol. 
cxlviii., p. 285; Verhandlungen des Cong. f. innere Med., 1896, 
vol. xiv., p. 405.) 

He states that when ui'ic acid is added to an alkaline fluid the 
base combines with it to form a urate, and that when, for any 
reason, the liquid becomes saturated with the urate so formed it 
is thrown down in the form of minute spherules which grow by 
accretion. The constitution of such granular urates (kugelurate) 



GOUT AND RHEUMATISM. 131 

\ aries according to the amount of alkali present, and when de- 
posited in the tissues they become converted in time into the 
crystalline biurate. Saturation with urate is brought about 
either : — 

By addition of more uric acid ; 

By removal of the water in which the urate is dissolved ; 

By cooling of the solution ; or 

By reduction of its alkalinity. 
Mordhorst dissents completely from Ebstein's well-known view 
that necrotic changes precede the deposition of sodium biurate in 
the tissues, and attributes the turbidity of the corneie of rabbits 
which Ebstein observed after the injection of a solution of urate 
to the deposition of granular urate in the tissue. 

He holds that under unfavourable conditions the fluids of the 
tissues liable to gouty inflammation may become neutral or even 
acid in reaction, and that the granular urate, which he believes to 
be always first deposited, or even sodium biurate itself, may con- 
sequently undergo decomposition with the formation of crystals 
of free uric acid, which may block even the larger lymphatics of 
the part, and so set up an acute gouty inflammation. Since, 
however, the acidity of the affected tissues can only be tem- 
porally, the free ciystalline uric acid will be reconverted into 
granular urate when alkalinity is restored, and ultimately into 
sodium biurate, which forms the basis of the crystalline gouty 
deposits. 

On this view the inflammatory process may be regarded as 
curative, since it causes an increased flow of alkaline blood 
through the part and encourages osmotic interchange between the 
focus of inflammation and the neighbouring capillaries. 

In a paper entitled " The Uiic Acid Diathesis : Are we to 
Continue to Believe in It? " (Edin. Med. Jourji., 1897, n.s. vol. ii., 
p. .3-5) A. Haig entirely discredits the existence of a uric acid diathesis, 
which he defines as a supposed tendency to excessive formation of 
uric acid. He attributes any excess of uric acid present in the 
body simply to its introduction in the food, and asserts that it is 
easy to show that a man on ordinary diet may put into his mouth 
as much as 6 to 8 gr. of uric acid each day. He states that uric 
acid is introduced into the body in the dead tissues of all animals, 
their extracts and decoctions, and in the alkaloids of tea, coflee, 
and cocoa. By putting a patient who suffers from symptoms due 
to uric acid upon a diet which introduces no uric acid Haig has 
found that when, in the course of a year or eighteen months, the 
previously stored up acid has been eliminated all the symptoms 
to which its presence gives rise disappear. 
J 2 



132 THK YKAIl-ROOK OF TREATMENT. 

Ill a paper in the Clmjs Hasp, lieports, 1895, vol. lii., p. 115, 
J. Fawcett gives the rtisults of tlie oxaminatiou of the urin«^ in a 
.seii(!s of cases of gout. He found the amount of uric acid excre- 
tion (which was estimated by the Gowhmd llojikins metliod) to 
be very variable, but in the majority of cases it was below the 
average of h(!althy people on a like diet. During acute attacks an 
increased excretion was observed, usually most marked towards 
tlie end of tlie attack. The uric acid excretion did not vary 
inversely with the acidity of the urine, nor was tliere any definite 
relation between the amount of urine passed and the uric acid 
excretion. 

As a rule, no increase of uric acid excretion followed the 
administration of colchicum, and an increase observed in two 
cases could be attributed to the supervention of acute attacks 
of gout. 

Fawcett confirms Haig's observation that the outj)ut of uric 
acid is markedly increased by the administration of sodium 
salicylate, but he does not agree with tliat observer in attributing 
this to a clearing away of retained uric acid, because when this 
drug is given the excretion, after suddenly rising, may remain 
high, and may sometimes reach an even higher point during its 
continued administration. In two cases in which the leucocytes 
in the blood were counted before and during the administration of 
salicylate no conspicuous alteration in their number was observed. 
This last observation bears upon the suggestion of Bohland 
{Centralb.f. innere Med., 1896, vol. xvii., p. 70) that the salicylate 
causes an increased out[)ut of uric acid, by producing leucocytosis, 
and consequently an increased breaking down of nuclein. 

His {Berliner klin. Wochenschr., 1896, voh xxxiii., p. 70), who 
studied the uric acid excretion in seventeen cases, obtained 
regular results in all but three. He found that the acute attack 
was preceded by a diminished excretion followed by an increase 
to aljove the normal limits in the course of a few days. When 
attacks followed one another in rapid succession, this series of 
events was apt to be shortened or altogether masked. 

Further observations have failed to confirm the opinion 
of Kolisch (see "Year-Book," 1897, p. 124), who, having found an 
increase of alloxuric substances (xanthin bases and uric acid) in 
the urine of gouty patients, based upon this an elaborate theory 
of the pathology of gout. 

His, in the paper above referred to, states that he was unable 
to find any definite relation between gout and the alloxuric excre- 
tion. Laquer {Verliandlungen des Cong./, innere Med., 1896, vol. 
xiv., p. 33) also failed to detect any constant increase of alloxuric 



GOUT AND RHEUMATISM. 133 

substances in the urine in this disease, or any constant increase 
in tlie lelative proportion of xanthin bases to uric acid ; and 
Mafatti ( IViener klin. Wochenschr., 1896, vol. ix., p. 723) was equally 
unsuccessful in detecting any excessive alloxuric excretion beyond 
the physiological limits. 

On the other hand, Laquer confirms the observations of Vogel 
and Schmoll, who found a well-marked diminution of the total 
nitrogen excretion in gouty patients, who in this respect resemble 
sufferers from renal disease. 

An interesting survey of the older and of the more recent treat- 
ments of gout is given by M. Sternberg (Deutsche med. Wochenschr., 
1897, vol. xxiii., p. 167). He states that in Germany all are agreed 
that alcohol should be forbidden, and considers that the distinctions 
drawn in France and England between the various alcoholic 
liquors as regards their injurious influence in gouty cases rest 
upon no sound basis. 

It is curious to find colchicum spoken of as an almost forgotten 
specific which was largely used in the first quarter of the present 
century, and the value of which might profitably be tested 
afresh. 

His general conclusion is that, in spite of the researches of 
recent years, little progress has been made in the treatment of 
this disease. 

In a paper on Piperazine (Gity's Hosp. Hejmrts, 1894, vol. li., 
p. 67) J. Fawcett discusses the solvent action of this drug upon 
uric acid calculi, its value in the treatment of gout, and its 
effect when administered to birds in which ui'ic acid deposits had 
been induced by injections of chromic acid. 

His investigations led him to the following conclusions : — 

(1) After the administration of piperazine in 15 gr. doses 
daily, the urine is useless as a solvent of uric acid calculi, and 
although a watery solution of piperazine (about 1 in 1,000) has a 
marked solvent action, a solution of piperazine in urine of the 
same strength is quite devoid of solvent action (see M. Mendel- 
sohn, "Year-Book," 1894, p. 161). 

(2) He reports as unfavourably upon its action in gouty cases. 
He found no constant increase in the uric acid excretion under 
its use, nor in most cases was any relief of pain obtained in the 
acute stages. In two cases attacks of acute abdominal pain, 
resembling renal colic, followed the admiuisti-ation of the drug. 

(3) Lastly it w^as found that in pigeons injected with chromic 
acid the simultaneous administration of piperazine^ did not pic- 
vent the deposition of urate. 

W. Armstrong [Lancet, 1897, vol. ii., p. 1 1) has seen great benefit 



134 THE YEAU-BOOK OF TKKATMENT. 

from an exclusively red-meat diet in certain selected cases of 
chronic gout. The diet consists in the early stages of 2-4 lbs. 
of minced beef-steak gently heated to brownness, the whites of 
several poached eggs, with a very scanty allowance of well-toasted 
bread and several pints of water at 100" to 120' F. daily. At a 
later period of the course a little variety within rigid limits is 
permitted. Full details will be found in the paper referred to. 
The course lasts from four to twelve weeks. Armstrong's ex- 
perience leads him to regard the following as indications for 
the adoption of this treatment : — 

(1) Obstinate and refractory chronic gouty arthritis. 

(2) Recurrent uric acid calculi. 

(3) Frequent and intractable migraine. 

(4) Obstinate gouty dyspepsia ; 

more especially if these conditions be attended by amylaceous and 
intestinal dyspepsia with acidity, pyrosis and flatulence, heaviness 
and irritability after food, excessive formation of sulphuretted 
hydrogen in the intestine, persistent lithiasis, oxaluria, excess of 
indican, a purple or red reaction of tlie urine with nitric acid, 
or a wine-red reaction with ferric chloi'ide. 

In cases with damaged kidneys or a weakened heart he con- 
siders that exceptional care should be taken, and that many such 
cases are quite unfit for the treatment. 

Armstrong is inclined to attribute the favoui'able results to a 
more perfect digestion of the food taken, to diminished fermenta- 
tive changes in the intestine, and to flushing by the hot water taken 
— in a word, to the cessation of a pre-existing auto-intoxication. 

In conclusion, he insists upon the irksome and trying character 
of the treatment ; its limited application ; its uselessness if not 
strictly carried out, and the necessity of a careful selection of 
cases ; its unsuitability in most cases with persistent albuminuria 
or organic heart disease ; and, lastly, the great improvement 
which may result from it in suitable cases. 

T. Lauder Brunton (Practitioner, 1896, vol. Ivii., p. 48) calls 
attention to the value of bromide of potassium and salicylate of 
sodium in the treatment of the irritable temper so often met with 
in gouty persons as well as in suff'erers from cardiac disease. 

W. Knowsley Sibley (Lancet, 1897, vol. ii., p. 88), whose results 
with the Tallerman hot-air baths in the treatment of rheumatoid 
arthritis were referred to last year (see "Year-Book" for 1897, 
p. 135), speaks equally favourably of their effect in gouty cases. 
In cases of acute articular gout so treated, the local pain and 
congestion were quickly relieved, and although in some cases the 
disease appeared in a second joint, these secondary attacks also 



GOUT AND RHEUMATISM. 135 

quickly yielded to the treatment. The duration of the attacks so 
treated was considerably less than that of previous attacks in 
the same patient. The results obtained did not appear to be in 
any Avay attributable to drugs simultaneously administered. 

In very chronic cases in which there were tophaceous deposits 
around the joints, such deposits diminished in bulk or disappeared 
under the treatment. Sibley quotes the results of some observa- 
tions carried out in the clinics of Landouzy and Dejerine, which 
were published by Cretien [La Presse Medicate, 1896, Dec. 26). 
It was found that a series of liot-air baths caused an increased 
elimination both of ui'ic acid and urea in the urine, as well as of 
all salts, and especially of chlorides. 

Taking these obsei'vations in conjunction with the solvent 
effect upon tophaceous deposits which he has observed, Sibley 
draws the inference that it is desirable, during the course, to 
assist the kidneys to act as freely as possible. He attributes the 
diminution of the tophi to the increased circulation in the part 
which results from the local application of the heated air. 

Any resume of the literature of the year would be very incom- 
plete which did not refer to the appearance of W. Ewart's work on 
" Gout and Goutiness," and to Sir William Roberts's article on Gout 
in the third volume of Professor Allbutt's '-'System of Medicine." 

2. Kheuinatisiii. 

Achalme, who in 1891 obtained and cultivated a bacillus from 
the heart and pericardium of a patient who succumbed to an 
attack of rheumatic fever, has recently found an identical 
bacillus from a second case (C. R. de la Soc. de Biologie, 1897, 
iv., p. 270). It was found abundantly in the pericardial fluid, 
heart's blood, iliac veins, and cerebro-spinal fluid, but not in 
the synovia of the affected joints. J. Thiroloix (ibid., p. 268) 
has also obtained a similar organism from blood removed 
during life from the veins of patients suffering from acute 
i-heumatism. The bacillus, which is described as large and of 
slight motility, is stained by Gram's method. It is rapidly fatal 
to guinea-pigs, kills rabbits only occasionally, and is innocuous 
to the rat and mouse. 

F. Steiner (Deutsches Archiv f. klin. Med., 1897, vol. Iviii., 
p. 237) gives brief notes of thirty-five cases of rheumatic fever 
in which there was tenderness over nerve trunks and pain along 
their course, which he is inclined to attribute to an inflam- 
mation of the nerve sheaths comparable to that of the pericardium 
and pleura. The observed phenomena could not be ascribed to 
mere extension from the inflamed joints, for the pei'ineuritis was 
sometimes much more extensive than the articular lesions, and 



136 TUK YEAK-UOOK OF TKKATMENT. 

the nerves were sometimes affected in limbs the joints of wliich 
hiul escaped. Steiner also thinks that in many instances the so- 
called rheumatic muscular paralyses have this origin, and also 
arthritic muscular atrophy in so far as disuse will not account 
for it. Females were more often attacked than males, but age 
did not appear to exert much influence upon the development 
of perineuritis. 

Steiner recommends the administration of potassium iodide 
with salicylate in these cases, and for the relief of pain in the 
nerves, when it is very severe, lie prescribes antifebrin, antipyrin, 
or salipyrin. 

L. Bergamaschi (// Alorgagni, 1896, vol. xxviii., p. 623) has ob- 
tained very satisfactory results from the intra-muscular injection 
of calomel in cases of acute and sub-acute rheumatism. The 
drug is injected, with strict antiseptic precautions, in doses of 
10-15 centigrammes, intimately mixed with about a gramme of 
vaseline oil. In mild cases, without complications, a single injection 
is usually sufficient, but in severe cases it may require to be 
repeated. The chief claim which Bergamaschi makes for this treat- 
ment is that it tends to control the endocardial lesions, and in 
cases of first attacks with signs of incipient endocaixlitis these 
signs tended to disappear after the injections. In simple cases, in 
which the only local manifestations were in the joints, the drug 
acted promptly, and the symptoms tended to disappear in a few 
days. 

M. Lannois and G. Linossier {Lyon Med., 1896, vol. Ixxxiii., 
p. 75), who have made experiments upon the absorption of drugs 
when applied to the healthy skin, consider that the amount of 
absorption is chiefly dependent upon the volatility of the drug. 
They found that the methyl salicylate, which constitutes 90 per 
cent, of the oil of winter-green, is well absorbed, and appears, 
to a large extent, in the urine as salicylic acid. 

They have treated cases of rheumatism and other articular 
diseases by such applications, carried out as follows : — A large sheet 
of guttapercha tissue is passed under the joint, and the salicylate 
is directly applied by means of a drop bottle ; the tissue is then 
brought up so as to surround the joint, and is enclosed in some 
cotton wool and a bandage. When a large dose is gi^'en a 
piece of gauze may be laid upon the skin to suck up the salicylate 
of methyl, which is a liquid which boils only at 222° C, but emits 
vapour even at a low temperatui^e. If the wrappings are care- 
lessly applied, so that the vapour escapes, its effects are not 
observed, and salicylic acid does not appear in the urine. The 
dose employed is from 1 to 4 grms. daily 



GOUT AND RHEUMATISM. 137 

In acute rheumatism the results obtained were comparable to 
those with sodium salicylate given by the mouth, and were very 
satisfactory. In rheumatoid arthritis remarkable relief of pain 
was observed, but was almost confined to the joint treated. 

Further favourable results with this treatment have also been 
recorded by G. H. Lemoine [Bull, et Mem. soc. Med. des Hop., 
1897, 3^, xiv., p. 678), and Armand Siredy (ibid., p. 688). 

The advantages claimed for this treatment are : — (1) That it 
causes no digestive disturbance such as is not infrequently pro- 
duced by salicylate of sodium ; (2) that in doses of 4 grms. daily 
it causes no toxic symptoms such as malaise, giddiness, and tin- 
nitus ; (3) that it has the advantages of a topical application 
to the seat of pain. 

Beyond the care required for the satisfactory application of the 
drug, the only disadvantage appears to be its smell, which Lannois 
and Linossier describe as agreeable, but which Siredy says often 
becomes insup[)ortable after a ft^w days. It is less marked the 
more carefully the application is made. 

Lemoine has used the salicylate in doses up to 12 grms. in the 
twenty-four hours, and found that with larger doses than this 
there was not apparently any increase in the amount absorbed. 

Among the more lengthy contributions to the literature of rheu- 
matism which have appeared during the present year, reference 
should be made to the articles of Church and Cheadle in the third 
volume of Prof. Allbutt's " System of Medicine," and articles by 
Stephen Mackenzie on the various forms of rheumatism in . the 
Edin. Med. Journ. for January and February, 1897. 

3. RlieiiHiatoid arthritis. 

G. F. Still {Medico-Chirurgiccd Trans., 1897, vol. Ixxx., p. 47) 
discusses certain forms of chronic joint disease occurring in 
children, which are usually described as rheumatoid arthritis, but 
which present for the most part important differences from that 
disease as seen in adults. He calls special attention to one form 
in particular, which is characterised by chronic progressive 
enlargement of joints, coupled with enlargement of the spleen and 
of the lymphatic glands. The disease is usually insidious in its 
onset, and begins, as a rule, before the second dentition. Some- 
times the onset is more acute, with rigors. The changes met with 
suggest a general thickening of the periarticular structures rather 
than a development of new bone, and osteophytes are wanting even 
when the disease has persisted for years. The joints first affected 
are usually the knees, wrists, and joints of the cervical spine. 
The sterno-clavicular joint was attacked in two cases out of twelve, 
and the temporo-maxillary in three. There is no tendency to 



138 THE YEAK-liOOK OF TREATMENT. 

suppuration or to bony ankylosis. Muscular atrophy is con- 
spicuous in the ncighliourhood of the affected joints. Tiio glands 
related to the affected joints are chiefly enhirgfid, Ijut the other 
palpable glands do not escape. The enlarged glands are firm, 
painless, and do not tend to break down. The glandular enlarge- 
ment may vary side by side with the articular affection. Splenic 
enlarg(;ment is common in these cases, and bears some relation to 
the degree of glandular affection. 

The cardiac valves are not affected, but in three cases pericardial 
adhesions were found j^ost mortem. 

Other symptoms observed were moderate anaemia, prominence 
of the eyeballs, periods of pyrexia, or even hyperpyrexia, and 
sweating. There is usually some arrest of bodily development. 

The disease progresses very slowly, and death, when it occurs, 
results from intercurrent disorders. , In three fatal cases the 
articular cartilages were found to be normal, or merely pitted at 
their edges, the pits being occupied by processes of thickened 
synovial membrane. There was marked thickening of the joint 
capsules and surrounding connective tissue. The spleen and 
glands appeared normal on section, but the latter sometimes 
exhibited small ecchymoses. 

The paper concludes with a differentiation of this disease from 
certain other forms of chronic joint disease met with in children. 

Cases of chronic arthritis in children affecting many joints 
have also been recorded by F. G. Finley (^Montrecd Med. Journ., 
1896, vol. XXV., p. 94), and A. G. Nicholls {ibid., p. 98). 

In some observations upon the blood-changes in rheumatoid 
arthritis Bannatyne {Lancet, 1896, vol. ii., p. 1510) shows that the 
anpemia which not infrequently accompanies that disease is of the 
chlorotic type, being due to deficient hsemoglobin-worth of the 
corpuscles, and, regarding rheumatoid arthritis as a bacterial 
disease (see " Year-Book," 1897, p. 132), he is disposed to attribute 
the blood-change to the action of toxins upon the hajmogoblin. 



INFECTIOUS FEVEUS. 

By Sidney Phillips, M.D. Lond., F.R.C.r., 

Senior Physician to the London Fever Hospital ; Physician to and Joint-Leciurcr on 
Medicine at St. Mary's Hospital. 



]. Diet ill typlioid fever. 

A. G. Bans (i)Vi7. 2Ied. Journ., Jan. 19, 1897) contends that 
" we should enforce no further departure from the normal diet of 
health than the disease itself enforces by the inevitable loss of 
appetite and impaired digestion of the pyi'exial state. When a 
patient suffering from typhoid fever expresses a genuine desire 
for solid food, and his expressed desire is confirmed by his 
physical condition, I give him such food as he can take, especially 
meat." He points out that perforation is not a common cause of 
death in typhoid, and he believes that " too much has been made 
of the ulceration in typhoid fever"; and "whatever food we put 
into the stomach, if it is digestible and the stomach is digesting," 
will reach the " seat of the typhoid lesion in the same state of 
fluidity, whether it be milk, beefsteak, bananas, or what not." 

Barrs records two cases. One was that of a lady convalescing 
from typhoid, which began eight weeks before, but with an 
evening rise of temperature to 100° ; she was put at once on a 
full diet. The other was that of a man who had had a severe 
attack of enteric. On the twenty-sixth day, his temperature being 
102° in the evening, he was put on minced meat diet, and 
continued to take it, the pyrexia gradually lessening. Both cases 
completely recovered. 

[Barrs's two recorded cases show that in some cases of typhoid 
fever solid food may be given before the establishment of 
a normal temperature without ill effect; it is, in the author's 
opinion, however, certain that in other cases the administration 
of solid food as soon as the patient craves for it has been followed 
by relapse, by rapid re-rise of temperature, or by htemorrhage or 
by death. The author and othei'S have recorded cases in which 
the ulceration of typhoid fever was very slight, and in such cases, 



140 THK YKAR-nOOK OF TIIKATMENT. 

possibly, solid diet niif^ht do little harm even while pyrexia still 
exist(!d ; .and no douht, if the stomach is dij^esting well, solid food 
will in the main he licjuefied before reachiiif^ tlie lower part (jf 
the small intestine. But the patient's ci'aving for food can hardly 
be taken as a 2)ositive assurance of this, and it is not always 
possible to tell whether there be open ulcers or not in a <j;ivcn 
case of typhoid fever ; the author therefore considers that licjuid 
food should not be given until the temperature has been normal 
for three days, unless some local cause not in the intestine can be 
found to account for pyrexia. That perforation is not a common 
occurrence at present is in part, no doubt, due to the care taken 
to avoid solid food. — S. P. P.] 

2. Ti'catiiiciit of perforating^ typlioid iilror by 
opci'iitioii. 

In the Med.-Cltir. Society Transactions, \o\. Ixxx., p. 119, Lauder 
Brunton records the case of a man, aged thirty-seven, whose tem- 
perature had remained normal or sub-normal for twenty-five days 
after an attack of typhoid fever, when slight pyrexia recom- 
menced. A week later sudden abdominal pain, with tympanites 
and fall of temperature to 97°, suggested perforation of the intes- 
tine. The abdomen was opened by Mr. Bowlby ; some dirty 
yellow fluid was found in the abdominal cavity, and a perforation 
of the ileum. Lembert's sutures were used to bring together the 
edges of the perfoi'ation, and recovery ensued. 

In the Transactions of the same Society Herringhani records a 
case in which a girl of thirteen experienced sudden severe pain 
in the abdomen seven days after convalescence had commenced 
from a typhoid attack ; signs of collapse with tympanites and 
repeated retching came on, pointing to possible perforation of the 
bowel. The abdomen was therefore opened by Mr. Bowlby ; no 
perforation was found. The girl recovered. 

This case, in which symptoms occurred which are generally 
taken as indicating perforation and in which it was proved that no 
perforation occurred, is calculated to engender great doubt as to 
whether the cases of reported perforation and cure in typhoid with- 
out operation were ever cases of perforation at all ; it is highly 
probable they were not, and it becomes more improbable than ever 
that spontaneous recovery after perforation in typhoid ever occurs. 
Any operation that afibrds the smallest chance is, therefore, 
justifiable, and the two cases of which abstracts are given above 
encourage operation in cases of perfoi-ation. Heri'ingham's case 
shows that little hamn may result even if no perforation has 
occurred, and Brunton's case supplies encouragement to hope 
that operation may be successful. This is the first successful 



INFECTIOUS FEVERS. 141 

case of this nature pr-rfoniu'd in Englaud ; the other two successes 
were in America by Van Hook and Abbe respectively. 

3. Widal's soriiiii «liajiriio$is test of typlioitl Icyer. 

Many observations have been made on the reliability of this 
test in the diagnosis of typhoid fever. The method was dealt 
with in the "Year-Book" for 1897, p. 144. It depends on the 
observation fhat the serum from a patient suffering from typhoid 
fever possesses the power of arresting the movement and 
"agglutinating" together the bacilli of Eberth from a culti- 
vation. 

R. Stern {Centralbl. f. inn. Med., Dec. 5, 1896) says that the 
ninth day of typhoid fever was the earliest at which he obtained 
the serum reaction. Whereas Widal gives the requisite proportion 
of serum and culture to be 1 in 60 or 1 in 80, Stern finds it 
much more : 1 in 100 to even 1 in 2,000. A constant relation 
between agglutinative action and the severity of the disease 
could not be proved. Pughesi [Rep. Med., Oct. 2, 1896) withdrew 
the serum from blisters in 16 cases of typhoid ; in 13 of these the 
reaction was obtained. Delepine concludes from observations on 
nearly 90 cases that Widal's method gives very reliable results. 

Hardke (Deut. med. Woch., Jan. 7, 1897) obtained a positive 
result in every one of 22 cases ; sometimes the agglutinating 
effect was instantaneous, and Hardke believes such cases may 
be looked upon as certain cases of typhoid fever ; in other cases 
the bouillon test should be used in addition. 

Widal and Sicard (Anncd. de Vlnstiinit Pasteur, 1897, No. 5) 
found the reaction absent in only 1 of 163 cases of typhoid. The 
reaction was found as early as the fifth day, and as late as 
twenty-six years, after convalescence ; the date of its appearance 
bears no relation to the severity of the attack. The authors 
conclude that the agglutinating action is one belonging to the 
period of infection, and a positive reaction obtained according to 
the rules laid down by them (the serum being diluted never less 
than ten times) can be considered a pathognomonic sign of typhoid 
fever. 

4. ^^Vaccination agiainst typhoid fever." 

Under this title Professor A. E. Wright and Surgeon-Major Semple 
contribute to the Brit. Med. Journ. of Jan. 30, 1897, an article 
of great interest. The " antityphoid vaccines " are made from 
agar cultures of typhoid bacilli which have been grown for 
twenty-four hours at a blood heat. The cultures thus obtained 
are emulsified by the addition of measured quantities of sterile 
broth ; the emulsion is sealed up in glass pipettes. These 
" vaccines " are inoculated into the fianks. With small inoculations 



142 TTTE YKAR-BOOK OF TREATMENT. 

tlio syinptoins aro slight — a little uhilliiioss and pyrexia passing off 
in twenty-four hours ; with lai'ger doses the site of inoculation 
becomes inflamed, and red lines of inflamed lymphatics extend 
up to the axilhe. In two or three hours there is some faintness 
and collapse, and a good deal of fever and sleeplessness ensue. 
By the next day these symptoms have passed off. 

Wriglit and Semple inoculated 18 persons, IG of them being 
army medical oflficers. The blood required for testing the effect 
of the vaccination was obtained by pricking the finger ; this 
blood was filled into capsules. After clotting, the serum was 
drawn off, diluted, and a small quantity of typhoid culture added 
to it. It was found that this serum possessed the power of 
immobilising and agglutinating the typhoid bacilli. This 
"sedimentation power" varied in degree, which could be esti- 
mated by making a so'ies of successive diluti<^)ns of the serum, 
and b}' determining how far the blood may be diluted without 
losing its sedimentation jDOwer. 

The authors then discuss whether we have any warranty for 
inferring that the blood of the pei-son inoculated will exert such 
a deleterious influence on typhoid bacilli with which it comes 
into contact as will protect the person against typhoid. They 
give many reasons which tend to show that this is so, and since 
these vaccinations are unattended with risk, being inoculations 
of dead bacteria, they suggest it would be expedient for every- 
one who is likely to be frequently exposed to the risk of typhoid 
infection to undergo the vaccination, and particularly young 
soldiers going to typhoid-infected districts abroad and to persons 
in a district where there was an epidemic of typhoid. 

PfeiflFer and Kolle {Deut. med. Woch., Nov. 12, 1896) have been 
working on the same subject, and have shown that a single injec- 
tion of a minimum dose of killed typhoid cultures induced a 
specific change in the blood, and regard it as more than probable 
that the appearance of specific bactericidal substances in the 
blood of patients who have had typhoid fever represents the chief 
cause of their immunity ; if this is correct, then it is to be 
expected that these prophylactic inoculations in the killed typhoid 
cultures can produce the same immunity as that of an actual 
attack of typhoid fever. 

5. Treatnieiit of typhoid fever by antitoxic seriiiii. 

F. Pope, of Leicester, gives notes of four cases of tjqihoid fever 
treated in this manner in the Brit. Med. Jo-urn,, Jan. 30, 1897 ; 
in one case the temperature was 105° when the first injection 
was given. The pulse rate, already rapid, rose to 144 per minute 
next day ; eight injections were given, each 5 c.cm. ; the patient 



INFECTIOUS FEVERS. 143 

recovered, and in all the cases defervescence soon connnenced after 
the injections. Pope considers, and the reports of the cases 
appear to support his view, that the serum had a beneficial action 
on the course of the disease. 

P.R.Cooper, of Bowdon [Brit. Med. Journ., Feb. 27, 1897), 
also records a case in which a case of severe typhoid, with 
melfena and hismoptysis, recovered after several injections, each of 
5 to 8 c.cm., of the serum were made. 

Ernest Steele, of Plaistow {Brit. Med. Journ., April 17, 1897), 
records the case of a female in whom, at about the end of tlie 
first week, he commenced the treatment by inoculations ; five 
injections altogether were given, each of 10 c.cm., of Burroughs 
and Wellcome's serum. The headache was relieved by the injec- 
tions, and Steele believes the attack was lessened in severity and 
duration by the treatment. 

6. Treatment of scarlet fever by liot batlis. 

Schill {Jahr. f. Kinderheilkunde, Bd. xliii., p. 260, and 
Epit, Brit. Med. Journ., Jan. 16, 1897) advocates this 
mode of treatment. The cases in which it was tried were 110 
in number; the temperature of the baths was 95° F., and the 
duration of each 10 minutes ; they were given twice a day during 
the fii'st week of the illness, afterwards once a day. In these 
cases desquamation occurred only on the fingers, the daily baths 
removing the epidermis as it exfoliated. Schill believes the 
scarlet fever poison is eliminated by the skin, and that this is 
favoured by the constant removal of the desquamating epidermis 
by hot baths ; for the same reason he condemns greasy applica- 
tions to the skin. [No doubt warm or hot baths are useful after 
the first week of scai'let fever, assisting the action of the skin ; 
their use during the pyrexial period, however, appears inadvisable, 
and especially in cases where the temperature is very high ; the 
author quite agrees that oily applications to the skin are pre- 
judicial.— S. P. P.] 

■y. Treatment of scarlet fever by hypodermic injec- 
tions of oil of turpentine. 

The favourable results obtained in puerperal injection by oil of 
turpentine suggested its use also in grave scarlatina. One or two 
hypodermic injections of 1 gramme of oil of turpentine are used 
for children of three to six years, and two or three times as lai'ge 
a dose in adults, some alkali, such as bicarbonate of soda, being 
used with the turpentine to prevent local irritation. The turpen- 
tine is said to exert a favourable action in albuminuria following 
scai'let fever ; not only does it appear to prevent its occurrence, 
but it soon increases the secretion of urine when that has become 



144 TIIR YEAR-BOOK OP TKRATMKNT. 

dcficiout, and it rapidly dispei'.scs dropsy and albuminuria. The 
turpentine may he given l)y the mouth in capsules or in syrup 
{La A[('<le('/Di(i InfiDdUe, Sept., ISilT.) 

§. Aiitisti'4'|»tococcic «!«4'i-iiiii ill scnrli't fever. 

In tht! " Yeai-Jjook " for 1897, p. 147, this treatment, first 
suggested by Marmorek, was dealt with ; he pointed out that 
though the microlie of scarlet fever has not yet been discovered, 
the streptococcus plays an important part in the disease, and that 
to it many of the complications of the disease are attributable. 
The treatment with antistreptococcic serum was tried by Josias at 
the Trousseau Hospital ; he found the course of the disease un- 
influenced, though possibly the severity of the throat and glandular 
lesions was lessened. 

In the Epitome of the Brit. Med. Johdl, Jan. 21, 1897, the 
results of the treatment in 16 cases liy Rappapart are given. He 
used a solution of tlie serum containing "5 per cent, of phenol ; the 
serum, even when injected repeatedly, had no influence on the 
temperature or on the complications : 4 of the 16 patients died. 

Baginsky has not found any marked advantage in the treat- 
ment. 

H. Jackson (^Boston Med. Journ., No. 9, 1896) summarises 
reports of this mode of treatment. Marmorek used it in 96 cases, 
of which 17 were complicated with diphtheria; 10 c.cm. of the 
serum were injected daily till the temperature fell ; the most 
marked effect was in cases with enlai-ged glands, 19 cases 
occurring without suppuration. Baginsky cured 48 cases with 
the serum ; several had enlarged glands which went on to sup- 
puration, and Baginsky merely says that the i-esults were not less 
favourable than in previous years. 

9. The antitoxin treatment of <li|>litiiei-ia. 
It would serve no useful purpose here to give even an abstract 
of the numerous statistics which have been published during the 
year on the results of this treatment. Statistics as to the effects of a 
mode of treatment of any disease are merely misleading unless the 
ages of the patients and the character of the epidemic are taken 
into account, and, above all^ unless the cases ti^eated are undoubted 
cases of the disease in question. But, on the whole, the general 
consensus of opinion is favourable to the treatment, though it is 
yet far from having realised the extravagant claims at first made 
for it. 

In England the largest body of figures are those published 
in the report on the antitoxin treatment by the medical officers 
of the Metropolitan Asylums Board infectious hospitals. Un- 
fortunately, the criterion of diagnosis of the tabulated cases 



INFECTIOUS FEVKRS. 145 

in these reports was clinical, not bacteriological ; hence the figures 
given cannot be accepted as any absolute measure of the results 
of the treatment. 

Nor can the comparison between the mortality percentage in 

1894, before antitoxin, and the mortality percentage in 1896, be 
regarded as even approaching to accui-acy, for the reasons : first, 
that in 1894 many cases were called diphtheria which were not 
true diphtheria; secondly, that in 189G the very severe and the 
very mild cases were excluded from the antitoxin treatment ; 
and thirdly, as above remarked, the cases in 1896 submitted to 
treatment as diphtheria were diagnosed by symptoms and not 
by bacteriological examination. These sources of fallacy are so 
important as to make any comparison of little value. 

The opinions, however, of the results of the treatment, apart 
from figures, formed by the medical ofiicers themselves, must be 
i-egarded as of great value, and they are almost united in their 
favourable opinion of the treatment. 

It is satisfactory to find that the whole mortality, including 
those cases treated by antitoxin and those not, fell from 25 '5 in 
1895 to 20'8 in 1896, and the mortality percentage of those 
treated with antitoxin in 1895, which was 28"1, fell to 25-9 in 
1896. In both these years antitoxin was used, and the reduced 
mortality goes to show that increased experience in dosage and 
frequency of administration have had favourable effects. 

The fact which was insisted on last year in the " Year-Book," 
that the diminished mortality was almost wholly in the laryngeal 
cases, is even more evident in the statistics of 1896 than of 

1895. In 1894, before the employment of antitoxin, the moi-- 
tality in the laryngeal cases was 62 per cent., whereas in 1896, 
when antitoxin was used, it was 29 '6 per cent. — a reduction of 
32 per cent. ; in the non-laryngeal cases the reduction in the 
mortality was only 4-2 per cent, (from 23'8 to 19-6). 

The reasons why the laryngeal cases are those that benefit 
most from the treatment are : Such cases early produce symptoms 
that call for treatment, and allow of the early administration of 
antitoxin, while cases of pharyngeal diphtheria give rise to less 
urgent symptoms, and often do not come under medical notice until 
the diphtherial poison has been absorbed beyond any power of 
antagonism. Another reason why the laryngeal cases derive so 
much more benefit from antitoxin than other cases is that in them 
the most urgent danger is the mechanical obstruction of the larynx 
by the membrane, the separation of which is hastened by antitoxin. 

A somewhat important point comes out in the report of the 
Biedical ofiicers — viz., that the death-rate of the cases treated by 
K 



146 TJIK YKA1M500K OF lUKATMK.NT. 

antitoxin, but wliicli subsequently proved to be not diphtheria 
cases, was 36*1 per cent., a considerably higher mortality than tliat 
of the diphtheria cases themselves. This is somewhat important, 
as tending to show that antitoxin in cases other than real diph- 
theria may bo actually harmful. 

Taking this fact together with the very small reduction in 
the mortality in the non-Iaryngeal cases, it is quite open to 
(juestion whether it is advisable to give antitoxin in such cases. 
The dangers of non-laryngeal diphtheria are, as a rule, toxic or 
paralytic; and toxic symptoms once set up, the antitoxin is of 
but little avail, and of none whatever in diphtheritic paralysis. 

10. Antitoxin injections as a propiiylactic a^^ainst 
diphtliciia. 

Karman {Pester mecl. chir. Fresse, Oct., 1896, and Epit. Brit. 
Med. Journ., Jan. 16, 1897), on behalf of the Hungarian 
Government, tried preventive inoculation in 114 children in a 
village in which diphtheria was prevalent up to the date when 
the inoculations were performed ; only one subsequent case of 
diphtheria occurred, and this was in a non-inoculated child. 

Of 400 persons immunised at the Poliklinik in Berlin, 18 
contracted the disease, but none died (Archiv. of Pediatrics, 
Feb. 18, 1897, p. 127). [Numerous deaths have been recorded 
after preventive injections of antitoxin serum ; these were de- 
tailed in the "Year-Book" of 1897. Taking this with the above 
evidence that the inoculations do not in all cases produce 
immunity against diphtheria, and that there is some evidence that 
antitoxin given when no diphtheria is present may produce 
injurious effects, the writer considers that the injection of anti- 
toxin as a prophylactic is not justifiable. — S. P. P.] 

11. Treatment of diphtherial conjunctivitis. 

Rotch {Archiv. of Pediatrics, Oct., 1897) records the case of a 
boy of nine years of age, who suffered from a membranous exudation 
on the conjunctiva of each upper lid, with great oedema of the 
lids. Cultures showed typical KlebsLoefller bacillus. Antitoxin 
was injected, and improvement ensued which was temporary only. 
On the advice of Dr. Standish, the injections of antitoxin were 
repeated every sixteen hours ; in all eight injections were given. 
The eyes progressively improved, and eventually qiiite recovered. 

[There seems no reason why antitoxin should not benefit 
diphtheritic exudation on the conjunctiva as well as on the 
mucous surfaces, but, so far as we know, no such cases have been 
previously recorded. — S. P. P.] 

The temperature previous to the antitoxin injection was not 
over 100°, but during the treatment there was considerable 



INFECTIOUS FEVERS. 147 

pyrexia (up to 105°), with enlarged cervical glands, and strepto- 
cocci were found in the throat, but no Klebs-Loeffler bacilli. 
There was also abundant urticaria, and it would appear that 
these eftects were attributable to the antitoxin, 

12. Troatiiieiit of siiiall-pox by iciitliyol. 

Kollbassenko (^La Medecine Moderne, April 21, 1897) recom- 
mends ichthvol locally applied in small-pox. As soon as the 
pustules appear the skin should be anointed with ichthyol, 
30 draclims ; oil of sweet almonds, 2| ounces ; lanolin, 5 
drachms. This allays itching and pain, and modifies suppuration 
and pitting. 



K 2 



MEDICAL DISEASES OF CIIILDIIEN. 

By Dawson Williams, M.D. Loxd., F.R.C.P., 

I'liysician to the East London Uospital for Children, Shadxcell. 



Occasion has been taken in several previous issues of tlie " Year- 
Book " to observe that one of the most important advances, 
probably the most important advance, which has been made in 
that department of medicine which is particularly concerned with 
the treatment of disease in infancy and childhood, is the more 
general recognition of the importance of infectious processes in 
the production of those disorders of the gastro-intestiual tract 
which are the cause of so large a part of the very high mortality 
that still prevails in the early years of life. The influence of 
ideas of this order has been shown by the very general adoption 
of sterilised milk as an article of diet, and by the very general use 
of antiseptic remedies in the treatment of acute diarrliO:?a and 
also of chronic enteritis. 

1. Sterilised and modified milk. 

Among the objections which have been raised to the use of 
sterilised milk are that it produces scurvy, and perhaps rickets 
and amemia, and that it tends to render the infant constipated. 
Kingston Barton has given {Brit. Med. Journ., 1897, vol. i., p. 14) 
the results of his experience during two years in a series of pi'o- 
positions which may be summarised as follows : — (1) Completely 
sterilised milk — that is, milk which will keep fresh in bottles her- 
metically sealed for several or many days — will produce scurvy 
unless some fresh food is administered daily. (2) Milk raised to 
the boiling-point or, better, to within two degrees of the Ijoiling- 
point, and maintained at that temperature for five to fifteen 
minutes, is " comparatively " sterilised, will never produce scurvy, 
and is almost quite safe from pathogenic organisms. (3) " Com- 
paratively sterilised " milk, if administered at once in perfectly 
clean bottles, spoons, or cups, can be relied upon as free from any 
pathogenic bacteria. (4) The heating of milk alters very slightly, 
if at all, its nourishing qualities. (5) If " completely sterilised " 
milk is used, scurvy may be avoided by giving one meal of fresh 



MEDICAL DISEASES OF CHILDREN. ' 149 

wIr'v ilaily to infants too young to take fresh vegetables, meat, or 
fruit. Various writers, especially Angel Money, have drawn 
attention to the freedom with which fruit and vegetables, if wisely 
selected, raay be given ; and Lahmann (quoted in Pediatrics, April 
15, 1897) gives fresh fruit juice after the twelfth week, and after 
the tifth month one meal of vegetables also. When there is a 
tendency to constipation, he gives fruit juices earlier than the 
third month. Among fruit juices he prefers that of the orange ; 
among vegetables, to begin with, spinach reduced to a pap. Rotch 
has recurred to the advantages of inodilied milk — that is to 
say, cow's milk prepared in a laboratory, so that it contains the 
precise proportion of fat, sugar of milk, and proteid which may 
be ascertained to be most appropriate to the digestive powers of 
each individual child. He expresses (Arch, of Fed., April, 1897) 
the opinion that many premature infants have died owing to 
failure to recognise the need for such modification based on the 
assumption that the mother's milk must be suitable. In a 
premature child the gastro-intestinal tract is imperfectly developed, 
and its functions, in consequence, are overtaxed by normal human 
milk. For a child born at the seventh month the percentage 
composition of the modified milk should, as a rule, be : Fat, 1 ; 
sugar, 3 or 4 ;, proteid, 0'35. Smaller percentages might be used 
even in an infant born at term in some cases ; and he found it 
advisable to increase the percentages of the constituents, of the 
proteid especially, slowly and gradually. In a large number of 
infants of about six months, treated for diarrhcea, his average 
presci'iption had been: Fat, 2-6; sugar, 5-8; proteid, 1*2; and 
the average quantity at each feeding had been 4 '5 oz. In the 
healthy adult the gastric juice has an antiseptic action, and the 
stomach has been called a "sterilising chamber"; but Soltau 
Fenwick concludes (" Disorders of Digestion in Infancy and 
Childhood," London, 1897) that in the infant it " must rather be 
regarded as a natural form of incubator, in which every species of 
micro-organism that finds an entrance with the food is afforded 
every facility for growth and multiplication." Free hydrochloric 
acid in |)roportions greater than 0-17 per cent, exerts an in- 
hibitive action on the growth of micro-organisms, and the plentiful 
secretion of gastric juice in the adult has probably for this reason 
a valuable antiseptic power ; but he has found that in the infant 
the projjortion of free hydrochloric acid is inconstant, and that, 
as a rule, none can be detected until eighty minutes after a meal 
of breast milk has been taken ; after a meal of cow's milk, though 
the total acidity of the gasti'ic contents is more pronounced, free 
hydrochloric is only to be detected towards the end of digestion. 



150 TIIK YEAH-]!OOK OF TRRATMRNT. 

This absence of free liydrochloiic acid is due to the fact that tlic 
proteid constituents of milk possess tlie i)Ower of entering at 
once into conilnnation with the hydrochloric acid as it is secreted; 
consequently there can be no free hydrochloric acid in the stomach 
after a meal of milk until all the proteid has been saturated, and 
therefore any bacteria which obtain entrance to the stomacli with 
the food are permitted to flourish until at least the end of 
digestion. It may be added that in many infants, owing to the 
unnecessary frequency with which they are fed, the stomach 
must seldom or never be empty, and the antiseptic powers of the 
gastric juice can rarely come into play. 

2. Acute gastro-eiitcrilis. 

The doctrine that the more acute forms, at least, of enteritis 
are due to infection is generally accepted, but hitherto very little 
precise information has been obtained as to the nature of the 
infection. Lesage has shown that one form, probably a rare type, 
of summer diarrhea is associated with the presence in the intestines 
of a special bacillus which produces a green pigment. In this 
form lactic acid gives good results. Luebbert (quoted in Rev. des 
Mai. de VEnf., Jan., 1897) has isolated from milk which had 
been boiled a bacillus whicli grew easily at body temperature on 
agar, serum, and potato, and produced spores which were not 
killed by a temperature of boiling water for two hours. This 
bacillus when grown in milk did not alter the smell or taste, did 
not attack the sugar or fat, but peptonised the casein. Such milk 
produced violent diarrhcea in young guinea-pigs. If the milk, 
however, were again boiled before administration, and then given 
at once, it did not produce diarrhcea, an observation which is 
quoted as a further proof of the undesirability of keeping even 
sterilised milk for any length of time before it is used, since this 
particular bacillus, if present, would be able to multiply in the 
milk, which would then, in all probability, cause diarrhoea. 
Finkelstein (^Brit. Med. Journ., Upit., 1896, vol. ii.. No. 398) has 
described a bacillus present in the purulent masses contained in 
the stools of acute follicular enteritis ; and Escherich and his pupils, 
Hirsh and Libman (Cent. f. Bakt., Bd. xxii. S. 369 and S. 376), 
appear to have proved that a form of acute enteritis, characterised 
by severe general symptoms and the passage of muco-purulent 
bloodstained stools, is due to infection by a streptococcus, which 
is not streptococcus pyogenes, and is probably a species hitherto 
undescribed. It was found abundantly in the stools during the 
persistence of the diarrhoea, and in one case, which recovered, 
when the number diminished the diarrhoea also diminished, and 
the general condition of the child improved. In the fatal cases 



MEDICAL DISEASES OF CHILDREN. 151 

the streptococcus was foun<l in the blood and urine, but not 
in the case which recovered. In the treatment the best results 
were obtained from the use of clysters of the solution of acetate 
of aluminium ; by the mouth small doses of calomel were given, 
followed l)y tannallun. Taiiiisilbiii is a compound of tannin and 
albumin. It contains 50 per cent, of tannin and is not decom- 
posed in the stomach, but decomposition takes place slowly in the 
intestines. It is a pale yellow, tasteless powder, and the dose 
recommended for a child of four years is about seven grains 
repeated every two hours, or in very sevei'e cases every hour, 
xuitil three or four doses have been taken. The course may be 
repeated on the next day if necessary (Form, des Medicam. Nouv., 
Paris, 1897). The drug lT5s been found useful not only in acute 
but also in chronic diarrhoeas, even in those due to tuberculosis. 
There seems to be at present a disposition to recur to the use 
of astringents in the treatment of infantile diarrhoea, and to have 
recourse to compounds of tannin, from which the tannin is liberated 
in the intestines. Vandenberghe {Brit. Med. Journ. Ejnt., 1897, 
vol. i., No. 84) speaks highly of tannigen (diacetylic tannin, see 
"Year-Book" for 1897, p. 160) both in acute and chronic 
diarrhoea ; and Comby commends both tannigen and tannalbin, V)ut 
in infective cases combines them with calomel or some other 
antiseptic {Brit. Med. Journ., Epit., 1897, vol. ii., No. 258). The 
good results which commonly follow the withdrawal of milk and 
other easily decomposed forms of food at the commencement of an 
attack of acute diarrhoea has been very generally recognised, and 
Heubner, a couple of years ago (see "Year-Book" for 1896, 
p. 155), recommended the use of weak starchy mixtures. Watu 
has since {Brit. Med. Jonrn., Epit.., 1897, vol. i., No. 307) reported 
that in Grancher's service in Paris infantile diarrhoea is treated 
by a strict regimen of boiled water cooled to a suitable tempera- 
ture, and given in small quantities every hour or half-hour, or as 
thirst demands, for eight, twelve, or twenty-four hours. The 
results in children not very young are reported to be extremely 
satisfactory in acute diarrhoea. The water, it is assumed, dilutes 
the toxic matters, washes away debris of decomposing food, 
dissolves toxins attached to formed elements, and tends to increase 
the blood pressure. Epstein, some years ago, reported very favour- 
able results in the acute summer diarrhoea of infants from the 
injection into the connective tissues of saline solution (10 c.c. 
three times a day). He attributed the good effect to dilution 
of the blood. Injection of blood serum, it is asserted, is 
followed by dilution of the Ijlood owing to transudation of lymph 
from the tissues into the blood ; V. Ranke, of Munich, therefore 



152 THE VKAR-ROOK OF TUEATMKXT. 

sug<^(!.st(;(l the use of iiij(!ctioiis of blood seruiii in Huniiiiei' (liarrlid^a, 
on tho ^'rouiid that it woukl not only jiioduce the desired alteration 
in tli(! l)lood l)iit would supply the system with a certain amount 
of nutriment. The results of the test are report<;d by Reinach 
(quoted in pHdhdrks^ April, 1897). The serum used was that of 
cows previously ascertained to be in good health. The injections 
were given in fifteen cases, all severe examples of gastro-intestinal 
disturbance in bottle-fed infants. The injections were made under 
the skin over the thorax, usually in tlie evening, and the quantity 
used was 10 to 20 c.c. ImproAement was, as a rule, first noticed 
on the following morning. If the child had been collapsed it was 
brighter, the temperature had become normal, tlie circulation 
better, the fontanelle more tense, and the extremities warmer. 
Eleven of the patients recovered. In one only a measles-like 
eruption appeared two weeks after the injection, and lasted two 
days. 

3. Acute abdoniinai <listeii«»ioii. 

Still, in a paper on "Acute Abdominal Distension in Children," 
illustrated by pliotographs of typical cases has given {Pediatrics, 
September, 1897) an excellent description of a condition which, 
as he observes, is often one of the immediate causes of death in 
vai-ious exhausting diseases in childhood and infancy, but especi- 
ally in those in which intestinal disorders are the primary or one 
of the complicating conditions. Three main seats of the disten- 
sion may be distinguished according as the stomach, the small 
intestine, or the large intestine is chiefly involved. Any one of 
these parts may be affected alone, or all three may be distended 
together. Still concludes that the distension is due, probably in 
all cases, chiefly to loss of tone in the gastric or intestinal walls 
owing to the exhausted condition of the child, but that other 
factors are probably often present, such as catarrhal conditions of 
the gastrointestinal tract. The distension produces rapid and 
laboured respiration, due to interference with the action of the 
diaphragm, but Still believes that in some cases there is also 
interference with the action of the heart, and that this may cause 
sudden death. Tlie condition is an extremely serious complication, 
but treatment is not very effectual. The pressure on the dia- 
phragm may be diminished and some relief obtained by propping 
the child up with pillows, and causing it to lie on the side instead 
of on the back. Ammonia and ether by the mouth, and hypo- 
dermic injections of strychnine and brandy, should be used as 
remedies for the general exhaustion. If the immediate danger 
be tided over, the most valuable drug is creasote. Mechanical 
treatment for the relief of the distension appears to be indicated, 



MEDICAL DISEASKS OF CHILDREN. 153 

but has not been found very easy of application. If localised 
distension makes it probable that the stomach is specially affected, 
the passage of an oesophageal tube may give great relief. The 
passage of a long soft tube (soft catheter) per rectum may bring 
away some gas, but more often it fails. This failure is explained 
by the observation post mortem that in most cases in which the colon 
is distended throughout the rest of its course the sigmoid flexure, 
which in early childhood is long and tortuous, as well as the 
rectum, are empty and contracted. If the small intestine be 
the part distended, very little can be expected from the use of 
the rectal tube. He thinks enemata of soap and water or of 
turpentine worthy of trial, though they have generally proved 
useless, and if retained may aggravate the condition. He 
suggests that puncture of the intestine may be justifiable as a 
last I'esoui'ce. 
4. Tetany. 

The nature and pathology of tetany have continued to attract 
much attention. It was one of the main topics of discussion at 
the meeting of the Gesellschaft fiir Kinderheilkunde at Frankfort 
{Verliandlunyen, Wiesbaden, 1897), and again in the Section of 
Paediatrics at the International Congress at Moscow. The fre- 
quency with which the condition occurs appears to vary in dif- 
ferent counti^ies, but as in a large proportion of cases the symptoms 
are latent — e.g. in 83 out of 109 observed by Fischl, [loc. cit. S. 
27) — it is probable that many cases are overlooked. The main 
point at issue is whether tetany is, or is not, a direct product of 
rickets, which certainly co-exists in a very large proportion of 
cases — according to Fischl, in 60'4 per cent. Kassowitz has again 
argued strongly in favour of this connection (JS'^eur. Cent., 1897, 
S. 238). He believes the immediate cause to be some toxic bodies 
which are absorbed by the respiratory passages from the foul air 
of crowded rooms, but that this cause is able to jDroduce the char- 
acteristic effect only in rickety subjects. He concludes, therefore, 
that the treatment should be directed to tlie cure of rickets. For 
this purpose he uses a phosphorus which lie regards as specific for 
rickets. Oddo, in a very admii-aVjle review of the literature (Jiev. 
de Med., 1896) has argued in favour of the view that the essential 
cause of tetany in childhood is, in most cases at least, a toxaemia, 
due to the absorption of the products of imperfect digestion 
associated either with dilatation of the stomach or enteritis, or 
both. To this view Kassowitz has objected that tetany in chil- 
dren and infants is most common in the winter months, whereas 
gastro-intestinal disturl^ances are most frequent and severe in 
sumnier ; but, as Biedert pointed out during the discussion at 



154 THE YEAR-nOOK OP TREATMENT. 

Frankfort, tetany occurs as a coiiij)lication of clironic digfstivo 
disturljaiices wliicli favour the absorption of toxic substances, and 
not of acute disturl»ances in wliich probably toxic matters are 
more quickly eliminated. TIk; condition is of practical import- 
ance, because its recognition will put the practition(^r on liis 
guard ; cases of rickets and gastroenteritis in wliicli it occurs 
very often turn out to be of a serious character, even though 
at the time the general condition may not appear to justify any 
atixiety. In many cases the symptom which attracts attention 
first is oedema of the backs of the hands and feet, though other 
symptoms of tetany may be elicited. In all cases the first indica- 
tion, as Oddo observes, will be to correct any discoverable errors 
in diet. When gastric digestion is incomplete and delayed, a 
small dose of hydrochloric acid, with or without tlie addition of 
pepsin, shortly after each meal will be desirable ; and it may be 
necessary to reduce the bulk of the meals while decreasing the 
intervals between them, should there be evidence of dilatation 
of the stomach. Calomel in small doses frequently repeated is 
recommended as the l:)est corrective of the decomposition within 
the intestines, but it may be replaced or supplemented by benzo- 
naphthol or bismuth subnitrate. Cold is a frequent determining 
cause of the attacks during which the child suffers much pain ; 
and care should therefore be taken to guard it against exjjosure, 
as well as to protect the patient from excitement. During an 
attack,- when there are extensive and painful spasms, warm baths 
are the most effective remedies, but it may be necessary also to 
give chloral, jireferably by enema. When an attack is compli- 
cated by laryngeal spasm, relief may often be obtained by apply- 
ing a sponge soaked in very hot water to the front of the neck ; 
if this fail, chloroform should be administered by inhalation. 

5. Whooping' cough. 

Ritter, in a paper on the setiology and treatment of whooping 
cough, read at the Frankfort meeting of the Gesellscliaft fiir 
Kinderheilkunde (Verhandl., Wiesbaden, 1897) advanced addi- 
tional evidence in support of the view that the diplococcus tussis 
convulsivte described by him in 1892 is the specific cause of 
whooping cough. He finds it to be sparingly present during the 
primary catarrhal stage, exceedingly plentiful during the spas- 
modic stage, and scanty in the later stages. Koplik has since, at 
the Montreal meeting of the British Medical Association, described 
a small bacillus which he found to be the predominating 
organism present in 13 out of 16 cases examined for this purpose. 
The two observations appear to be incompatible, but Ritter's 
views on the value of drugs in the disease are worthy of record, 



MEDICAL DISEASES OF CniLDREN. 155 

since they are founded upon a large number of comparative trials. 
He considers that the only drugs upon which any reliance can be 
placed are quinine and bromoform. Treatment by belladonna, 
potassium bromide, chloral hydrate, and morphine he regards as 
merely symptomatic, while antipyrin should he avoided owing to 
its undesirable secondary effects. He treated 200 out of 215 con- 
secutive cases with quinine or bromoform. The first two cases 
were treated with quinine, the next two with bromoform, and so 
on alternately until each drug had been taken by 100 patients. 
He gave the hydrochlorate of quinine ; the dose was 1-| gr. 
for each year of age, and for children under one year ^ gr. 
for each month of life. Of bromoform he gave to infants 
under six months one drop three times a day, from six to 
nine mouths one drop four times a day, from nine months to 
two years two drops thi-ee times a day, and above that age as 
many drops as many times a day as a child had years; thus a 
child of five years had five drops five times a day. These doses, 
rather smaller than those recommended by Stepp, were found to 
be quite as efiectual as the larger. The result of this comparison 
was very much in favour of bromoform. Of the 100 children 
treated with quinine two died, of the 100 treated with bromo- 
form one died, and these must be eliminated from the list. 
Of the 99 treated by bromoform 42 had recovered by the end of 
three and a half weeks, and 71 at the end of the fourth week; 
-whereas of those treated with quinine only one had recovered in 
three and a half weeks, and only five at the end of the fourth 
week. Severe vomiting and bleeding after the paroxysms ceased 
earlier in those cases treated with bromoform than in those treated 
with quinine. Thus these sjnnptoms disappeai'ed on or before 
the sixth day of treatment in 55 cases under bromoform, and 
in only 11 under quinine within the same period. 



ANAESTHETICS. 

By Dudley W. Buxton, M.D., B.S., M.R.C.P., 

Anwsthetist and Lecturer on Ana:sthetics in University College Hospital, Anrnsthetist 

to the National Hospital for Paralysis am) Epilepsy, Queen's Square, and to 

the Dental Hospital of London. 



I.— LOCAL ANAESTHESIA. 

Considerable attention has been paid to Schleicli's infiltra- 
tion nictiiod (see "Year-Book of Treatment," 1897, for de- 
tails) and several surgeons have reported many successful 
operations performed by its aid. 

Anesin (Vamossy : Ungarische med. Presse, No. 2, 1897; 
also Centralbl.f. Chirur., Aug. 14, 1897) is a watery solution of 
acetonic acid trichloride (acetone chloroform). A 1 per cent, 
equals a 2 or 2| per cent, solution of cocaine. It is sterile, and 
remains so, is non-irritating and non-poisonous. 

Alexander (Bellevue, N.Y. Med. Journ., 1897, Jan. 30) uses 
cocaine in litholapaxy in the following way : The bovvels being 
emptied, a subcutaneous injection of gr. 1 morphine and ^Tio S^'- 
of atropine is given half an hour before the operation. Fifteen 
minutes later, glonoin -J-^ gr. and strychnia ^^ gr. are given. The 
patient is then placed on the table, and after the bladder is 
washed out with boric acid solution, 2 ounces of a 4 per cent, 
solution of cocaine are injected into the bladder, the catheter 
being withdrawn into the prostatic urethra so that the solution 
is brought into contact with the deep urethra. The anterior 
urethra is then filled with cocaine solution, whicli is retained for 
five minutes. 

The use of giiaiacol, first suggested as a local antesthetic 
by Lucas-Championni^re, has been extensively employed in nasal or 
laryngeal surgery by Laurens (^Ann- des Malad. de VOreiUe, xxii., 
1896, p. 9). He makes a solution in previously purified oil and 
wipes it over the field of opei-ations or, in the case of tlie ear, by 
in.stillation fifteen or twenty minutes before the operation. He 
first washes out the nose with solution, then puts in a tampon 



ANAESTHETICS. 1 57 

saturated with it. He was able to remove the posterioi- extremities 
of the turbinates, but had to wait fifteen or twenty minutes. 
There is less retraction of the tissues than, is the case with 
cocaine. In tonsillotomy and intra-laryngeal operations guaiacol 
seems less useful. Gerondi used an alcoholic solution of guaiacol 
(guaiacol 2 grammes, alcohol and distilled water aa 15 
gx-ammes at 90^, with a few drops of oil of bergamot or oil of 
vanilla to cloak the odour). He succeeded with this solution 
whilst cauterising the turbinates and pharyngeal granulations, 
and in removing naso-pharyngeal polypi and aural polypi. It 
was of less value in dealing with middle-ear trouble, as the field 
became obscured. J. E. Newcomb (N'. Y. Med.Journ., Aug. 28, 1897) 
found the following formula to answer best : To a given weight 
of oil 10 percent, of dried sulphate of zinc (by weight) is added, 
and the mixture heated over a water bath for an hour. After 
filtration, 12|^ per cent, absolute alcohol is added. After keeping 
a few days it is decanted, and then the guaiacol added to the 
required strength. Newcomb has used it for the nasal polypi, 
middle turbinates, curetting ethmoid cells, sawing of septal 
spurs, cauterising the turbinate bones, tonsils, and granular 
phaiynx. He obtained anaesthesia in ten minutes, and did not 
observe any more hfemorrhage than occurred when cocaine was 
used. 

Chronic cocaine poisoning is not always easy to diagnose. 
According to Rybakofif {Neurolog. Centralblatt, Aug., 1896), 
Magnan's "symptom" is pathognomonic. It is a sensation of 
some foreign body beneath the skin, variously described by the 
patient as "sand,"' "microbes," "worms," "crystals," etc. 

£iicaiue. 

Home and Yearsley [Brit. Med. Jourii., Jan. 16, 1897) describe 
their investigations into the action of this drug. A 2 per cent, 
solution sufficed for laryngoscopic rhinoscopy and aural examina- 
tions. For operations on the nose, throat and ear they employed 
a 5 per cent, or 8 per cent, solution. They instil warm solution 
into the ear ; for the nose or throat swabs are soaked in the solution, 
which may, or may not be, left in the nose. About five or ten 
minutes sufficed to produce anaesthesia lasting twenty minutes. 
They never spi-ayed eucaine, and never had bad results. Slight 
salivation appeared in some cases. They deny the statement that 
eucaine makes the tissues hypersemic. Charteris (^Proc. Roy. Hoc. 
Edin., 1897) has arrived at similar conclusions. Eucaine kills 
more slowly than cocaine, and a larger dose is required. In 
dental practice 5 drops of a 10 per cent, solution injected into 
the gum are used to prevent pain during extraction. 



158 TlIK VKAU-BOOK OF TRKATMKNT. 

A<1v:iiil:iu:<'«i :iii«l 4lisii4lv:iiif:iK(>s of <'ii4-:iiii4> in 
siir;;i4-:il li-4>iitiii4'iit 4>r Ili4' C'y4r. 

Wustefeld {Munch, med. WocL, Dec. 22, 1890) used 5 per cent, 
watery solution in twenty oj)erations on the eye. The patient 
complained of sharp burning pains, which persisted. There was 
enlargement of the sclerotic vessels. The antesthesia equalled 
that of cocaine. The pupils were unequal, and paralysis of ac- 
commodation took place in thirty minutes. Microscopic examina- 
tion of rabbits' eyes under eucaine showed that the epithelial cells 
were swollen, and in some cases the upper layers separated. 

Hackenbruch (quoted in Wien. med. B/dU., July 22, 1897) 
used equal parts of cocaine and eucaine, and found the combina- 
tion more useful and less poisonous than cocaine. 

Spencer {Med. and Surg. Heporter, Nov., 1896) has iised 5 per 
cent, eucaine solution in major operations, injecting as much as 
2 drachms without unpleasant symptoms. 

Scognamiglio {TJierapist, No. 4. 1897) affirms that the 
anaesthesia produced by eucaine is more complete and pei'sistent 
than that due to cocaine. He employed an 8 percent, and a 10 
per cent, solution for diseases of the throat, and found a more rapid 
and extended area of anaesthesia than with cocaine. Perlati has 
used eucaine successfully in dental practice. In minor surgery 
injections of 10 per cent, solution are recommended. It is far 
less toxic than cocaine. 

De Mets {Deutsche med. Zeit., July 29, 1897) has used eucaine 
extensively. He finds that antesthesia appears in seven minutes 
after instilling a 20 per cent. It lasts thirty minutes, and is 
followed by no mydriasis or unpleasant symptoms. 

Lewis Somers {Therap. Gaz., Jan., 1897) speaks well of eucaine 
in non-inflammatory affections of the nose and naso-pharynx. 
He employs a 4 per cent, solution. 

Reichert (Berlin) claims for it that it exerts a curative influence 
on the Schneiderian membrane. 

Guttmann {Deutsche med. Wochensch., No. 11, 1897) de- 
scribes the properties of liolocaiiie (p. diajthoxyfethenyldipheny- 
lamidin). The chloride of the crystalline base is soluble in 
2^ per cent, of cold water. Boiling does not decompose a 1 per 
cent, solution. In ophthalmic practice instilling 2 to 5 drops 
of this causes burning sensation, which is lost in a minute. 
Three to 5 drops produce absolute anaesthesia of the cornea in a 
minute, lasting for nine minutes. The tension of the eyeliall and 
accommodation were unchanged. It is poisonous if injected 
beneath the skin, and cannot be sterilised except in A^essels — e.g. 
porcelain — free from alkali. 



ANESTHETICS. 159 



II.^GENEPvAL ANAESTHETICS. 

Tlie propai'atioii of a patient f'oi; an ana;<s>tliotic 

is dealt with by Silk ("Treatment," March 23, 1897). He recom- 
mends giving a purge the night before the administration of the 
an:v;sthetic. In ordinary cases a cup of hot broth, beef-tea, or 
some light fluid food should be given three or four hours before 
the operation. jNIilk is liable to delay digestion. A too pro- 
longed fast is to be deprecated. In cases of special gravity — i.e. 
either fi'om the feeble condition of the patient or probable shock 
from the operation — other measures are suggested. These consist 
in giving half an hour before the opei'ation a nutrient enema of a 
yolk of an egg and an ounce each of beef-tea, milk, and brandy, 
the whole being peptonised ; taking cai'e to wash the bowel out 
with warm water before giving the enema. The only occasion 
when it is justifiable to give stimulants by the mouth before the 
ana?sthetic is, Silk thinks, when the patient is threatened 
with syncope from fright. Otherwise he regards the practice as 
irrational. Hypodermic medication, the same writer thinks, 
should be used with caution. The routine employment of 
morphine before chloroform is, he considers, dangerous, since 
it may "mask the symptoms of over-narcosis." Bernard, Nussbaum, 
Kappeler, and Koenig, who analysed seven thousand such cases, 
pointed out that if a small dose of the opiate (gr. i) be given 
twenty-five or thirty minutes befoi'e the chloroform, not only was 
less of the anresthetic required but the narcosis was more quiet 
and more peaceful than when morphine was not used. Strychnine 
(gr. -^jj) may be injected immediately after anpesthesia has been 
induced, to counteract operation shock in the case of very feeble 
subjects. By some stx^ychnine thus given is believed to lessen 
the liability to sickness. The injection may be repeated if occa- 
sion seems to demand it. Ramsay and Newman (^Lancet, Jan. 2-3, 
1897) point out that the tendency of chloroform to decompose by 
access to air leads to sickness and imperfect anpesthesia. If the drug 
is well shaken with slaked lime and filtered this is prevented. 

Writing upon chloroform in obstetrics, E. P. Davis 
(Boston Med. and Surg. Journ., Aug. 26, 1897) remarks that 
pregnancy lessens anaemia, increases vascular tension, produces 
eccentric cardiac hypertrophy, while during labour the abdominal 
muscles, the diaphragm, and the uterus are intermittently active, 
thus causing an intermittent compression upon the abdominal 
vessels. All these conditions lessen the dangers of chloroform to 
the parturient woman. Blood pressure is much increased during 
the painsj while the activity of the respiratory centre is naturally 



160 TIIK YKAK-UOOK UK TKKA'IMKN'T. 

enliancod. He recoinnieiids cliloioforiii in tlio natural laljour of 
women whose apprfshonsion of pain is exceptionally acute, to 
relieve the reflex inhibition of the uterus and reflex spasm set 
up by the severity of the pangs. For some obstetric operations 
ether is, he thinks, to be preferred. Doinhofif (Archiv /. O'ynd- 
koL, Bd. 42, Sept. 2, 1897) gives his results oljtained Vjy the use of 
the tokodynaujometer, which prove that light ansesthesia does 
not afl'ect, while deep chloroformisation will check, uterine con- 
traction. In transverse presentations, after loss of the amniotic 
fluid, with threatened rupture of the tetanic uterine muscle, 
chloroform will, Davis finds, give a far better chance for suc- 
cessful version than ether. Similarly he prefers it in cases of 
retained placenta when uterine tetanus exists ; for eclampsic 
conditions chloroform, being, it is asserted, less irritating to the 
kidneys, is to be preferred to ether. It is contended that the fear 
that post-jMrtum htemorrhage will result if chloroform is employed 
during labour or operative interference is not supported by 
experience, provided care be taken that the anajsthesia is not 
too profound or continued for too great a length of time. Ether 
is to be preferred when forceps have to be applied, in order that 
the uterine contraction may be retained as fully as possible. 
Davis, however, does not appear to recognise the fact which 
Snow pointed out fifty years ago, that etlier acts even more 
powerfully in relaxing muscular tissue than does chloroform, only 
it requires a larger dose acting over a longer time. No doubt if 
ether is used simply as an analgesic it is, as Davis says, more 
valuable than chloroform in forceps operations. Worcester (^loc. 
cit.) points out that ether is of less value in parturition than 
chloroform, because the patient has not time between the pains 
to get sufliciently under its influence to become relieved. This 
is probably the result of imperfection in his methods. With 
a hand Clover's inhaler or an Ormsby there would be no difficulty 
of this kind. He speaks well of a mixture suggested by Otis, 
of Boston, composed of one part bromide of ethyl, three parts of 
chloroform, and four parts of alcohol, but does not specify the 
apparatus he employed for its use. 

Green, of Boston, who employs etlier in normal labour, gives 
it to light anaesthesia when the cervix is approaching full dilata- 
tion if the pressure of the head causes much pain. He then 
waits until the head is passing the perinpeum, when ether is again 
given, at first lightly, but afterwards to full surgical anaesthesia. 

Chenery (Boston) prefers chloroform in labour, as he believes 
it places the child in less danger, and is less prone to produce after- 
hsemorrhage. 



ANESTHETICS. IGl 

Cottam [Therap. Gaz., Nov., 1896) advocates tlie use of 
sulphate of sparteine as an antidote to chloroform syncope. 
He points out that fatal synco'pe sometimes occurs in the first 
stages of anaesthesia, in prolonged anresthesia, or in ana?sthesia 
when the patients are very feeble or debilitated. The pulse in 
these cases is rapid and of small volume^ and alcohol, digitalis, 
and strychnine are not always capable of counteracting the 
depression. He injects y^^ gr. of sparteine hypodermically 
before the anjesthetic is given, and finds it lessens shock, stimu- 
lates the heart, and brings about rapid reaction. 

Anaesthesia in cases of enierg:ency operations for 
strang-iiiation of tiie intestines, etc. 

Spellissy reports the following case (Annals of Surgery, Feb., 
1897, ]). 183). A stout woman suffering from a strangulated 
hernia requiring operation had ether given her, "a few drops at 
a time." After taking about 3) she vomited slightly as she was 
being lifted on to the table, became blue, and died. Laryn- 
gotomy was done, but the necropsy showed no vomit had entered 
the air-passages. The heai't and kidneys w^ere extensively 
diseased. White, commenting upon this case, believes the patient's 
death is merely coincidental with the ansesthetic, and he cites an 
example. Hunt, in recording a similar case, in which, however, a 
large quantity of vomited matter flowed from the stomach and 
entered the air passages, discusses the first course for lavage in 
such emex'gencies. Greig Smith (Zawce^, vol. i., p. 582, 1892) laid 
down the law that when the stomach was distended with fluid 
ana?sthesia should never be practised until the viscus was emptied 
artificially, or a local anaesthetic should be employed, and that 
the ana?sthesia should only be continued so long as to allow 
of the incision into the parietes and the placing of the sutures. 
Hunt (Lancet, Sept. 2.5, 1897) recognises three ways of dealing 
with such cases : (1) To employ lavage, and so avoid the vomiting 
and risk of asphyxia and septic pneumonia. Against this method 
is the undoubted danger of collapse, which has been brought 
about even in a healthy subject wdien washing out the stomach 
had been practised without the use of an anesthetic. (2) To avoid 
lavage and take the risk of the sucking in of vomit and fecal 
matter. (3) To adopt a midway course (which commends itself 
to the author of this paper) and administer the anesthetic, per- 
forming lavage before the operation is attempted. 

Ernest Stokes, of Baltimore (Annals of Surgery, "Ante-Opera- 
tive Asphyxia," 1897, p. 346) also deals with this subject. In 
tw^o patients, the subjects of intestinal obstruction, chloroform was 
first given and well taken, then ether was substituted, and the 



162 TIIK YEAR-ROOK OF TREATMENT. 

patient carefully lifted upon the oporatirig talkie. When complete 
Init not profound ana-sthesia was_ produced the f;ecal contents of 
the stomach were passively expelled from it, and entered the air- 
passages, in spite of all efforts, producing aspliyxia. The relaxa- 
tion caused by the ansesthetic was, it is surmised, the reason for 
the sudden and uncontrollable regurgitation of the fluid till then 
pent up under considerable pressure in the stomach. McLane 
Tiffany reports two cases in which he had the patients placed face 
downwards, thereby, he l)elieves, saving their lives. Kussm;iul 
{Berl. klin. Woch., 1884) had succe.ssfully dealt with a ca.se of an 
ileus by lavage. Stokes would trust to lavage and maintaining 
the patient in a raised posture so that his head was in a higher 
plane than his stomach. Trendelenburg's, or even the horizontal 
position, are most dangerous, as in them the over-distended 
stomach naturally eni])ties itself on to the pharynx. 

Keen, of Philadelphia, regards Trendelenburg's position as the 
safest for operations on the naso-pharynx. He places the patient 
with the head down at an angle of 35° to 45° to the horizon, and 
so, when the patient is anesthetic and cannot clear his throat, the 
blood and other fluid, being unable to ascend, cannot enter the 
air-passages {Annals of Surgery, 1897, p. 97). A preliminar}'^ 
tracheotomy is thus avoided. He gives ether from an Allis's 
inhaler, but subsequently replaces this by chloroform, which is 
exhibited f)om a good-sized pledget of cotton held in ring forceps. 
Rawlings Nichol {N. Y. Med. Record, Sept. 25, 1897) advises no 
food for eight hours before the chloroform, a saline purge over- 
niglit, and a warm-water clyster the morning of the operation. 
He passes a thread through the tongue to keep it from falling 
back. He prefers the dorsal or left-sided decubitus, and the early 
morning for oj^erating. He emphasises the importance of main- 
taining the body tempei-ature of patients v/ho are put under ether. 
The importance of complete anjvsthesia, especially under chloro- 
form {TherajJ. Gaz., Jan., 1897, Editorial) is dwelt on, and it is 
pointed out that "fear" is a potent factor making for danger 
during light ansesthesia. The irregular breathing of partial 
ana-sthesia is another peril, as it is impossible to tell how much 
chloroform is being taken by the patient. 

Action of cliloroforiii upon the tissues. 
Ajello, JNIilan (in Monograph, 1896 ; Anna! s of Surgery, March, 
1897), has studied the urine carefully in 214 cases of chloroform 
narcosis. Albuminuria occuri-ed in 80 per cent., and lasted two 
to six days. Age, severe illnesses — e.g. of heart and blood vessels, 
diabetes, and protracted or repeated anaesthesia. Neither sugar 
nor acetone was found. In 60 per cent, casts, mainly hyaline, 



ANAESTHETICS. 163 

were found, but a few epithelial and granular. In four deaths 
(luuuan) and twenty (dogs) he found all degrees of kidney trouble 
from liyper;enua and capillary Inenionhage, to extensive coagulation 
necrosis of renal epithelium, and exudation into capsules. The 
livers showed fatty degeneration and necrosis. Loss of striation 
and fatty changes were seen in the muscles, Avhile in the blood 
vessels fatty hyaline degenei'ation had taken place. 

Willett (.S7. Bart.'s Hosp. Reqwrts, vol. xxxii.) has noted for a year 
cases in which ether rash is developed. The eruption is roseolous, 
appears suddenly after three or four minutes, gradually disappear- 
ing after two more minutes. It is more common in women, and 
appears over the area supplied by the superficial cervical plexus. 
The appearance of a rash after chloroform is very rare. The 
nature of the operation and the age do not seem material factors 
in its causation. 

H. A. Hare [Therap. Gaz., Feb. 15, 1897), after cai-eful 
research work, has come to the conclusion that death from chloro- 
form is due to vasomotor depi-ession. The arterioles have under- 
gone dilatation, and so the blood drains rapidly through them 
from the arteries and heart into the large areas of blood vessels 
formed by the veins and capillaries. The patient is, in fact, bled to 
death, but into his own capillary areas. These areas are capable 
of containing man}' times all the blood which usually constitutes 
the circulation, as is shown by the fact that saline solution may 
be injected into the circulation in very large quantities without 
affecting the blood pressure. He quotes the experience of 
Chisholm^ of Baltimore, and other American surgeons, which 
went to show that inversion, with compression of the floating ribs, 
during the performance of artificial respiration had many times 
saved life. Their proceeding would, of course, have the effect of 
forcing blood from the splanchnic areas into the thorax. The 
sitting posture favoured the deportation of blood from the 
brain into the splanchnic areas, and hence the frequent deaths 
when this posture was adopted. Hare advocates as measures 
to prevent chloroform death the giving of belladonna or atropine 
before the antesthetic, and bandaging the limbs. Injecting saline 
solutions he thinks is valueless. Ihe conclusions Hare comes 
to are : (1) the qviestion of blood pressure is the most important; 
(2) the heart becomes affected. Hare (Medical JVetvs, New York, 
March 6, 1897) further enters into the way in which chloroform 
acts upon the various tissues. Its dominant action is depressing ; 
coming in contact with the heart, even in medicinal doses, it 
weakens that organ. It lowers the vitality of the protoplasm of 
the respiratory centre to an extent proportional to the quantity 
L 2 



1G4 TIIH YKAK-UOOK OF TREAXMENT. 

inhaled. Death, ho Ijelievos, may occur from lieart failure or 
rcispiratory failure, the latter being by far the more common. In 
the former case cardiac disease is present, either in the shape of 
a pernianeut lesion or as the result of engorgement or enlarge- 
ment, the result of struggling. No doubt many such deaths 
occur with or without the use of chloroform. Leonard Hill 
(address before Society of Antcsthetists, Brit. Med. Journ., April 
17, 1897) discusses the pathological cause of chloroform syncope. 
The experiments instituted by the Hyderabad Commission he 
regards as open to adverse criticism on two counts : (1) because the 
experiments themselves were carelessly executed, and (2) the con- 
clusions drawn from them are, in fact, in many cases the reverse 
of what the manometric and other tracings show. His own ex- 
periments {Journ. of Pliysioloyy, May, 1897, and vol. xviii., p. 15) 
demonstrate that paralysis of the respiratory centre depends 
on the chloroform in the circulation poisoning the respiratory 
centre, and upon the blood pressure. The higher the pressure 
the less is the failure of the respiration. The depth of the 
anaesthesia also depends upon the de[)th of the fall of blood 
pressure. He admits, however, that chlorofoi-m also acts upon 
and damages the respiratory centre, and so weakens the respira- 
tion, but insists that the respiration would not fail at the point it 
does unless the poisoning of the respiratory centre was associated 
with the fall of blood pressure, due also to the action of the 
chloroform. In all cases the posture of the patient plays an 
important part. The chloroform, by acting upon and depressing 
vasomotor action, allows the force of gi'avity to come into un- 
restrained play. In the feet-down position as in sitting, or in 
the semi-recumbent posture, the blood drains from the brain and 
thorax into the splanchnic system of veins, leaving the bulbar 
centres aiijemic. His conclusions are : (1) Chloroform produces a 
primary failure of the circulating mechanism^ and a secondary 
failure of the respiratory centre ; (2) there are two kinds of 
chloroform syncope :— («) Dui-ing primary ansesthetisation ; the 
patient struggles, holds his breath, raises the intrathoracic 
pressure, congests his venous system, lowers his arterial tension, 
and finally takes deep inspirations and surcharges his lungs with 
chloroform. In the first stage his heart becomes impoverislied, 
in the second suddenly filled. This supply is drawn from the 
luno-s, and is overfilled with chloroform, passing through the 
coronaries to the muscle of the heart, paralytic dilatation takes 
place. (J)) During prolonged amesthetisation : this state of affiiirs 
arises from gradually giving chloroform to too great an extent. 
The horizontal posture and artificial respii-ation will resuscitate in 



ANESTHETICS. 165 

this {b) form of syncope. In the iirst (a) form the same 
measures shouhl be adopted, and the heart rhythmically com- 
pressed by squeezing the thorax, and, failing success, the patient 
should be put in the feet-down posture in order to empty the en- 
gorged heart, then placed horizontally while artificial respiration is 
steadily kept up. This manoeuvre can be repeated. Inversion 
and compression of the abdomen are said to be dangerous as they 
tend to force more blood into the paralytically -distended heart. 
(.3) Vagal inhibition does not take an important part in pro- 
ducing, chloroform syncope. (-1) " Ether is, in every way, a safer 
anaesthetic than chloroform." A writer in the Therap. Gaz. 
(July, 1897) points out the danger of lung and kidney disease 
following the lowering of temperature incident to the taking of 
an anaesthetic, amounting in some cases to 3° or 4°. C. Allen 
(A))ier. Journ. of Med. Sciences) has made a similar research 
upon dogs, obtaining like results. 

An important communication bearing upon the elTeff vtliich 
ethor has upon the kidneys has been made by Lemoine and 
Gallois (abstract in Journal des Praticiens, July 3; New York Med. 
Joiirn., July 24, 1897). In the severest forms of uraemic respira- 
toiy disturbance, when actual (chronic) renal lesion is absent, 
repeated and large doses of ether given by the mouth and hypo- 
dermically invai-iably relieve the condition. Uraemia due to acute 
nephritis, acute I'enal congestion, renal congestion occurring in 
the course of sclerotic nephritis and of infectious forms of 
nephritis, is much benefited by ether. Chronic renal disease is not 
benefited by this treatment. The obvious corollary from this 
would seem to be that ether when inhaled, unless very enormous 
quantities are taken, is probably not injurious to the renal 
tissues, and is not likely to set up nephritis or cause uraemia. 
Lemoine and Gallois give 2 to 3 dr. every half-hour. An 
enormous quantity taken by the lungs would Ije required to 
correspond to this dose by the mouth. J. B. Ogden brought to the 
notice of the Boston Society of INIedical Sciences the results of his 
research upon the effect ofellier upon the kidneys. A very 
careful examination was made after ether was given in cases in 
which there was little or no pre-existing renal disturbance. 
Seventy-five cases were under observation, and were all of them 
those in which only a minor surgical operation had been per- 
formed and little or no blood had been lost, so that anaemia was 
not a disturbing factor. In 34 '6 per cent, albumin was not present 
before, but was found afterwards. In 34'6 per cent, albumin was 
present before the etherisation, and was increased afterward.s. 
Thus 69*2 per cent, of the cases showed albumin or an increase 



IGO THE yp:ar-rook of treatment. 

of alliiiinin aftiM- takiiifj other. In 1 "54 per cont. allminiii was 
iieitlici- found Ix'fore iKn' aftci- ctlicr. In 1 S.'i per ct-nt. alhuiiiin 
existent ljef(ji-e was lesseiuid after; and in 1'33 per cent., tlioui,di 
albumin was detected before, n(me was founrl after ether was 
given; but these changes were piobaljly duo to the pi-e.sence of 
blood corpuscles; 

Albumin may, however, be pre.sent without any renal lesion, 
so Ogden relied for evidence of kidney disturbance not only on 
the appearance of alljumin but also upon the presence of renal 
elements — casts, etc. In 14-0 per cent, casts were increased in 
number ; in 57 '3 per cent, casts v/ere found after, not Itefore, 
ether; so that in 7r9 percent, renal disturbance, as shown Ijy the 
presence of casts, was either initiaterl or increased after ether. 
In 22-6 per cent, no change in the quantity of cast« was observerl ; 
in 5-3 per cent, casts were absent alike befoi'e and after; while 
in 22-G per cent, more concentrated urine was voided alter ether. 
It is suggested that the concentration of the urine may account 
for some of the hypenemia and consequent renal disturbance. The 
profuse diaphoresis usually set up by ether may be the cause of 
the concentration of the urine. The quantity of ether given was 
130 to 800 c.c, and the administrations varied from ten minutes 
to an hour and a half. The amount of ether inhaled, and the 
time the patient was under its influence, did not appear to bear 
any ratio to the amount of albumin. Children did not appear to 
sutler from ether albuminuria more than adults. In one case 
out of the seventy-five saccharuria developed after ether, and 
per.sisted three days. Von Lerber {La Presse Medicale, Nov. 11, 
1896) examined the blood in 101 patients before and after 
etherisation. The luemoglobin was found unchanged in sixty- 
five, increased in nineteen, and lessened in fourteen cases. He 
concludes, therefore, that ether produces little change In fifty- 
five cases the red corpuscles were increased, in forty-two 
diminished, unchanged in four. It was also found that spectro- 
scopy of the urine showed no increase of urobilin (eighty-three 
cases), as must have occurred had the corpuscles been damaged. 
In ninety-six cases the leucocytes were increased in number, in 
five decreased. This diminution was due apj)arent!y to con- 
ditions peculiar to the individual. 

APPARATUS. 

IScllainy Gardner's etiier iiilialer consists of a cylindrical 
reservoir containing 6 ounces of ether, sun-ounding a bn-athing 
chamber 2 inches in diameter (Fig. 1). A small metal .shaft runs 



ANJSSTHETICS. 



167 



vertically from the tap above through the breathing chamber, 
communicating below with the ether chamber. A hollow metal 
plug tits this shaft, and through a pinhole in the axis of the 
breathing chamber a tine stream of ether is directed upon the 
sponge, through which the patient breathes. The warmth of 



^^^^'^^irx 




* Fig. 1. — Bellamy Gardner's ether inhaler. 

the hand of the administrator is sufficient to vaporise the con- 
tained ether, and the tension thus developed forces a stream of 
ether through the pinhole into the sponge. Tlie special merit 
claimed for this inhaler is that it is light to hold, and produces 
efficient antesthesia without causing cyanosis, pupillary dilatation, 
or distressing symptoms of any kind. The tube seen attached to 
the bag is for the use of nitrous oxide as a preliminary to the 
ether. It is claimed that this inhaler combines the advantages of 
the Clover's portable ether inhaler and Orinsby's instrument. 

Hobday's cliloroforiii inhalers. 

These inhalers are intended to ensure a very high dilution of 
the anaesthetic . In one case (Fig. 2) the air is sucked in by the 
hand bellows, and passes over the surface of the aniesthetic, and 
is then presented to the patient. In the other and later form the 
air is pumped into the vessel containing the chloroform, and 
escapes along the affluent tube (Fig. 3). The principle is that of 
Junker, only in Hobday's inhaler the air tube does not pass down 
into the liquid. A very small percentage of vapour is in this way 



168 



THR YEAR-BOOK OF TREATMENT. 



ensured. It is important to avoid tilting tlie Ijottlo. In the lower 
animals the designer has found it safer than any other inhaler. 




Fig. 2. — Hobday's chloroform inhaler. Showing the arrangement of the bellows 
whereby air is sucked over the surface of the anesthetic and the mixed 
vapour steadily forced into the mask on the patien.t's face. 



He reports (The Veterinary Record, Sept. 25, 1897) on 2.oO cases 
of dogs successfully antesthetised by veterinary inhalers con- 
structed on this principle. In the Lancet (July 24, 1S97) he 




Fig. 3. — Hobday's chloroform inhaler. Showing the arrangement of the bellows 
whereby air is forced over the surface of the anesthetic and tb.e mixed 
vapour thus steadily forced into the mask on the patient's face. 

describes his inhaler as applied to human beings, and states that 
it is of especial value for children and persons for whom a very 
small dosage is considered advisable. 



GENERAL SURGERY. 

By William Kose, M.B., B.S., F.R.O.S., 

Professor of Clinical Surgerxj in King's College, and Senior Surgeon to King's College 
Hospital; and 

Albekt Cakless, M.S. Lond., 

Senior Assistant-Surgeon to King's College Hospital, and Teacher of Operative Snrgeru 
in King's College. 



I.— GENERAL METHODS. 

Aoitistreptococcic serum as an ivimunising agent prior to 
operation. — One of the most valuable suggestions of the year is 
that when patients are exposed to the risk of sepsis after opex'ation 
they should be pre\'iously rendered immune to the action of strep- 
tococci by the use of this serum. Boucheron was one of the first 
to call attention to this practice [Amiales cf Oculistique, August, 
1896) ; he was treating a case of lymphangitis in a diabetic by 
means of Marmorek's seruin, and thought that the opportunity 
would be good for the removal of a cataract, which was also 
present in the same individual. Such cases are always liable to 
suppurate, but in this instance the recovery was satisfactorily 
uneventful. Durham ( Trans. B. Med.-Cld. Soc.^ London, vol. Ixxx., 
p. 191) also suggests that in cases of laparotomy, where the 
patient is liable to be infected with streptococci, it is a wise and 
rational proceeding to immunise them with antistreptococcic 
serum on the previous day ; especially is this desirable when 
dealing with peritonitis or abscesses arising during the 2:>uerperium 
or after abortion. The most important communication on this 
subject was that of Watson Cheyne {Practitioner, April, 1897), who 
had utilised it as a preliminary measure before some extensive 
operations on the tongue and pharynx. In the first patient half 
the tongue had to be removed, together with the tonsil and 
anterior pillar of the fauces — just the type of case in which septic 
pneumonia is likely to develop. Two days before the operation 
20 c.c. were injected, and on the following day 10 c.c. The 
progress of the case was remarkable ; there was no elevation of 
temperature after the first twenty-four hours, with the exception 



170 THE YKAR-BOOK OF TREATMENT. 

of ;i slit,'lit ri.sc! soiiie days later, evidently in conn(;ction with the 
at'tcr-(^n'('cts of the sei'Uin. There was no innaiiuiiatioii alx^nt the 
wound, no tendency whatever to any septic infection or septic 
pneumonia, and no sloughing of the surface of the wound. 
Uh(;yne ex[)lains this by the statement that the growth of 
streptococci induces the sloughing of the surface, and decom- 
position taking place in these sloughs causes the discharge to 
become offensive. Similar results have occurred in other cases, 
and from our own subsequent experience we can fully confirm 
the benefits derived from this procedure. It usually suffices to 
inject about 30 or 40 c.c. in all, distributed over the preceding 
twenty-four hours, and, if need Ije, another 10 c.c. can be given 
after the o[)eration. It sometimes induces a slight rise of tempera- 
ture for a day or two, but this is not a matter of any serious 
moment. Another condition in which it might be desirable to 
utilise this prophylactic is in operating on joints, where strepto- 
coccal infection is very liable to follow in spite of every pre- 
caution. 

Asepsis usque ad absurdum I — The latest development of the 
aseptic craze hails from Breslau, where Mikulicz now operates in 
gloves and with a wet towel tied over the lower half of his face, 
similar precautions being also insisted on for a period of tliree 
mouths for all his assistants (Dent. ined. Woch., June 21, 1897). 
Failure in maintaining asepsis in operation v/ounds is often 
attributed to the catgut, but, as Mikulicz points out, this can 
scarcely be the explanation in every case, since different results 
ensue though the catgut is taken from the same bottle. The 
hands are a much more likely source of contamination ; even after 
cleansing with alcohol and sublimate the purification is only 
superficial, ex[)eriments having shown that the deeper parts often 
contain organisms. This point is interesting, as it emphasises the 
opinion always expi'essed by Lord Lister that carbolic acid is a 
more reliable agent for this purpose than sublimate, since it 
penetrates further into the tissues. The gloves iised are simple 
white cotton gloves, known to tlie trade as "footmen's thin 
gloves " ; a dozen pairs cost half a crown. They are sterilised, and 
one or more pairs may be needed during an operation according to 
the amount of bleeding, whilst, of course, they are changed if 
anything septic is touched ; they can be used over and over again 
after washing. Necessarily, even when the gloves are used, the 
hands must first be thoroughly sterilised. After a little practice 
it is said that they do not in any way interfere with palpation, 
grasping, or sewing ; in fact the seizing and retention of tissues is 
much easier with than without them. There is no object in using 



GENERAL SURGERY. 171 

them for operations wliere sepsis is certain to be pres(!nt or to 
follow, as about the mouth, gullet, or rectum. 

It lias also been proved that even in .quiet conversation 
bacteria are ejected in [larticles of saliva into the air around the 
speaker. Hence Mikulicz prohibits talkiiag, but as it is impossible 
not to say a word sometimes, he and his assistants wear moist 
towels around their mouths and noses, including the beard if one 
is worn. Another point insisted on is that visitors should not be 
admitted to see operations without thorough preparation, and then 
only in limited numbers. The result of these precautions is said 
to have been most encouraging ; in three months he has not had 
any inflammation in incisions which were completely closed, and 
hence has utterly discarded drainage for clean wounds which may 
be expected to heal by first intention. Stitch suppuration has 
also disappeared. 

It is evident that the limitations introduced by following such 
a pi'actice must be considerable, and Mikulicz himself admits that 
as all the conditions for aseptic surgery are difficult to fultil, it is 
wiser for the general practitioner (and we would also add for the 
surgeon) to keep to antisepsis. One need only consult the 
statistics given on a later page as to the results of operations per- 
formed for the radical cure of hernia to see that thei-e is little to 
be gained from such extravagant precautions. 

II.— SURGERY OF THE OSSEOUS SYSTEM. 

The treatment of fractures by the open method is coming more 
and more into favour, thanks to the impunity with which we can 
now deal with such conditions when antiseptic precautions are 
observed. A very thoughtful and suggestive paper is contributed 
by 0. H. Allis [Annah of Suryeri/, June, 1897) to the Philadelphia 
Academy of Surgery, in which this subject is judiciously dis- 
cussed. He points out the small amount of risk associated at the 
pi-esent day with the treatment of compound fractures. It is a 
matter of almost every-day occurrence for such lesions to be dealt 
with by immediate purification after laying the tissues freely open, 
fixation of the fragments by wires or pegs, and the application of 
a permanent dressing which may or may not need to be replaced, 
the whole lesion healing without the slightest difficulty or danger. 
Such proceedings have always brought to light the fact that there 
has been a much greater disturbance and injury inflicted on the 
parts than was at first anticipated, and the same may be assumed 
to hold good for fractures where the skin has remained intact ; 
from this he argues, and with justice, that if an operation was 



172 TIIR YRAR-nOOK OP TREATMENT. 

iiocilnd for tlio former whero infection had possibly occurred 
tliroui^li tli(! l(!.sion in the skin, it is equally rc(|uired in ruaiiy cases 
of th(( latter when reposition of tlie fragments is oL'tained with 
dirticiilty, since wound infection is practically out of the question. 
Th(! distinction ])etween the so-called simple and compound frac- 
tur(!s ought scarcety to be insisted on at the present day, or, at 
any rate, the terms open and closed might he applied with more 
justice. A patient is told that he is suffering from a simple 
fracture, and yet at the end of six or eight weeks' discomfort and 
treatment he may be left with a deformed or useless limb, show- 
ing that the injury was of a most serious character and anything 
but simple. 

Of course tliis contention is by no means novel, and in Great 
Britain Lane has been teaching the same doctrine for some years. 
He contributes a lecture to the Clinical Journal (July 7, 1897) 
in which he repeats many of the considerations lie lias already 
brought forward ; and from a more |)rolonged experience is able to 
recommend still more forcibly this line of treatment. He again 
points out that one of the chief hindrances to reduction of the 
deformity is extravasation of blood around the broken ends, and 
maintains that contraction or spasm of muscles has compai'atively 
little influence since it can be easily eliminated by deep anaesthesia, 
and yet in spite of this the difficulty of securing complete apposition 
in closed fractures is very evident. He particularly insists on the 
necessity for operation in oblique fractures of the tibia and fibula, 
and in the different varieties of what is known as Pott's fracture. 
Illustrations of the drills, plated screws, and modified lion forceps 
used in these proceedings are given, as also skiagi'ams of the 
limbs showing the bones in perfect apposition with the screws i7i 
situ. Lane maintains that Pott's fracture cannot l)e reduced satis- 
factorily by the simple movements of extension and adduction of 
the foot ordinarily employed, and that the fibula should be cut 
down on in all cases, the fragments prised into jiosition with ele- 
vators and screwed together ; when this has been accomplished the 
internal malleolus, even if at first separated from the end of the 
tibia by an interval, will usually lie in close contact with it. 
Lane's contention that the bone in a fracture ought to be restored 
to its oi-iginal form is a perfectly just one, and the value of skia- 
graphy in determining whether or not this has been accomplished 
cannot be overrated. Naturally a considei'able amount of opposi- 
tion has been raised by these radical suggestions, but the old bugbear 
of surgeons, viz. the danger of converting a closed into an open 
fracture, is doomed, and there can be but little doubt that the 
younger generation will resort to this practice much more freely 



GENERAL SURGERY. 173 

tliiiu tlieir ancestors, and the deleterious results Mdiich have 
so constantly followt'tl this type of accident will, we hope, become 
a rarity. Prof. Annandale, of Edinburgh University (iScottish 
Med. mid Surg. Journ., Oct., 1897), recommends the use of steel 
]jins for tlu; tixation of bones, whether after operation, or for 
simple or compound fractures ; they are made of difierent sizes so 
as to suit vaiying i-equirements, and are of good steel with rounded 
heads. For oblique fractures of the tibia he uses one or two pins 
passing through both fragments ; in one case of ununited fracture, 
where it was difficult to drive the pin into position, he introduced 
one into the bone on each side of the gap, and then brought them, 
and at the same time the ends of the bone, .securely together by 
means of a loop of wire introduced subcutaneously, its ends being 
twisted and brought out at the upper pin puncture. As a rule, 
the pins become loosened in fi-om two to four weeks after their 
insertion, and can then be removed without trouble. J. B. Roberts, 
Professor of Surgery, Philadelphia (Medical News, Jan. 16, 1897), 
also maintains that complete reduction, exact restitution of con- 
tour, and perfect retention are the conditions of full success in 
the treatment of fractures. Skiagraphy has frequently demon- 
strated that fractures which were apparently reduced most 
satisfactorily have in reality a considerable amount of deformity 
persisting, and hence also advises recourse to operative proceedings. 
The ope7i treatment of fractured patella is still looked on 
askance by many, but it is gaining ground as the most certain 
means of securing pei-fect apposition and union of the fragments, 
and the fact that a surgeon of St. Bartholomew's Hospital has 
commended its use is very significant. Butlin in a clinical 
lecture {St. Bart.'s Hosp. Journ., Aug., 1897) showed four cases 
on which he had operated in this way with complete success. The 
first operation for wiring a recent fracture of the patella in this 
hospital only dates back four years, and it is satisfactory intelli- 
gence to hear that the practice is being followed by others, and 
that in none of the open operations has any suppuration occurred. 
" In transverse fractures, in young and active subjects, or even in 
men under sixty years of age, who are in sound health, I wire the 
patella whenever the patient will permit it. . . . I do not 
think that wiring is so necessary in women, but there is no objec- 
tion to it in good subjects." Butlin makes a semilunar incision, 
and uses two silver wires coming out of the fractured surfaces 
just short of the cartilages ; he considers it a most im[)ortant 
detail tliat no foreign body should remain in the joint. The limb 
is kept on a back splint for ten days, and a week later the patient 
is allowed to move the limb in bed, but in an elastic bandage. 



174 THK YEAR-BOOK OF TREATMENT. 

He is usually dischari^ed at tlie end of a montli or iive wct'ks from 
the operation, wearing an (elastic l)andaj^e and walkinj^ slowly 
about. Lucas-Championniere {.lonnt. tie M(kl. et da Chir., June 25, 
1897) repoi-ts oU cases opera({!il on l)y the open method, and in 
no instance can any bad result l)e strictly attributed to it. One I'at 
woman died of chloroform ; one man of a kidney complication 
ten days after operation, but the articular lesion was in a most 
satisfactory condition ; a third fatality was due to gout, but again 
the bone had united perfectly. A fourth case had been operated 
on many years previously, and the fragments ap])roximated by 
silver wires, although they were not apposed ; owing to a fresh 
accident the wires broke, and the lesion was reproduced ; a col- 
league had opened the joint and suppuration ensued, which finally 
led to a fatal issue. Apart from these cases, of which the last 
should scarcely be included at all, the results were in every way 
satisfactory. The author alludes to the importance of removing 
all tags of fibrous tissue which are plastered down between the 
fragments, and maintains that if this is not accomplished osseous 
union cannot occur, in spite of the statements to the contrary by 
the advocates of subcutaneous operations. He turns up a large 
flap reaching nearly to the tibial spine, and employs two silver 
wires rather than one, each of them a millimeti-e in diameter. 
Drainage is always employed to secure the patient from pain and 
tension. It is not considered a point of much importance 
whether or not the cartilage is encroached on in the passage of 
the wires, as Lister oi'iginally maintained ; the one great and 
essential desideratum is to obtain a secure hold of the fragments. 
When, therefore, the bone is very friable, or if several fragments 
exist, none of which would be likely to hold the wire securely, 
it will suffice to encircle the fragments by the wire. This is quite 
a different matter from encircling the bone without opening the 
joint ; such a proceeding is of no value. No splints are applied, 
and movements are permitted from the earliest days. The 
solidity of the union is commented on in this paper, and Lucas- 
Championniere states that he has never had a case of refracture 
of the patella after wiring. Occasionally when the fragments 
have been mei-ely approximated but not apposed, the wires have 
broken, and separation has again occurred; but the introduction 
of fresh and stronger wires has sufficed to give the patient control 
once more over the limb. 

Lejars (Presse Medic, March 20, 1897) relates his experience 
with what is termed "cerclage" of the patella, a proceeding that 
he considers simpler than wiring, and equally efficacious. He 
opens the joint after turning up a large semilunar tlap, cleai's 



GENKKAL SURGERY. 175 

away all clots and fibrous tags, and then passes a silver wire 
above through the tendon of the rectus, and below through the 
ligameiitum patelU^, twisting the ends tirndy together. The wire 
must pass close to the bone both above and below, and must be 
equidistant between the anterior and posterior surfaces, otherwise 
the fragments may be tilted slightly, and the cartilaginous 
apposition may not be perfect. The fragments are carefully 
wedged together by the lingers, the wire adapted closely to the 
inner border of the bone, and when it has been twisted upon the 
outer side, the patella should feel quite solid. Sutures are applied 
to the torn capsular and aponeurotic tissvies on either side, the 
bursa patella?, which is usually torn, is dissected out, and the 
wound closed. The limb is kept on a splint for twelve days, 
and a few days later movements and massage are commenced, so 
as to restore the functions of the quadriceps. Lejars has operated 
on six cases in this way during the last yeai', and has even dealt 
at one time with both patelhe, which had been broken simultane- 
ously. 

Treatment of ununited fractures by thyroid medication. — 
Gauthier {^Lyon Medical, June 27 and July 11, 1897) writes a 
suggestive article dealing with this subject, and relates two cases 
in which thyroid treatment brought about the consolidation of 
ununited fractures. The influence of the thyroid secretion on the 
growth and nutrition of the tissues is well known ; the associa- 
tion of myxoedema with cretinisnr has been frequently noted, and 
the value of tliyroid extract in this condition has been conclu- 
sively established. Patients with exophthalmic goitre are some- 
times affected with mollities ossium, and acromegaly is supposed 
to depend on an enlargement of the anterior lobe of the pituitary 
body, which is identical in structure with the thyroid. Experi- 
mental work has also demonstrated the same facts : thus rickets 
develops in the foetuses of animals that have undergone total 
thyroidectomy during pregnancy (Trachewski); whilst von Eisels- 
berg removed the thyroid from two lambs, keeping another of the 
same age as a control. In the two former growth was very 
considerably affected, the head becoming flattened from before 
backwards, and the horns atrophying. The suggestion as to the 
use of thyroid extract in the treatment of ununited fractures was 
first made by Hanau and Steinlein at the Frankfort Congress in 
1895, but appai-ently the two cases reported by Gauthier ai-e the 
first in which it has been employed in pi-actice. The first of these 
was a girl of fifteen, well developed, and with apparently no 
deficiency in the size of the thyroid body. She experienced a 
fracture of the lower third of the left femur, with overlapping of 



176 TIIK YKAK-HOOK OF TltKAl MKX'I. 

tlie fragtnoits, Ijut with no aitpreciaVjle or serious complication. 
It was easily I'educed and put up in splints. At the end of a 
month perf(!ct coaptation of the fra<^ments was present, but not a 
trace of consolidation. The apparatus was leapplied, and phos- 
[)hatc of lime administered, but at the end of the second month 
lier condition remained unaltered. The ends of the bone were 
well rubbed together, and blisters aj)plied at the level of the 
fracture, but at the end of another month, i.e. 110 days from the 
accident, the fragments were still quite movable, and the parts 
tender on pressure. Thyroid medication was then commenced ; a 
glycerine extract of the fresh gland was employed, an amount 
corresponding to 6 grammes of the t)rgan being administered per 
diem. Although some general disturbance was at first caused, the 
treatment was persisted in. At the end of a fortnight consider- 
able progress had been made in the consolidation of tlie fracture, 
and in six weeks from the commencement of the thyroid treat- 
ment the limb was firm enough to allow the patient to stand on 
it. The second case occurred in a man of forty-eight years, of 
apparently healtliy constitution and with a normal thyroid. The 
upper third of the radius was broken by direct injury, and a light 
plaster support was applied to prevent rotary movements of the 
hand. At the end of three months no union had been obtained, 
and crepitus on movement of the part was distinct ; the site of 
fracture was painful and swollen. Thyroid medication was 
adopted for twenty-five days, about 160 grms. of the active agent 
being absorbed. The crepitus had then entirely disappeared, the 
pain and swelling had gone, and the arm was nearly as strong as 
the other, although pronation and supination were a little limited. 
Certainly the account of these cases is both instructive and in- 
teresting, and since the treatment suggested is devoid of risk, it 
may well be utilised before resorting to other more serious means, 
such as operation. 

The closure of large osseous cavities left after the removal of 
considerable masses of bone, whether for disease or accident, 
is always a somewhat tedious proceeding, owing to the rigidity of 
the walls and the want of vascularitj^ of the tissues from which 
the granulation tissue has to be formed. One method of dealing 
with this condition is to allow the cavity to fill with blood clot 
and then wait for this to organise, whilst -others have employed 
methods such as sponge-grafting. In all of these, however, the 
material which occupies the cavity merely acts as scaffolding on 
which the gvanulation tissue is built up, and the pi'ocess of 
healing is always prolonged. Oilier (^Gaz. Med. de Paris, July 17 
and 20, 1897) discusses various osteoplastic methods of com- 



GENERAL SURGERY. 177 

bating this couditiou. The tihia is the long bone which most 
often requii'es such treatment, and the os calcis is similarly 
troublesome after the removal of its interior for tuberculous 
disease. The plan Oilier recommends is to suppress or mobilise 
one of the walls of the cavity, so as, in the first place, to allow 
the periosteum to fall down and come into contact with the 
opposite bony wall, and in the latter to allow the two bony walls 
to be approximated. Of course when the whole of the osseous 
tissue is removed on one side, the strength of the bone is for 
a time diminished, but the new formation which occurs on 
the under side of the periosteal flap quickly restores it to a 
normal condition. This type of ti-eatment is especially useful 
when a bone is thickened as a result of osteomyelitis. In dealing 
with a long bone, where a large cavity containing a sequestrum 
of considerable length is opened up, the best plan is to detach 
one side of the hollow freely by transverse cuts above and below 
and by a longitudinal incision through the base. The whole of 
one side of the sequestral cavity can thus be freed and displaced 
inwards, being secured to the other side by a metallic suture, and 
thus the space to be filled up with granulations is greatly 
diminished. In a few cases it is even possible to undertake this 
at the same time as the removal of the bone, but if there is any 
sepsis present, it is wiser to delay matters for awhile. Occasion- 
ally several flaps of varying size and shape are required in order 
to conform with the special peculiarities of the case. Osseous 
gi-afts obtained either from the neighbourhood or from outside 
may also be utilised in some circumstances. In Ollier's com- 
munication various cases illustrating the value of these suggestions 
ai"e related. 

Partial removal of the sternum for tumoiirs. — Only within the 
last few years has this proceeding been undertaken, with any 
reasonable hope of success, and even now it is only justifiable to 
operate in picked cases. Keen, of Philadelphia, has recently 
recorded two instances in which he has succeeded in removing 
portions of this bone for tumours {Med. and Surg. Reporter, 
March 27, 1897), and appends to his account a summaiy of the 
other cases on record. In his first patient the inner tliird of the 
clavicle was involved, together with the upjDer left portion of 
the manubrium, whilst two nodules could be felt in the lower 
third of the sterno-mastoid on the same side. The disease was 
evidently sarcomatous in nature. The first step in the operation 
was to ascertain whether or not such adhesions existed behind as 
would render removal impossible. This was done through an in- 
cision above the sternal notch, the finger being worked downwards 

M 



178 THE YEAR-nOOK OF TREATMENT. 

.sii(K(;i(*iitly io make out tliat tlie postorior surface of the Ijoue 
was frcM!. Tlie lower tliird of the st<!rno-uiastoi(l was <Uvi(hd and 
reinoveil, together with all the superficial tissues in front of the 
clavicle and sternum ; the clavicle was divided at the junction 
of its inner and middle thirds, and the inner third removed 
entire. The first rib was next dealt with, a full inch of its 
anterior extremity, together with the cartilage, being freed and 
taken away. It was then possible to detach the manubrium 
from all its posterior connections, and to remove the diseased 
portion by horizontal and vertical incisions made with cutting 
pliers, the former at thejunction of the manubrium and gladiolus, 
the latter just to the left of its right Vjorder. None of the vessels 
of the neck were laid bare, with the exception of the left jugular, 
although the pulsations of the aorta could be clearly detected. 
The patient did w-ell although some suppuration occurred, and 
fifteen months afterwards tliei'e was no sign of recurrence. The 
second case was one of carcinoma secondary to scirrhus inammaj. 
The disease first appeared in the left breast, which, together with 
the axillary contents, was removed. Soon afterwards a swelling 
of the sternum was noticed at the junction of the manubrium 
and gladiolus, and following this a nodule was discovered in the 
right mamma. An attempt was made to remove the disease, and 
the breast, together with the second and third costal cartilages, 
the intercostal tissues down to the pleura, and a portion of the 
sternum were taken away. The patient recovered, but within 
a few months died of recurrence. 

Keen has been able to collect 17 other cases of operation on 
the sternum for the removal of tumours, and of these 9 were 
sarcomata. He notes that fortunately adhesions to the posterior 
tissues are late in forming, and that therefore, if the case has not 
been neglected too long, operation is justifiable. Even should 
the tumour be adherent and the pleura opened dui'ing the opera- 
tion, the result is not necessarily bad, since collapse of the lung 
does not invariably follow. The results of 18 of the above- 
mentioned cases are recorded, and of them only 4 died, a very 
excellent result when one considers the extent of some of the 
operations, which have included removal of the whole gladiolus. 
Details of the technique are given. Carless has also undertaken 
an operation for the removal of a huge sarcoma of the manubrium 
{lifed. Press, October 6, 1897), but was unfortunately obliged to 
desist owing to the extent of the posterior adliesions, which could 
not be detected before division of the bones. He draws the con- 
clusion that unilateral tumours are the most favourable to attack, 
since probably only one pleural cavity is likely to be opened if 



GENERAL SURGERY. 179 

tlioy are at all adherent posteriorly. It is scarcely wise to risk 
the opening of both pleurte at one time, although such has been 
done without a fatal issue, and therefore he recommends that 
tumours involving both sides of the manubrium should not be 
touched. 

III. —SURGERY OF JOINTS. 

The treatment of tuberculous arthritis. — When it was first 
proved that afiections of joints which were formerly known as 
strumous were dependent for their incidence upon the bacillus 
tuberculosis, a considerable impulse was given to their treatment 
by surgical means, so as, if possible, to eradicate all traces of dis- 
eased tissue, and it was even taught that the great essential was to 
remove every portion as thoroughly as one does for malignant 
disease. The pendulum is now, however, tending to swing back 
in the opposite direction, and much more reliance is being placed 
on constitutional treatment and prolonged rest. In some cases 
this seems to be insufficient to bring about a cure either on 
account of the weakness of the individual or from the virulence 
of the organisms. In such cases where tlie surgeon does not wish 
to resort to operative measures, an important adjuvant is to be 
found in iodoform, which has been proved to have marked inhibi- 
tory influence upon the development of the specific bacillus, 
even if it is not actively germicidal. Gilbert Barling (Treatment, 
May 27, 1897) speaks with the utmost confidence of the benefit 
which can be derived from the injection into and around affected 
areas of an emulsion of this substance of glycerine (10 per cent.). 
He advises that the fluid should be sterilised immediately before 
use, although this is not absolutely essential. A syringe is employed 
capable of holding about 6 drachms, and must be taken to pieces 
and thoroughly boiled prior to use. The amount injected varies 
with the particular joint and the age of the patient ; into the 
knee of a child five or six years old about 2 drachms is intro- 
duced, whilst an adult's knee will take about twice that amount. 
The immediate eft'ect is to produce a good deal of effusion, leading 
to an increase of pain, swelling, and perhaps temperature for a 
few days. Where there is considerable thickening around the 
joint, injections into these pulpy masses may be practised, and 
then the amount of swelling and pain is not so great. Of course 
where deep bone lesions are present, the emulsion is of no good 
since it cannot reach them ; but if only the articular exti-emi- 
ties are afiected, the emulsion is often sufficient to bring about a 
satisfactory result. Barling does not consider that such treat- 
ment acts by inducing sclerosis of the surrounding parts, since he 
M 2 



180 TIIK YKATM'.OOK OF TIIRATMKNT. 

finds that no good follows similar injections of diloiidc of zinc. 
Of course, all cases do not improve under this rcyime, hut even 
then no harm is a^jparently done Ijy it. The injections may be 
repeated several times, but an interval of at least a fortnight is 
advisable. Duplay and Cazin [Gazette des Hop., Sejjt. 28, 1897) 
related to the Moscow Congress some experiences illustrating the 
point that the intra-articular injection of iodoform is most 
valuable in this affection. Formerly they had employed iodine 
for this purpose, but have now given it up in favour of iodo- 
form, and prefer to use it suspended in mucilage rather than 
dissolved in ether, the latter causing too much pain. Of 9 
patients treated in this way, 7 were cured in periods ranging from 
four to six months ; the other 2, which were advanced cases, 
with .sinuses already existent when treatment commenced, were 
unimproved. The 7 cures included 5 cases of disease of the 
knee joint ; they have been watched since their discharge from 
the hospital, and no recurrence has been noted, in spite of the 
fact that when first seen it seemed impossible to deal with them, 
except by excision. 

A number of interesting notices have appeared during the 
year concerning the treatment of hip disease, and to some of these 
we must draw attention. 

In the first place a valuable discussion has arisen between 
Tobin, of Dublin, and Howard Marsh as to some of the prin- 
ciples which should govern us in the treatment of this affection 
(see Brit. Med. Journ., April 24, May 8 and 29, and Aug. 14, 
1897). In the causative communication Tobin suggested the 
early performance of a sub-trochanteric osteotomy of the femiu- in 
order to remedy the deformity of the limb. He argued that the 
position of greatest ease for the joint, viz., flexion, abduction, and 
eversion, is one of great awkwardness for the limb, and that the 
means taken to correct this deformity are unsatisfactory. Thus 
after causing the limb to assume this attitude by injection of fluid 
into the joint, he forcibly straightened it and caused the fluid to 
be squirted out again forcibly. It is therefore assumed that any 
method, whereby extension is obtained, will exaggerate the 
symptoms of tension, and therefore the application of a weight 
and pulley is objectionable, since it is usvially applied with 
the limb straight. He also maintains that a considerable 
proportion of the cases in which flexion has been treated 
by extension with weight and pulley go on to suj)puration, 
quoting in support of this view some old figures .(which 
still remain in Erichsen) dealing with results obtained at 
the Alexandra Hip Hospital twenty or more years ago ; his 



GENERAL SURGERY. 181 

explciiiation of this fact is that extension can never give the joint 
absohite rest, and inasmuch as Nature tlexes the limb, he thinks 
it right to attempt to meet the difficulty without disturbing the 
false position of the head of the bone. Once more he claims that 
the section of the femur is itself beneficial, since it reduces the 
amount of vascular tension in the bone. Marsh has but little 
difficulty in meeting each and all of these points and shows 
that osteotomy is quite superfluous. Thus he first states a fact 
that must be abundantly obvious, viz., that the position of the 
joint is not dependent on an increase in the fluid contents, but is 
assumed in order to relax the tense and swollen articular tissues, 
and hence the restoration of the limb to a correct position cannot 
increase the pain in the way that Tobin suggests. The application 
of extension in an incorrect manner is admittedly capable of in- 
creasing the pain ; thus if the weight is applied to the flexed 
limb lying flat upon the bed, the only I'esult is to tilt the pelvis 
forwards, producing thereby lordosis, and increasing the inter- 
osseous pressure. This can be obviated by making extension 
with the limb flexed into the attitude of ease ; by this means 
muscular spasm is diminished quickly, and the limb falls natur- 
ally into the desired attitude in a short time. A Thomas's 
splint can bring about the same result if it is applied with 
the limb suitably flexed at first. As to suppuration being 
more common when extension has been adopted. Marsh states 
that the later reports (not quoted or mentioned in Erichsen 
or by Tobin) show that of the cases treated at the Hip 
Hospital only 15 per cent, suppurate. The last advantage 
claimed by Tobin for his method of sub-trochanteric osteotomy, 
viz., the relief of osseous tension, is certainly a novelty, but the 
evidence adduced as to its possibility and value can scarcely be 
called sutiicient. The outcome of this interesting discussion is 
to emphasise again the principles relating to the treatment of early 
hip disease, and especially that connected with the direction in 
which extension can be best and most safely employed. 

The treatment of this affection has also been discussed at 
some -length in tlie Paris Societede Chirurgie ((?«;:. MM. de Paris, 
April 10, iMay 29, June 5 and 12, 1897). Menard, of Berck-sur- 
Mer, who has charge of a hospital close to the sea, dealt with his 
method of treating the abscesses consecutive to this trouble ; if 
they are unopened, and therefore aseptic, the majority of them 
can be cured by injections of camphorated naphthol, 2 to 10 injec- 
tions being required at ii\tervals of from ten to fifteen days. In 7 
out of 55 cases treated in this way the abscesses did not entirely 
disappear, although they diminished in size, and for such he 



1^2 Tine YKAU-nOOK OF TKKATMKNT. 

rccoininonds oxcisioM. The abscess slioulfl be opened, tlio fistulous 
track into tlie joint followed and scraped, the liead of the bone 
removed, and tlie acetal)ulum thoroui,ddy curetted ; the wliole 
wound is then well washed out witli hot sterilised or sublimated 
water, and the wound closed without drainaff(! ; in only one case 
has he failed in. obtaining ])riinary union. Kinnisson took a wider 
view of the subject, and described his method of treatment in 
the different stages. In the eaidy pre-suppurative stage he 
prefers total immobilisation by plaster, splints, etc., to prolonged 
extension, since by the former the child is not debarred from 
taking exercise in the fresh air. He also draws attention to the 
fallacy of making extension with the limb apparently straight in 
consequence of an associated lordosis. Should the limb be in a 
bad position to start with, it is most essential that no forcible 
reposition be attempted, as thereby diffusion of tuberculous material 
may occur throughout the body, and a fatal issue by tuberculous 
meningitis, or some similar complication, be the result. In 
five cases he has seen mishaps of this nature following, and pre- 
sumably due to, such treatment. We are delighted to see this 
warning given by so caj^able an authority ; the dangers of careless 
manipulation of tuberculous foci have several times lately been 
brought before our notice ; in particular we would allude to the 
importance of gentleness in handling tuberculous glands during 
their removal ; undue compression is, without doubt, liable to lead 
to dissemination of the virus. With the exercise of care and 
patience these t\d)erculous foci can usually be removed by a clean 
process of dissection rather than by rough handling and traction. 
The reduction of the deformity in hip disease should be made 
slowly, and if continued extension fails, section of tendons may be 
undertaken, or even in the worst ca.ses (according to Kirmisson) 
sub-trochanteric osteotomy. In the second stage of suppuration 
Kirmisson recommends the injection of an etherial solution of 
iodoform after partial evacuation of the pus ; the injections, how- 
ever, should not be made too frequently, but sufficient intervals 
allowed to elapse between them. In the last stage of the disease 
excision is required, but it is imnecessary to follow up and 
extract every particle of tuberculous granulation tissue ; if the 
general health is satisfactory, Nature can deal with the portions 
that may be left behind. Broca fully agreed that conservative 
treatment is the correct line to follow, but con.siders that pro- 
longed extension is better than simple immobilisation. He, too, 
treats abscesses by injection of an etherial solution of iodoform, 
'and reserves excision for the later stages ; he thinks it hopeless 
and unwise to attempt union of the wound without drainage. 



GENERAL SURGERY. 183 

Townsend, of New York {Medical N&ws, Juik; 20, 1897), dis- 
cusses the (juestioii of excision of the hip, and relates the experi- 
ence gained at tlie Hospital for Kuptured and Crippled daring the 
years 1888 to 181)6, during which period 2,'295 patients were 
treated for hip disease, of whom 119 were subjected to excision. 
The operation was resorted to only as a last resource when other 
methods of treatment had apparently failed, and when it seemed 
certain that unless some operation were undertaken death would 
inevitably follow. Abscesses or sinuses, more often septic than 
t)ther\vise, were present in 113 out of the 119 cases. The results 
have been traced in 99 patients, and of these 52 are dead, all but 
one dying as the result of the disease ; in the ma,jority of cases 
the fatal event was more due to sepsis than to tuberculosis. Of 
tlie -16 known to be living 26 alone are cured, and a considerable 
proportion of the remaining 20 are likely to die from exliaustion. 
In 24 cases the anterior operation was employed, and in the 
remainder the posterior, although necessarily no typical operation 
could be utilised owing to the presence of sinuses. 

The outcome of these diiferent communications tends to prove 
that there is now a greater reliance placed on conservative 
measures than on operative, and that excision is being relegated 
to the position of a dernier ressoi-t. Whether this is entirely wise 
is a question that is open to discussion. Necessarily the type of 
patient that one has to deal with and the surroundings have a 
considerable influence both on the evolution of the disease and 
on the practice of the surgeon. If a patient's environment is 
good and sanitary, and if prolonged rest in such circumstances 
can be maintained, conservative measures may well be relied on 
and excision will be seldom needed ; but when one is dealing 
with slum children of poor physique and hopelessly unhygienic 
surroundings, an early excision is more frequently required, 
though it should never be undertaken until it has been demon- 
strated that conservative measures are a failure, or unless the 
disease has progressed too far for recovery by such means to be 
expected. Our usual practice in dealing with hospital patients is 
as follows : In the early pre-suppurative stage the child is kept 
in bed, and usually with extension applied until the pain and 
tenderness have disappeared, when a Thomas's splint is fitted on 
and the child allowed to get about. If there is no great amount 
of deformity the extension is put on witli the liml) lying flat on 
the bed, and though at first a little lordosis may be })resent, it, 
soon disappears as the spasm of the muscles ceases ; when, how- 
ever, there is a considerable degree of flexion the extension is 
inade in the direction of the Ijmb, which is gradually brought 



184 THE YKAK-BOOK OK TItKATMKNT. 

down into tlio correct posture. If this treatment fails to nilieve 
the pain and the patient is evidently losing ground, or if an 
abscess appears, an incision is made into the articulation usually 
from the front, and if considered necessary the head of the bone 
is removed and the acetabulum curetted. Our experience has 
almost always been that there is much more disease present than 
we had anticipated, and we have rarely regretted undertaking 
the operation. In the later stages where sinuses exist, or 
an abscess is pointing in the gluteal region, the posterior opera- 
tion seems to be more suitable. Drainage is almost always 
employed, and preferably by means of a gauze plug infiltrated 
with an emulsion of iodoform. In the great majority of cases 
these children do extremely well, the wounds soon healing, and a 
fair amount of mobility being secured ; of course the limb is 
immobilised in a Thomas's splint for some months after cicatrisa- 
tion is complete. 

Bardenheuer (^Centr. filr Cliir., Feb. 20, 1897) has recently 
undertaken the somewhat heroic operation of removing the leg 
and half the pelvis for extensive tuberculous disease of the pelvic 
bones as a consequence of hip disease. The patient was a woman 
aged 46, who had been the subject of coxitis from quite early 
years, the leg being atrophied and crutches always employed. 
Several septic sinuses existed, and the phenouiena of amyloid 
disease were becoming urgent. The leg was much flexed and 
internally rotated, and the trochanter was 15 cms. al)0ve ISTelaton's 
line. Flaps were fashioned from both the inner and outer aspects 
of the limb, and connected by an oblique incision along Poupart's 
ligament. The peritoneam was freed from the iliopsoas, and the 
vessels traced up high enough to enable both external and 
internal iliac arteries and veins to be tied and divided. The 
thigh was then removed at the hip-joint with scarcely any bleed- 
ing, and subsequently the innominate bone was taken away. The 
horizontal ramus of the pubes was sawn across close to the 
symphysis, and the descending ramus of the ischium divided. 
The iliopsoas was separated from the underlying tis»sues, and the 
muscles inserted into the crista ilii cut across. The innominate 
bone was then dragged outwards and forcibly detached from the 
sacro-iliac synchondrosis. The psoas was stitched across to the 
remains of the adductor tendons and muscles, and the wound 
closed after provision had been made for drainage. The patient 
suffered but little from shock, and made an uneventful recovery. 
Wolff, who reports the case, lays great stress upon the preliminary 
ligature of both the iliac vessels, and also upon the absence of 
chiselling, which seems so often to determine a considerable 



GENERAL SURGERY. 185 

amount of shock. He thinks it would be wise in another similar 
oper-ation to retain the glutei muscles, at any i-ate in part, so as 
to form a more satisfactory covering to the peritoneum behind. 
Of course such a procedure as this can only be called for under 
very exceptional circumstances ; the maximum that is usually 
required even in cases where there is a certain amount of pelvic 
disease, associated with septic sinuses of the hip, is an amputation 
through the hip joint, to which may subsequently be added 
curetting of the pelvic bones. 

IV.— SURGERY OF THE VASCULAR SYSTEM. 

Woitnds of the heart and pevicardium. — Since the publication 
of Capellen's case of successful suture of a wound in the heart 
a considerable amount of attention has been directed to this 
subject, and a number of cases, the majority of them attended 
with fatal results, have been published. Rehn, of Frankfort-on- 
Main, called attention to it in a paper read at the German Surgical 
Congress {Centr.f. Ghirurg., App. to No. 28, 1897, p. 456), and 
gave a number of intez'esting general facts connected with the 
subject. Puncture of the heart leads to a momentary arrest, 
followed by irregular and tumultuous action. Small wounds gape 
but little, larger ones considerably, although this is influenced by 
the direction of the incision. Medium-sized wounds of the right 
ventricle always bleed more than those of the left. In small 
wounds the bleeding stops spontaneously after a time, but 
secondary hajmorrhage is very likely to follow ; in larger wounds 
death is due to arrest of the heart owing to the intrapericardial 
tension. The value of suture is emphasised, and Rehn is able 
to report a case in which he had successfully accomplished it. 
A young gardener, aged twenty-two years, wounded in the 
fourth left intercostal space, was taken to hospital blanched 
aud almost pulseless from loss of blood. He rallied after a 
time, but suffered severely from dyspnoea owing to the amount 
of intrathoracic extravasation. The fifth rib was partially re- 
sected, and after cleai'ing away all the clot a small incision into 
the pericardium came into view, from which venous blood was 
escaping. On enlarging this aperture and exposing the heart, 
it was found that during diastole an incision a centimetre and 
a half in length became evident in the centre of the right 
ventricle. Three silk stitches were inserted and the bleeding 
was at once controlled. Owing to the rolling movements of the 
heart it was only possible to introduce the needle during diastole, 
since the systole caused the right ventricle to disappear behin<l 



186 THE VEAR-BOOK OK TKKATMKNT. 

the stornum. It w;i.s internsting to noto that tlie lioart tolerated 
well the pressure of the lingers in onUir to control the bleeding, 
hut that each prick of the needle and the traction of th(! suture 
led to a momentary cessation of action. The patient finally did 
well, although the after-treatment was prolonged considerahly 
owing to pneumothorax and the persistence of a purulent 
discharge. 

There has been some discussion during the year as to the 
best method of exposing the pericardium so as to deal with 
wounds either of that membi'ane or of the heart, or for pui'])oses 
of drainage in suppurative pericarditis. Several authors favour 
the turning up of a trap-door consisting of the fourth and fifth 
costal cartilages and connecting soft parts, using the tissues of 
the third inters2:)ace as a hinge. The internal mammary vessels 
and left pleura are thus exposed and pushed to the left, so that 
the pericardium is left uncovered and accessible to operation. 
[See J. B. Roberts, and H. Williams, New York Med. Record, March 
27, 1897.) 

End-to-encl union of arteries. — In the last edition of the 
" Year-Book " we noted some work which had been undertaken 
in this direction, and leported one or two cases of arterial suture. 
A further communication on this subject has been puljlished by 
J. B. Murphy, of Chicago (Medical Record, Jan. 16, 1897), who has 
experimented largely on animals, and relates two successful cases. 
The method of union which he recommends is diflerent from that 
suggested by Jaboulay, consisting in invagination of one end 
into the other. Three doubled-needled silk sutures are employed 
for the purpose, each needle being inserted from without inwards 
through the intussusceptum, so that a loop is left externally, and 
then from within outwards through the intussuscipiens. About 
one-third of an inch of the upper end is invaginated by this 
means. It is also advised that the threads should not pass 
through the whole thickness of the wall in the upper end, but 
just miss the tunica intinia, so that no portion of the suture 
should be exposed within the lumen of the vessel, as otherwise 
it might determine thrombosis. In order to facilitate this in- 
vagination, a small incision parallel to the long axis is made in 
the lower end, extending for about a third of an inch from the 
site of section. Four or five interrupted stitches are then in- 
serted into the intussuscipiens, binding it to the surface of the 
intussusceptum, the suture in the latter entering only the adven- 
titia and media. A large surface contact of vessel is thus 
secured, and the arterial blood pressure tends still further to 
approximate the walls together and prevent haemorrhage. The 



GENERAL SURGERY. 187 

1-esults of Murphy's experimental work were on the whole 
satisfactory, but great care and delicacy are needed in hand- 
ling the parts, and failures occurred in a certain proportion 
of cases. 

As to the value and utility of this proceeding in man, Min-phy 
points out that it is never needed in cases where the unassisted 
collateral circulation inay be expected to keep alive the parts 
supplied by the divided artery. " We are called upon to suture 
arteries and veins only in cases in which, by their oblitera- 
tion, there would probably be a necrosis or impairment of the 
vitality of the tissue supplied by them to such an extent that its 
normal functions would not be performed. Therefore, in the 
upper extremities we shall not be concerned with the arteries 
below the brachial ; in the neck not above the common carotid ; 
in the abdomen we are concerned with injuries to the aorta, 
renal, splenic, hepatic, and iliac vessels. Suture of the portal 
vein is particularly desirable, as in President Carnot's case. The 
greatest need for artei'ial suture exists after injury to the so-called 
terminal vessels, but they are the least accessible." In discussing 
the extent to which an artery can be safely cut away, Murphy 
says : " I cannot believe that a vessel can be repaired with safety 
when more than three-fourths of an inch is removed, except 
possibly in the popliteal space, Scarpa's triangle, or in the axillary 
space, where the position of the limb can be made to relieve the 
tension of the vessel." 

Longitudinal wounds of arteries or veins are more easily 
dealt with, and Murphy agrees with the opinions formerly 
published by Jassinowski in Langenbeck's Archiv in 1891. 
Fine twisted silk is the best material to employ, and the sutures 
should merely penetrate the tunica adventitia and media, the 
intima being avoided. The sutures are inserted every one- 
sixteenth or one-twentieth of an inch, are interrupted, and 
should enter the vessel one-sixteenth of an inch from the margin 
of the wound. The ordinary double knot must be used, but not 
too tirmly tied. 

For partial circular wounds of an artery, it is recommended 
that if the lesion involves more than one-half of the circum- 
ference the edges should not be united end to end, but the injured 
portion should be resected, and the divided segments treated by 
invagination. 

In illustration of his remai'ks, Murphy reports two interesting 
cases of injuries to vessels dealt with by suture. In the first the 
patient received a bullet wound in Scarpa's triangle, and on 
dissection it was found that the internal saphena vein was per- 



188 TIIK YKAK-IJOOK OF TUEATMKNT. 

foratc'd back and front, the bullet liavinj:^ passed through its 
middle ; both openings were closed by silk sutures. A similar 
perforation existed in the common femoral vein, just above its 
juncticm with the profunda, and it was necessary to tie this latter 
trunk before the openings in the main vessels could Ije secured. 
The femoral artery had a fragment of tissue torn fi-om the sicle of 
its sheath, but the vessel wall was apparently uninjured. After 
the compresses had been removed not a drop of blood escaped 
from either vein. There was some inflammatoi'y reaction, but 
the patient did fairly well, until ne.arly a month had elapsed, 
when bleeding occurred from a sinus which had remained un- 
healed, and a tumour of some size developed in the upper part 
of the thigh. This was opened up, and on removing a large clot 
bright red blood escaped ^>er saltum from the bottom of the 
wound. On compressing the external iliac, it was found that 
the inner wall of the artery had been eroded for the space of 
an inch, and that several perforations were present. It was 
carefully dissected out and an inch and a half of the trunk was 
x-esected, ligatures being applied both above and below. The 
case then ran an uninterrupted course towards I'ecovery. In the 
second case the Inillet entered the groin just below Poupart's 
ligament. There was but little hiemorrhage ; a few days later 
a slight swelling developed, in which a very loud bruit could 
be heard, and the pulsation in the distal vessels of the limb 
was considerably diminished. An incision five inches in 
length was made in the course of the vessels, and the femoral 
artery was readily discovered. Clamps were applied to the 
trunk above and below, and bleeding from a wound in the vein 
controlled by digital compi-ession. A small aneurysmal sac was 
thus ex[)Osed, arising from a perforating wound of the artery, 
which involved both anterior and posterior walls ; in fact, only 
about one-eighth of an inch of the wall was intact on the outer 
side of the ])erforation, and a sixteenth of an inch on the inner 
side. The vein was also torn at one spot, and this was first 
dealt with by suture after controlling the circulation in it, as 
well as in the profunda vein. On releasing the clamps it dilated 
owing to the blood pressui'e, but was only about one-third of the 
normal size ; there was no bleeding from it. The opening in the 
artery was then examined and found to be about three-eighths of 
an inch long ; one-half inch of the vessel was resected, and the 
pi-oximal end invaginated into the distal for a third of an inch 
with four double-needled threads. The adventitia was peeled 
off the invaginated portion for a distance of a third of an inch ; 
a row of sutures was placed around the edge of the overlapping 



GENERAL SURGERY. 189 

clistul portion, the sutures only penetrating the media of the 
proximal portion ; the adventitia was then drawn over the line 
of union and sutured. On removing the clamps no blood escaped, 
and pulsation was at once restored in the vess(d below the union. 
The wound suppurated, but the patient did well and recovered 
without ojdema or any circulatory disturbance. Of course 
sufficient time has not yet elapsed to enable us to come to any 
final conclusion as to the value of this method of treatment, and 
it will be interesting to hear later on whether or not any 
aneurysmal development occurs ; but at any rate Murj)hy is to be 
congratulated on his success. 

Schwartz (^Qaz. des Hupitaux, Dec. 3, 1896) relates a somewhat 
similar case in which he treated a tear of the lateral sinus by 
suture. The case was that of a coachman who had been kicked 
by a horse behind the left ear, producing a depressed fracture. 
Various cerebral symptoms resulted and for these trephining was 
considered necessary. During the opei'ation a portion of bone 
adherent to the dura mater had to be extracted, and in spite of 
every precaution the lateral sinus was torn to the extent of about 
a centimeti'e. A linger placed on the sinus controlled the 
bleeding, and it was then found that the lesion could be secured 
without much difficulty by suture. Such an observation is valu- 
able, since the sinus is not uncommonly exposed to injury during 
opei'ations on the mastoid, and it is certainly desirable to control 
the bleeding without having recourse to plugging, whereby throm- 
bosis is almost certainly induced. 

Orlow (Ref. in Centr. fiir Chir., May 29, 1897, No. 19) 
relates a case in which he made an incision in the popliteal 
artery during an operation, the wound being from a half to three- 
quarters of a centimetre long. He stitched it up by means of 
thi'ee stitches inserted through the whole thickness of the walls, 
and two over-stitches including merely the adventitia and sur- 
rounding connective tissues. In three days distinct pulsation 
was noticed in the vessels of the leg. Later on the limb required 
amputation, and it was then found that the artery, though 
narrowed, at the site of suture, was quite pervious. 

Treatment of aneuri/sms. — A number of interesting cases 
have been published during the year which serve to illustrate 
some of the more recent ideas as to the way in which aneurysms 
can best be dealt with. 

D. D. Stewart, of Philadelphia (Brit. Med. Jonrn., Aug. 14, 
1897) reports the necropsy on a case of innominate aneurysm of 
large size, completely cured by the employment of electrolysis 
through 10 feet of snarled, coiled, fine gold wire, introduced into 



190 TIIK VKAIMiOOK OK TUKATMKXT. 

the sac ; ilw paticiiL lived three and a lialf years afler treatment, 
and died of cerebral tliroiiiljo.si.s. On jjosl-jnoi'teni examination it 
was found that the aorta was dilated in a fusiform manner from 
its commencement to the left suljclavian trunk, whilst the 
innominate aneurysm was represented l)y a tirrn fibroid tumour 
al)out the size of a foetal head, 13 cm. long by 9 cm. wide; the 
mass consisted of organised fibrin in the midst of which was 
found the coiled-up mass of gold wire. The author states that 
he has now treated two cases of sacculated aneurysm by electro- 
lysis through coiled gold wire and has directed the treatment of 
another case; the results, at any rate in the two last cases, have been 
most gratifying. Gold or silver wire should be employed, after being 
carefully drawn so that it can pass without ditticulty through an 
insulated hollow needle. The most complete antiseptic precau- 
tions arc called for, and then the needle is inserted in a valvular 
manner by drawing the skin aside. The amount of wire intro- 
tluced varies with the size of the sac, but Stewart states that for 
a globular aneurysm of 3 inches diameter 3 to 5 feet are suflicient, 
whilst for one 4 or 5 inches in diameter 8 or 10 feet are required. 
The positive pole of the batteiy should be attached to the wire, 
and the negative pole to an electrode placed on the back or 
abdomen. The current is very gradually increased in strength 
up to about 60 or 80 milliamperes, and then slowly dimin- 
ished ; the application should last about three-quarters of an 
hour or more. The battery is then disconnected, the needle 
gently withdrawn, and the wire cut off short and pushed back 
beneath the skin, the valvular opening in which tends to 
cover it completely. By this means a large extent of surface is 
exposed to coagulation, and should the wires touch the sac wall 
so much the better, as thereby changes are induced which lead to 
subsequent proliferation of the endothelial or connective tissue 
elements. Ten cases are mentioned as having been treated in 
this way, and certainly in four of them prompt coagulation of the 
contents of the sac occurred with consolidation of the tumour. 
There can be but little doubt that this plan of procedure is an 
improvement on either that of simple needling as proposed by 
Macewen, or of electrolysis by means of a couple of needles, or 
of the simple introduction of wire. Several of the cases were 
totally beyond the hope of cure by any other method of treat- 
ment. 

Subclavian aneurysm. — Glutton (J/ef/ico-CAi. Trans., vol. Ixxx., 
p. 371) relates a case in which he cured an aneurysm involving 
the third part of this vessel by ligature of the first part of the 
subclavian artery. The aneurysm was of three years' duration. 



GENERA.L SURGRRY. 



191 



and about as large as a walnut, reaching from the vscalenus anticus 
to the clavicle. At the tirst operation (Fig. 1) the trunk was tied 
at the junction of the first and second parts after the scalenus had 
been divided ; the superior intercostal was also ligatured. The 
material employed as a ligature was gold-beater's skin, which had 
been speciall}' prepared by Ballance ; it was tied in a stay knot, 
sutiicient force being used to stop the pulsation beyond, but not 




/xr^ 



innom. A. 



Fig. 1. — Ligature of 1st subclavian (first operation). 



to divide the coats. The wound did well although there was 
a little superficial suppuration, but the pulsation returned in 
the aneurysm, which in the course of eight or ten weeks was as 
large as before, and pulsating with equal force. A second operation 
(Fig. 2) was thei'efore undertaken in order to secure tlie artery on 
the proximal side of the former ligature. A curved incision was 
made above the clavicle, the outer fibres of the stern o-mastoid were 
divided, as also the origins of the sterno-hyoid and -thyroid. The 
carotid artery and jugular vein were now seen lying side by side 
ill the centre of the wound, and after a little careful dissection 



192 



TIIK YI0AII-15OOK OF TKKATMKNT. 



tlie foiiiK!!' was (li-awii in\v;uds tujjetlicr with the pneumogastn'r, 
ami Iho latt(;r outwards with the phiciiic nerve. The verLcl>ral 
vein liad to he divided to give access to tin; subclavian tiunk, 
which was then secuied witlujut much dilHculty ; the ligatui:c 
was a])|»lied on the proximal side of the inteinal mammary and 
thyi'oid axis, which were also tied. The wound healed satisfac- 
torily, hut in a week's time it was foun<l liiat pulsation was 



Tied at l%* Open 




AxY A 



Innom.A. 



Fig. 2. — Ligature of 1st subclavaan (second operation). 



still present, and therefore the first part of the axillaiy was 
ligated. The pulsations then finally ceased, and the sac gradually 
diminished in size. Silk was the matei'ial employed for securing 
the first part of the trunk, tied as before in a stay knot, and 
without attempting to divide the coats. Glutton considers that 
if the inner tunics are divided, the blood pressure in the neck 
is siifiiciently great to determine the formation of an ant^urysra 
at the site of ligature. The successful issue of the case may be 
attributed to two factors : the aseptic condition of the wound and 
the tying of the internal mammary and thyroid axis, by which any 



GENERAL SURGERY, 193 

backwash of blood was preveuted. The latter point is a most 
important one, and is recognised as an essential detail in securing 
other large vessels, such as the innominate, hgsmorrhage almost 
always occurring unless the carotid and also sometimes the verte- 
bral are tied at the same time. 

In the discussion that ensued on this case Bernard Pitts related 
a somewhat similar case in which he had tied the tirst part 
of the artery for an aneurysm involving the second and third 
portions ; the sac was here so large that it was impossible to 
secure the neighbouring bi'anches. A silk ligature was applied, 
and it was thought that only sufficient force had been employed 
to bring the vessel walls into apposition without dividing the 
tunica intima. Pulsation recurred, and the wound was again 
explored by Ballance, who found a pulsating swelling which 
seemed to spring from the aorta, and entirely precluded any 
further })roceedings in this region. The first part of the axillary 
was therefore tied, but the patient died a month or two later 
from diftuse hsemorrhage from the site of the exploration. It was 
found jjost mortem that an aneurysm of some size had developed at 
the point of application of the first ligature, and was evidently 
due to the tunica intima having been divided owing to the walls 
being soft and atheromatous. 

In both of these cases the aneurysm was situated on the right 
side, and there was no great difficulty in finding and tying the 
fii'st part of the vessel. When, however, the left side is aflfected, 
the condition of aftairs is very different, and the operation 
becomes veiy serious. Thus Mitchell Banks [Brit. Med. Journ., 
Feb. 6, 1897, p. 335) relates a case where he attempted it and, 
owing to the difficulties present, had to desist. A long incision 
Avas made down the middle line of the neck, and at either end 
of this a transverse cut was made so that a flap was formed and 
thrown outwards. The clavicle was cut through and the inner 
third removed, a piece of the first rib excised, the internal jugular 
and innominate veins were tied, and the left subclavian vein, 
which caused some trouble, was plugged with cyanide gauze. 
The aneurysm did not pulsate much, and this want of pulsation 
increased the difficulty of finding the artery. During the pro- 
longed operation the left pleura was accidentally opened and 
stuffed with gauze. It was at last deemed necessary, on account 
of the condition of the patient, to desist from further attempts 
to find the vessel. The patient died seventeen days later fi-om 
pleurisy. 

Carotid aneurysm. — Delageniere (^Archives Prov. de Chir., 1896, 
p. 225) recommends extirpation in dealing with primitive 
N 



194 THK YEAR-1500K OK TKKATMENT. 

aneurysms of this trunk as safer than simple ligature of the 
cartoid, owing to the diminished risk of setting free emboli. 
The value of this proceeding for aneurysms of the extremities has 
of late been frequently noticed, but its extension to large vessels 
of the trunk or neck has not hitherto Ijecn attempted. The 
author recommends that in order to prevent venous l)leeding it 
is advisable to divide the internal jugular between ligatures. 
The artery is clauiped below the sac, and then tied and divided 
iunnediately below the clamp. The sac can thus be lifted up, 
any vessels arising from it secured, and the posterior wall 
freed from its connections. The greatest care has to be taken 
not to injure the pneumogastric and sympathetic chain. He 
relates a successful case which he treated in this way in 
a girl sixteen years of age who had been stabbed in the 
neck nine months previously ; the aneurysm was as large as an 
orange. 

Cirsoid aneurysm. — Two cases of this rare affection have been 
recorded diiring the past year. In the first, treated by Beaumont 
{Brit. Med. Jo^irn., July 31, 1897) the patient, a servant girl of 
twenty-two, complained of a pulsating tumour on the left side of 
the forehead, running up from the inner angle of the orbit, and 
covering the left side of the frontal bone. Strongly pulsating 
nutrient vessels were traced into it from the occipital, temporal, 
and angular arteries of the same side, whilst others reached it 
from across the middle line. As the condition was progressing, 
surgical treatment was undertaken. This consisted in the first 
place in tying all the main nutrient vessels ; each was cut down 
on individually and secured, before they became dilated, and in 
this way eight arteries were secured. The thrill and pulsatioii 
were thus very much diminished. The next step was to insert 
subcutaneously and in an opposite direction to each other two 
needles, with an exposed surface of about an inch, into the 
anterior and outer part of the tumour. An electric current of 
100 milliamperes was passed for ten minutes, and then, after 
gradually diminishing it, the needles were withdrawn ; each 
of the four segments of the tumour was dealt with in the same 
way, ten minutes' electrolysis with a current of 100 milliamperes 
being allowed for each. It was then found that all parts of the 
mass were harder, that its resiliency was less, and that pulsation 
could scai'cely be felt. A week later two fresh vessels were 
detected at the postero-external portion, and these in turn were 
tied, and electrolysis was once more employed. The final result 
was most satisfactory, the whole mass, which originally measured 
7 inches by 5, being consolidated. Nothing was done directly to 



GENEUAL SUKOEKY. 195 

the orbital portion, but it partook of the general benefit, due 
probably to the starvation resulting from distal obstruction, 
the shrinkage being sufficient to allow the 'eye to return to 
its usual situation in the orbit. The second case was reported 
by Summers, jun. (^Annals of Surgery, May, 1897, p. G20)j it 
occurreti in a man aged forty-five, and occupied the forehead, 
but without encroaching on the orbit. The chief nutrient vessels 
were tirst of all ligatured, and then a large horse-shoe incision 
was made with the base upwards, and the whole growth excised. 
The operation was a bloody one, as several vessels entered the 
mass which had not been formerly noticed. The outer wall of 
the skull was found to have been absorbed, and there was a free 
anastomosis with the dij^loic vessels. The wound healed entirely, 
but five or six months later recurrence was noticed. It was then 
found that the mass was larger than before, and the annoyance 
almost unbearable. Both external carotids were therefore secured 
below the origin of the linguals, and by this means all pulsation 
was checked, but in order to favour the permanency of the cure the 
common carotid \vas tied a few days later. The patient promptly 
recovered from both these operations, and no cerebral disturbance 
followed. A twelvemonth later there was some enlargement 
and pulsation of the terminal branches of the ophthalmic artery; 
these were in turn tied, and since that date there has been no 
sign of recurrence. 

The result in these cases is most satisfactory, since the treat- 
ment of this condition has always been a matter of extreme 
difficulty. It is interesting to note the recurrence which took 
place in the second patient after simple ligature of the nutrient 
vessels and apparently complete excision ; this agrees with the 
usual experience. On the whole one cannot but think that the 
plan adopted by Beaumont is the more rational, and holds out 
the best prospect of a cure. 

v.— SURGERY OF THE LUNGS. 

Tuffier [Gaz. Med. de Paris, Aug. 21 and 28, 1897) read a 
long and interesting paper on this subject at the Moscow Inter- 
national Congi'ess, in which the most complete summary of what 
has been attempted and done in this direction may be found. 
In the main it merely confirms and expands in details Reclus's 
paper referred to in the last edition of the "Year-book" 
(p. 203). One or two points may, however, be noticed. Ex- 
ploratory punctures, in order to assist in making a diagnosis, 
are considei'ed to be not devoid of risk, and the surgeon should 
N 2 



196 TIIK YKAU-UOOK OK TUICATMKNT. 

1)0 ready to follow this proceeding by an iniinediatc opera- 
tion if positive results are obtained. The existence or not of 
pleural adhesions is easily determined as soon as the pleura is 
opened ; if none are present, suture of the two layers together is 
recommended as the proceeding of choice. It is scarcely wise to 
trust to the coheJ4ion of the two walls, as should a pneumothorax 
subsequently develop, .septic and other trouldes may arise and 
jeopardise tlie patient's chances of recovery. The incision and 
drainage of tuberculous cavities is not favoured, and according to 
his tigurcs 50 per cent, of the cases may be expected to succund), 
whilst no permanent benefit has arisen in tho.se patients who 
survived. The disease usually runs its normal course, even 
though the walls of the cavity were scraped and disinfected, and 
subsequently plugged with iodoform gauze ; they seldom healed 
completely. It has been suggested that this was largely due 
to the walls being unable to contract owing to pleural adhesions, 
and hence excision of the overlying ribs has been practised ; the 
records are, however, at present too scanty to warrant us in 
drawing any conclusions as to its value. Pidmonary abscesses 
following pneumonia are favourable for operation, but although 
the result of dealing with bronchiectases is to improve the 
symptoms, absolute cures are not very common. The removal of 
foreign bodies from the lungs is not associated with a great degree 
of success, since that is only one of the troubles present ; a septic 
bronchiectasis also exists, and this is by no means so amenable to 
treatment. The localisation of gangrene of the lung is often a 
difficult matter, but the practitioner ought not to call to his 
assistance the aspirator needle, as thereby septic infection of the 
pleural cavity is easily brought about, and the case is consider- 
ably complicated. For the same cause it is most essential that 
solid adhesions should be present in these cases between the lung 
and the parietes, and the surgeon is quite justified in delaying the 
further steps of the operation a few days in order to determine 
their formation by plugging the wound. Tuffier recommends that 
the lung should be incised with the red-hot cautery knife, holding 
that infection of the lung tissue penetrated by it is less likely to 
ensue than if a bistoury is employed. The cavity, having been 
opened, is thoroughly explored, necrotic tissue removed, and 
drainage by tube or gauze provided for. It siiould not be washed 
out, however, for fear of filling the bronchial tubes with lotion 
and " drowning " the patient ! 

Macewen, of Glasgow [Med. Record, Sept. 17, 1897), agreed in 
the main with Tuffier. He laid special emphasis upon the fact that 
the lung does not necessarily collapse after opening the pleural 



GENERAL SURGERY. 197 

cavity, the cohesion of the two smooth serous surfaces being usually 
suliicient to prevent this. He also stated that a small inci.sion 
into the pleura is more likely to lead to pneumothorax than a 
large one. With i-egard to tuberculous cavities the following 
]u-actice is adopted by him : If the cavity is small, resection of 
three or four ribs causes the cavity to collapse. Larger ones 
should be freely incised, emptied and drained. Very large 
vomicie should be thoroughly scraped and packed with iodoform 
gauze. The improvement noted after such procedures was often 
immediate and striking. 

VI.— SURGERY OF THE NECK. 

Foreign bodies in tlie ossophag^is. — Two or three interesting 
cases have been reported during the year, illustrating the possible 
methods of dealing with this condition. The fii'st and most 
important point to be mentioned is the value of skiagraphy in 
guiding the sui'geon to the site of obstruction, as also in settling 
whether the foreign body has been swallowed or still remains 
impacted in the gullet. Thus in a case recently under our own 
observation we were able to determine accurately that a hairpin, 
said to have been swallowed, was lodged in the upper part of the 
tesophagus, just above the top of the sternum ; two days later 
further examination proved that the pin was absent from its 
former situation, and had presumably passed into the stomach, 
a fact confirmed subsequently by its passage in the faeces. A 
still more valuable fact is tliat reported by Delatour (Med. Record, 
May 1, 1897), who not only utilised the cryptoscope for localising 
a metal washer that' had been swallowed but was also enaV>led 
by its assistance to grasp the foreign body with forceps and 
remove it. The blades of the forceps could be clearly seen in the 
screenand guided to the washer. 

Bull and Walker [Med. Record, March 6, 1897) relate a suc- 
cessful case of removal, by external cesojyhagotomy, of a tooth- 
plate, which had been impacted in the gullet for twenty-two 
months. The oesophagus was opened just aljove the sternum 
upon a bougie, and the edges of the incision were held apart by 
loops of silk. The walls were here healthy, but an inch lower all 
instruments were at first arrested, apparently by soft tissues. 
After a little manipulation it was found that the plate was lying 
in a pouch in the posterior wall, leaving only the u^^jier and lower 
ends exposed. The incision in the oesophagus was enlarged 
downwards till it was about an inch and a half long, but even 
then the plate could not be removed until the mucous membrane 



198 TriF. VKAU-liOfiK OF TURAT.MKNT. 

lying over iL had Ixjcu divided by scissors. A drainage tulic was 
Hulisequeutly introduced about four inches into the rt'sopliagus, 
and a gauze packing around it; rectal feeding was maintained 
for ten days, })y which time the wound had contracted to a con- 
sid(!rable extent ; merely a gauze wick was then allowed in the 
wound, and ordinary swallowing permitted. The wound was 
soundly closed in seven weeks. A statistical account of 1G7 
cases dealt with in this way is appended ; in an earlier series 
there was a death-rate of 24-2 per cent., but in 32 Jiew ones here 
collected it had been reduced to 15'6 per cent., an improvement 
mainly due to earlier interference. It is also shown tliat the 
mortality increases directly with the duration of tlie case. The 
most common causes of death are septic complications, especially 
involving the mediastinal tissues. Tlie practical outcome of this 
inquiry is to suggest that if removal by operation is to be under- 
taken at all, the earlier it is proceeded with the better. 

Treat)aent of cut throat- — The rules laid down for the guid- 
ance of surgeons in their treatment of this condition have been 
considerably moditied of recent years, thanks to the influence of 
antiseptic precautions. It was formerly considered essential to 
success that no stitches should be put in these wounds if they 
communicated with the air-passages, except, perhaps, at the 
extreme limits of the incision, and a large percentage of patients 
were expected to die of septic pneumonia or some such complica- 
tion. It is, therefore, extremely satisfactory to note that Piatt, 
of Manchester, has been able to record 10 cases of cut throat 
involving the air-passages with 8 recoveries (Brit. Med. Journ., 
May 8, 1897). In one of the fatal cases no sutures were in- 
troduced and no attempt to close the wound instituted ; whilst 
in the other the patient, who was an unhealthy man with 
diseased liver and kidneys, died of acute pneumonia, but 
with no evidence of its being septic in origin. In all the 
other cases the wound in the air-passages was moi'e or less 
completely stitched up ; in 4 it was totally closed and no tracheo- 
tomy tube was introduced, and of these the lesion was twice 
tlirough the thyro-hyoid membrane, and twice involved the crico- 
thyroid space. In the remaining four cases a tracheotomy tube 
was inserted — in one through the crico-thyroid interval, which had 
been opened ; in another through the trachea, which hud been 
completely divided, the divided segments being an inch apart ; in 
a third case, where the thyro-hyoid membrane was involved, a 
high tracheotomy was performed; and in a fourth, involving the 
ciico-tracheal membrane, a fresh vertical slit in the trachea was 
made for the tube. Piatt suggests that, if it is practicable, it is 



GENERAL SURGERY. 199 

wise to anaesthetise the patient with chloroform, as thereby the 
wound can be dealt with much more efficiently ; if he is suffering 
severely from shock it may be wise to dela}^ the operation for a 
few hours, whilst intravenous infusion may be employed when he 
has lost much blood. Piatt recommends that a tracheotomy tube 
should be introduced in all cases where the larynx or trachea has 
been completely divided, as also when the wound is in the thyro- 
hyoid space and has severed the epiglottis, since (jedema of the 
larynx is very likely to supervene. It is also suggested that 
the tube should only in rare cases be inserted through, the 
suicidal wound ; it is much better to make a fresh incision 
through the ti-achea at a lower level. His own experiences 
lead him to believe that it is frequently possible to close the 
air-jiassages entirely. The wound is cleansed, and the mucous 
membrane first dealt with. None of the stitches employed should 
penetrate the mucous membrane, but they must secure a good hold 
of the tibrous and cartilaginous tissues around it. The lateral 
stitches should be introduced first, and finally the central portion 
of the wound dealt with, but none of the sutures should be 
tightened till all are inserted. As soon as the air-passages are shut 
off a much more thorough purification of the wound is possible. 
The divided muscles and fascisB are then dealt with layer by layer, 
and the neck is thus built up again to a more or less normal con- 
dition. It will usually be necessary to insert a drainage tube at 
one or both angles of the wound. As to after-treatment, the tube 
need not, as a rule, be maintained in jjosition beyond two or three 
days, by which time the risk of dangerous swelling of the mucous 
membrane lias passed. The question of feeding is an important 
one ; Piatt is convinced that in most cases it is unnecessary to 
feed by a tube or by the rectum, and that the patient may be 
safely allowed to sw^allow fluid food. In cases, however, where 
the epiglottis is injured, where the larynx or trachea is completely 
divided, or where the pharynx or oesophagus is opened, it is better 
to adopt rectal alimentation for two or three days. 

In wounds of the neck not involving the air-passages, primary 
suture is also advisable in most cases, after thorough purification. 
Of 25 cases thus treated in the Manchester Infirmarj^ to which 
Piatt refers, 19 healed by first intention. 

Similar conclusions as to the value of primary suture are 
arrived at by Hogarth [Brit. Med. Joiirn., Aug. 21, 1807) and a 
successful case is recorded by him. The thyro-hyoid membrane 
was almost entirely divided, and the epiglottis cut across, the 
wound extending on each side as far as the sterno-mastoid muscles. 
The whole wound was closed, and the divided tissues of the neck 



200 TIIIC YKAR-BOOK OF TKKATMKNT. 

united layer liy layer. No tracheotomy tul>o wa.s introduced, 
and the patient did perfectly well. He maintains that a tube 
should he employed only wlien secondary swelling causes obstruc- 
tion to the respiration. 

The sriryical treatment of exophtlidlndc yoitre. — Tn the last 
number of the "Year-Book" we noticed the fact that Jaboulay 
had operated thrice for this affection by dividing the cervical 
sympathetic chain, and that he had lieen well satisfied with 
the results. During the past year several communications 
dealing with the same proceeding have been made, and three 
or four papers relating cases were read at the French Surgical 
Congress in October. The most important of these was con- 
tributed by Jonnesco, of Bucharest {Presse Mklicale, Oct. 2.3, 1897), 
who, after mentioning the former operative n:easui'es that have 
been utilised, described mox'e in detail the three plans that have 
been followed in dealing with the sympathetics, viz., simple 
division, partial extirpation, and complete removal of the chain 
and its ganglia. The first plan included merely the three opera- 
tions of Jaboulay noted last year ; the operation has apparently 
not been repeated. Twelve cases of partial removal of the 
sympathetic chain, including the superior and middle ganglia on 
l:)oth sides, have been reported, and the patients all recovered. 
Finally, Jonnesco and one or two others have practised total 
removal of the entire sympathetic tract on each side of the neck. 
The operation itself does not appear from the descriptions to 
have proved especially difficult ; an incision is made along the 
posterior border of the sterno-mastoid, and the muscle for its whole 
length drawn forwards together with the sheath of the A^essels ; the 
sympathetics are found immediately in front of the transverse pro- 
cesses of the vertebrae, lying on the longus colli. The results a})pear 
to have been manifested immediately : the exophthalmos diminished 
rapidly, so that even on the day following the operation some 
change was noticeable. The tachycardia similarly was influenced 
for good, although the pulse occasionally remained at 80 to 90 
for some few days. The goitre quickly shrank, and the tremor 
disappeared. The results, extending back in some cases for two 
years, seem to be durable, and although two relapses have been 
noted, yet they are not of a very serious nature. Abadie, who 
was the first to reconnnend on theoretical grounds this proceeding 
(Progres Me'cL, Oct. 23, 1897) is amply satisfied with the results 
hitherto gained. He maintains that the primaiy mischief is in 
the upper part of the medulla, and that thence excitation of the 
vaso-dilator nerves is transmitted through the sympathetic chain, 
which is itself neither abnormal nor degenerate. Hence he 



GENERAL SURGERY. 201 

couoIikIcs that simi»le section is quite sufficient to brin<^ about all 
the good results obtainable, and that total resection is absolutely 
unnecessary. Naturally it is desirable to divide the trunk as high 
as possible, so as to eliminate the vaso-dilator' fibres of the orbit 
which pass upwai'ds from the superior ganglion, and hence 
removal of this structure is perhaps advisable ; if the cord is 
merely divided below it, some degree of exophthalmos may 
persist. The operation is not one that can be hurried over, aud 
must take some time, and hence it is undesirable to do more than 
is necessary, since these patients never take an ant^sthetic well. 
Faure's experiences in three cases {ibid., p. 266) illustrate this 
point ; in the tirst all went well ; in the second the right chain 
was satisfactorily dealt with, but during the proceedings to ex- 
pose the left a grave attack of syncope supervened, possibly from 
interference with the vagus ; the thii'd case was fatal from chloro- 
form syncope. 

On the other hand it must not be forgotten that partial thyroid- 
ectomy is also a pi-oceeding by no means devoid of danger, both 
from heart failure and also from that mysterious group of symptoms 
which, coming on witiiin a few hours of the operation, rapidly lead 
to a fatal issue. Lejars (Bull, et Mem. de la Soc. de Chir. de Paris, 
March, 1897) relates a case in point. Against this, however, 
may be mentioned the fourteen successful cases of Kummell's, 
reported by Schultz (^Berlin. Klin., June, 1897). In most of the 
cases the symptoms were well marked, and life was even seriously 
threatened. There were no mishaps during or after the opera- 
tions, and twelve are claimed as being totally cured, the remaining 
two being much improved. The cases have been under observa- 
tion for from two to seven years, and no tendency to relapse has 
been noted in any. Paul, of Liverpool [Brit. Med. Journ., July 3, 
1897), reports six cases of partial thyroidectomy operated on 
successfully as far as regards the immediate results, but in none 
of them can he claim a total cure. Veiy frequently the imme- 
diate effects are startling, but after the temporary rapid improve- 
ment comes a period of slow pi-ogress, and the cases must be 
watched for years before the final results can be accurately 
gauged. All of his six cases have, however, been permanently 
benefited. 

Excision of both external carotids for maliynnnt disease of 
the jaw. — Dawbarn (Annals of Surgery, Sept., 1897, p. 366) relates 
a case in which he had utilised this proceeding in dealing with a 
sarcoma involving the superior maxilla. The growth was noticed 
in August, 1895, and the diagnosis was confirmed by micro- 
scopic examination. In April, 1896, the left external carotid was 



202 TiiK VKAR-1500K OF tkeatmp:nt. 

c(>iii[)lotoly (!xcis(;il, and this was followed a luontli later by 
excision of the right external carotid and of the superior maxilla ; 
a year later then; was no sign of recurrence. I>)awljarn Ijclieves 
(hat the removal of the two vessels would have sufficed to hring 
about a cui(! alone, without resorting to the extirpation of tin; 
growth. ]I(! speaks of other cases in which he had undertaken 
tlie same type of treatment, and in none had there ijeen any 
recurrence ; there had also been no fatal i-esult. Considerable 
stress is laid upon the necessity of excising the whole artery ; 
simple ligature of the trunk does not suffice, since the collateral 
circulation is so abundant. Tlie operation is tedious and rather 
lengthy ; it is not advisable, therefore, to undertake it on both 
sides at the same time. Dawbarn recommends that one should 
begin from below and work upwards, tying all the branches up 
to the terminal divisions. Owing to the freedom of the anasto- 
mosis through the angular branch of the ophthalmic, he also 
suggests that the latter communication should be secured. It 
certainly seems that this proposal is a useful one, and that it 
would be wise to undertake it either with or without removal of 
the growth ; in inoperable cases it ought certainly to be per- 
formed. Dawbarn is doubtful whether this practice is of much 
use in growths of the naso-pharynx, but for tongue and jaw cases 
it may well be tried. 

VII.— SURGERY OF THE ABDOMEN. 

The treatment of general septic peritonitis is a subject that 
must necessai'ily obtrude itself continually on the surgeon. Left 
to itself or treated by means of opium, as was formerly the case, 
it is almost certain to prove fatal, and there is no dissentient 
from the general acceptance of the statement that the only hope 
for the patient lies in laparotomy. Truly that hope is often but 
a slender one, owing to the condition of toxjemic depression 
into which the patient quickly passes, and until general practi- 
tioners realise more clearly the hopelessness of this malady 
apart from surgery, and the necessity for that interference being 
undertaken at an early date, the statistical records will not 
improve. The present status of the operation may be gauged 
from the following figures, which have been reported during the 
year:— Korte {Centr. f. Ghir., App. to No. 28, 1897, p. 60) has 
had under observation 99 cases of general peritonitis during the 
past seven years, due to infection from the viscera (exclusive of 
puei'pei'al, cancerous, tuberculous, and chronic cases), and of this 
number 71 were operated on with 25 recoveries (35-2 per cent.), 



GENERAL SURGERY. 203 

and 28 were treated without operation with hut 6 successes 
(21-1: per cent.). Perforation of the appendix was responsible 
for 34 of these cases, and 13 were saved ; perforation of the 
stomach or duodenum was the cause in 6, and Only one I'ecovered ; 
au intestinal origin in 6 cases resulted in G deaths, and of the 
14 secondary to disease of the female genitals, only 3 were saved. 
Other surgeons have liad much the same type of results ; 
Sonnenburg has saved 3 cases out of 20, and Lenander 1 out of 6. 
In America the same sad story has been told. McCosh saved 7 
out of 43 cases, whilst Weir has not been successful in a single 
case out of 20 he has had under his care. (Annals of Surgery, 
June, 1897, p. 687, and August, p. 235.) 

Under circumstances apparently so hopeless, we are glad to 
note anything which seems to hold out a hope of better things, 
and it is most satisfactory to report that McCosh {loc. cit.) has 
been able to report 7 recoveries out of his last 8 cases, and this does 
not seem due to the fact that they were in a more favourable state 
for operation than others. With two exceptions, the condition of 
all seemed desperate, and certainly in three spectators considered 
that the condition of atlairs seen inside the abdomen precluded 
the slightest hope of recovery. The cause of his success is 
attributed by McCosh to thorough removal of all the septic 
material accunmlated in the abdomen, and the early restoration 
of intestinal peristalsis ; the first of these desiderata was obtained 
V)y irrigation, the latter by the intra-intestinal injection of a con- 
centrated saline injection. The general plan of operation was as 
follows : — Chloroform was usually employed as the anaesthetic. 
The incision is five or six inches in length, its position being 
modified according to the organ supposed to be the cause of the 
trouble ; the purulent fluid is allowed to flow away by turning 
the patient on the side. The intestines are usually permitted to 
escape from the abdomen into hot towels held by assistants, though 
if they ai'e enormously distended and the heart's action is weak this 
is not advisable. Should the distension be so great that replacement 
is diflicult, the ileum is opened in one or more places and an exit 
given to gas and faeces, the incisions being sul^sequently secured 
by Lembert's sutures. The cause of the trouble is then dealt 
- with, and afterwards the intestines and peritoneum are thoroughly 
irrigated with hot normal salt solution. If the intestines have 
been removed, they are gently washed with the contents of 
several flasks of lotion, whilst at the same time a stream from an 
irrigating jar is running into every corner and crevice of the 
abdominal cavity. If the intestines are left in situ, the edges of 
the incision are raised by an assistant and flask after flask is 



204 THE YEAU-nOOK OP TREATMENT. 

oiiqjticd into LIh; cavity, so that tin; iIlt(^stiI)(^s can l>c .scparatcfl 
and all rct;iincd fluid nMiiovod. irrigation is prcferalile to 
sj)onL(in<^ or swaljl)ing, since hy the latter the sujxji'ticial endo- 
th(!liuiii is likfily to be removed, and the vitality of the walls 
diminished. Of course;, no amount of cleansin;:^ can thoroui,ddy 
sterilise the peritoneum. Th(! t(Miiperature of the lotion should 
be at h^ast 110" F., prefei-ably 112" or 114", and by this means 
tlu; heart is usually stimulatiHl rather than depressed. A <^ood 
deal of lotion may with advantage be left in the cavity. The 
injection of magnesium sulphate is then made and, if possible, 
into the u])per end of the jejunum ; about an ounce of the salt in 
a saturated solution should be introduced through an aspirator 
needle, and the small puncture closed by a Lembert's suture. 
The peritoneum is then drained by strips of gauze placed amongst 
the intestines in various directions, and perhaps a glass tul;e niay 
be inserted into the pelvis. The wound in the parietes is left 
partially ojDen, but it may be well to insert some silkworm-gut 
stitches and tie them loosely, so that at a later date the wound 
may be more effectually closed. After the return to bed, if the 
condition of the stomach permit, a ten-grain dose of calomel may 
be administered with advantage. In several of these cases which 
seemed at first absolutely hopeless the patient commenced to ex])el 
flatus before twenty-four hours, and this was soon followed by the 
passage of a motion. The two deaths of the eight operated on 
according to these directions were due, one to the effects -of the 
peritonitis, and the other to pulmonary complications five weeks 
after operation, so that this case may in reality be claimed as 
a success. In the discussion which followed this report (New 
York Surgical Society) most of the speakers agreed as to the 
value of the suggestion, but did not entirely concur with the 
necessity of allowing tlie intestines to escape. Abbe thought that 
after the operation the application of ice to the abdomen was 
valuable in stimulating peristalsis, and diminishing bacterial 
activity. He also thought it better not to remove the lymph 
which adhered to the coils of gut, as it was Nature's method of 
l^rotecting a weakened tissue. When the patients I'ecovered, the 
lymph was readily dis23osed of, so that in six months' time the 
intestines would be found entirely free. In the discussion at the 
German Surgical Congress (loc. cit.) Korte stated that he thought 
irrigation of the peritoneum was immaterial so long as good 
di-ainage was secured ; he also emphasised the importance of 
establishing early action of the bowels and refraining from the 
use of opium. Sonnenburg always opens the abdomen in the right 
iliac fossa since so many of these cases oi'iginate in the appendix ; 



GENERAL SURGERY. 205 

lie incises it freely and packs with antiseptic gauze for drainage. 
Israel, of Berlin, utilises a free crucial incision, and packs in 
iodoform gauze ; he claims to have had mori? successful results 
since he adopted this method. E. Owen relates an interesting 
case, followed by recovery, in a clinical lecture [Clin. Journ., 
June 30, 1897) ; he, too, insists on the importance of irrigation 
with hot saline solution, and never uses a sponge. Warm lotion 
is of no use in the suppurating peritoneal cavity of a boy in a 
state of collapse, whilst a really hot saline solution is not only 
a cleanser, but is a valuable stimulant, and thus greatly helps in 
diminishing the shock of the operation, and tiding over the 
crisis. 

An important point in the operative treatment of acute intes- 
tinal obstruction is noted by Ernest Stokes of Baltimore {^Annals of 
Siiryerij, Sept., 1897), and although it is by no means novel, yet 
it is worthy of comment. He reports two cases of severe intes- 
tinal obstruction, where fiscal vomiting had been continuing for 
some time, and indeed the gastric contents were being poured out 
at intervals without much effort. The patients were aniBsthetised 
in the horizontal position, and then lifted on the table. In the 
first case, as soon as the surface of the abdomen had been 
cleansed, the thin offensive yellowish fluid began to pour out of 
both nose and mouth, and the patient was rapidly asphyxiated. 
In the second case ether was employed as an anaesthetic, and the 
abdomen having been cleansed, the patient was placed in the 
Trendelenburg position, when a similar contreteinjjs hapjjened, 
resulting in immediate death. The point suggested by these two L 
cases is that in cases of acute obstruction where the stomach is rL/r<« 
evidently filled with liquid ftecal or semi-ffecal material readily '^" 
ejected, the greatest care must be taken in administering an 
anaesthetic. In many cases it will suffice to use cocaine for 
the parietal incision, and such is always preferable under 
these circumstances ; if, however, a general anaesthetic is con- 
sidered desirable, the stomach should always be thoroughly 
washed out prior to its administration, and the patient must 
never be placed with the pelvis higher than the head, or even on 
the same level ; the shoulders should always be well raised. 

Intestinal resection and suture. — Strenuous endeavours are still 
being made by surgeons to secure an ideal form of suture or some 
simple and safe contrivance for bringing about intestinal reunion. 
The old-fashioned methods of suture, though satisfactory and safe, 
are open to the objection that they take much longer time than is 
desirable, since the patients on whom the operation is performed 
are often in a very debilitated condition. The introduction of 



206 



'IIIK YKAlt-HOOK OK TUKATMKNT. 



Murphy's Imtton was a new departure, wliicli demonstrated that 
rapidity of execution was obtainable together witli security. 
During the past year many suggestions have been made for 
securing similar ends, and to a few of these we must njfer. 

Maunsell's operation has always had a select few who iiave 
recommended it a>j one of the Ijest metluxls to employ for end-to- 
end union ; the principle is good, and the results liitherto 
oljtained have been very satisfactory. A modification of value 
has lieen proposed by Ullmann, \vhicli promises to Ijring about 
a consideral)le reduction in the time required for its execution 
{Centr. f. Chir., Dec. 19, 1897). The longitudinal incision is 




Fig. 3. — Ullmann's method of intestinal anostomosis. Tbe accentuated line 
denotes the serosa of the proximal end ; unaccentuated line, the serosa of 
the distal end ; dotted line, the mucosa. 



made in the anti-mesenteric border as usual, and the invagina- 
tion performed (as in a and b of the accompanying diagram. 
Fig. 3), so that two tubes of intestine project through the 
opening one within the other, lying with their peritoneal 
surfaces in contact, and the mucous membrane of one segment 
is directed inwards, that of the other outwards. In the original 
opei-ation these two circles were sewn together by sutures 
which passed through the whole thickness of the walls of 
each segment. Ullmann's modification consists in the use of a 
bobbin, round which the two segments are tied together. A 
piece of carrot, prepared in the shape of a hollow cylinder, 
2 to 2^ centimetres long and 1| to 2 centimetres broad, with a 
groove running transversely around its middle, is placed inside 



GENERAL SURGERY. 207 

the inner segment, and a single silk thread tied round the two 
segments so that the thread lies in the groove, and, of course, 
since it is in apposition with the mucous, membrane, it lies 
inside the lumen of the gut (c). The invagination is now reduced 
by traction abo\e and below, and the longitudinal incision closed 
by interrupted or continuous sutures (d). The carrot lies within 
the lumen of the bowel, and the hole in its centre allows for the 
onward passage of the intestinal contents. Of course it is not 
essential that carrot should be employed ; turnip, potato, or 
decalcified bone will do equally well, provided that tlie bobbin is 
sufficiently firm to stand a ligature being tied tightly round it, and 
that the passage through it is large enough. If carrot is em- 
ployed, it must be fairly hard, but not fibrous ; there is sufficient 
resistance in it to withstand the action of the intestinal juices 
until union has occurred. Ullmann has carried out this operation 
with success in a number of dogs, and twice in the human subject, 
once for intestinal exclusion on account of an artificial anus, and 
again in a case of tuberculosis of the caecum ; in both cases the 
recovery was quite uneventful. Pilcher (A nnals of Surgery, April, 
1897, p. 485) has recorded a case in which he utilised it after 
removing a large growth from the splenic flexure of the colon : 
he employed, however, a potato bobbin instead of one made of 
carrot. The patient did well for ten days as far as the operation 
was concerned, but then died of tetanus. Eix (Centr. f. Chir., 
Oct. 30, 1897) has also employed this method with success after 
removing a portion of the bowel which had become gangrenous in 
a strangulated obturator hernia, and this in spite of the fact that 
withdrawal of the gut from the site of strangulation led to its 
rupture and extravasation of the fsecal contents into the 
peritoneal cavity. There can be no doubt that this proposal 
is a most valuable one, and has considerably added to the 
already gi-eat advantages of Maunsell's operation. 

Murphy's button still forms a fruitful subject of discussion, 
but as we formerly anticipated, it is beginning to be replaced by 
other less objectionable appliances. Its most vigorous supporter 
is Willy Meyer, and at the meeting of the New York Surgical 
Society on March 10 he read a paper dealing with its value in 
gastro-enterostomy, and showed five patients on whom it had been 
employed {Annals of Surgery, July, 1897, p. 31). He quotes a 
variety of statistics to prove its merits, and has collected a new 
series, mainly from the practice of American surgeons, gi^'ino- a 
death-rate of 36-66 per cent. Of the 60 cases, 51 were for 
malignant disease of the pylorus, and of these 22 died (43-13 per 
cent.), whilst of the nine operated on for simple stricture all 



208 Tit 10 YKAIM50OK OF TUICA'I'MKNT. 

recovered. This diiference in the results, according to whether 
the pyloric obstruction is simple or malignant, is marked in all 
the records. A few of the points suggested \)y him as to the 
lochni(|ue of the operation are worthy of note. In the first place 
lic! considers that additional supporting stitches should always be 
(Miiployed ; whether one operates by the Wolfler or the von Hacker 
nictliod (i.e. wliether one brings up the jejunum to the anterior 
wall of the stomach across the transverse section, or unites the 
bowel to the posterior wall through a hole in the transverse 
iiuisocolon), there must always be traction upon the line of union, 
and this in itself is sufficient to predispose to a mishap. Murpliy 
was at first strongly opposed to this additional precaution, but 
experience is beginning to prove its advisal^ility. Meyer advises 
a continuous suture to be used, and that it should be inserted at 
least a quarter of an inch away from the edge of the button. Of 
39 patients in whom the additional sutures were employed, 29 
recovered, and none of the fatal cases died from perforation. 
Another point strongly emphasised is the need for stitching the 
margins of the opening in the mesocolon to the stomach wall vv^hen 
doing posterior gastro-enterostomy ; if this is not attended to, 
contraction of the aperture is almost certain to follow, although 
under other circumstances the fistulous communication has no 
tendency to shrink. In benign strictures, even Meyer recommends 
that the button had better not be employed, since it has 
often been found to fall back into the stomach even when the 
posterior operation is utilised, and no means of preventing this 
occurrence has been discovered. Of course, in malignant cases, 
where the operation is merely a palliative measure, this is 
of little consequence, since the brief spell of life remaining 
to the patient is not likely to be appreciably shortened by it ; 
but where the stricture is simple, and many years of life may 
follow the operation, it is better not to expose the patients to 
the risk of such an accident. In these cases, also, the gastric 
wall is considerably hypertrophied, and some difficulty may be 
experienced in tucking the whole thickness comfortably within 
the cup. Another important point is to secure the correct portion 
of the bowel with which to connect the stomach. If a point low- 
down the gut is selected, the patient is likely to die quickly from 
inanition, even should the anastomosis be successful ; this is due 
to the large section of absorbent surface thrown out of function. 
Such an accident leadily happens even in the hands of those who 
are alive to its possibility ; thus in one case where the surgeon 
quite thought he had secured the upper end of the jejunum, it 
was afterwards found that a nutrient enema was vomited after a 



GENERAL SURGERY. 209 

short interval and almost uuchauged (Briddon, N.Y. Med. Record, 
Feb. 20, 1897, p. 280), and after the patient's death in twenty days 
the lower part of the ileum was found to be attached to the gastric 
wall. To avoid this misadventure, the surgeon sliould always 
withdraw the colon and omentum from the wound ; the hand is 
then inserted along its under surface to the left side ; the lowest 
portion of the duodenum as it crosses the base of the mesentery 
is then readily detected, and no possible mistake can ensue. Graff 
also reports favourably of the button, quoting Schede's and Sick's 
statistics, which give twenty-five cases of gastro-enterostomy and 
end-to end suture ; with fourteen deaths, it is true, but in none 
of them could the button be held responsible for the fatal 
issue [Von Langenheck^s Archiv, Bd. lii., Hft. 2). Marwedel 
(Centr. f. Chir., App. to Nov. 28, 1897, p. 99) reported to the 
German Surgical Congress the results gained with this appliance 
in the Heidelberg clinique. Fifty-five cases in all had been 
operated on, including 35 gastro-enterostomies with no death 
directly attributable to the button, although 12 died within 
three weeks of the operation; in only 15 of the 23 recoveries 
was the button evacuated, but it does not seem to have given 
rise to any inconvenience. Cholecystenterostomy was undertaken 
thrice, with 2 recoveries, but in the fatal case the button was in 
situ. Of the 17 operations on the intestines, 6 were for gangrene 
of the gut, with 3 recoveries, but in the 3 fatal cases diffuse 
peritonitis was present at the time of operation. There were 8 
intestinal anastomoses with 1 death, and 3 resections of the 
cfecum, of which 2 were fatal. These results are remarkably 
good, and fully justify Marwedel in summing up in favour of the 
button. At the same time he maintains the importance of 
adhering strictly to Murphy's original rules, and points out 
that many of the failures were due to defective buttons being 
employed. 

On the other hand there is a strong and growing feeling 
against putting such a hard and rigid contrivance within the 
bowel. This is evidenced by the multiplicity of new bobbins 
and buttons wdiich are almost weekly being announced. The 
majority of them are probably of little value, but amongst all 
these suggestions we hope that sooner or later some more perfect 
ap[)liance may be forthcoming. One or two are perhaps worth 
mentioning. Ball, of Dublin [Brit. Med. Journ., April 24, 1897), 
has contrived a decalcified ivory or bone ring (Fig. 4), which is 
made in three sizes, the centre of each being perforated to allow 
the passage of intestinal contents. The upper and lower ends 
are smoothly rounded off, whilst around the circumference a 



210 



TIIR YEAU-nOOK OF TP.RATMRVT. 



(leap j^roove is turii(!il, wide, enough to allow involution of the cut 
eilires of tii(^ intestines wliilst kecipiiig the peritoneal surfaces in 
toleral)ly close contact ; a consi(l(!ral)le undercuttiui^ of this 






Fig. 4. — Balls ring. 
A, vertical view ; b, c, lateral view showing grooves. 

aroove provides accommodation for any excess of involuted 
intestine. The chief feature in the application of this ring is 
the fact that a continuous lacing suture connecting both portions 




Fig. 5. — Ball's ring. The lacing su- 
ture complete liefore introduction 
of the ring. 



Fig. C— Ball's ring. Diagram uf 
section siiowing the ring in posi- 
tion, with involution of edge of 
the intestine after tiglitening the 
lacing suture. 



of the intestine is passed loosely through the entire circumference 
of the divided ends of the bowel before the ring is placed in posi- 
tion (Fig. 5). To do this the loose threads are separated, and then 
the sutures are gently pulled on loop by loop in the same way as 
one tightens a boot lace, so as gradually to draw the ends of the 



GENERAL SURGERY. 211 

bowel into the groove, tucking them in so as to bring the peritoneal 
surfaces into close apposition (Fig. 6). After tying the thread, 
a continuous Lembert stitch is introduced all round. Four cases 
have already been ojierated on by this means, with three recoveries, 
and from the symptoms of the fatal case it was evident that 
death was not due to any imperfection in tlie anastomosis. Frank 
(New York Med. Record, Oct. 3, 1896), Cheatle {Lancet, May 
22, 1897), and others liave also devised methods of intestinal 
anastomosis which, though successful in animals, have not yet 
been used in the human subject. 

Radical cure of hernia. — Lucas-Championnifere [Joiirn. de Med. 
et de Ghir., Aug. 25, 1897) made a most important communica- 
tion to the Moscow Congress and also to the Academie de 
Medecine dealing with this subject, taking as his basis the 
results of 650 operations which he had himself undertaken. 
Of this number 556 were inguinal, and all but 49 in men ; 
46 were femoral, 13 men and 33 wouien ; 22 were umbilical, all 
in females; 14 epigastric, all men; and 12 ventral, only 2 of 
which were in men. In discussing results he is able to state 
that only in 23 cases had there been any recurrence ; it was 
more or less anticipated in half of these, owing to their obesity, 
age, or to the large intestine being involved, or possibly to tlieir 
suffering from chronic bronchitis or emphysema. The other 
half were due to the patients being careless, and overstraining 
themselves at too early a date ; of the whole number of relapses, 
in only one had the hernia become of any size. No truss was 
ever employed or worn after the operation, and indeed the 
author states that he does not consider any cure radical if such 
is needed. The principles which should guide the surgeon in liis 
operation are then indicated. All accessible omentum should be 
removed, and not merely that which is in the sac ; it is one of 
the most fruitful causes of recurrence, insinuating itself into any 
small infundibuliform depression which may exist. Then, too, 
the peritoneum must be destroyed not only up to the neck of the 
sac, but beyond the internal ring, so that it is flush on the inner 
aspect, and presents no funnel-shaped depression. Again, the 
abdominal wall must be reconstituted so that it forms a solid 
barrier against possible recurrence. Drainage is considered an 
important element in securing firm union, in that it tends to 
promote solidity of the deep cicatrix. As to indications for 
operation, radical cure is essentially an operation for young 
people, and, indeed, up to the age of forty no other proceeding 
should be attempted. After that age it should only be under- 
taken to meet special requirements, such as pain, irreducibility, 
o 2 



212 TiiK yp:au-»ook of trf.atmicnt. 

.iiicl uccideuts of tliuL nature. ]ii woiiuiii iiif^uiual licniia should 
always be operated on, since the euro can b<; made so absolute 
that no tendency to recurrence is likely to be noted. Femoral 
hernise are so liable to strangulation that operation should be 
freely undertaken, and at a more advanced age than for the 
inguinal variety. Epigastric hernia, ]>eing extremely jjainful, 
should also be submitted to operation in all cases. Umbilical 
and ventral hei'niio cannot be in any way controlled by trusses, 
and are likely to threaten life, so that active interference is 
always justifiable and even advisable. As to mortality, Lucas- 
Ohampionniere is able to report that only 5 deaths occurred 
as the result of his G50 operations, and he once had a run of 
2G5 operations without a single mishap ; the death-rate thus 
only amounts to -7 per cent. It is interesting to note that some 
of these operations date back sixteen years. 

Even better from a percentage point of view are the results 
given by Coley (Annals of Surg., March, 1897, p. 270), who has 
operated on 360 cases with but one death {i.e. with a mortality 
of -28 per cent.). Of this number 326 were for inguinal hernia, 
25 for femoral, 6 for umbilical, and 3 for ventral. As to the 
methods employed in the inguinal variety, Bassini's operation with 
kangaroo tendon was utilised in 300 cases, with but 2 I'elapses ; 
Bassini's, with silk sutures, 1 case with 1 I'elapse ; sutui'e of the 
canal without transplantation of the cord, 24 cases with 3 relapses. 
In the femoral and inguinal hernia in females there were no 
relapses ; of the 9 umbilical and ventral herniee operated on, 4 
have relapsed, all of them apparently in fat women. This last 
experience is by no means uncommon ; in anybody's hands recur- 
rence is very likel}^ to follow, and unfortunately even when the 
extremest precautions are taken, sepsis is only too likely to 
develop in these unhealthy patients. One reason for Coley's 
success lies in the fact that 250 of his patients were under the 
age of fourteen, thus again emphasising the opinion that the 
operation may be most beneficially undertaken in children ; the 
tendency to recuri-ence increases with the age of the patient. 
Some surgeons still object to operating on children on the ground 
that sucli proceedings are moi-e dangerous ; to meet this objection 
Coley has collected 832 cases operated on under the age of four- 
teen by Broca, Felizet, and himself, and the mortality works out 
at the insignificant rate of less than "5 per cent. He holds, 
however, that operation should not be undertaken until treatment 
by truss pressure for two years has been ti'ied and failed. 

As to the carrying out of Bassini's operation Coley gives a 
few hints. In the first place he considers the change from silk to 



GENERAL SUKGERY. 213 

kangaroo tendou important ; he has had fewer cases of sup- 
puration since the change ; it is also advisaljle to place one 
suture above the cord so that it emersies between the two highest 
stitches ; all these deep sutures should be interrupted. Another 
important point is carefully to dissect back the aponeurosis on 
the external oblique, especially on the inner side, so that it may 
be brought together without difficulty over the cord, and for this 
a continuous suture is advised. After suturing the skin incision 
a moist dressing is applied held in place by a spica bandage, and 
in children this may be reinforced by a plaster-of-Paris spica. 
The patients are kept in bed for abmit two weeks, and allowed 
to leave the hospital in three weeks from the operation. No 
truss is ever employed afterwards. 

Other methods of operation have been suggested during the 
year, but none of them are of any great importance. Bassini's 
operation seems to be coming more and more into favour, and all 
less extensive proceedings are a little untrustworthy. 

It is interesting to note that in Roux's clinique {^Rev. mecl. de la 
Suisse Roma nde, July 20, 1897) the results of 324 operations give 
a percentage of relapses after Bassini's operation three times as 
great as that following the use of what is known as Ferrari's 
method, which is, apparently, similar to tliat which we know as 
Mitchell Banks's operation. Suppuration occurred in about 20 
per cent, of the cases, and recurrence was much more frequent 
after siippuration. Atrophy of the testicle was noted in 12 cases, 
and relatively more frequently after Bassini's operation. These 
figures, so different from both Bassini's own and Coley's, suggest 
the question as to whether the operation was correctly carried out. 

One other suggestion must be noted in conclusion. Lannelongue 
{Rev. de Ther. Med. Chirurg., Aug. 1, 1897) reports a series of 
51 operations for hernia undertaken by the injection of a solution 
of chloride of zinc into and around the inguinal canal, and claims 
to have cured all with the exception of two, one of which was 
operated on again with success. None of the results, however, 
are of longer dui-ation than one year. The object of the proceed- 
ing is to set up a sclerosing inflammation in the inguinal region 
which shall lead to the occlusion of the sac and the closure of the 
inguinal canal. Lucas-Championni^re (foe. cit.) urges very strongly 
objections which will present themselves at once to the minds of 
all surgeons. This proceeding is a distinct step backwards towards 
the uncertain surgery-in-the-dark of the Middle Ages ; no two 
hernife are alike, or capable of being dealt with in the same way; 
the effect of the injection is not limited to the sac, but necessarily 
involves the surrounding tissues, including those of the cord, and 



214 THE YEAR-BOOK OF TREATMENT, 

tlie vascular supply of tlie testis is liable to suffer in consequence. 
Certainly Jjannelongue has not yet noticed any testicular trouble, 
but the majority of the patients operated on were children, whilst 
suiiicient time has scarcely elapsed to know whether or not 
mischief has been done. Our only object in mentioning this 
suggestion is to i)rotest against it. 

Partial resection of the liver. — Elliot, of Boston (Annals of 
Surgery, July, 1897, p. 83), reports a most successful case in 
Avhich he removed a tumour of the liver, including about one- 
fifth of the whole organ, together with the gall bladder, for what 
proved to be an alveolar sarcoma, probaljly starting in the neigh- 
bourhood of the latter structure. The mass was adherent to the 
intestines, but on freeing it removal by the thermo-cautery was 
possible. The wound surface was five inches long and two broad. 
The bleeding was profuse, but was conti'olled by pressure forceps 
and gauze ]>ackirig. The cystic duct and most of the vessels were 
tied with silk, and a few clamps were left in situ. The peritoneal 
cavity was walled off by gauze pads, and the cavity stuffed with 
iodoform gauze. In spite of some discharge of bile the wound 
healed rapidly, so that the patient was discharged from hospital 
on the twenty-first day. Death ensued three months later from 
recurrence in the intestinal walls. Heidenhain (Deut. med. 
Wochs., Jan. 21, 1897) relates a very similar case in a woman 
aged Gl. The disease started in the gall bladder, and the 
neighbouring hepatic tissue was infiltrated. The whole mass 
was removed with the cautery, the cystic duct being tied. 
The patient made a good recovery, and was discharged in six 
weeks. Unfortunately recurrence ensued in the liver substance, 
and death followed in three months fron\ the operation. MQller 
(Centr.f Chir., App. to No. 28, 1897, j). 118) reported to the 
German Surgical Congress a patient still well from whose liver 
he had removed a cysto-adenoma seven years previously. He 
also related two other cases of partial resection of the liver. 
In the first he controlled the bleeding by a double ligature of 
iodoform gauze passed deeply through the hepatic substance and 
tied fii-mly ; there was scarcely any loss of blood, and the stump 
was fixed to the al)dominal parietes by a few stitches. The 
wound healed quickly, but recurrence followed, and the patient 
died eight months later. The second case was a cysto-adenoma 
of the right lobe ; removal was not difficult, and all went well 
till the eleventh day, when the patient succumbed from a pul- 
monary embolus. In Elliot's paper (loc. cit.) an excellent account 
is given of the chief cases in which resection of portions of the 
liver has been undertaken, and it appears that of the i6 cases 



GENERAL SURGERY. 215 

there recorded ouly four died as the immediate result of the 
operation, giving a mortahty of less than 10 per cent., a remark- 
ably satisfactory result when one considers the friable natui'e and 
extreme vascularity of the organ, and the fa;ct that in 1886 the 
calculated mortality of wounds of the liver was 62 per cent. 

Kousnetsoff and Pensky (Revue de Chir., Nos. 7 and 12, 1896) 
luxAe studied the best methods of dealing with hepatic wounds 
and of removing portions of the viscus by means of experiments 
on dogs and rabbits. Their conclusions are as follows: — (1) 
Ligatures applied lightly to the liver substance ai'e not sufficient 
security against either the early or late bleeding; (2) the intra- 
peritoneal treatment of the stump, combined with tamponnade, is 
the most satisfactoiy method to employ, although extraperitoneal 
treatment is, perhai)s, a little more secure ; (3) for the api)lication 
of sutures through the liver substance rounded blunt needles 
should be employed ; (4) bleeding is most securely controlled by 
the insertion of deep ligatures through the hepatic tissue, drawn 
slowly but firmly together ; (5) the application of ligatures of 
single vessels is scarcely practicable^ since the friable vessel walls 
are almost certain to be cut through ; (G) the suturing of omentum 
over the stump is uncertain and takes up valuable time ; (7) for 
the thorough exposure of the liver an incision parallel to the costal 
border is recommended. Auvray [ibid., No. 4, 1897) has repeated 
the experiments of the above observers and fully confirms them, 
especially as to the value of the constriction of the liver with 
deeply placed gauze strips passed through the organ by means 
of a blunt needle, and slowly though firmly tied. He removed 
portions of the liver from seven dogs, and of the five that survived 
the chloroform narcosis all recovered satisfactorily. 

Hydatid cysts of the liver. — O'Conor (Annals of Surgery, May, 
1897, p. 547) gives some useful hints as to the method of dealing 
both with hepatic abscess and hydatids, whilst relating a series 
of cases which have come under his treatment, and some of these 
will serve to indicate the present attitude of surgeons in dealing 
with the latter affection. In the first place he alludes to the 
risks of puncturing these cysts for diagnostic purposes ; they 
are always extremely tense, and not even the finest needle can 
be introduced through their walls without causing a subseijuent 
leakage, and this may induce toxjemic symptoms of some gravity. 
Usually a marked urticaria follows, and this may break out in 
a few minutes, whilst even a fatal result may follow. If a needle 
is used at all the sui'geon must be ready, in the event of a posi- 
tive result being obtained, to operate immediately. Again, lie 
notes that in the majority of cases whex'e the endocyst is not 



216 TIIK YKAH-IiOOK OF TltKATMKNT. 

coiiiplctcly itiiiioved ;it the first operation, .supi)uration more or less 
profuse almost invariably follows; lie therefore advises that an 
attempt should be always made to extract it; seizing it with 
force|)s is unsatisfactory since tlie membrane is always friable, 
and he recommends tliat a Jac(|ues catheter should be introduced 
into the cavity and tin; nozzle of an irrigator attached to it ; the 
quivering mass is then probably forced )>y the pressure of the 
lotion into the wound, and can easily Ik; extracted by a pair of 
fingers. 

An interesting case of the removal of nndtiple hydatids from 
the interior of the abdomen is related by Moore {intercolonial 
Med. Journ. of Australasia, June 20, 1897). The whole interior 
of the abdomen was studded with hydatid cysts, the omentum 
and pelvis being especially affected. Four operations were per- 
formed in all and forty-seven cysts were taken away. Some of 
them were removed together with the affected portion of the 
omentum, whilst many in the pelvis had to be opened, and the 
contents evacuated before the cyst wall could be withdrawn. 
All the operations were recovered from in a most satisfactory 
manner, and no complications arose. Considerable stress was 
laid upon the importance of not attempting to do too much at 
any one time ; those hydatids .should be dealt with which could 
be easily reached through the incision, and then the wound 
closed. At the next operation a fresh incision should be made 
to enable the surgeon to reach those wliose presence he had been 
able to detect on a former occasion. 

Operative treatment of cholelithiasis. — -There is now but little 
diversity of opinion as to the desirability of removing gallstones 
as soon as possible after their detection if they are giving rise to 
any serious symptoms. The risks of leaving them in situ are 
becoming constantly more obvious, and the fact that cancer of 
the gall bladder is almost invariably associated with their 
presence is a potent alignment for early interference. One point, 
however, has not yet been sufficiently realised by physicians— viz. 
the risks of leaving a patient for a prolonged period in a con- 
dition of intense jaundice. In such individuals surgical measures 
are always more risky than in others, septic troubles and 
secondary h;emorrhage being readily lighted up. Moreover, the 
longer they are left the greater likelihood is there of the formation 
of adhesions around the gall bladder which will add considerably 
to the dangers of subsequent operations. Wlien a patient is 
suffering continually from biliai-y colic, when jaundice is well 
marked and resistant to treatment, when a tumour can be felt, 
when obstruction is present owing to ileus of or traction upon 



GEXEHAL SURGERY. 217 

the neighbouring coils of intestine, or when suppuration within 
the gall bladder is threatening, as indicated by the pi-esence of 
a localised peritonitis in the right hypochopdrium — under any 
of these circumstances surgical assistance ought to be called 
in. A large amount of material lias been publisheil during the 
past year dealing with this subject, and it is only possible here 
to refer to some of the more prominent pronouncements. A 
})rolonged discussion arose in the Surgical Society of Paris 
{Bull, et Mem. de la Soc. de Ghir. de Paris, vol. xxii., pp. 245-439) 
in reference to a paper of Tuffier's, relating 14 cases in which he 
had operated with 11 recoveries and 3 deaths, only one of them 
due to septic peritonitis. He considers that ideal cholecystotomy 
— i.e. immediate closure of the gall bladder by suture after 
removal of the calculi — is indicated only in rare instances when 
the interior is healthy and the biliary passages evidently per- 
vious. Several speakers wex'e in favour of total ablation of the 
gall bladder whenever practicable. Thus Michaux pointed out 
that extraction of the calculi is not always an easy matter, as 
some of them may remain caught between folds of mucous 
membrane ; septic infection may also arise, and the walls of the 
bladder are sometimes so friable as to tear on any attempt to 
introduce sutures. He also claims that statistics of this opera- 
tion are quite as favourable as those of cholecystotomy, whilst 
the patient is saved from the dangers and inconveniences asso- 
ciated with the formation of a biliary fistula. Schwartz held that 
the patient must be fairly sound, the liver healthy, and the 
common bile duct patent if removal is to be attempted. Monod 
gave the following statistics from the experiences of his chief, 
Morin : — 44 cholecystostomies with 4 deaths ; 14 cholecystotomies 
with immediate closure of the gall bladder, resulting in 2 deaths ; 
and 17 cholecystectomies, all of which recovex-ed. From these 
facts he argues that closure of the wound with sutures is not 
advisable, and that as a general rule di'ainage should be under- 
taken ; removal of the gall bladder must be resorted to only 
when it is in a condition of hydrops, with the cystic duct 
obliterated, and with the common duct free. Reynier added tliat 
such conditions were usually found apart from jaundice, and that 
if this symptom were present drainage is advisable. All the 
speakers admitted that after cholecystostomy recurrence of gall 
stones was very uncommon. Mayo Robson (^Brit. Med. Journ., 
March 13, 20, and 27, 1897), in his admirable lectures to the 
College of Surgeons, discussed the same subject in extenso. He 
considers that immediate suture is I'arely called for except when, 
on account of the depth at which it lies, a contracted gall bladder 



218 THK YKAR-BOOK OF TREATMENT. 

cannot be brought to the surface or even (IraiiKnl by the intro- 
duction of a tube ; he thinks that th(! risk of the process is 
somewhat greater than that associateil with the formation of 
a fistula. His conclusions as to removal of tlie gall bladder are 
very much the same as those mention(;d above as heM by Parisian 
surgeons. For iin impacted stone in the common duct Uobson 
describes all the many methods that have been suggested, but 
evidently seems to favour pressing the stone forwards or back- 
wards with the fingers, combined perhaps with compression so as 
to break it up, but no instruments must be used to accomplish 
this : should this fail, incision of the duct is required if the con- 
dition of the patient or of the part permits it with any reasonable 
degree of safety ; in other circumstances a fistula may be formed, 
and solvent injections subsequently utilised. 

As to results of these gall bladder operations, the most 
extensive series published lately are those of Hans Kehr [Archiv 
f. Chir., 1896, vol. liii., p. 362). He records 209 cases of 
laparotomy for gall stones on 174 different patients, of whom 
only 23 were men. Out of 127 simple operations on the gall 
bladder with immediate closure or drainage, only one patient 
died, and that an old man with pulmonary emphysema and 
arterial sclerosis. In 21 cases the gall bladder was removed 
with only one death. In 30 cases the common duct had to be 
opened or handled for impacted stone, and two deaths resulted. 
Other conditions accounted for the remaining cases, but of the 
209 operations only 17 were fatal (8 per cent.), a most gratifying 
result. Relapses were uncommon ; in only one case was there 
genuine evidence of this having occurred. In several instances 
stones were left behind in the common duct, and for these second 
operations were sometimes needed. Kehr'.s results for choledo- 
chotomy give a death rate of 6 '6 per cent., whereas the mortality 
in other lists amounts to at least 22 per cent. 

(See also an interesting discussion on this subject in the New 
York Academy of Medicine, reported in the Medical Becord, 
April 24, 1897 ; and papers by Duncan, Intercolonial Med. Journ. 
of Atistralasia, Oct. 20, 1896 ; Maniere, Chicago Med. Recorder, 
May 9, 1897 ; and Beck, New York Med. Journ., May 8, 1897.) 



ORTHOPyl^:DIC SUliGEUY. 

Bv W. J. Walsham, F.H.C.S., 

Senior At^sistani-Surgcon, Lecturer on Surgery, and Surgeon in Charge of ilie 
Orthopoedic Department, St. BarthoJomew's Uospital. 



1. Tieatiiioiit of Mortons disease or nietatarsal^^ia. 

Robert Jones ^Liverpool Med. C/iir. Joiirn., Jan., 161)7). 
The autlior does not agree with Morton's theory of the compres- 
sion of the digital nerves between the heads of the metatarsal 
bones, but believes that clinical observations accord much better 
with a theory of treading upon rather than with tliat of pinching 
a nerve. He is strengthened in this opinion by three anatomical 
facts : " (a) The proximit}^ to the painful area of the communi- 
cating fourth branch of the superficial divisions of the external 
plantar ; (6) the collapse of the anterior arch in most of the cases ; 
(c) the bulk of superincumbent body weight in walking on the 
toes is borne on the first and fourth joints." From the persistence 
of pain in certain cases, even after pressure has been withdrawn, 
and from the immediate sensitiveness when walking is practised, 
Jones is inclined to believe that a neuritis of the plantar nerves 
involved exists in the more acute cases. This view he considei's 
is confirmed by the fact that, even after a long rest, pinching the 
spot between linger and thumb gives rise to severe pain. Treat- 
ment must vary with the stage of the affection. In the first stage 
the affection should be prevented from further developing by (1) 
abstaining from continuing any action which produces the j)ain ; 
(2) increasing the depth of the inner aspect of heel in order 
to produce slight inversion of foot ; (.3) wearing thick soles 
with well-fitting insteps, and roomy around the heads of the meta- 
tarsals ; and (4) insisting that the sole be at least one-fourth of 
an inch thicker a little behind the bases of the metatarsals. These 
preventive measures should also be directed to the cure of the 
second stage, with certain additions — viz. (1) a thick bar placed 
about half an inch behind the metatarsal heads ; (2) a band of 
non- irritating plaster around the instep ; (3) massage of the foot 
with contrast baths of hot and cold water; (4) elevation of the 
foot of the bed at night-time. 

The advantage of thick-soled boots is obvious ; they prevent 



220 THK, YKAK-HOCJK OF TUKATMKNT. 

excessive mobility at the articulation, and niinimise sharp bony 
pressure upon the nerves. Tlie boots should be roomy at tli<; 
toes, not merely to give more room to the metatarsal heads Ijut 
to allow freeflom to Hex the toes, and to perform other movements 
to avoid pain. The heel of the boot is slanted to correct the 
common tendency to valgus and to vary the pressure point. 
In a case where there is no collapse of the arch, the heel may 
with advantage be elevated on the obiter side to deviate the body 
pressure. Most important of all, however, is the thickening of 
the sole in the early stages (or bar in later) behind the metatarsal 
heads. This gives rest to the articulation, even during the act of 
walking, and is of more advantage than any other mechanical 
detail of treatment. This alteration, even in the case of an 
inflamed or gouty toe-joint, allows the patient to travel in com- 
parative comfort, and should always be prescribed in all stages of 
plantar neuralgia — for a time even in those cases where an oi)era- 
tion has been performed. 

Although advanced cases can be relieved ])y mechanical 
measures, Jones prefers excision of the metatarsal head to either 
excision of the joint or to amputation of the metatarsal head 
and toe. He performs it as follows : — After the part has been care- 
fully asepticised, an incision should be made a little over an inch 
in length, starting above the metatarso-phalangeal joint, and 
extending over the middle line of the toe. The extensor tendon 
is divided, the capsule opened, and the head of the metatarsal 
dissected out by a blunt instrument. With fine bone nippers 
the head is removed and the flexor tendon below divided. The 
wound is then sutured, and, as a rule, no vessels need securing. 
The after-treatment consists in keeping the patient in bed for 
about ten days with the foot elevated. Massage should then be 
commenced, and the patient, with a bar under the boot, allowed 
to walk. There is usually nothing to hinder complete recovery 
in from five to six weeks, when the previously described boots 
should be prescribed. .- 

[The reporter quite agrees with Mr. Robert Jones that meta- 
tarsalgia is not due to the nipping of the nerve between the bones. 
In several cases of Morton's disease that have come under his 
notice he has had skiagraphs of the feet taken, and the heads 
of the metatarsal bones were shown to be at such a distance from 
each other that the nerves could not be readily nip[)ed between 
them.] 

2. TIm' ti'eatnieiit of linlliix valgus. 

Delbet {lUUlntbi de la Socicte dr. Chiruryie, 189G, JSTo. 22), 
after he had removed the head of the metatarsal bone and 



ORTIIOP.EDIC SURGERY. 221 

superimposed buisa, finding that the phahmx was still tirawn by 
the extensor tendon into the valgoid pusition, freed the tendon, 
drew it into the wound, and fixed it to the metatarsal bone 
by a periosteal flap in such a position that it' held the toe in a 
straight line instead of, as heretofore, deflecting it. 

This little procedure is worth remembering should any diffi- 
culty be found in maintaining the toe in a straight line after 
excision of the head of the metatarsal bone, but the straight 
position, so far as I know, can always be obtained by removing 
sufficient of the head of the bone — a procedure which, I should 
imagine, w^ould be more likely to have a permanent result than 
the fixation of the tendon by an artificial sheath. 

it. Tlio treatiiieiit of claw toes au<l pes caviis. 

Davies-CoUey {Guy's Hosp. Hep., 189G). In all severe cases of 
claw toes and pes cavus, Davies-Colley removes a piece of the ex- 
tensor proprius hallucis, and implants the proximal end upon the 
base of the first metatarsal bone. He makes an incision about 
2 inches long upon the tendon over the tai-so-metatarsal joint, 
cuts away 1 inch of the tendon, and fixes the proximal end to 
the metatarsal bone, about | inch in front of its base. The 
tendon is secured to the bone by reflecting two triangular flaps of 
the periosteum, beneath which, and in contact with the bone, the 
tendon is placed and secured by chromicised catgut sutures. 
Through the same incision he also divides the innermost tendon of 
the extensor brevis digitorum, and if the small toes as well as the 
large are clawed he further removes a portion of each of their 
tendons ; but he does not attempt to stitch them down to their 
corx'esponding metatarsal bones because of the hindrance oS'ered by 
the short extensor. He believes that when healing has taken 
place the extensor tendons act directly upon the front part of the 
instep and, consequently, that the incurvation of the toes is much 
diminished. 

4. The treatment of Pott's disease. 
^Calot {Bulletin de V Acadeniie de Aledecine, Dec, 1896) ; Chipault 
{ibid., No. 3,1897); Menard {ibid.. No. 19, 1897); Monod (i^,i(/., 
No. 23, 1897); Jones and Tubby {Lancet, Aug. 7, 1897). 

Calot rectifies angular deformity of the spine at one sitting in 
the following manner : — The patient is held by the arms and legs 
Ijy four strong assistants. The sui-geon applies his hands over 
the curve and presses vigorously upon the displaced vertebrae 
until they are forced into line with those above and below, or even 
beyond their level, the giving way of the bones being distinctly 
felt and heard. The patient is then immobilised in a plaster case, 
which is changed two or three times at intervals of three or four 



222 TIIK YF.AIl-liOOK OF TKKATMKNT. 

iiiontlis. He is Llioii allowed lo walk aljout in LIh; case. (Jalot 
lays great stress on the |)roper application of the plaster case. In 
thirty-seven cases in which Calot has performed this operation the 
curvature was immediately overcome. All the patients recovered 
without any untoward symptom. Sufficient time, however, has 
not elapsed to judge of the permanent value of this treatment. 
Chipault practises the same forcible rectification as Calot, with 
t'lis dillerence, that he applies a figure-of-(ught ligature of silver 
wire to the bony apophyses corresponding to the curve, believing 
that this gives a better chance of maintaining the corrected posi- 
tion. Further, he immobilises the patient, not in a plaster case, 
but on a board. Menard condemns forciVjle rectification, believing 
it dangerous and inefficacious. It is true that his experiments on 
tlie dead body show that, in spite of the dislocation of the column 
which follows forcible rectification, the marrow and the meninges 
remain intact; l)ut on the other hand, in one case rupture of the 
membranes, which bounded a collection of pus at the axis of the 
curve, was produced ; tliis in the living would have flooded the 
mediastinum. But the point upon which Menaixl places most stress 
is that the forced rectification necessarily produces the separation 
of the two sections of the spinal column and the form ition of a 
vast cavity, measuring, according to Menard's experiments, 2, 4, 
and 6 centimetres. For cure to result it is necessary that this 
cavity should become filled by a bony callus. If this does not 
form, the fibrous cicatrix will yield when the plaster apparatus is 
left ofi". It is easy to see by post-inortejn examinations and in 
musuem specimens that in Pott's disease the periosteum of the 
vertebrae is greatly altered and destroyed, and does not produce new 
bony tissue, nor does one find in patients who have been cured 
any hyperostosis either over or between the diseased vetebne. 
These considerations lead Menard to the conviction that the 
curvature will reproduce itself, and that it is better not to 
interfere. 

In a resumd of these papers Monod sums up " that there are a 
certain number of cases that should not be touched — i.e. those 
where the separation following rectification would be such that 
consolidation would be impossible." This is especially the case 
where the hump has existed four or five years or longer. There 
are, besides, the risks of accidents, which in Calot's series were 
happily absent — i.e. rupture of adherent membranes, intra-rachitic 
haemorrhage, lesions of the mediastinal vessels and intra- thoracic 
organs, and opening tuberculous cavities, with subsequent general 
infection. On the other hand, in some of the cases operated on 
by Calot the deformity had only lasted five, six, seven, and nine 



ORTHOPEDIC SURGERY. 223 

montlis. In this chiss of case it appears that correction is very 
easily obtained, and apparently with great benefit to the patient. 
With regard to the intermediate cases where the curve had lasted 
two, three or four years, two of the patients shown by Oalot, 
in whom the hump had existed from two to three years, could 
now walk about free of their jackets ; on the other hand, in one 
of the operations performed by Menard on the dead body, 
rectification produced a separation of more than 4 centimeti'es, 
corresponding to the destruction of three vertebral bodies ; and 
in this child the atfection had not lasted more than three years. 
Before operating, therefore, JMonod concludes that it would be 
well toascertain the number of vertebral bodies that are destroyed ; 
this number, according to Menard, usually corresponds to the 
number of the bony apophyses that apparently belong to the 
pathological curve. If by this means one finds that the cavity 
produced by the rectification is sufficiently large to remain unfilled 
with callus, one ought not to operate even if the curve dates 
from less than three years. In the contrary case, one may 
operate even if the curve is of this duration. 

Jones and Tubby have recently tx'eated eleven cases of angular 
deformity in this manner. In six of them immediate and com- 
plete reduction was gained. In two of these which were ex- 
tremely deformed the reduction was very remarkable on account 
of the facility with which it was efiected. In five of these 
eleven cases only partial I'eduction was obtained, but in two of 
these, being the first cases tried, sufficient force was not used ; 
and the remaining three were so consolidated as to resist a large 
amount of force. The method followed was that of Calot except 
that, instead of assistants, a special apparatus was devised by 
which traction is simultaneously made on head, arms, and legs, 
after steady extension of the spine for a few minutes with the 
patient in the prone position, care being taken that the pull is 
equal in all directions. Downward pressure is made by the 
surgeon's hands in all directions, counter-pressure l^eing aftbrded 
by the open palms of an assistant, placed on the abdomen. The 
patient's bowels should be well emptied before the operation, and 
then the assistant's hands readily support the anterior aspect of the 
spine, and so prevent too rapid reduction of the deformity, 
When the projection is dorsal, counter-pressure can be made 
through the chest walls. The plaster-of-Paris corset is then put 
on over the head (except the face) and neck as well, pressure 
being maintained during the application of the jacket on the site 
of the deformity. An important point is that the S2)ine must be 
maintained in hyper-extension. No case was followed by paresis. 



224 



TIIK YKAR-I300K OF TliKATMKNT. 



paralysis, or oLlicr bail syinptoni. In nomo, cases a iiioili(icatioii 
of the double Thomas's liip splint, with a Iieacl rest and lej,' support, 
was used, so constructed as to keep the spine in extension. In 
dealing with these cases the authors have expeiienced that the 
correct way of preventing deformity from arising or increasin<' in 
1 ott s disease is t(j maintain the spine m hyper-extension by suitable 
support b(!neath it, and not simply to place the patieait upon a 
bed or straight splint, which favours rugging of the spine at the 
site of disease, and increase of int(!rvert(!bral pressure. 

5. I'lic i-:i|>j<l ti-esttiiieiit <»! iatoial ciirvatiirc. 

'^^^G^m^x {Trans. Amer. Ortlioi^ Assoc, 1896) claims to have 
cured deformities of the spine in which bony and ligamentous 
changes and marked rotation are present by what he terms his 
"corrective method." This consists in the use of heavy dumb- 
bells and bars at each visit of the patient. The bells weigh 
from 5 to 80 lbs. each, the steel bars and bar bells from 
26 to 111 lbs. The bells are pushed from the shoulders 
above the head alternately as often as the patient can. 
The patient is instructed to swing a heavy l)ell with one hand 
from the floor, above the head, and down again, the elbow and 
wrist being fixed and the motion repeated as often as pos.sible in a 
systematic majmer ; then with the other hand the same number of 
times, and later with both. This exercises all the extensor 
muscles from the toes to the head in rapid succession. When a 
heavy bell is pushed or swung above the head on the side opposite 
the scoliosis, the action of the back muscles to sustain the weight 
and equililjrium is such as to cause the curved spine to approxi- 
mate a straight line. A similar result is produced wdien a heavy 
weight is held by the side of the erect body on the scoliotic side, 
the arm being at full length. "When a heavy bar is raised above 
the head with both hands the patient must fix the eyes upon the 
middle of the bar to maintain an equilibrium. This necessitates 
tlie bending of the head backward, the straightening and hyper- 
extending the spine, and consequently correcting a faulty position 
with a weight superimposed. The heavier the weight put above 
the head, whether with one hand or with two, the more the 
patient must exert herself to attain and maintain a correct or an 
improved attitude in order to sustain the equilibrium. Hence, 
the greater the weight the more forcible the actions of the muscles 
become, and the greater the temporary reduction of a deformity. 
It is by means of frequent and forcible temporaiy reductions of 
deformities by voluntary muscular actions that we can hope to 
improve, and do improve, those cases which are amenable to any 
form of active treatment. 



ORTHOPEDIC SURGERY. 225 

When a patient, lying supine on the floor, raises a heavy bar 
above tlie liead so that the arms are perpendicular to the floor, 
the weight of the bar, the position and w^eio-ht of the body, and 
the action of the muscles tend to broaden the entire back and 
shoulders, and a slow downward movement tends to widen the 
entire chest, and most markedly the shoulders. The frequent 
repetition of the upward and downward movement plays an 
important part in the rapid development of the chest and back. 
Pushing the bells above the head, swinging them with each 
hand separately and with both hands together, raising a bar above 
the head, standing and lying down, and the exercises before 
enumerated constitute one day's work. Most ^^atients can well 
stand three treatments a week, and each record must be improved 
upon at each succeeding visit. In mild habitual cases improve- 
ment in deportment is noticed within the first two weeks. In 
these cases two months' treatment usually suffices to effect a 
complete cure. In the more severe cases it is not and cannot be 
expected that such rapid results will be obtained, but a certain 
appreciable improvement is effected, and the amount of improve- 
ment depends upon persistent continuance of the treatment. 
Where tliere is a flxed rotation of long standing, with bony and 
ligamentous changes, the prospects are not so good ; but even in 
those cases Teschner affirms that there has been considerable 
improvement in their conditions. 

The weight treatment of lateral curvature is no doubt a most 

useful one in suitable cases, but it is not a panacea. Where there 

is much rotation, with osseous and ligamentous changes, I have 

found it, like all other forms of treatment, of little use, except in 

so far as it strengthens the muscles generally and improves the 

patient's general health. 

6. The treatment of coiig^eiiital dislocation of the 
liip. 

Elliott (Section of Orthopaedic Surgery, New York Academy of 
Medicine, April, 1897 ; Revue d'Orthope'die, Sept., 1897) showed 
a child of twenty-two months on whom he had operated by the 
bloodless method of Lorenz — i.e. reduction and bringing down 
the head near the acetabulum, the formation of a new cavity by 
manipulation, and the fixation of the thigh in a ])laster case in a 
position of abduction of 90°, the child being allowed to get about. 

Myers (ibid.) has obtained a very goo 1 result in a child 
three and a half years old by Paci's method— namely, forced 
extension, flexion, and forcible drawing downwards. Considerable 
force was used in order to bring about inflammatory adhesions. 
The limb was immovably fixed at an abduction angle of 30°, 
p 



22G TIIR VKAR-noOK OK TKKATMENT. 

tlx! Itamlage was cliaiiged several times in the course of six 
months, and at the time the report was n\ade the child could walk 
about with a movable apparatus and a slioe raised on the sound 
si(k^. Townsend {ibid.) gave it as his opinion that after the open 
method patients still walked lame, and the dislocation often 
returned. On the other hand, the new methods still wanted 
their proof. Sayre {ibid.) had only seen one case where the iiip 
could have been completely reduced by Bigelow's method. 

Whitman [ibid.) had operated on three patients Ijy Lorenz's 
method, and had found the great advantage of placing a weight of 
25 to 30 lbs. upon the limb for three weeks before tlie operation. 

7. The treatment of spasinixlic torticollis. 
Walton (American Neux-ological Association, May 5, 1897 ; 

Medical JVews, May 22, 1897) thinks that treatment other than 
operative is ineffectual is well established. The only operations 
to be considered are resection of nerves and section of muscles. 
Operations are generally too limited rather than too extensive. 
In most cases it will be necessary to resect the spinal accessory 
and the first three posterior branches of the cervical nerves, and 
genei-ally wiser to cut the affected muscles. Muscle section alone 
has given good results, but there is no reason to abandon nerve 
resection. 

Leszynsky (ibid.) has treated the affection successfully by 
increasing doses of atropine injected into the spasmodic muscles. 
In a case where this treatment could not be carried out on 
account of personal idiosyncrasy the clonic spasm was absolutely 
cured by rest, tonic treatment, local massage, passive movements, 
and gymnastics. A remittent tonic spasm, however, persisted. 

8. The treatment of coiig^eiiital torticollis. 
Bracken (Meeting of the American Orthoppedic Association, 

Washington, May 4, 1897 ; Medical News, May 22). The 
structural changes in the ligaments, muscles, etc., should be over- 
come by stretching or by massage. When the head was put up 
in over-correction it was continually stretched, but in selected 
cases one could depend upon the intermittent traction resulting 
from active massage and exercises. A I'oll should be placed under 
the neck of the j)atient, who should lie with the head turned to 
the opposite side in such a way as to cause over-correction of the 
deformity. In that position deep massage should be practised on 
the corrected structures and on the trapezius of the opposite 
side. The next step was to make up to the point of tolerance 
forcible manipulations, depressing the head, etc. In the next 
place, the head being held as nearly in the correct position as 
possible, the patient should be required to do heavy work with 



ORTHOPEDIC SURGERY. 227 

dumb-bells, the muscles being made to work in their long arc 
instead of the short one. 

Hubbaxd, in the discussion that followed, said he had treated 
a recent case by the open incision, dividing the sterno-mastoid 
in the middle, and also the trapezius and all contracted tissues ; 
then he stretched the parts under ether, and put the head up in 
plaster-of-Paris in the over-corrected position. The plaster was 
removed in ten days, the wound having healed, and ])arts further 
corrected before it was reapplied. Tlie patient was subjected 
later to manipulation. He thinks that stretching and massage 
are very important factors. 

Shaffer thouirht that cei"tain cases of torticollis could be 
relieved by systematic massage and intermittent traction, the 
great difficulty being to get the proper points for extension and 
counter-extension. 

9. The sitrg:ical treatment of spastic paralysis in 
children. 

Jackson Clarke (^Lancet, 9, 1897); Ketch, Sayre, Shaffer, and 
Taylor (New York Academy of Medicine, Feb. 19, 1897) ; Lorenz 
{Wien. klin. Rundschau, 21-26, 1897). 

In those cases where the intellect is unaffected and the spasm 
is limited to the leg with resulting talipes equinus, equiuo-varus, or 
equino-valgus, and the uselessness of electricity, massage, and 
retentive apparatus has become evident, Jackson Clarke advises 
that every resisting tendon should be completely severed and the 
limb fixed in an over-corrected position, and so left for four or five 
weeks. It is then found that the tendency for the defoi'mity to 
return is greatly diminished and walking is again possible. If the 
patient is intelligent, this tendency may soon be entirely overcome 
by the exercise of the will, so that retentive apparatus may be 
dispensed with in the day, and at night only a light and simple 
shoe may be required to render the cure a permanent one. The 
contra-indications to the operation are much impairment of the 
intellectual faculties or the presence of chorea, epilepsy, or 
general rigidity. The paraplegic form of spastic paralysis is the 
most amenable to treatment, especially when the chief part of 
the disability consists in spastic club-foot. At the Section of 
Orthopaedic Surgery in the Academy of New York, Ketch, Sayre, 
and Taylor agreed that tenotomy was advisable in these cases, in 
that it produced a diminution in the spasms. Taylor would 
extend the operation of tenotomy to adults. Shaffer, however, 
considered that it is only indicated where the spasmodic contraction 
has terminated in permanent contractions, and after the intellect 
has impi-oved. He thinks better results are obtained by waiting 
p2 



228 THE YEAR-P.OOK OF TItKATMKNT. 

foi- tliis tliaii l)y early interfcri'iicc Lorenz not only advisus 
tcnotoiiiy but (Ik; actual excision of portions of the allected 
tendon. In the cas(^ of spastic contraction of the knee he 
advises forcible straightening after 1 to H inch of the hum- 
string tendons lias been removed. Reunion of the divided ends 
has always occurred. For severe cases of adductor spasm he 
recommends the excision of a portion of the obturator nerve. 

For many years now I have practised tenotomies for s[)astic 
paraplegias, and with the best results ; but I cannot conceive the 
advantage of tlie removal of portions of the contracted tendons. 
After tenotomy I have always found the tendons retract, leaving 
a very considerable gap. Tenotomy of the adductors in the usual 
situation has siithced without excision of the obturator nerve, 
after which one would imagine paralysis of the muscle would 
ensue. 



THE SURGICAL DISEASES OF CHILDUFN 

15v Edmund Owen, M.B., F.R.C.S., 

Senior Surgeon to St. Marifs Uusiiital, and to the Uosjiitnl for Sick Chihlren, Great 
Orinond, Street, London. 



1. Osteotomy of tlie roiiiiir as n treatment for 
tiibereiiloiis disease of Ifie hip in its early stages. 

R. F. Tobin deals with this subject in the Brit. Med. Journ., 
April 14, 1897. He begins his paper on what he calls a new 
departure in the treatment of hip-disease, with the incontrovertible 
statement that the pi'oblem of cure is narrowed into one of giving 
rest to the joint, combined with constitutional treatment. 

With regard to the treatment by weight and pulley, he says : 
" This appliance does not act in the way it is represented as 
doing in the plates in handbooks of surgery. In these you see a 
patient, w4th a weight attached to the leg, lying supine, his back 
and knee flat, and both touching the mattress. What happens in 
reality is this. If the weight is heavy enough to keep the leg 
straight, the spine is dragged into a position of lordosis ; if it is 
less heavy, there is less straightness of leg and less lordosis ; in 
each case the lordosis is an indication of force exerted on the 
joint, to its discomfort." 

This is true in very many cases, but if a surgeon understands 
the proper method of applying the stirrup and weight in the case 
of a flexed thigh, he is careful to keep the thigh and leg duly 
raised upon a soft inclined plane, or upon a thick wedge-shaped 
pillow, so that the traction may always he in the axis of the femur. 
In this way the flexion is in due course corrected, the loins always 
lying flat upon the mattress, and the pelvis being squared. And 
when at last, by patient and gentle treatment, the limb is brought 
down and the body is straight and flat, the case is ready for tlie 
artist to make a drawing for the hand-book. If, howevei', his 
pencil is set to work upon the limb and the weight and pulley 
whilst the irritable muscles are still holding the femur rigidly 
flexed upon the pelvis, and the extension is along the level of the 



230 THE YEAK-COOK OK TKEATMENT. 

top of tli(^ iiialtrcss, tlic cliaiiictcnistic f(;ature of the sketch will, 
or, at least, ou^ht to be, tlu; arching of the loins. 

Tol)iii remarks that Thomas's splint leaves som<.'thing to 
be desired in the treatment of hip-joint disease. And I think 
that almost every hospital surgeon will agree with him in the 
following opinion : " I am ashamed to say how many patients T 
can recall whom I have treated for two or three months in my 
wards with a weight and pulley, and htted with a Thomas's splint, 
who were then unavoidably discharged and lost sight of for a 
time, and who at a later period turned np with a suppurating joint, 
due in part, no doubt, to the Thomas's splint having been thrown 
aside as soon as it had got in any way awry." 

[Arbutlinot Lane has lamented the want of originality of 
surgeons in the treatment of hip-joint disease. He says [Clin. 
Journ., Oct. 20, 1897, p. 402) :— "I think I will be able to show 
you at the present time that treatment is founded upon our habits 
of imitation or mimicry of one another's surgical procedures, 
rather than upon any well-understood scientific mechanical basis."] 

Tobin, then, dissatisfied with the result of the orthodox but 
humdrum treatment of hip disease, says : — " I have, in the early 
stages of the disease, done an osteotomy of the femur on a level 
with the lesser trochanter (Gant's operation), and put the limb 
in a straight position as regards the body generally, leaving the 
upper fragment to retain its position of ease." 

Daring the osteotomy, to prevent jarring of the joint, a large 
moist sandbag is made to support and steady the bone on its 
inner aspect, the patient lying on the sound side, with the affected 
limb drawn well in front of its fellow. In this position, with 
a sandbag of suitable size and shape, an assistant can, by depress- 
ing the knee, divert all concussion from the joint. The orsteotome 
is made fully to divide the bone. The })atient is then turned on 
his back, and while an assistant keeps the spine in contact with 
the table by flexing the sound thigh on the abdomen, the affected 
one is brought down till the i)Osterior surface of the knee is also 
in contact with the table. To guard against abduction or adduc- 
tion both limbs are " dressed " (using the word in its military 
sense) by a straight rod resting transversely on the anterior 
superior spines of the ilii/ O^ 

The wound in the soft parts is partially closed, and a gauze 
aseptic dressing applied. The limbs are then fixed straight and 
flat in a box-splint. 

"The jiatients to whom I consider this treatment applicable 
are cases in which there is no real shortening, in which there is 
no indication of suppuration, and in which the thigh on the 



SURGICAL DISEASES OF CHILDREN. 231 

affected side (the patient lying on his back, and lordosis guarded 
against) makes an angle of thirty or more with the bed. 

" In very late cases, where suppuration is present, the operation 
is barred by the danger of sepsis." 

JNIr. Tobin says that this line of treatment commends itself to 
him because he knows that " unrest is fatal " to the cure of joint 
disease. He submits his paper " rather with a view of illustrating 
the plan of treatment employed than of proving its utility, and 
with no suggestion that anyone should use it who is getting good 
results by other means." 

Coming from so able and enthusiastic a surgeon as Mr. Tobin, 
this conclusion strikes one as half-hearted, halting, and diffident. 
It has not convinced its author, and I feel sure that it will fail 
to carry conviction to his readers. At least, I hope so. 

All surgeons will agree with Mr. Tobin in this, that what the 
diseased hip needs is complete rest, and most of us tliink that by 
fixing the trunk and the limb in a Thomas's splint we manage to 
obtain it. But, in one way or another, the limb must be kept 
quiet. Tobin effects it by dividing the femur, and his paper 
shows that he does this somewhat early in the course of the 
disease — at that stage, in fact, in which the treatment by 
Thomas's splint may be expected to bring down the limb with 
ease and certainty ; for, gradually, under this gentle treatment, 
the femur does come down straight and flat. 

Amongst Mr. Tobin's " conclusions " we find the following : — ■ 

" That a large proportion of cases of this disease, especially 
those in which flexion has occurred, go on to suppuration, and 
that one of the chief causes of their doing so is the difficulty of 
giving the joint rest. 

" That much of this difficulty lies in the fact that the position 
of greatest ease for the tuberculous hip-joint is one in which it is 
very awkward for the patient to carry the limb, very difficult for 
the surgeon to fix it, and therefore one in which the joint is 
constantly exposed to disturbance. 

" That it is possible, and in many cases advisable, to remove 
this difficulty by such an osteotomy of the femur as will allow 
the limb to be put straight, while the upper of the fragments 
retains ' the natural position of rest.' " 

A serious, and, I should think, an insuperable objection to 
the osteotomy treatment of hip-joint disease is that if, when the 
limb is obstinately flexed to a right angle, inverted and adducted, 
the bone is divided, and the femoral shaft is Ijrought down flat 
and straight, the cut ends of the bone will be so far asunder that 
either non-union will follow and the child will be left with a flail 



232 THE YKAR-BOOK OP TREATMENT. 

linil), or else tliiii union will take y)liK;e at such an aiit^le that the 
in(!vital>l(; shorteninj^ beconies j^reatly intensifiefl. 
"2. Aiii|»iil:iti4»ii :it IIk' lii|»*i<»iiil. 

A coiisi(l('fal)l(! amount of attention lias of late heen flirected 
to the best method of performint^ disarticulation of the femur, 
especially with a view to limiting the loss of blood, and to 
diminishing to the utmost the amount of the inevitable shock. 
The old showy operation by transfixion, as performe<l by Listen 
and other masters, with a bulky anterior flap is, I think, a thing 
of the past, though it is still described with other obsolete pro- 
cedures of a like nature in modern text-books. 

Davy's lever for compressing the common iliac artery through 
therectum was an ingenious suggestion, but its use in the adult 
was found to be not free from danger, while in the case of a 
weakly child it would have been extremely hazardous. 

In former years, when amputating at the hip-joint in a thin 
child, I have occasionally had the circulation effectually controlled 
by backward pressure upon the anterior wall of the alxlomen, 
just below the umbilicus — the flow through the aorta being thus 
easily and com])letely controlled. 

Chalot, Professor of Clinical Surgery, Toulouse, has recentlj'^ 
advised (ffuitieme Congres de Chirurgie) direct compression of 
the common iliac arteiy, made through a small opening above 
Poupart's ligament, with the view of effectually controlling 
hfemorrhage in disarticulation at the hip-joint. I cannot think, 
however, that such a procedure is advisable, more especially when, 
as so often happens, the limb is being removed for chronic septic 
disease. 

In the Annals of Surgery (Feb., 1897, p. 129) is published a 
paper read before the New York Surgical Society by Wyeth, in 
which he once more directs attention to his method of controlling 
hsemorrhage in amputation at the hip-joint by means of two steel 
skewers which transfix the limb, and by rubber tube tourniquets, 
which tightly encircle it above the pins. The great feature of 
this method is that slipping of the tourniquets is impossible, and 
that practically every vessel is subjected to its compression. The 
paper is well illustrated, and those who are not familiar with 
Wyeth's method, and are liable to be called upon to disarticulate 
in cases in which hfemorrhage would likely be disastrous, would 
do well to refer to the Annals for February, 1897. I may say 
that I have adoi)ted Wyeth's plan in disarticulating according to 
Furneaux Jordan's method, and am bound to speak well of it. 

In the Centralhlatt fur Chirurgie (Feb. 20, 1897, p. 18.'')), Oscar 
Wolfif gives an interesting report of a case of chronic tul)erculous 



SURGICAL DISEASES OF CHILDREN. 233 

disease of the hip-joint, in which he not only removed the limb, but 
the chief portion of the carious os innominatum. He began by 
tying the iliac vessels — a very necessary precaution, one would 
think. After the operation albumin cjuickly disa])peared from 
the urine, and the patient made an excellent recovery. 

3. Kiieo-joiiit disease. 

At the Congi-ess of American Physicians and Surgeons which 
was held at Washington in May, 1897, the treatment of deformi- 
ties of the knee, the result of tuberculous disease, was discussed. 
From the report of the meeting which is given in the Medical 
Week (May 28), I find that for correcting the characteristic 
threefold displacement of the tibia in advanced disease an instru- 
ment known as the " genuclast " is somewhat widely used. 

Early in the coarse of the disease the head of the tiljia 
becomes displaced backwards, and in this position, .sometimes 
even on the back of the femoral condyles, it is firmly held by the 
contracted hamstrings, popliteus and gastrocnemius, as well as 
by the shortened posterior and lateral ligaments. Brute force, 
such as would be brought to bear, I suppose, by the "genuclast," 
might have the effect of effi^cing some of the flexion, but, I would 
maintain, with so much risk, that its employment could not be 
justified. I have no fear in admitting a very strong conservative 
prejudice in this matter, nor in confessing that I have no personal 
experience with the method in question. In the application of 
force to the contracted knee of the tuberculous child something 
must needs give way, and if, during the process, it happened that 
the head of the tibia glided forward to its proper place beneath 
the femoral condyles, the gain would be considerable. But long 
before the impatient and aggressive spirit of modern measures 
gave birth to the "genuclast" it was known that rough inter- 
ference with a deformed, tuberculous knee could not readjust the 
articular surfaces. 

According to the report before me, five sui-geons gave tlieir 
experience : — 

Goldthwait (Boston), who introduced the subject, said that one 
of his first cases operated on was a young girl. " Failing to 
reduce the deformity with the genuclast, I opened the joint and 
removed the patella. It was then easy to bring the bones into 
place. The convalescence was tedious, and the joint remained quite 
sensitive for about two years." My friend Dr. Ridlon (Chicago), 
whilst attempting to reduce the deformity of the knee in one 
case, produced a large rent in the soft ports behind the knee. 
Gillette (8t. Paul), in one case, " met with paralysis — loss of 
sensation — below the knee " (probably from injury to the popliteal 



23] TlIK YEAU-nOOK OF TUKATMKNT. 

nerve). H. A. Wilson, wlieii usiii^ tlic; ffeiiucbiHt, fractured the 
femur a litth; ahovc, llie condykss — tliou<^Ii lie did not think that 
he " was using excessive force." Gibney (New York) said that 
he was accustomed to use consideraVde forc(!, )mt that it had 
often been inipossilde to secure a good positi<jn. He therefonj 
urged the adoption of subcutaneous osteotomy of the femur aljovc 
the condyles, in order to correct tlie deformity. 

Had it been my good fortune to ])e present at that meeting, I 
would have ventured to urge in these cases tlie jjatient employ- 
ment of Thomas's knee-splint, with which great iraj)rovement in 
the position of the deformed limb can Vje slowly and gradually 
accomplished. When the disease has then absolutely passed 
away, the deformed joint is found either synostosed or capable of 
a certain amount of movement. If the latter, a supra-condylar 
osteotomy, as advised by Gibney, should be resorted to. But if 
the joint be solidly fixed, the improvement in position is to be 
secured by the removal of a wedge-shaped piece of bone from the 
part at which femur, patella and tibia are fused together. It is 
a simple and a highly successful operation. 

In connection with the rough manipulation of a tuberculous 
joint, 1 may here remark that at a meeting of the Societe de 
Chirurgie, held in Paris, May 26, 1897, Menard (Berck-sur-Mer) 
expressed an adverse opinion upon the forcible straightening of 
the spine, the hip, and the knee in deformity following on 
tuberculosis. In five cases under his observation, in which 
the flexed femur had been forced down into the straight line, 
tuberculous meningitis followed in a short while. 

In the discussion upon hip-joint disease before the Societe de 
Chirurgie, at Paris, June 23, 1897, Gerard-Marchant said that 
he had been watching for some yeai's a case of tuberculous knee 
which was doing well. At last the joint grew painful and 
became flexed. He forcibly straightened the limb under chloro- 
form, and fixed it in gy})sum splints ; tuberculous meningitis 
ensued, and his patient died. He said that death thus occurring in 
a comparatively healthy child had left a deep impression on 
him. 

4. C'liiiical observations ii|>oii the use of antitoxin 
in diphtheria. 

Joseph E. Winters, who last year read a paper on this subject 
before the Academy of Medicine of New York, is Professor 
of Diseases of Children in the Medical Department of the New 
York University. This suffices to show that he understands 
what diphtheria is, and that, more than most people, he is 
anxious to l)e provided with a sure remedy against it. He has 



SUUUICAL 1;ISEASES OF CHILDREN. 235 

weighed Behring's antitoxin in the btihince of clinical experience, 
and has found it not only wanting but harmful. 

Winters says : — " Behring's antitoxin was given to the world 
as a specific against the toxins of the diphtheria bacillus ; it has 
no action on the bacillus, it is not I'endered less virulent, it is in 
no way influenced by the treatment. Behring has told us that 
his remedy has no influence on the poisons of other bacilli. 
Diphtheria in man scarcely ever occurs from pure infection by the 
Loefiler bacillus. Almost invariably we find in addition to the 
specific diphtheria bacillus, streptococci, staphylococci, etc. The 
poisonous substances of the latter bacilli are in no way influenced 
by antitoxin." 

Winters concluded his paper by saying : — " With reference to 
a ' prejudice,' it is monstrous to speak of it — a prejudice against 
anything which could do any good in such a disease as diphthei'ia ! 
A man who would have a prejudice against a specific for diph- 
theria should not be allowed to practise Medicine. If there is a 
specific for diphtheria, I want it. Could I have found that anti- 
toxin did not do any harm, even though it was valueless in the 
treatment of diphtheria — even though it did not reduce the 
mortality — I would never have said anything against it. It is 
because I believe that it is dangerous that my convictions compel 
me to speak. The time will come, gentlemen, when every 
member of this Academy will feel with reference to it as I do 
to-night, and you will come to it from conviction, as various 
members have already." 

Certainly, the perusal of the paper should render the more 
enthusiastic disciples of Behring cautious in their recommending 
the use of antitoxin as a prophylactic. In one such case the 
verdict of a coroner's inquest ran to the eflect that the cause of 
death was the injection of diphtheria antitoxin. 

In this paper there is a considerable collection of similar 
reports ; I will, however, content myself with quoting one only. 
Alfoldi relates a case of a girl, three years old, who I'eceived a 
preventive injection of two cubic centimetres of Behring's serum, 
January 16. January 18 her temperature rose to over 104° F. 
On the 19th there were severe albuminuria and luematuria, 
petechite appeared over the whole body, and on the twentieth day 
the child died. Alfoldi attributed death to anti-dipbtheritic 
serum. 

" The resident physician in the diphtheria ward of the 
Children's Hospital at Sti'assburg said to me during my visit 
there last year : ' I have seen three children who, 1 think, were 
killed by the serum,' " 



2'.U') THK YKAIt-HOUK OF TrtKATMKNT. 

MacNeal jiiid Heywood, of Illinois, say (/'edialrics, Feb. 1, 
IS'JT) tliat they art; convinced that tliere would l)e fewer fatal 
cases fioni the use of antitoxin if we were to consider carefully 
the condition of the patient before the injection is made. " It is 
glaringly unfair to claim that the last straw broke the camel's 
back. What is the degree of poisoning] How is the heart? 
How is the nervous system 1 If the patient is very drow.sy from 
sepsis, wake him up with a good full dose of strychnia." 

Per contra, in the Harben Lectures upon the bearing of recent 
bacteriological investigations on public health, Sims Woodhead 
maintained that in those cases in which nerve and muscle changes 
have taken place before the toxin is neutralised by an antitoxin 
we may expect evidence of these changes to make their appear- 
ance. The fact that a number of cases recover wliich under the 
old methods of treatment would have succumbed at an early stage 
of the disease, must lead us to expect that the number of cases in 
which paralysis is present may even be increased ; these paralyses 
and other complications must be attributed to their proper cause, 
the toxin, and not to the remedy, as has been by many incon- 
sequently done. 

He said that as to the results of the treatment, it has been 
found that in the hospitals of the Metropolitan Asylums Board 
the percentage mortality, as a whole, has fallen from 29 -G — the 
lowest previously reported — to 20-8. Of the cases that came 
under treatment on the first day the death-rate has fallen to the 
remarkable figure of 4 "7 per cent., as compared with 22-5 \)Qv cent, 
in 1894. For the five years 1890 — 1894 the mortality amongst 
the post-scarlatinal cases was slightly over 50 per cent., while now 
that most of these cases are treated by antitoxin the mortality 
has fallen to 5 per cent., although the mortality amongst the 
cases treated on the fourth or fiftli day and later is over 40 per 
cent. Amongst those treated on the first day it is 2-8 per cent. 
Taking those treated with antitoxin only, the mortality is 5-7 on 
the total and 2-3 on the first day; indeed, out of 250 cases 
treated at once only six died. 

Dr. Woodhead concluded by alluding to the serious responsi- 
bility incurred by those who were antagonistic to the new 
treatment. 

And in the debate upon the antitoxin treatment at the New 
York Academy of INledicine (Dec. 10, 1896), Henry F. Koester said 
that he had seen such good results from the ;intitoxin treatment 
that he had come to look upon the physician who did not employ 
■it as guilty of criminal neglect. 

What impresses me much in connection witli the diphtheria 



SURGICAL DISEASES OF CHILDREN. 237 

antitoxin tivatment is tliat tlic diagnosis of iliphthciia is now more 
a (luestion for the bactt riologist than the medical attendant — that 
the diagnosis is now made in the laboratory, and not in the ward or 
sick room. Though the presence of one swallow does not make a 
summer, the pi-esence of a single Klebs-Loeffler bacillus in a 
specimen of viscid mucus, removed from a doubtful patch upon 
a boy's tonsil, suffices to warrant the bacteriologist in sending in 
the verdict that the angina is "diphtheria." And from this 
verdict there is no a[)peal. The child is therefore straightway 
treated with the antitoxin ; he gets well, and the case is put upon 
the file as a success after, and thei'ofore due to, the antitoxin 
treatment. Probably, had it not been for the report of the 
bacteriologist, the case would never have been considered one of 
diphtheria. Years ago most of these cases escaped recognition, 
though they might, nevertheless, have been the means of spreading 
the disease. 

I am not, for a moment, finding fault with the autocrat of the 
laboratory, to whose conscientious work the practitioner, as well 
as tlie hygienist, is iunnensely indebted ; but supposing that in the 
course of an epidemic he reported twenty such cases, how greatly 
would their inclusion have helped in the favourable consideration 
of the antitoxin treatment, and how usefully they would after- 
wards come to the hand of the statistician who is prepai'ing his 
battery of columns and figures on the side of antitoxin ! To me, 
personally, statistics are hateful things ; and when they are 
applied to surgical matters they are more than apt to be mislead- 
ing, not to say untruthful. To the antitoxin statistician the case 
of the slight sore-throat from which the viscid mucus was brought 
which contained the guilty bacillus — the object of his search — 
was just as much "diphtheria" as was a case in some other 
epidemic in which the child came under treatment with sloughing 
tonsils and toxa?mic pallor. But, unfortunately, the compiler of 
statistics does not loeigh his cases ; he merely counts them. In 
these circumstances who can deem his method scientific or trust- 
worthy 1 I certainly cannot. And sometimes, indeed, it appears 
to me as if the practitioner were, consciously or unconsciously, 
playing into the hands of the cold-blooded statistician by declining 
to give an antitoxin injection to a child who has diphtheria so 
severely that, in all probability, he is going to die from it, lest 
the death of the child should help to discredit the antitoxin. 
Surely no treatment could be established upon a sound basis if it 
stood in need of such mean support ! 

In what I have written, be it clearly noted, I have not said a 
word against a resort to the antitoxin treatment of diphtheria. 



238 THK YRAR-nOOK OF TUF".ATMKNT. 

Iii(1(h;(1, 1 adopt it iiiyscdf, uiid I urge its adoption 1-y others ; Init, 
ill tlie nicanwliile, tlio ])ractitioner should keep his mind open 
upon tlio question of the exact value of the treatment. Nolxidy 
can estimate yet with certainty. I believe that Beiiring said 
tliat lie had jjrovided us with the means of leducing the mortality 
from diphtheria to one-tenth of its former rate, that is, to ahout 
3 per cent. We are yet, however, a long way from having reached 
this desirable consummation. But in the meanwhile let the 
bacteriologist continue to work on in enthusiasm and the 
practitioner in hope, and let them both beware of the statis- 
tician. 

Then comes the question, What is a full dose of antitoxin 1 
Hitherto the preparation of the material has been carried out in 
such a manner by its various dispensers, that when it found its 
way into the hands of the practitioner he knew practically 
nothing of its strength. So it happened that he might be in- 
jecting it in superfluity and in danger, or, on the contrary, might 
be using it in doses so small as to be inoperative either for good 
or evil. To remedy this unsatisfactory state of affairs, the 
Superintendent of the Laboratories of the Royal Colleges 
upon the Thames Embankment, Dr. Sims Woodhead, visited 
Germany in order to compare his methods with those in 
use in that country, and the following is extracted from 
his report on the subject : — " On my arrival in Berlin my 
first object was to obtain a comparison between our results 
in serum-testing and those by Professor Ehrlich. At the 
same time I carried out a series of dilutions according to the 
methods used in our laboratories. From day to day the reactions 
obtained in the different animals injected by Dr. Donitz were 
noted and the experiments compared, and it appeared that our 
readings, obtained by the old method, differ to the extent of only 
about 5 per cent, from those obtained by the new method. Pro- 
fessor Ehrlich expressed the opinion that the serum he had 
examined for us was equal to any in the market. He also stated 
that our methods were thoroughly reliable. In this he was 
corroborated by Dr. Donitz. They were greatly interested in the 
new method of preparing serum, and have determined to try it. 
In every case six samples are taken from large bottles containing 
several litres. These and the stock-flask are then placed under 
seal for future reference. The samples are tested as to the 
presence of micro-organisms ; for the quantity of preservative 
material added, and for the number of units in each c.c. of 
the sample. If the strength does not come up to the standard it 
is returned. The new method of testing the serum with large 



SURGICAL DISEASES OP CHILDREN. 239 

quantities of toxin is that now used, as it is sufticicntl}' tlelieate 
to measure to within 1 per cent." 
5. Iiitus»ii$«co|>tion. 

It had not been my intention to refer again' this year to the 
treatment of intussusception, but the subject is of sucli prime 
importance, and is, I am ghid to say, now occupying so prominent 
a phice in surgical attention, that T have little hesitation in so 
soon again considering it, and especially from the point of view of 
operative interference. 

I do not propose to discuss the treatment of intussusception 
by inflation or injection, as I consider these measures to be 
always speculative, and sometimes dangerous, whilst if the in- 
vagination be in the small intestine they are certain to fail. Mr. 
D'Arcy Power remarked in his Lectures at the Royal College of 
Surgeons* that a pint of fluid had proved suflicient to rupture 
the bowel in a child aged three months, though the injection 
was made by one of the most careful and experienced surgeons in 
the profession. He goes on to say that the surgeon should keep 
one hand flat upon the abdomen whilst irrigation is being per- 
formed, and he must carefully avoid great variations of pressure. 
A sudden and uniform enlargement of the whole abdomen during 
irrigation raises a strong suspicion that the bowel has been 
ruptured, because rupture of the colon almost always takes place 
before there is any great distension of the small intestine, and 
that a laparotomy must be done at once when this accident 
happens. 

It seems to me to be tolerably certain that if in any case 
hydrostatic pressure could reduce an intussusception, the same 
could have been efiected by a small incision into the abdomen, 
and without subjecting the child to risk. Power truly remarks 
that a great disadvantage attends the use of irrigation for the 
cure of intussusception apart from the danger of rupture — namely, 
the liability to recurrence after reduction. Dr. F. H. Elliott has 
published the details of a case of recovery from intussusception in 
a child aged eight weeks, in whom recurrence took place twenty- 
fom- hours after the first reduction, five days after the second 
reduction, and thirteen days after the third reduction. Dr. 
Chafl:ey had a less satisfactory experience, for an intussusception 
recurred on five separate occasions until the patient, a boy aged 
three years, died of exhaustion. When recurrence is a feature 
in a case, it is better to open the abdomen at once. 

Mr. Power concludes his remarks upon laparotomy by saying 
that the surgeon must then be prepared to deal effectually with 
* Lancet, Feb. U, 1897. 



240 TIIK YEAR-r.OOK OF TRRATMKXT. 

the conditions lie may find, liy sucli (jjH'i-ativ*! moans as in; can 
carry out witli the; least amount of sliock, and in trie shortest 
space of time tliat is compatiljle witli the safety of the patient. 
This will 1)0 ensured if he uses the method with which he is the 
most familial-. But he should hear in mind that liardly ;i case 
can ari.se in which he is justified in closing the abdominal wound 
without at least an attempt to complete the operation hy reducing 
or removing the intussusception. Such halt-measures as the 
formation of an artificial anus are hardly ever justifia]>Ie, and the 
results obtained by them are disastrous. In the light of our 
present knowledge it appears that the use of a button or bobbin 
is most likely to give good results when enterectomy has to be 
done for an enteric intussusception, whilst Maunsell's operation 
is best adapted for the cure of ileo-ca!cal and colo-colic forms of 
intussusception. 

It is becoming a matter of increasing difficulty to keep pace 
with the reports of cases of intussusception which have been 
successfully treated by laparotomy in Britain and abroad, English 
medical literature being especially rich in them. 

With regard to laparotomy for chronic intussusception (which 
is beginning to acquire a highly respectable position in surgical 
literature), reference may be made to a paper [Lancet, May 22, 
1897, p. 1411) containing the report of a case treated by resection, 
and by Murphy's button by Boyce Barrow. 

Whilst Bernard Pitts has reported seven consecutive cases 
of intussusception in infants treated by abdominal section, with 
six recoveries {Lancet, June 13, 1897, p. 1602). He truly re- 
marks that (on account of delay) cases are almost hopeless from 
the first moment they are seen in hospital. A run of successful 
cases must depend either upon immediate treatment or the 
fortunate absence of severe damage to the bowel. Until the last 
few years it has been the practice to exhaust all other methods 
of treatment before abdominal section was resorted to, and it is 
not surprising that a successful case of surgical interference was 
most exceptional. Physicians, under whose care these cases are 
generally admitted, now employ inflation and manipulation, how- 
ever, only when the patient is in good condition and has come 
very early under observation ; they are satisfied that abdominal 
exploration should be undertaken without delay if complete 
reduction is not at once brought about. In all the acute cases 
recorded by Mr. Pitts the physician in charge requested the 
sui'geon's immediate attendance, and to this sa\'ing of valuable 
time the successful results must certainly be attributed. Children 
under one year of age are commonly supposed to be unfavourable 



SURGICAL DISEASES OF CHILDREN. 



241 



subjects for abdominal exploration. Witli proper precautions, 
however, abdominal section may be performed without great risk 
from shock, but the temperature of the body must be maintained 
by wrapping tlie extremities in cotton wool, operating on a liot- 
water cushion, and taking care that the manipulations are carried 
out quickly and with great gentleness. 

The tirst of Pitts's cases was that of an infant of eighteen 
months with chronic intussusception in which, reduction being 




Fij 



. 1. — Cfficum laid open from the front to show ileocolic invagination, a 
Sutures introduced round neck of intiissusception. h Line along which 
intussusception was removed, c Apex of intussusception. 



impossible, the invaginated part was removed through the colon, 
after Barker's method. The child made a perfect recoveiy (Fig. 1 ). 
The second was one of chronic ileo-csecal intussusception due 
to complete inversion of the appendix in a female child of two 
and a half years. The intussusception protruded four inches 
beyond the anus. Laparotomy having l)een performed, it was 
noticed that after apparent complete reduction no appendix was 
visible. At the position where it should normally be attached 
was seen a dimple ; here also was the base of its mesenteric 
Q 



242 



'I'lIK YKAK-1500K OF TUKATMKNT. 



attachtiient. On examinjiti(jii of the caecum an elfjngated 
swelling could be felt within it resembling a thickened appendix. 
A vertical incision of two inches long was now made, having its 
centn; at the j miction of the csecuin and ascending colon, anrl a 
chronically thickened and coinpletcly invertefj appendix was 
found. All atti^inpts at reduction f;iih'd, so the appendix was 
cut away and its Ijase sutured, and then further secured by 




Fig. 2. — Csecum laid open on its inner side to show invagination of the vermiform 
appendix, a Apex of invaginated appendix, h Depression in csecum indi- 
cating attachment of appendix, c Lower end of ileum. 

stitching the peritoneal coat of the cfecum over it. The incision 
in the large bowel was sutured and the alxlominal wovnid closed. 
The child was kept under the influence of small doses of tincture 
of opium. Recovery was uninterrupted, but the child was kept 
in bed for a considerable time on account of the tuberculous 
condition discovered at the operation. The diagram shows the 
appearance after I'eduction of the intussusception and retraction 
of the sides of the incision in the large bowel (Fig. 2). 

Pitts remarks that it is highl}^ probable that some condition 
of irritation within the appendix caused it to turn inside out as 



SURGICAL DISEASES OF CHILDREN. 243 

the first commencement of trouljle ; the inverted appendix thus 
acting as a polypus within the bowel, produced the ileo-cjecal 
intussusception. 

Then follow live cases of acute intussusception in which success- 
ful results were secured by laparotomy — results which should go 
a long way towards placing prompt abdominal section in its 
proper position in the treatment of intussusception. 

Pitts ends his valuable paper with the advice that if treat- 
ment by rectal injection is thought expedient, the surgeon should . 
be present and prepared to open the abdomen at once if a satis- 
factory result is not quickly obtained. That in many cases the 
effect of such inflation is to reduce the main mass of the tumour, 
but to leave an irreducible portion. And that exploratory 
operation should be undertaken without preliminary inflation, 
when from the severity of the symptoms, or the chronicity of 
the case, there is reason to believe that such inflation would be 
dangerous or unlikely to succeed. And that it must always be 
remembered that the time taken up by the inflation adds consider- 
ably to the shock. 

G. B. Morgan, of Sunderland, published {Brit. Med. Journ., 
1896, vol. ii., p. 847) the case of an infant of nine months 
with acute intussusception on whom he successfully performed 
abdominal section within twelve hours of the appearance of 
symptoms. He remarks : " The day is gone by when expectant 
treatment is justifiable in intussusception." 

At the Carlisle meeting of the British Medical Association 
last year, Crawford Renton read {Brit. Med. Journ., Oct. 17, 1896, 
p. 1113) "Notes on Three Cases of Acute Intussusception in 
which Abdominal Section was Performed, with Recovery." 

One case was in an infant of ten months ; one of eleven 
months ; and one of three months. 

This is certainly a delightful record. Mr. Renton truly says 
that there is nothing to be gained by delay, as almost every child 
dies if not operated on, but that it is relieved with speed. 

From the Hartlepools Hospital comes the report of a case 
{Brit. Med. Journ., July 10, 1897, p. 83), in which T. G. Ainsley 
successfully performed Maunsell's operation for an intussusception 
in a boy of fifteen years. When seen three days after the onset 
of symptoms the boy lay in a state of semi-stupor. He referred 
the pain to half an inch above the umbilicus. The abdomen was 
flaccid and slightly tender, but no tumour could be detected. 
Examination per rectum gave negative results. He vomited at 
intervals, but retained a good deal of food. On the third day he 
had some straining and passed a little mucus and blood. The 
o 0. 



244 TIIK YEAR-BOOK OF TKKATMP:NT. 

case was tlien diagnosed as one of intussusception, and it was 
decided to operate. Under cliloroforni an indistinct swelling 
could be felt through the up])er part of the I'ectal wall. On the 
abdomen being opened, the intussusception was readily found 
among the coils of small intestine and brought out at the wound. 
The tumour was situated on the small intestine, some distance 
above the caecum. On attempting reduction, it was found to he 
gangrenous. " I had now some hesitation whether to use a 
Muiphy's button which was ready, or perform the resection 
known as Maunsell's. As the patient was bearing the operation 
well, and I looked with some suspicion upon Murphy's invention, 
the latter course was decided on. The intestine was clamped, 
suri'ounded by sponges, the tumour cut away, and the ends well 
washed with warm boracic lotion. The time occupied by the opera- 
tion was one hour. The pulse was then 1 G5 ; the temperature never 
rose above 100° F. The patient had a natural motion on the fifth 
day, and recovery was uninterrupted. He left the lios2:)ital three 
weeks afterwards, and is now, fifteen months after the operation, 
in perfect health." 

Stanley Boyd showed in his clinique an infant of eight 
months (Clin. Journ., June 2, 1897, p. 89), who had recovered 
after his performing laparotomy on her for acute intussuscep- 
tion. His house-surgeon had already endeavoured to reduce the 
intussusception by means of water-pressure. AVhen Mr. Boyd 
examined the child the swelling was confined to the riglit side 
of the navel. He made a median incision above the umbilicus, 
and, inserting two fingers, was able to tilt the invagination 
through the wound. " After the operation the child did well, 
and we ceased to anticipate trouble. But one morning the tempera- 
ture ran up to 104° without obvious cause, but the child seemed 
so well that we were never very anxious about it. The tempera 
ture fell after three or four days, and progress once more set in, 
but we had another slight and short rise a few days later, also 
unaccounted for. The wound healed by first intention." 

Lawford Knaggs (Zffl^ce/;, April 24, 1897, p. 1137), in an 
impoi-tant essay, reports two cases of successful operation, in one 
of which reduction was easy of accomplishment after symptoms 
had existed for forty-four days. In Mr. Hutchinson's well-known 
case disinvagination was safely performed at the end of a month. 
But neither of these approaches the case recorded by Dr. 
Handfield-Jones and Mr. Page, in which an invagination was 
reduced after a probable duration of three months. 

Doubtless I might have multiplied the number of reports of 
successful results of laparotomy in acute and in chronic intus- 



SURGICAL DISEASES OF CHILDREN. 245 

susception, Imt little would liuve been gained thereby. What I 
wished to do was, like the lly on the wheel, to help in an important 
revolution, and to plead for early operatioi; in these cases. I 
remember being called some years ago to a consultation on an 
infant who was in artictdo mortis from acute intussusception. 
When the general practitionei' — a very practical man — learned 
what my inclination was, he said that nothing would induce him 
to agree to an abdominal section, that he had seen several such 
operations, and that every one had ended fatally. The case under 
consideration looked so hopeless that I, with more discretion than 
valour, did laot urge operation. Doubtless he was correct in his 
statement, and that in those sad cases which he had witnessed, 
laparotomy had been resorted to after valuable time had been 
fruitlessly expended, and the children's power of endurance 
wasted, by unsuccessful attempts at reduction b}^ inversion and 
injection. And hosv, in such circumstances, could any other issue 
be expected ] Laparotomy for acute intussusception should no 
longer be considered as an adjunct to inflation and injection ; it 
should absolutely and entirel}'' replace them. 

6. Hernia of the ovary with twisted pedicle. 

In the previous issue of the " Year-Book," p. 242, brief 
reports were given of two cases of hernia, with some symptoms 
of strangulation, in which an engorged ovary was found with 
a twisted pedicle in the inguinal region of a child. A resem- 
blance between these cases and those of axial rotation of the 
testicle was then suggested. Such cases are sufficiently rare to 
be deserving of report in this article. 

In the Lancet (May 15, 1897) John H. Morgan reports a case of 
right ovarian hernia with twisted pedicle which had been under 
his care iii the Ureat Ormond Street Hospital a few weeks before. 
A female infant, aged eight months, was admitted on March 9, 
1897, with a lump in the right groiii ; it was of interest to note 
that a brother had died from strangulated hernia. The infant 
had always been delicate, and ever since she was four days old a 
small swelling had been observed in the right groin. Four days 
before admission this swelling underwent great increase in size, 
the skin over it became red, and the parts appeared to be painful, 
the child screaming constantly and drawing up the right leg. 
She was convulsed on two occasions, but had not vomited, and 
the bowels were quite regular. On admission, the child appeared 
to be happy, and free from symptoms. The temperature was 
normal. Extending over the right external abdominal ring was 
a rounded, semi-elastic swelling, which was not altered in size 
when the child cried ; pitting of the skin could be made out on 



246 TIIK YKAPv-ROOK OF TREATMENT. 

prossuro. The child was fat, hut an indistinct irrcdiicihle hody 
could h(! felt, and could lj(( freely moved about, having, as it 
seemed, no connection with the interior of the ahdomen. 
Morgan made an oblique incision over the swelling, and exposed 
a thin-walled sac ; an incision through this membrane allowed the 
escape of blood-stained fluid, leaving exposed a phuD-coloured 
bodj' about the size of a small damson. Attached to the upper 
end of this, which on closer inspection proved to be the ovary, 
was a pedicle twisted upon itself two and a half turns. This 
stalk consisted of the right Fallopian tube and the broad ligament, 
and upon pulling them outwards the fundus of the uterus entered 
the wound. The portion of the twisted pedicle, almost to its 
attachment to the uterus, was in a congested condition similar to 
that of the ovary. A ligature was passed round the pedicle, the 
ovary and pedicle were cut off, and the uterus was dropped back 
into the abdomen. A suture was })assed through the external 
abdominal ring, and the surface-wound was closed. The child 
recovered without a bad symptom. 

7. A fatal case of operation for toiijfiie-tie was re- 
ported {Lancet, Jan. 22, 1897) by Hamilton A. Ballance. It occurred 
in the practice of a sage-feinme at Norwich. Ballance says that the 
report may be of interest to medical men owing to the prominence 
of the " midwives question " at the present time. An inquest 
was held and the jury returned a verdict of " Death from mis- 
adventure." They also recommended that in future a medical 
man should be consulted should this operation be thought 
necessary, and they considered that the midwife was deserving of 
censure for undertaking it. At the inquiry the woman stated 
that she had frequently performed the operation before ! 

About an hour after the birth the midwife said that the 
child was tongue-tied, and using a sharp-pointed pair of scissors 
she proceeded to liberate it. She did not notice bleeding at the 
time of the operation, but on the same evening blood was 
observed to be issuing from the child's mouth. Next day, as the 
bleeding continued, the father went to the midwife's house and 
fetched her to the case. The woman told the parents that there 
was no need to be frightened. The haemorrhage did not cease ; 
and the midwife was therefore again fetched on the evening 
of the following day. She then washed the mouth and the face 
of the child in warm water. The father requested that a medical 
man should be called in, but the midwife said that it was un- 
necessary and that if she was to blame she would take the 
responsibility. Eventually, however, she took the child herself 
to a medical man, who, after examining him and giving directions 



SURGICAL DISEASES OP CIIILDKEN. 247 

to the friends as to treatment, recouinieiuled tliat lie should be 
taken to Mr. Burton. Mr. Burton found arterial bleeding in tlie 
anterior part of the floor of the inouth and placed two ligatures 
on the bleeding points. He then sent the child to the hospital. 
A cut was seen, half an inch long, at the junction of the tongue 
and the tioor of the mouth and exposing the muscular substance 
of the tongue. The bleeding seemed to have stopped from the 
time of the application of the ligatures. The child died next 
morning. While in the hospital he passed some dark blood by 
the bowel, having apparently swallowed the blood as it exuded 
from the wound. 

It w^ould be interesting to know where the nurse obtained the 
knowledge which she deemed sutiicient to justify her in perform- 
ing a surgical operation. Possibly she had attended a course of 
semi-popular instruction on "Nursing" ; perhaps she had enjoyed 
the advantage of a course of lectures by the matron of a lying-in 
hospital, or had even obtained the diploma of some obstetric 
association. But what would this all amount to ] A lying-in 
nurse is none the worse for possessing a veneer of surgical know- 
ledge — indeed, she is probably all the better for it — -but if such an 
one is under the impression that this minimum of information is 
to equip her for active surgical practice she becomes a positive 
danger to the community. I am afraid that this Norwich mid- 
wife is not the only unqualified woman in England who considers 
herself to be a competent medical practitioner and who acts 
accordingly. 

Another fatal case of hfemorrhage after division of a tongue- 
tie was reported to the Association Frav raise pour V Avancemp.nt 
des Sciences by Reboul (Aug. 9, 1897). The usual precautions had 
been taken before operating, and when the bleeding appeared 
obstinate almost eveiything was tried, but in vain. Reboul 
makes reference to another case under the care of Ricken, and 
attributed to the hfemorrhagic diathesis. He says tliat the opera- 
tion for tongue-tie ought not to be considered destitutt; of 
importance. 

NEW PUBLICATIONS. 

A new edition of the " Surgical Diseases of Children," * by the 
writer of this article, appeai-ed early in the past summer. The 
book is partly re-written and considerably enlarged, and it is now 

*" Surgical Diseases of Children." B\- Ednmnd Owen, M.B., F.R.C.S., 
Senior Surgeon to St. Jlary's Hospital, and to the Hospital for Sick Children, 
Great Ormond Street, and Lecturer on Clinical Surgery at St. Mary's Hospital. 
"With 5 chromo plates and 120 engravings. Third edition, revised and en- 
larged, 21s, Loudon : Cassell and Companj-. 



248 TIIR YKAR-nOOFf OF TRRATMRNT. 

taken out from the series of l)lue, clinical volumes. Though 
a sense of propriety prev(!nts tlie writer from liei'(! setting forth 
certain improv(;m(^nts in this volume, it need not hinder his calling 
attention to the print of a llontgen-ray picture of a case of tuber- 
culous liip-joint, which is shown opposite page 424. The plioto- 
gi'ani was taken hy Dr. John Macintyre, of Glasgow, and the 
print comes out with a clearness which apparcsntly leaves nothing 
to be desired. It shows that the shortening of the limb in old 
hip-disease is due to several causes — to disappearance of the tri- 
radiate cartilage at the bottom of the acetabulum, and a resulting 
arrest of development of the os innominatum, to absorption of the 
head and neck of the femur, and to atrophic influence which has 
hindered the growth of the femur. In connection with this 
pliotogram Dr. Macintyre has remarked that the arrest of develop- 
ment of the OS innominatum occurring in a female suljject might 
have an important and prejudicial influence from an obstetric 
point of view. 

"About Children"* is the title of a volume of under 200 
pages by Samuel W. Kelley, containing a short course of Lectures 
given by him to the nurses in the Training School of the Cleveland 
General Hospital. The instruction tiius imparted is just what it 
should be ; it gives a general survey of the province in which the 
nurses' work is cast without imparting to them the delusive 
suggestion that if they digest and absorb what they are taught 
they may consider themselves competent to start as medical 
practitioners. 

* Medical Gazette Publisliing Company, Cleveland, Ohio, U.S.A., 1897. 



DISEASES OF TllP] GENITO-URINARY 
SYSTEM. 

By Reginald Harrison, F.R.C.S., 

Surgeon to St. Peter's Hospital. 



1. Renal siirg^ery. 

Albarran contributes an article (G'az. Med. de Paris, and 
Brit. Med. Journ., Oct. 9, 1897) advocating the more systematic 
adoption of catheterism of the vireter in cases of hydronephrosis. 
This he considers should he the tirst step in the surgical treat- 
ment of this aifection, the ureteral catheter being retained if the 
mere introduction of the instrument fails to continue to empty 
the kidney. Should nephrotomy eventually prove necessary, he 
has found that this preliminary shortens the duration of a fistula 
that may result on the same principle that a retained catheter 
will sometimes promote the healing of a sinus caused by a urethral 
stricture. Similarly he treats fistula; connected with the kidney 
arising spontaneously. 

The various valuable papers that have recently drawn attention 
to the surgery of the ureters, with special reference to their 
catheterisation, amongst which I would particularly mention 
that by Howard Kelly (Tventietlt Century Practice of Medicine, 
New York, vol i., 1895), clearly show that these tubes, though so 
small, permit of treatment much on tlie same principle as that 
applicable to the male urethra. Further, it should be noted here 
that in wounds of the ureter the restoration of the duct may be 
efiected without necessarily sacrificing the kidney connected with 
it, as was formerly often tlie case. Bovee [Annals of Surgery, Jan., 
1897) narrates a case of this kind in which a ureter had been com- 
pletely severed in the course of a complicated abdominal operation. 
By splicing the cut ends of the tube, not only was the life of the 
patient saved but the permanent continuity of the duct estab- 
lished. For testing such a jDoint as tlie latter, the use of the 
cystoscope can now be relied upon. 

3. Exploration of tlic kidney for stone. 

Hiirry Fenwick, writing on this subject I^Brit. Med. Journ., Oct. 
16, 1897), with special reference to an exposed kidney, observes: 



250 THK YEAU-BOOK OP TRF.ATMENT. 

"To oljviiite opcniii;^' the kidney ;it all when no sloiic is ]nc.si'iit, 
iiiiil to render ■.\n incision on to <a located stone more precise, I liav(; 
lately been workin<,' with the R(jentgen Hays from a 10-in. coil. 
These are thrown upon the exposed kidney (illustrated), and the 
viscus is then examined with a fluoroscope screen. Althouf(li the 
method has marked disadvantages for routine operations, I believe 
it may be of occasional value to those surgeons wlio can command 
the rays in private or hospital practice. I'ersonally I should 
employ them when called upon to deal with a kidney which had 
been negatively exj)lored before." 

3. Koti'o-pei'itoiioal iii'Ctci'o-litliotoiiiy. 

H. B. 'Robinson (Brit. Med. Jourit., Sept. 11, 1897) reports a 
case where, in a woman suffering from hydronephrosis of the i-ight 
kidney due to the impaction of a stone in the lower part of the 
corresponding duct, this operation was successfully performed. 
Catheterisation of the ureters by Howard Kelly's method was first 
practised, and the diagnosis made. Tlie duct was exposed by 
abdominal incision and the stone removed. The latter measured 
1^ in. in length and weighed 97 grains. It was composed mainly of 
oxalates. After the removal of the stone the ureter was stitched 
up by interrupted sutures. A somewhat similar case is reported in 
the "Year-Book" for 1895 as having been practised by Cotterell. 
Both may be regarded as indicating the i:>rogressive work that is 
now being done in connection with the surgery of this small but 
most important duct. 

That an impacted stone in the ureter often escapes detection 
there can be no doubt. Larkin (Liverpool Med. Chir. Jonrn., July, 
1897) states that, in cases of suspected stone in the kidney, but 
where none was found by exploration, he was in the habit of 
turning the kidney out upon the loin and examining the whole 
length of the ureter by passing a probe along it into the bladder. 
On three occasions he had by this means detected a stone in the 
ureter. This is a precaution worth taking. 

4. Operative treatment of exstrophy of the bladder. 
Tietze (Beit, zur klin. Chir., Band xviii.. Heft i. ; and Annals 

of Surgery, Sept., 1897) describes and illustrates his method of 
treating this deformity, which has been practised with some degree 
of success. The operation is divided into three stages, viz. : 
(1) Formation of a bladder, (2) repair of the urethra and penis, 
and (3) closure of the neck of the bladder with the object of 
making a complete urine passage from the bladder downwai'ds. 
The first step consists in providing ample lateral flaps from the 
parietes by which the protruding bladder can be covered over. 
The wall of the bladder itself is then dealt with, and dissected 



DISEASES OF THK GENITO-URINARY SYSTEM. 251 

sufficiently free that it may be brought together as a hollow 
space. In doing so special care must be taken not to injure the 
ureters or the peritoneum. This being done, the inverted edges 
of the viscus are brought together with Lembert sutures of cat- 
gut, arranged if possible in a vertical line so as to preserve the 
natural outline of the organ. The lateral flaps are then united in 
the middle line with silver wire. The second part of the opera- 
tion consists in making a lateral incision on either side of the 
urethral mucous membrane, and thus converting a groove into a 
tube by suturing with catgut over a catheter. The third stage 
completes the proceeding by the closure of the neck of the 
bladder in the interval remaining between the bladder and the 
urethra. This is done by means of two oval incisions and 
sutures. Throughout each stage the bladder is drained by a 
catheter, as any leakage of urine into the surrounding parts is 
liable to be followed by serious consequences. The original paper 
contains illustrations which are almost necessary in following the 
various steps and details of the operation. That this operation, 
when it can be completed in accordance with the author's plan, is 
an improvement on others that have preceded it, there can, I 
think, be no doubt. We have, however, yet to learn liow far the 
bladder, thus so completely covered in and connected with the 
urine passage, permits of retentive control over its contents. The 
difficulty of eflecting this has been experienced in all the plastic 
operations that have hitherto been devised. Though a comfort- 
able watei'-way may thus be provided, and the patient's condition 
to this extent be improved, the formation of an efficient reservoir 
has yet to be attained. 

Recognising the latter difficulty in connection with this de- 
formity, I recently published the particulars of a case {Trans. 
Med. Soc, London, 1897) in which I practised a proceeding from a 
diflerent standpoint. It consisted (1) in the removal of one of 
the kidneys in a boy, aged 15, who was in a most miserable con- 
dition from the state of his abdomen, thighs, and legs, caused by 
the constant trickling of urine over them. Twelve months were 
then allowed to elapse to enable the opposite kidney to hyper- 
trophy. And (2) after this interval of time, the transplantation 
of the inferior opening of the remaining ureter from the bladder 
to the loin. This was successfully done, and the boy was fitted 
with a bag, arranged somewhat like "a bustle," with which the 
urine was collected from the solitary ureter in the loin. I showed 
the patient at the Medical Society of London, and for six months 
whilst he was constantly under our observation he derived great 
comfort from what had been done, and he ceased to be an offensive 



252 TlIF, YKAR-nOOK OF TREATMENT. 

ol)ject. After he left the hcjspital, ami tlie care and hygienic 
attention that the hitter means, he fell into ill health and re- 
turned, to die veiy speedily of surgical septic kidney. There 
were many points in connection with this case of much interest 
relative to the treatment of this class of deformities which space 
will not jiermit nie to refer to here. This method of proceeding 
was suggested to nu; mainly by seeing a patient going about in 
good health where all the urine was collected from a single lumljar 
urinary fistula, with l)ut little inconvenience either to himself or 
others. 

.1. Kesi'ctioii of ^^r<»\vtlis froiii tlio l>i:i<l<l<>r. 

Kuster i^Verlumd. dar dautscli. (Jen. J'iir Citir., XXV. Congre.s.s, 
and Annals of Surgery, May, 18!J7) reports two cases of excision 
of growths from the bladder — a villous polypus, and an endo- 
thelioma — which was successfully practised through a supra-pubic 
opening. In the first case the growth, as it usually does, sur- 
rounded the orifice of the right ureter. The involved portion of 
the latter was removed along with the mucous mendji-ane to 
which the growth was attached. The divided end of the ureter 
was opened up by an incision and fixed by sutures on either side 
to the mucous membrane. The latter also was brought together 
as far as possible by sutures. Cystoscopic examination four days 
later showed perfect healing, with preservation of the newly-made 
ureteral orifice, through which urine could be seen escaping. 
The bladder was left open for some days, and subsequently 
sutured. Cases of this kind illustrate the progress that is being 
made in the direct treatment of certain forms of vesical growth. 
The value of the cystoscope as an instrument of precision both 
before and after operation is well shown in this class of cases. 

6, The operative treatment of eiilarg^ed prostate. 

Erdberg {Petersburg, med. Woch., No. 33, 1897), in reporting 
a successful ease of double vasectomy for urinary trouble arising 
from prostatic obstruction, draws the following conclusions 
relative to vasectomy as compared with castration: — (1) The 
former is a less serious operation, and does not entail confine- 
ment to bed or the use of an ansesthetic ; (2) it is unlikely to 
cause any temporary or permanent mental disturbance, such as 
not unfrequently follows castration ; and (3) it is no barrier to the 
subsequent performance of castration, though the latter is not 
likely to prove successful if resection of the vasa fails. 

Though it is now three years (1894) since I drew atten- 
tion to the subject of this article in a previous volume of the 
"Year-Book," the position of matters is still surrounded with 
so much that is new in the way of experience and interest, 



DISEASES OF THE GENITO-URINARY SYSTEM. 



253 



that it is not necessary to offer an apology for again r(iferring 
to it. 

The conclusions arrived at by Erdberg in preferring vasectomy 
to castration accord so entirely not only with' my own experience, 
but with that of many others who have had some practical 
experience of these operations, that I have no hesitation in 
endorsing them. There can be no doubt that the operation of 
castration, however performed, is not only a serious and depressing 
mutilation, but one that is attended with considerable risk to 
life and mental activity, to say nothing of its liability to 
failure. On the other hand, the risks to which I have just 
i-eferred in connection with vasectomy are undoubtedly consider- 
ably less, whilst the beneficial results obtainable are in no sense 
less than in the case of castration. There are, however, a few 
points upon which I laid stress in my Bradshaw Lecture at the 
College of Surgeons {Lancet, December 12, 1896), to which I 
should here like to refer. In the first place, it must be noticed that 
in bringing about prostatic atrophy, or inactivity, by section of the 
vasa it is through the medium of a double process, or rather by 
the induction of an atrophy by an atrophy. The testicles may 
then be seen to atrophy just as completely as if they had been 
removed ; when this has taken place the prostate usually shares 
in the change. Hence, the effects of vasectomy upon the prostate 
are longer delayed and more gradual than when the testes are 
abruptly removed. The process varies much in its duration ; 
though it commences from the time of operation, it may not be 
completed for twelve months, or even more. This is not very 
remarkable when we consider the years the prostate has taken to 
enlarge, and obstruct. In the second place, I would urge that the 
vasa be resected on two different occasions, with an interval of 
certainly not less than a week between the two operations. I 
have never seen any harm, either mental or physical, follow, when 
this rule has been attended to. On the other hand, simultaneous 
resection of the vasa is not free from danger on both of these 
grounds. The process of atrophy-induction, to be safe, must be 
gradual, and this cannot be said to be so in the case of simul- 
taneous double vasectomy or castration. The future of vasectomy 
largely depends not only upon a careful selection of cases, but 
also upon the mode in which the atrophic process is induced. 
Amongst other articles on this subject which have recently 
appeared, I would draw attention to a very able one by Freemantle 
{Guy's Hospital Gazette, 1897), where the pros and cons of this 
exti'emely important question are carefully discussed and illus- 
trated by cases. 



254 TIIK YKAK-BOOK OF TKKATMKNT. 

7. Ciiroiii*- <-4»iitr:i<*ti4»ii of |»rost:tti4- fibres cn- 
cii'4'liii;; IIk' V4'si4-:il ii<M-k, :iii4l its tr4>:iliii4'iit. 

E. F\x\leT [Aiiierican Joiirn. 0/ Med. Sciences, October, 1897) 
writes of this condition as one of spastic muscular contraction, 
which is often attended with very painful symptoms coimected 
with the function of micturition. 

The article is worthy of careful study in connection with the 
clinical aspect of many chronic spasmodic affections of the urinary 
organs. Civiale referred to some of these states under the title of 
" Contracture du Col Vesical." With regard to the treatment, it 
is observed: "The only remedy for chronic contraction of the 
prostatic fibres encircling the neck of the bladder, which in my 
experience has shown any favourable results, consists in thoroughly 
rupturing, or in cutting through, them. This can be accomplished 
by means of the finger or the knife, as the case may l)e, intro- 
duced through a perineal incision. Vesical drainage should be 
practised after the operation. Treatment such as this has been 
followed by complete disappearance of all suljjectival symptoms." 

The spasmodic grip these fibres are capal:)le of exercising can 
be fully appreciated only in some of those cases where it has been 
necessary to adopt the practice here recommended through a 
median opening in the perineum. The succeiss of the treatment 
by drainage is no doubt another illustration of the advantages 
connected with securing for the part that physiological rest which 
Hilton contended for in connection with many painful affections. 

§. The treatment of some iiifectioiis commuiiie- 
sible between the testes and prostate by occlusion 
of the vas deferens. 

Reginald Harrison (^Tri-State Medical Journ., U.S.A., May, 
1897) draws attention to certain affections where these ducts are 
the mediums for the transference of the bacilli and micro-organisms 
of certain well recognised diseases, both in upward and downward 
directions. Urinary tuberculosis commonly commences either 
in the testis or epididymis, and then invades the urinary appa- 
ratus above by the migration of the bacilli along these canals. 
In the same way, inflammatory products from the bladder and 
prostate descend and produce orchitis and epididymitis. He 
illustrates the ascent and descent of these diseases and the 
practice he suggests by the following two cases : — (1) Three years 
ago, and shortly after I had published an article {Brit. Med. Joiorn., 
Sept. 23, 1893) on division of the vas deferens, relative to 
prostatic hypertrophy, I saw a delicate-looking man with a strong 
tuberculous family history, with a nodule in his left testicle re- 
mainins: after an acute gonorrhoja. This nodule was deemed to be 



DISEASKS OF THE GENITOURINARY SYSTEM. 255 

tuberculous, or likely to become so. The question then raised had 
reference more especially to the removal of this by operation, on 
the ground of its suspicious nature. The urine was healthy, and 
so was the opposite testicle and its tubes ; nor was I able to 
discern any evidence of deposit, so far as the fingers could reach, 
either in the vas or the prostate. The patient, who had had some 
medical education, was anxious that either the nodule or the 
testicle should be removed. I did not feel disposed to recommend 
either course. Having regard to the fact that the disease ap- 
peared limited to the nodule, and tliat any infection would 
probably pass along the canal of the vas deferens, I proposed to 
excise a portion of the latter. This Avas done, and the wound 
healed in a few days. A year afterwards it was found that the 
testis and nodule had both completely atrophied. The opposite 
testicle had enlarged as a consequence of this, and no sign of 
tuberculous infection could be detected. The patient's health and 
sexual powers were unimpaired. (2) Early last year (1896) I 
saw a gentleman approaching seventy years of age, otherwise in 
good health, who, in addition to much prostatitis, repeatedly 
suffered from most painful orchitis in one or both organs, though 
sexual power had ceased for some years. He was dependent on 
the catheter, and these attacks had been going on for some months, 
almost entirely confining him to bed and preventing him attending 
to his business. I divided his vasa for him, with great relief so 
far as his prostatic symptoms generally were concerned. Since 
this was done, he has had no further trouble with his testicles; and 
this is the point I wish here more particularly to illustrate. I 
have tried various methods for resecting the vasa. The simplest 
appears to consist in rendering the vas superficial by manipulation 
and making a small incision over it. It can then be easily seized 
with a Spencer Wells's clamp forceps and brought to the surface, 
where it is cleaned by a little dissection and a blunt hook or 
aneurysm needle passed beneath it. A loop is included by a silk 
ligature, and the free portion removed by scissors. To ligature the 
duct is insufiicient, it being necessary to resect a portion of it. 
After the loop has thus been removed, the stump is returned with 
the ligature cut short, and the little wound is then closed with a 
suture or collodion. Union usually takes place in the course of a 
day or two. In this way the operation can be performed 
quickly, almost bloodlessly, and under the influence of a 
hypodermic injection of cocaine, no general anesthetic being 
required. 

9. The stei-iiisatioii of urine by pyoktaniii. 

R. A. Stirling [Australasian Med. Gaz., Sept., 1897) narrates a 



20G TIIK YEAU-JIOOK OF TltlCAIMKNT. 

case when; exti'avaKation of uiiiu!, consoqucnt on a vircthral 
stricture, was not followed by the serious and painful effects on 
the parts which usually follow this occurrence. For three days 
previous to this the patient had been taking 3 {grains of 
pyoktaniu three times a day as an urinary antisej)tic. The oper- 
ator, in performing perineal section, was surprised to find, though 
the extravasation was extreme, how comparatively little the part 
had sutl'ered. He observes, " Pyoktanin is said to be one of the 
most powerful of antiseptics ; and as the patient's urine had been 
completely sterilised by it for thr(!e or four days before the 
rupture, there can be little douljt that tliis accidental urinary 
asepsis explains the painlessness of so serious a condition, and the 
subsequent easy recovery." 

Though recognising the influence that various agents have 
in exercising a conti'olling power of this kind upon tlie urine, and 
the sufficiency of the explanation that is here offered, it is 
interesting to observe that urine which is deficient in urea when 
it becomes extravasated, as I have elsewhere illustrated (" Dis- 
orders of the Urinary Organs," 3rd ed., p. 46), also fails to be 
destructive to the tissues by reason of the absence of the source 
from which the ammonia is evolved. In the instance I refer to, 
the patient was suffering from Bright's disease. Stirling's case is 
sufficient to render a further trial of pyoktanin as a urine 
steriliser desirable in view of such contingencies as urinary ex- 
travasation. It is referred to by Martindale as having a slight 
antiseptic power, but I have had no exjDerience in its use. 

The sterilisation of the urine by drugs and other means 
administered by the mouth has now become a most important 
branch of therapeutics, in connection more particularly with 
certain purulent affections, and other conditions likely to become 
so, of the urinary organs. Any further additions to such 
sterilising agencies as quinme, borate of magnesia, boracic acid, 
salicylate and benzoate of soda, sandal, and others that might be 
mentioned, will be welcome. 

lO. A iie\v orig:iii of tiretliral fistula. 

Trekaki and Von Erchstorfif [Annal. des Mai. des Org. Gen.-Urin., 
1896, and Journ. of Gen.-Urin. Diseases, New York, Jan., 1897) 
make an interesting contribution to tlie study of the bilhai'zia 
hsematobia as a cause of urethral fistula, detailing the histories 
of seven cases. The fact has already been observed by Harrison 
("Lectures on Diseases of the Urinary Organs," 4th ed., 1893) and 
by Belleli l^Gaz. d. Ospitali, 1896) that this worm or its ova may give 
rise to the trouble. Unlike fistula consequent upon gonorrhoea or 
traumatism, these are, strictly speaking, not accompanied by 



DISEASES OP THE GENITO-URINARY SYSTEM. 257 

stricture. Tliese fistultv can be cured only by median perineal 
cystotomy and the introduction of a bladder di-ainage tube. The 
indurated tissues are at the same time opened up and scraped. 
The wound closes in from six weeks to several months. ] am 
indebted to Dr. Mackie, of Alexandria, for several pathological 
specimens illustrative of this form of fistula. 

11. A g^iant litliotrite. 

Keegan describes and figures (^Lancet, July, 3rd, 1897) an 
instrument for crushing stone in the bladder, which he thus 
designates. 

It is intended for use, as the author states, through a lateral or 
median perineal cystotomy wound, and it will readily break up a 
hard calculus weighing between six and eight ounces. It is, in fact, 
an instrument for use in connection with the revived operation 
of perineal lithotrity, as I have described in a former " Year-Book " 
(1893). In most cases of this 0[)eration, it will probably be found 
that crushing forceps will break and evacuate the stone quicker 
and more conveniently than any form of litliotrite. This, at all 
events, is my experience in connection with some very large and 
hard stones which have been successfully dealt with in this way. 
I entirely agree with Keegan in his concluding paragraph: "I 
feel confident that the mortality which has hitherto followed 
suprapubic lithotomy in dealing Avitii very large calculi occurring 
among men at the middle and advanced periods of life will be 
greatly diminished by carrying out a perineal lithotrity in such 
cases." - 

When we consider the extremely small mortality that now 
follows crushing operations for stone, no pains should be spared 
in keeping all calculi within this category by detecting them when 
they are in their initial state in the bladder. 



DISEASES OF THE RECTUM. 

By Alfrei) CoorEU, F.R.C.S., 

Senior Surgeon, St. Mark's Iloxpitul. 



I. Tlio troatniciit of liaMiioniioids. 

With one or two exceptions, no novel method of treating this 
common compkiint has recently been suggested, though contril)U- 
tions on the subject to various medical journals have been some- 
what frequent. For the radical cure of internal ha?morrhoids 
opinions are divided between the ligature and the clamp with its 
various modifications. Very good results are obtained from both 
forms of operation ; at St. Mark's Hospital it is rarely found 
desirable to adopt any other method than the application of the 
ligature. On the other hand, as will appear in the following 
summary, the use of the clamp is regarded with more favour in 
the United States. 

In Matliews' Med. Quarterly, July, 1896, p. 220, W. V. Laws, 
of Louisville, Ky., after discussing the palliative treatment of 
internal li;vmorrhoids, recommends the clamj) and excision method, 
as devised by S. T. Earle, of Baltimore. Each h;emorrhoid is drawn 
out with a catch-forceps and the clamp applied near to its base, 
and closed as tightly as possible. The pile is then cut off'; the 
suturing is begun at the distal end of the clamp, and is continued 
over and under the latter till the whole of the cut surface is 
included, but is not drawn tight. Then the clamp is loosened 
and withdrawn from between the suture, the ends of which are 
drawn sufficiently tight to bring the cut edges into apposition 
and to check bfemorrhage. The two ends are made fast by a knot 
in each, close to the mucous surface. The clamp is generally 
applied parallel to the long axis of the rectum, but it may be used 
in the opposite direction. Further details of this method are to 
be found in the "Year-Book of Treatment," 1897, p. 268. 

Another form of suture-clamp has been devised by W. Erwin, 
of Walter's Park, Pa. (^Mathews' Quarterly Journ., April, 1897, 
p. 184). It consists of two arms bent at a right angle at the lower 
end ; this bent portion, which is about an inch and a half long, is 
provided with a shoulder about a quarter of an inch high, and 



DISEASES OF THE RECTUM. 259 

perforated by five small opeuing.s ; tlu s'.iafts above the angle are 
pivoted and serrated to receive a ring which regulates compression 
and bleeding. After the usual preparation of the patient and 
dilatation of the sphincter, the pile is seized by the forceps and 
well drawn down : the champ is then applied as near the base of 
tlie hi>?morrhoid as possible, and the ring passed along the serra- 
tions until there is a sufficient amount of compression to control 
hsemorrhage. With a needle threaded with silk or catgut the 
pile is pierced through the needle-holes of the clamp. When the 
sutures are placed the pile is cut off with either knife or 'scissors, 
the sutures tied, and the clamp removed. The sutures are removed 
on the fifth or sixth day, when the wound is nearlj' healed. 
Should the stumps remain large, a weak solution of alum or tannic 
acid should be applied. 

In the same journal, p. 183, R. T. Morris, of Nesv York, 
advocates two methods of operating on internal haemorrhoids : 
(1) Ligation and excision, or (2) excision of piles and suture of the 
incisions. With regard to other methods, he objects to White- 
head's operation because it removes the special rectal sense 
apparatus, the pecten dentations and papillae. Moreover, if 
primary union be missed, contraction of the scar may cause grave 
complications. Injections he regards as dangerous, because of 
the possibility of septic infection. Slowness of healing after the 
clamp and cautery is the main drawback to that method. 

In Mafhe?cs' Quart. Journ., July, 181)6, p. 22.5, H. R. Coston, 
of Tennessee, discusses three methods of curing internal hemor- 
rhoids — viz. by injection, by ligature, and by clamp and cautery. 
He thinks the first should be used only in cases in which the 
patient refuses to submit to more thorough methods. In his 
experience ulceration and abscess are very prone to follow, 
and relapse is almost sure to occur. The treatment is unreliable, 
and attended with pain and danger ; it is the ideal operation 
of advertising charlatans and should receive no encouragement 
from the profession. 

The operation by ligature is performed by Coston in the usual 
way ; but he places the patient in the " extreme lithotomy 
position." 

The same position is adopted for the clamp and cautery 
operation. Each tumour is caught with the tenaculum forceps, 
and an incision is made with the scissors at the junction of the 
skin and mucous membrane ; the clamp is applied across the 
tumour, with the lower blade in the incision, and screwed down 
tightly. The top of the tumour is then cut off, leaving about 
one-fourth of an inch of stump above the blades ; the cautery is 
r2 



260 THE YEAR-HOOK OF TREATMENT. 

applied at a dull red heat, and the stump is Ijiirnt well down 
to the clamp : tlicn the latter is unscrewed and removed, care 
being taken that the eschar is not detached ; the stump is 
followed through the blades with the cautery. Small tiniionis 
may be simply burnt away with the cautery. If too large to 
be grasped by the clamp, the tumours should be split into 
parts, in line with the bowel, with the scissors, and each part 
treated separately. The risk of subsequent contraction may be 
avoided by not interfering with the healthy mucous mendn-ane 
between the piles. The stumps are to be replaced within the 
bowel. The patient may be up from the third day, l)ut should 
keep his room for a week. 

Coston prefers the clamp and cautery operation to all others, 
and for the following reasons: (1) The nerve ends are cut away 
and cauterised, and rapidly become cicatrised ; with the ligature 
the nerves are tied np, and more or less pain continues until 
the stumps slough. (2) There is no danger of secondary 
haemorrhage after the clamp and cautery. If luiemorrhage 
occurs, it does so immediately. (3) There is no danger of 
recurrence. (4) Convalescence is much more quickly completed ; 
for it begins at once under the eschar produced by the cautery, 
and would be completed by the time the ligatures come away 
should the two operations be used on separate tumours in the 
same case at the same time. (5) The mortality is practically 
nil. (6) The cautery method requires less care from the surgeon 
after the operation ; and (7) There are no unpleasant sequela^. 

Coston has evidently been very successful with tlie clamj? and 
cautery ; he seems to be unaware of the fact that several deaths 
froui hajmorrhage have taken place after this operation. 

The preference given in the United States to the clamp and 
cautery operation is shown by an analysis of 700 cases of 
hsemorrhoids treated during the last eight years in the IMount 
Sinai Hospital, N.Y. (Canadian Practitioner, December, 1896, 
p. 872). F. L. Vaux states that 500 operations were performed 
by the clamp and cautery; about 125 by ligature, and some 75 
by Whitehead's method. The following is the procedure 
generally adopted at the hospital : Ice-bags if piles are strangu- 
lated, or an antiseptic solution if only burning and smarting are 
present. Compound liquorice powder and copious enema for 
cleansing the bowel preparatory to operation, and a small enema 
just before. Shaving of the perineum and thorough cleansing 
with soap and water ; followed by ether and solution of the 
perchloride, after anaesthesia and dilatation of the sphincter. 
A good-sized sponge with a string attached, is wrung out of 



DISEASES OF THE RECTUM. 



261 



perchloride solution and introduced high into the i-ectum; any 
internal ha?niorrhoids are made to protrude by making traction 
on the sponge. 

The technique of the operation may he thus summarised : — 

1. Ap])ly the clamp in the long axis of the hannorrhoid, so 
that the scar may lie a radiating one, and thus avoid any chance 
of cicatricial stenosis. 

2. Dip the distal end of the clamp well down, so as to include 
the mucous membrane of the hjemorrhoid in its entire length, 
though only clamping off about one-third of its substance. Be 
sure that no skin is included, otherwise the subsequent oedema 
will be very great and the time of recovery lengthened. 

3. Sear the hfemorrhoid slowly from above downward, layer 
by layer, the cautery being only at a dull red heat. By observ- 
ing tliese precautions, subsequent hfemorrhage may be avoided. 

i. Insert a tampon cannula, which should remain until the 
bowels are opened. This cannula is made from a piece of hiilf- 
inch rubber tubing, sterilised, and having around it several layers 
of iodoform gauze. It is then anointed with sterilised vaseline, 
and inserted into the rectum after the operation. It allows the 
escape of secretions and flatus, and the first enemata may be 
given through it without causing much pain. 

Opiates are given to relieve the pain after the anaesthesia 
wears off. On the morning of the third day half an ounce of 
sulphate of magnesium is given and followed two hours after- 
wards by an oil enema f^hrough the tampon cannida. The 
magnesia is repeated on each successive morning, and l)y the 
eighth day the patient is ready to leave. No dressing is used 
save a piece of iodoform gauze and a T-bandage. 

Several advantages are claimed for the clamp and cautery 
method. It is antiseptic ; not only can the clamp be readily 
sterilised but the cautery itself is the most powei-ful germicide. 
There are no sloughs to separate, as in the ligature operation. 
No ligatures or sutures ofi'er any chance for infection. The 
operation is rapidly performed, and the cure is complete. Eight 
days suffice for convalescence. The record of hjemorrhage, 
pyaemia, or death is almost negative. Among the 500 cases 
referred to there has not been a single death. Thei*e were a 
few slight hajmorrhages, and one case of pyamiia, from which the 
])ati»;'nt recovered. Whitehead's method, formerly in vogue to a 
much greater extent, is now reserved for those cases in which tlie 
mucous membrane is involved too high up to be reached by the 
claipp, and for others in which previous operations have left a 
raw, ulcerated surface. 



262 TIIK YEAR-BOOK OF TREATMENT. 

2. Atony oT tlic rcctiiiii. 

W. Bodenhainer, of: New Roclielle, N.Y. (iT. V. Med. Journ., 
Juno 19, 1897, p. 831) comleiims the ])ractice of using warm or 
li(jt water injections for tlie purpose of securing a daily evacua- 
tion. If it ))(• necessary to use enemata for tliis purpose, cold 
water should be employed with the view to increase the tonicity 
of the muscular fibres of the rectum. But even, cold water 
injections, used daily for a lengthened period, may cause atony 
by unduly dilating the lower bowel. They are, however, very 
useful when properly employed ; but should Ije discontinued as 
soon as the object of their use has been attained. In specially 
obstinate cases powerful astringents should be employed as 
rectal injections, with nu.v vomica internally, either alone or 
combined with other drugs. The injections should not exceed in 
measure 5 or 6 ounces, and before their administration the rectum 
should be emptied o£ f cecal contents by a simple enema or an 
aperient. The astringent injection is to be_used once daily, and 
retained for a few minutes, if possible. Bodenhamer uses decoc- 
tion of galls, and also a strong decoction of white oak bark with 
alum. Internally, Extract. Aloes, gr. xxx. ; Extract. Nuc. Vom., 
gr. XX.: Extract, Hyoscyam., gr. xv. ; Ferri Sulph., gr. x. ; 
01. Caryophylli, gutt. v. Fiat massa in pil. xxx. dividenda. For 
atony of the anal sphincters, the cold ascending douche is the 
most valuable remedy. It should be ap|)lied to the anus for 
four or five minutes immediately after each action of the bowels, 
and once or twice besides during the twenty-four hours. 
Galvanism sliould also be employed, and nux vomica given 
internally. 

3. The ti'eatiiiciit of priiriliis aiii. 

E. Abrahams, Physician to the Mount Sinai Hospital, New 
York, states (Journ. of the American Med. Association., Jan. 30, 
1897, p. 212) that in the treatment of this distressing ailment 
there is nothing better or more effective than the vigorous appli- 
cation of a strong solution of nitrate of silver. The cause should 
always be sought for and, if possible, removed ; liut if tlie 
pruritus still continue, the application will seldom fail to aHbrd 
relief. The strength of the solution should be from 30 to 50 per 
cent., according to the severity of the itching. In apparently 
idiopathic cases the nitrate of silver proves to be a \'eritable 
specitic. Even if there be a palpable cause, the a[)plication will 
ensure rest at niglit and ease by day while the cause is being 
^removed. It should be applied once or tAvice a week, zinc 
bintment, either plain or mixed with 1 per cent, of cocaine, being 
used in the intervals. Before painting the anal region with the 



DISEASES OF THE RECTUM. 263 

solution, it is generally well to apply cocaine, in order to mitigate 
the burning sensation. 

A weaker solution than that recommended above often acts 
satisfactorily, and spirit of nitrous ether is a good solvent; gr. x-xx. 
to 5J. may be painted over the part with a camel-hair brush. 

The application of a 2 per cent, solution of nitrate of silver is 
recommended by Schmey for hannorrlioids and anal fissures (New 
York Med. Record, June 5, 1897, p. 828). Daily brushing with 
this solution is said to obviate the necessity for an operation. In 
a case of coccygodynia, refractory to other treatment, the solution 
was applied with great success to piles, from which the patient 
suifei"ed ; after eight applications the coccygodynia had also dis- 
apipeared. In a case of fissure of the anus, accompanying haemor- 
rhoids and preventing sleep by reason of pain, the same solution 
etiected a cui'e. 

Nitrate of silver thus applied would doubtless cure slight 
cutaneous excoriations and cracks ; but for true anal fissures 
caustic applications are useless and mischievous. 

Tlie application of collodion to pruritus ani and piles has 
been found useful by D. W. Samways [Brit. Med. Journ., vol. ii., 
189G, p. 1502). He states that after a few moments of somewhat 
intense smarting (which can be prevented by cocaine if necessary) 
no further itching is felt ordinarily for twelve or twenty-four 
hours, if at all. It may be supposed that the ether and alcohol 
in which the pyroxylin is dissolved stop the irritation, and the 
collodion film, by protecting from the air, prevents its recvirrence. 
When applied to external piles, he has observed that collodion 
stimulates contraction of the swelling ; that the hardening film 
supports the pile thus contracted, and that the contracting col- 
lodion further reduces it. The collodion is best applied by 
dropping it on a few fibres of cotton wool, which are spread over 
the pile each morning after deftecation. 

Among other papers on the treatment of Diseases of the 
Rectum, recently published but not coming under the ordinary 
scope of the "Year-Book," may be mentioned: Kraske, " Erfahrun- 
gen liber den Mastdarmki-ebs," being Nr. 183/84: of t\\Q Sammhmg 
klin. Vortr., 1897 ; an article by E. H. Taylor, of Dublin, Annals 
of Surgery, April, 1897, p. 385, on the "Operative Treatment 
of Cancer of the Rectum " ; papers by Swinford Edwards on 
" Removal of high-lying Cancer of the Rectum by Kra.ske's 
Method," Brit. Med. Journ., vol. i., 1897, p. 1210; by F. T. Paul, 
on " Excision of the Rectum," Bi-it. Med. Journ., vol. i., 1897, 
p. 856 ; and by H. Littlewood, " The Operative Treatment of 
MaligUcint Disease of the Rectum," Lancet, vol. ii., 1896, p. 745. 



VENEREAL DISEASES. 

Bv J. EuNEST Lank, F.li.C.S., 

Suryiioii tn Out-l'al inits ami Ijeclnrcr on Anntonfj, St. Mar'j':i Uospita' ; 
Surjcon to the London Lock llosjiitaL 



1. The tiM>atiii<>nt of sypliilis. 

At the Thirteeiitli International Congress of Medicine [Ann. 
de Derm, et de Sypli., Aug.-Sejtt, 1897) held at Moscow in August, 
1897, a discussion took place on the treatment of syphilis, and 
attempts were made to solve the following questions : When 
should the mercurial treatment of syphilis be commenced '] For 
how long should the treatment be continued ] Should one treat 
the disease onl}^ during the presence of symptoms, or should one 
have recourse to continuous treatment, with a view to preventing 
its subsequent manifestations % 

Schwimmer, of Buda-Pesth, advocated prolonged anti-syphilitic 
treatment in sufficient doses, and commenced directly the diagnosis 
of syphilis was made. 

Watrazewski, of Warsaw, was opposed to the preventive treat- 
ment on account of the possible supervention of mercurial anaemia, 
chronic mercurialism, and the too energetic action of the drug 
when introduced into subjects as yet unaccustomed to its action. 

JuUien, of Paris, said that the general consensus of opinion as 
expressed at every congress held within the past tliirty years 
inclined to early and energetic treatment ; to combat a general 
blood disease it was necessary to apply the specific treatment at 
the earliest possible date. His experience, based upon a systematic 
application of the method for some time past, led him to believe 
that injections of calomel formed the most efficient antidote to the 
disease. The cutaneous manifestations were suppressed by this 
treatment in a large majority of cases, or were so completely 
modified that were it not for the presence of the glandular 
enlargements the diagnosis might be open to doubt. He was 
unable to lay down precisely the length of time required for the 
treatment ; he considered that it should, at any i-ate, last foi- a 
year, and in many cases he luul continued it for two years or 



VENEREAL DISEASES. 



265 



more ; at the present time lie was unable to say if patients so 
treated were liable to subsequent tertiary manifestations ; he 
could, however, state that he had not yet met with any such 
cases. 

Barthelemy, of Paris, laid stress upon the two following points: 
to give mercury as soon as the diagnosis of syphilis was certain ; 
to abstain from all an ti- syphilitic treatment if there was any 
doubt as to the nature of the disease. It was necessary to treat 
the sy[)hilides, and not the syphilis, to combat the diathesis from 
the earliest possible date ; the most energetic method of treatment 
was by injections of the insoluble salts of mercury once a week ; a 
course which was to be continued for eight months in the first 
year of infection, for six months during the second, for thi-ee 
months during the third ; then should follow a year without 
treatment, and then for two months during each of tlie three 
following years the treatment should be resumed. 

Caspary^ of Konigsberg, said that the treatment of syphilis 
ought to be commenced on the appearance of unmistakable mani- 
festations on the skin or mucous membranes. The induration 
of the chancre and the indolent enlargement of the neighbouring 
lymphatic glands were probable, but were not certain indications 
of syphilis. Treatment should, during the first course, be energetic 
and should be continued for some weeks after the disappearance of 
all symptoms ; inunctions and injections were preferable to internal 
ti'eatment, but should be interrupted directly the patient's general 
health showed signs of enfeeblement. The succeeding courses will 
be more etficacious if given immediately on the appearance of any 
subsequent manifestation. 

Rosolimos, of Athens, stated that in all the cases of tertiary 
syphilis he had met with he had found that the previous anti- 
syphilitic treatment had been inadequate, or even 7iil. He 
advocated the continuance of treatment, with intermissions, for 
four or five years, even in the absence of all syphilitic manifesta- 
tions. 

A discussion on the same subject took place at the meeting 
of the British Medical Association at Montreal [Joiirn. of Cut. and 
Gen. Ur. Dis., Oct., 1897). 

Whitla, in opening the debate, laid stress on the following 
points:— (1) The action of mercury and of the iodides on the 
disease ; (2) The time when mercurial treatment should be com- 
menced ; (o) What method of administration should be adopted? 
(i) The treatment of tertiary and congenital syphilis. He recom- 
mended that mercurial treatment should 1*0 commenced as soon as 
the diai^rnosis was made, axad considered that inunction was the 



2GG THE YEAH-BOOK OF TREATMENT. 

most viseful metliod of administration. He began liis treatment 
by a course of Plunimer's pills, and continued with Pulv. Ifyd. c. 
Cret. in grain doses six or .seven times daily. He pushed the 
iodides in the tei'tiary stage, and prescribe-d them also in cases of 
pyrexia occurring early in the s(!Condary stage. 

Nevins Hyde had no opinion of the iodides, but considered that 
the constitution of the patient was a most important factor as 
regards the success or failure of treatment. 

Malcolm Morris laid stress on the antagonism between alcoliol 
and syphilis ; he connnenced mercurial treatment at once, and 
preferred inunction to other methods. 

C. W. Allen emphasised the point that it was the individual who 
had to be treated more than the disease. While inunction was 
in the majority of cases to be preferred, yet the injection of the 
soluble salts gave excellent results. He advocated immediate 
treatment, in opposition to the majority of his brethren in the 
United States, who })referred to wait until the diagnosis was con- 
firmed by the appearance of secondary sym^stoms. 

Bulkley believed that iodides removed the lesions, whilst 
mercury attacked the vital element upon which the lesion de- 
])ended for its existence. Whitla, in conclusion, confessed that he 
often eased ofT the continuous treatment, to permit evidences of 
the disease to appear, and to convince him that there had been 
no mistake in diagnosis. 

The general consensus of opinion was that mercury in some 
form should be given directly the diagnosis was made, but little 
stress was laid on the fact that in many cases the diagnosis was 
uncertain, and could only be deternnned by the appearance of the 
eruption. Caspary pointed out that induration of a sore accom- 
panied by enlargemei^t of the inguinal glands was not of necessity 
an indication of syphilis. Jullien in some of his cases appears to 
have been in some doubt, and depended for a diagnosis upon the 
glandular enlargements, and Whitla states that in some cases he 
has had to relax the mercurial regime, so as to allow some 
further manifestation of the disease to develop, and so to establish 
his diagnosis. 

*2. Iiitriiveiioiis iiijoctioii^ of itBori'iirinl salts iii 
sypliiiis. 

At a meeting of the 8oc. Franc;, de Derm, et de Syi)h., hehl in 
April, 1897 {Ann. de Derm, et de Syp]t., May, 1897), Abadie stated 
that since his last communication on this sul)ject {^vide " Year- 
Book of Treatment," 189G, p. 1^77) he had seldom employed any 
other mode of treatment. Among the principal advantages of 
these injections was the absence of pain and of subcutaneous 



VENEREAL DISEASES. 267 

nodosities. After the use of intramuscular injections of insoluble 
salts, such as calomel, and even with the soluble preparations, 
there was always considerable pain and subcutaneous thickening 
resulting therefrom. 

If ordinary antiseptic precautions were used, there was abso- 
lutely no danger from intravenous injections ; the only serious 
objection to them was the ditHculty in some instances of finding 
the veins, a ditficulty which could usually be overcome by cai-e 
cUid practice. Even if the vein was missed, the only result was a 
subcutaneous thickening which was absorbed in a few days. He 
introduced the injections every other day, using a Pravaz syringe 
full of a 1 per cent, solution of cyanide of mercury on each occasion. 
In certain grave ocular manifestations, such as parenchymatous 
keratitis and malignant irido-choroiditis, this dosage was not 
sufficient, and the injections should then be given daily ; this 
quantity was well borne, and was followed by no symptoms of 
mercurial intoxication. In the treatment of lesions of delicate 
organs, such as the eye and nervous system, not only was it 
necessary to effect a cure of the patient, but to bring about that 
result as speedily as possible. He brought forward two cases of 
syphilitic irido-choroiditis in patients o^'er sixty years of age : in 
the one case the veins were so ill developed that intravenous 
injections coidd not be carried out, and consequently recourse 
was had to intramuscular injections of calomel ; these, however, 
were not well tolerated, and he could not prevent destruction of 
the retina and loss of vision ; in the second case, which was an 
exactly parallel one, intravenous injections were given daily, the 
result being complete recovery with perfect vision. 

The writer of this article has adopted this form of treatment 
as a routine in hospital cases with the most satisfactory re- 
sults. 

3. The treatment of ^ypliilitie cliaiicre in it$ eoni- 
plieations. 

In a lecture on this subject delivered at the Hospital St. Louis 
{La Presse Medicale, July 7, 1897) Professor Fournier commenced by 
discussing the merits of the abortive plan of treatment, and con- 
demned it except in a small minority of cases, in which the 
chancre was situated either on a too lengthy prepuce, or on an 
exuberant labium minus ; in such cases the patient could l)e re- 
lieved of the chancre and of the deformity at the same time. It 
might be laid down that the excision of a well-developed cliancre 
was a perfectly futile measure, whilst it was very doubtful 
whether the excision of a chancre of four days' duration would 
in any way modify the subsequent course of the disease ; in the 



268 THE YEAR-BOOK OF TREATMENT. 

majority of cases the abortive treatment had failed ; indeed, in 
the Paris hospitals it had never yot succeeded. 

The syphilitic chancre was a lesion which tended to heal 
.spontaneously; nevertheless, one should endeavour to fui-ther the 
healini,' process by hygienic measures, and by certain necessary 
precautions. In the first j^lace, it was necessary to j)rescribe con- 
tinence, for to a large number of patients — specially female ones 
— the lesion appeared to be so trivial as to preclude the possibility 
of contagion therefrom ; secondly, to forbid all forms of stimu- 
lants which might injuriously react upon the chancre, and, finally, 
to recommend abstention from violent exercise and fatigue. 
Locally, the application of tepid water was recommended, either 
by means of general baths, or by ablutions of the chancre itself. 
Ointments were preferable to lotions, as they could be easily 
cliangetl, and had no tendency to adhere to the sore ; calomel, 
oxide of zinc, and subnitrate of l)isniuth being specially indicated. 
Any irritant, such as alum or sulphate of copj^er, was to be a\oided, 
wliile the em})loyment of iodoform was absolutely useless, and to 
n)ost patients insupportable on account of its smell. Nitrate of 
silver was rarely indicated, but might be utilised if the appear- 
ance of the chancre remained persistently unhealthy, or if during 
the later stages of cicatrisation the granulations were exuberant. 
In many instances the induration left after the healing of the 
chancre was a source of anxiety to the patient owing to the 
deformity resulting therefrom, and the surgeon was frequently 
importuned for treatment to remove this. As this thickening 
tended to disappear spontaneously, no surgical interference was 
justifiable, and any attempt at removal or scarification would be 
followed by further induration of the cicatrix. Their resolution 
might be hastened by mercury and iodide of potassium in con- 
junction, and locally by frequent ablution and application of 
non-initant ointments. In addition to the general principles of 
treatment, Fournier alluded to the special treatment required for 
chancres situated in unusual localities. Chancres of the meatus 
and of the urethra were difficult to treat owing to their inaccessi- 
bility, and owing to their being so frequently irritated by the 
passage of urine over them, which frequently gave rise to 
sloughing, and even to phaged?ena : scrupulous cleanliness and 
bathing after each act of micturition, dressing with cotton wool, 
and the avoidance of all sources of irritation, were the means 
specially recommended. These lesions might be followed by 
stricture of the meatus, which might be overcome by dilatation, 
or might possibly require incision. Chancres of the cervix uteri 
required but little treatment, but their cicatrisation might be 



VENEREAL DISEASES. 269 

hastened by mild antiseptic injections, and by applications of 
nitrate of silver or tincture of iodine. 

The principal complications of the syphilitic chancre, inflam- 
mation, gangrene, and phagediena, were closely allied to one 
another and sliould be treated on the same lines, mainly by 
scrupulous cleanliness, and by the removal of any cause for 
irritation. Should phimosis ensue, careful subpreputial injections 
should be practised, and should balano-posthitis supervene, with 
retention of its secretion beneath the prepuce and with threatening 
gangrene, free longitudinal incision of the prepuce was called for, 
while cases of paraphimosis, in which the chancre appeared to be 
affected by the constriction, should also be freely incised. 

Should the case go on to gangrene or phageda^na, the most 
powerful remedial agent consisted in batlis lasting for three 
hours at a temperature of 9-5° F., and repeated daily. The most 
efficient local application in these conditions was iodoform 
powdered freely over the atiected surface. 

4. Tlie treafinoiit of syphilis by iiiti-aiiiiis<iilar 
iiijectioiis of salicylate of mercury. 

Hallopeau and Bureau (^Journ. des Mai. Cut. et Sy])h., April, 
1897) employ as an injection 4 parts of salicylate of mercury to 
30 parts of oil of vaseline, the dosage used being | cub. centi- 
metre introduced into the buttock twice weekly. 

Their conclusions were as follows : — • 

1. Intramuscular injection of salicylate of mercury suspended 
in oil of vaseline was one of the best methods of administering 
mercury. 

2. The pain caused by the injections was well tolerated by a 
large majority of patients. 

3. They never caused salivation. 

4. They very rarely produced suppuration (12 times in 
176,000 injections practised by Tarnowski). 

5. In contrast to injections of grey oil, if by any chance they 
entered the circulation, the symptoms of pulmonary embolism 
rapidly disappeared and were of no gi*avity. 

6. They were remarkably active. 

7. They coidd enter into the routine treatment of syphilis. 

8. They were not contra-indicated in cases of sypliilitic 
albuminuria; in fact, they often produced a rapid cure of this 
condition. 

9. It was improbable, as had been stated, that relapses were 
more frequent after this method of treatment, for the conditions 
of the human organism were favourable to the absorption of the 
salic^date. 



270 THR YRAR-BOOK OP TREATMENT. 

'">. Soriinitli<M-»|>y in f^iypliilis. 

Tarnowski (Arrhlv f. Dorm. n. Si/ph., 1890, p. 03) onuiiioratod 
the diflerent incili<Kl,s of sei'umtlierapy wliicli had been employed 
ill the treatment of syphilis. 

1. Injections of the serum of healthy aniinal.s, d(j;,'s, lamljs, or 
calves. 

2. Tnjcctioiis of human serum from patients in the secondary 
and gummatous ])eriods, and from children the subjects of 
hereditary syphilis. 

3. Injections of the serum of animals previously inoculated 
with syphilis. 

So far .seruintherapy had given no curative results in .syphilis, 
but the success produced by this treatment in diphtheria and 
erysipelas gave hopes that a similar result might be obtained in 
syphilis, and stimulated the observer to furtlier research. But 
as tlie bacillus of syphilis could not be cultivated, nor its toxin 
artificially prepared, one was compelled to work in the dark in 
this direction, and to argue exclusively by analogy. 

Eepeated inoculations on a horse with the secretion of primary 
sores and mucous tubercles, and the introduction under the skin 
of fragments of mucous patches and of the primary syphilitic 
induration, did not produce any analogous symptoms in the 
animal experimented upon. But at the autopsy the microscope 
revealed in the lymphatic glands, in the liver, in the heart, and 
in the aorta, lesions which corresponded exactly with those of 
syphilis in the condylomatous stage. Horses, therefore, were not 
refractory to the contagion of syphilis, and by the employment of 
their serum perfect analogy with anti-diphtheria serum could be 
obtained. On one horse hfty-seven inoculations weie made in the ' 
space of seven months, the only noticeable reaction being in the 
appearance of several nodules on each side of the vertebral 
column of al)Out the size of a hazel nut. 

The serum was then carefully taken from the horse, and 
was employed on six syphilitic subjects with the following 
results : — 

The serum did not arrest gangrene of a primary syphilitic 
induration, nor the later development of the sclerosis, nor was the 
second period of incubation materially prolonged by the treat- 
ment. Tiie secondary eruption appeared in the ordinary course, 
the eruptive fever was not modified, and the development of a 
maculo-papular syphilide with polyadenitis followed the same 
course as in any case not submitted to treatment. In the gum- 
imatous period this treatment was powerless against nocturnal 
osteocopic pains, and did not prevent the aj)pearance of gummata ; 



VENEREAL DISEASES. 271 

nor did it improve the general condition of the patients, and loss 
of weight, albuminuria, purpura, and ])yrexia were noted. 

The erticacv of antitoxin did not depend upon the de.struction 
or the neutralisation of the toxins, but on the intensification of the 
re.sisting power of the individual. It was clear also that mercurial 
treatment did not directly react upon the toxin, but endowed the 
blood with a certain power of resistance against the syi>hilitic 
contagion. 

It was possible that tlie serum of animals liaving a certain 
receptivity for syphilis, if introduced as a vehicle for the adminis- 
tration of anti-syphilitic remedies, might produce favourable 
results, not only by reason of the mercury introduced, but by 
augmenting the imnmnity of the blood. 

With this view he proceeded to mercurialise liealthy liorses 
by repeated intramuscular injections of calomel, and proposed 
injecting patients with serum taken from the )nercurialised 
animals. 

The result of these experiments was not yet forthcoming, but 
would shortly be published. 

6. A case of syphilis g-ravis cured by the Aaclieii 
specific method combined ^vith siirg^ical treatiiciit. 

Brandis and Thissen [Brit. Med. Journ., Aug. 7, 1897) give the 
history of a case descril^ed as above, the salient features of whicli 
were as follows : — • 

The patient, a healthy subject, with the exception of a tendency 
to malarial attacks, aged 62, contracted a sore in Jan., 1895 ; this 
was followed by severe influenza and septic bronchitis. In August 
a smooth rounded swelling appeared on the right side of the 
thyroid cartilage, and almost occluded the glottis ; this improved 
under anti-syphilitic treatment. In September he had periosteal 
nodes on the shins and forearm, and the laryngeal swelling again 
appeared. Tracheotomy was performed, and some necrosed pieces 
of cartilage were removed ; there was subsequently suppuration 
over the left tibia. The patient had been for eight months 
treated with mercury and iodides, and was in June, 1896, sent to 
Aachen and underwent the customary routine of the place for two 
months, during which time a large piece of necrotic ossified 
cartilage was removed through the tracheal wound, and finally 
the patient was pronounced cured in May, 1897. In their 
comments on the unusual course of the malady, the authors 
attributed this either to the advanced age of the patient, or to 
a mixed infection of syphilis and influenza in a system where 
malarial fever had left its traces, and they attributed his so-called 
cure to two months' inunction treatment in combination with the 



272 THE YEAR-BOOK OF TREATMENT. 

use of tlio Aachou waters, which combination they said was one 
of the sti'ongfst antidotes, if not the most powerful, to the syphilitic 
poison. 

Commenting on this ease, Arthur Cooper [llrit. Med. Journ., 
>Se))t. 11, IcS'JT) expressed doubts as to wliether the wat(jrs of 
Aachen had any sj)ecific influence over syphilis, amd did not 
believe tliat the effect of mercurial treatment in that resort 
produced any more favourable results than similar treatment in 
England, provided that the patient was obedient to his instruc- 
tions, and paid due attention to details as regarded his treatment 
and his mode of living generally, nor was there any evidence that 
cases treated at Aachen were any less liable to relapses than those 
treated elsewhere. 

7. Tlic nboi-tivc treatineiit of ;;oii<»riiia'a. 

In a discussion on tliis subject {Ann. Mai. des Org. Qen.-Urin., 
189G. p. 1013) Janet held that before the discovery of the gono- 
coccus it was very easy to confound cases of simple urethritis with 
true gonorrlnea, and it was only in the former class that the 
abortive treatment was successful ; it was doubtful if a true 
gonorrhoea was ever aborted in those days. 

During the incubation period the gonococcus wtis, in Janet's 
opinion, penetrating into the epithelium and even into the sub- 
epithelial layer, and the treatment of this stage was nearly 
similar to that which should be employed later ; it was not, 
strictly speaking, abortive, for such treatment could only be 
carried out immediately after infection, or before the gonococcus 
could be recognised. 

In all cases in which Janet had applied his treatment 
(described in " Year-book of Treatment," 1896, p. 283) before the 
onset of acute symptoms, he had effected the complete suppression 
of the gonorrhceal process and all its complications, and at no 
period was there any sign of increase in the number of the 
gonococci. In from eight to twelve days a cure was effected if the 
patient was sober and regular in attendance, and gave the 
requisite amount of time, provided that an extra-urethral focus 
of infection in the neighbourhood of the meatus had not been 
overlooked. 

Such a result could be obtained only in a limited number of 
cases, and the treatment was not applicable to liospital patients ; 
and consequently Janet expressed a wish that the method known 
by his name might not entirely supersede the old-fashioned plans 
of large doses of balsams, of nitrate of silver and corrosive 
sublimate injections, etc., in which he conceded there might be 
some merit. 



VENERKAL PISEASES. 273 

De Vigneron, of Marseilles, liad employed Janet's ti'eatment for 
li\e years, and had met with twelve cases in which the patients 
presented themselves thirty-six hours after infection ; in these 
twelve cases, he had in nine instances been able to obtain absolute 
dryness of the ui'ethra in from six to ten days, and lie had con- 
tinued the irrigations for two days after the disappearance of the 
gonococci. In one case, in which the treatment was stopped 
immediately on the disajipeaiance of the gonococci, there was a 
recrudescence within forty-eight hours, which required eight days' 
further treatment. 

In cases of longer duration, he had brought about the disappear- 
ance of the gonococcus in from fifteen to thirty days, but in these 
cases there often remained a drop of mucous or mucopurulent 
secretion which necessitated further treatment. 

Guiard, though convinced of the value of the treatment, 
differed as to its technique. Finding that violent reaction and 
excessive pain frequently supervened, he had reduced the strength 
of the permanganate solution to 1 ad 1000, and had been sur- 
prised to find that the gonococci disappeared more quickly than 
with the solution as used by Janet, that the patients only 
experienced very trifling discomfort, and finally that there was 
no reactionary secretion. He further advocated the use of the 
syinnge instead of the iriigation method, on the ground that it was 
more convenient for the surgeon and safer for the patient, for by 
it the least sensation of resistance was conveyed to the hand of 
the operator, who could regulate the amount of pressure necessary. 
The irrigations were not applicable to all stages of the disease ; 
they were very valuable at the outset, but were harmful after the 
fourth day, though again in the later stages of the disease they 
I'esunied their former efficacy. 

Nogues, of Paris, considered the treatment to be applicable 
only in the very early stages of the disease, and he had met with 
but small success when employing it during the acute stage ; he 
used the irrigator, with a solution of 1 ad 4000 to 1 ad 500, the 
latter strength being justifiable only for the anterior urethra. He 
deprecated the persistent use of one drug, and in the event of the 
permanganate of potash irrigations failing to cure, he would 
change to a solution of nitrate of silver or oxycyanide of mercury. 

Evand, of Lyon, maintained that Janet's method, whilst 
modifying the period of sup^Duration and altering the nature of the 
discharge, did not merit the name of abortive treatment, for it 
lengthened the period of decline of symptoms, and consequently 
had no marked advantage over the older modes of treatment. 
Other substances, such as methyl blue, gentian violet, and other 
s 



274 TIIR YEAR-ROOK OF TREATMENT. 

{iniliiio colours, had a more marked .antagonism to tlie gonococcus 
than tlio permanganate salt. 

Desnos, of l^aris, limited the treatment to the anterior urethra, 
preferred the syringe to the irrigator, and allowed the solution 
to escape at once. He commenced witli a strength of 1 ad 500, 
on the second day reduced it to 1 ad 1000, and for the next tlircc 
days to 1 ad HOOO. 

H, Tlie trratiiioiit of ^oiioriiura by injectioiis of 
:ir^:<»niii. 

Christian (^Therap. fJaz., July 15, 1<^97) gives the results of his 
treatment of ninety cases of gonorrlifta by injections of argonin, 
which, though not so brilliant as those obtained by Jadassohn 
("Year-Book of Treatment," 1897, p. 278), were on the whole 
satisfactory. He arriv^es at the following conclusions : — 

1. Argonin is absolutely unirritating, and can be used in 
solutions from l.to 10 per cent. 

2. In the great majority of cases it lessens the discharge very 
ra])idly. 

3. Its use is generally followed in a short period by a 
disappearance of the gonococci. 

4. This disappearance of the gonococcus is not in all cases 
permanent ; in other words, there is in a large proportion of cases 
a distinct tendency to relapse, with reappearance of gonococci. 

5. It possesses distinct value as a hand injection (as distin- 
guished from irrigation) in the stationary period of the disease, 
but is of very little benefit in the mucous stage, or stage of 
decline. 

6. It produced no results in the treatment of chronic anterior 
urethritis. 

9. The dtiration of acute ^oiioi rlto a under treat- 
ment. 

Christian (Therap. Gaz., January 15. 1897) concludes his com- 
munication on this subject with the following very apposite 
remarks : — 

1. Gonorrhoea is a much more prolonged and serious affection 
than it is usually considered to be by genei'al practitioners of 
medicine and by the laity. 

2. In two-thirds of all cases uncomplicated, the i)eriod of 
time necessary to obtain a complete cure is from six to ten 
weeks. 

3. In that small proportion of cases whei'e the entire urethra 
does not become involved, the disease being confined entirely to 
the anterior urethra, we can, as a rule, expect complete recovery 
in about four weeks. 



VENEREAL DISEASES. 275 

i. The necessity of impressing upon the profession in general 
tlie importance of making examinations of the urine before 
tleciding that an attack of gonorrhoea is positively cui'ed. 

RECENT PUBLICATIONS. 

" Genito-Urinary Surgery and Venereal Diseases." J. William 
White, M.D., and Edward Martin, M.D. (Philadelphia : J. P. Lip- 
pincott ct. Co. 1897.) 

" A Manual of Venereal Diseases." J. R. Hayden, M.D. (Lea 
Bros, ct Co. 1890.) 

"A Pictorial Atlas of Skin Diseases and Syphilitic Affec- 
tions." In Photo-lithochromes from Models in the Museum of the 
Saint Louis Hospital, Paris, with explanatory woodcuts and text. 
By Ernest Besnier, A. Fournier, Tenneson, Hallopeau, Du Castel, with 
the co-operation of Henri Feulard and Leon Jacquet. Edited and 
annotated by J.J. Pringle, M.B., F.R.C.P. (London : F. J, llebman. 
Parts I.— VIII. Price 10s. 6d. each part.) 

" Der Syphilis Bacillus." Van Niessen. (Wiesbaden, 1896.) 



S2 



THE DISEASES OF WOMEN, 

By G. Ernest Hekman, M.li. Luxd., F.K.C.l'., 
Senior Ohsietric Phxjsician to the London IIospUul, etc. etc. 



The first subject that I notice is one wliich deals witli the 
fundamental pathology of the pelvic organs. It is therefore 
important to the practitioner, although he may be obliged to take 
upon trust what is stated. In bacteriology things become out of 
date in a year or two. But the important work I quote from is 
based upon most laborious researches, and embodies our know- 
ledge up to date. 

1. Tlio bactoriolog:y of the roinalc g:ciiit:il<>i. 

When the part played by microljes in the production of 
disease was first found out the word "germs " implied something 
maleficent, external, and foreign to the hea;lthy organisms. We 
are now getting to learn something of the enormous variety of 
the microflora, and to recognise that there are microbes which 
do not cause disease, and may even peihaps prevent it. S'onie 
surgeons have taken immense pains to sterilise, as they thought, 
the vagina an 1 cervix uteri, and have blamed what they called 
the septic cervical canal for bad results which followed the 
amputation of the body of the utei'us. Obstetricians have talked 
about " autogenetic " puerperal fever, or " self-infection," meaning 
by it that the lying-in woman was poisoned by germs already 
within her vagina before she was delivered. All this is mere 
guesswork until we know exactly what bacteria exist in the 
female genital passage and what they do. 

Menge and Kronig (" Bacteriologie des weiblichen Genitalkan- 
ales." Leipzig : A. Georgi, 1897) have published a large book giving 
the results of their investigation of the micro-organisms found in 
the female genital canal in health and in disease. I do not think 
that they have completed our knowledge of the subject, but their 
results are the latest and therefore worth quoting. They begin 
with the vulva. The bacterial floi'a of the oioriiial vulva is a 
^.very variable one. The mass of the bacteria wdiich lie in the 
'A'estibule are anaerobic saprophytes which descend from the 
vagina. Among them there are also found infective bacteria — 



THE DISEASES OF WOMEK. 277 

the staphylococcus pyogenes aureus, the streptococcus pyogenes, 
the bacterium coli commune, tlie gonococcus of JSeisser, and the 
bacillus tuberculosis. These infectious bacteria come from the 
internal genitals, from the vulvo-v;iginal glands, from the urinary 
passage, and from sources external to the patient. In disease of 
the vulva, infective bacteria — the staj)hylococcus pyogenes aureus, 
the streptococcus pyogenes, and the bacillus tuberculosis — may 
get from the tissues into the secretions. It is improbable that 
a specidc gouorrhoeal vulvitis exists either in adults or children. 
Gonococci found in "the secretions of the vulva have generally 
come from the vagina ; and when along with gonorrhoeal vaginitis 
there is vulvitis, the latter can be easily cured although the 
vaginitis remains the same. 

It is as yet undecided whether pathogenic microorganisms, 
or geims at all, exist in the normal urethra. Suppurative in- 
fiannnation of the female urethra is almost iavariably the work of 
Neisser's gonococcus. There are rare forms of purulent urethritis 
pi'oduced not by gonorrhceal infection but by infection with 
other germs — e.g. the bacterium coli commune and pyogenic 
staphylococci. 

The healthy Bartholiii s gland and its duct jirobably contain 
no bacteria. Intiammation of the gland is in most cases a 
gonorrhoeal disease. Gonococci can produce a large abscess of 
Bartholin's gland without the help of any other organism. The 
pus of such abscesses is often free from germs, but often it con- 
tains gonococci ; more seldom the staphylococcus pyogenes aureus 
or anaerobic saprophytes. 

We now ascend to the vagina. The microflora of the healthy 
vagina is difterent at ditFerent periods of life. In the newly born 
infant the secretions in the vagina are sterile and faintly acid. 
Soon after birth bacteria wander in, which make the secretions 
more strongly acid. Among them is the bacillus vaginalis of 
Doderlein. The bacterial flora of the vagina of the adult virgin 
is like that of the child. When sexual relations are commenced 
the biology of the vaginal secretions alters. Its flora becomes 
manifold ; it may become faintly or strongly acid, neutral, or 
alkaline. During pregnancy the bacterial contents of the vagina 
come to resemble those of the child. The vaginal secretions of 
the woman at the climacteric are more often alkaline in reaction, 
and present a very diversified microflora. The micro-organisms 
which are found throughout life in the normal vaginal secretions, 
in the forms of cocci, rods, and spirilhe, are mostly anaerobic. 
The reaction of the "vaginal secretions depends partly vipon the 
admixture of secretions from the uterus, partly upon the quantity 



278 THE YEAK-HOOK OF TREATMENT. 

of the vaginal secretion, and partly upon external influences. 
The vaginal socretions throughout life are antagonistic to the 
life of inicroorganisiiis, and this cirect is most marked during 
pregnancy and in children and virgins. The bacteria found in 
tins vagina are mostly those which grow upon alkaline culture 
m(!dia, and therofore the bacteiicidal power of the vaginal secre- 
tions is due to their acid reactions, aided by leucocytes and fluid 
transuding from the tissues. This self-cleansing power of the 
vaginal secretion can be artificially destroyed when the secretion 
has been removed from the vagina, and can be artificially weakened 
while it is still in the vagina. Even under natural conditions it 
may become weakened or lost, so that the vaginal secretion 
becomes then a fit soil for the growth of anaerobic saprophytes 
capable of infecting the body. It is very im])robable that this 
ever happens intra parhmi. In non-pi'egnant sexually mature 
women spontaneous infection and intoxication of the organism 
from the internal genitals are conceivable. Inftictive bacteria may 
be found in the vaginal secretions which are lieing eliminated by 
the vagina from diseased internal parts. 

From the bacteriological point of view the genital canal may 
be divided into (1) the pms copulationis, consisting of the vagina 
and the vulva, the vagina being generally aseptic, the vulva not. 
Both parts contain saprophytes under normal conditions. (2) The 
pars gestaiionis is sharply di\'ided from the part below it by the 
OS uteri externum, and is usually free from germs. The reaction 
of the vaginal secretion influences the bacterial condition of parts 
above, for it contains only those bacteria which thrive in an 
acid medium, while the secretion of the uterus is alkaline. The 
vagina of a pregnant woman who has been for long untouched 
is always aseptic. Before operations the vagina of anon-pregnant 
woman should be, if possible, sterilised. 

In the foregoing paragraphs I have summarised the author's 
investigations into the bacteria which inhabit the healthy vagina. 
I now biiefly review their investigations into the efi'ects of 
pathogenic microbes. They point out the great difficulty of 
drawing a definite line between health and disease. Their 
definition of a diseased vagina is one which presents signs 
of disease, and is accompanied by symptoms of disease. 
Among the diseases caused by bacteria they mention first 
amite and chronic colpitis. This may be caused by the 
staphylococcus pyogenes aureus. Its signs become marked about 
twenty hours after the introduction of the organism. It begins 
to subside about ninety hours after the entrance of the microbe, 
and by 120 hours after all signs of disease have disappeared. 



THE DISEASES OF WOMEN. 279 

Its signs are injection of the vagina and increased secretion. 
Erysipelas^ croup, and dtp/itJieria of the vagina may be set up by 
the inicro-organisins which produce these diseases ; but our 
authors have no new observations of these n'lorbid conditions to 
bring forward. With regard to gonorrlia'M in women, clinical 
observation and bacteriology seem at variance. The gonococcus 
seems to ditler from many pathogenic bacteria in being able to 
find its way quickly into uninjured tissues, while most infectious 
bacteria require a solution of continuity for their admittance. 
It penetrates easily mucous mendjranes, the peritoneum, and 
connective tissue, but not skin nor subcutaneous fat. The authors 
accept metastatic suppurations as being due to the gonococcus, 
and not to mixed infections, as some think. They think that 
the pavement epithelium of the vagina is very like that of 
the skin. In children they believe a true gonorrheal col- 
pitis may occur. In adults the authors have never found the 
gonococcus the only or the preponderating organism in the 
vaginal secretion. They have found gonococci in the uterus when 
there were none in the vagina. In cases of granular vaginitis, 
they have examined excised pieces of mucous membrane and 
failed to find gonococci. The a ■priori improbability and the 
negative result of search for the gonococcus make the authors 
doubtful whether there is such a thing as a true gonorrhoeal 
colpitis in the adult. [To my mind, the clinical fact that infection 
with gonorrhoea produces a purulent discharge from the vagina is 
too surely established to be set aside because some observers have 
in some cases failed to tind the micro-organism believed to be the 
cause of the inHammation.] Senile vaginitis the authors believe 
not to be a bacterial disease but an outcome of senile involution 
of the parts. Lastly, " colpitis emphysematosa." otliervvise called 
*' colpo-hyperplasia cystica," and in English " vaginitis with gas- 
cysts," the authors hold is produced by a bacillus. It is almost 
superfluous to add that tuberculous disease of the vagina is due to 
a bacillus. 

The next section of the genital canal is the cervix: Menge 
quotes the discrepant statements of former observers. His own 
observations lead to the conclusion that during pregnancy the 
cervical canal is free from germs, except in patients the subjects of 
gonorrhoea or tubercle. The cervix uteri in th(; non-pregnant 
female, whether normal, hy])erp]astic, atrophic, or the subject of 
the infiltration with small cells which indicates cer^-ical endome- 
tritis, is also free from germs, excepting when gonorrha'al or 
tuberculous disease is present, or when dead tissue on which 
saprophytes can feed is present in the cervical canal. Other 



280 THE YRAR-nOOK OF TREATMENT. 

germs may ha present when the Ijody of the uterus is the suhject 
of di.s(!iis(!, the bacteria liaving made their way (hjwn from th(! 
uterus into tlie cervix. Our author then asks the question, Why is 
the cervix g<;nerii]ly sterile? One reason is tliat tlie only gcn-ms 
that can live in the vagina are those for which an acid medinm is 
suitable ; as the secretion in the c(!rvical canal is alkaline, it does not 
suit them, and they do not wander in. But this is not the sole reason, 
for the cervical canal of the prolapsed uterus is free from germs ; 
and there are obvious ways in which germ.s might be conveyed 
directly to the os uteri. The mechanical etlect of the sudden 
narrowing of the genital canal at the os externum might be thought 
a reason, l)ut, in view of the size of the organisms, can hardly Ije 
thought a sufficient ex})lanation. Moreovei', the gonococci do 
ascend. Another mechanical explanation is the downward 
current of the secretions from the uterus into the vagina, so that 
microbes have, so to speak, to swim against the stream. iSIenge 
believes, and relates observations in su2:)port of his view, that the 
real reason is that the cervical se:;retion has a bactericidal power. 
The cervix, when uninjured and undilated, may be likened to a 
filter, which lets the gonococcus of Neisser pass, but filters off all 
other germs. The tubercle bacillus does not usually reach the 
cervix by way of the vagina, but comes down from the body of 
the uterus. The presence of the gonococcus in the cervical 
secretion is not necessaiily evidence of its having travelled 
upwards in the secretion, for this organism enters the tissues, and 
it may from the cervical tissue escape into the secretion tilling 
the canal. 

From the bacteriological investigation which I have sum- 
marised above, Menge draws the following important practical 
conclusions: — Disinfection of the cervical canal of a healthy 
])regnant or parturient woman is suj)erfluous and, indeed, injurious. 
Disinfection of the cervical canal of a pregnant woman affected 
with gonorrhoea is impossible, because the organisms ai-e in the 
tissues. Therefore attempts to disinfect the cervical canal before 
or during labour are to be condemned. The cervical canal of a 
non-pregnant woman, before or after amputation of the body of 
the uterus through the abdomen, should neither be mechanically 
cleansed, nor chemically disinfected, nor excised, nor burnt. No 
danger comes from the healthy cervical canal, and the proceedings 
referred to delay healing. Amputation of the uterine body, 
leaving the cervix, is better than the removal of the whole uterus, 
for if the latter operation be done, the peritoneum is placed in 
direct communication with the not always aseptic vagina, instead 
of being separated from it by the bactericidal cervix. 



THE DISEASES OP WOMEN. 281 

The next subject for investigation is the uterine body. Other 
observers liave examined this part with the same object, and 
tliscrepant statements hixve been made. The .following sentences 
express Menge's conclusion. Neither in the secretion nor in the 
nuicous membrane of the iioi'mal body of the uterus do bacteria 
live which can be cultivated in the media commoidy uscmI. 
Neither in the secretion nor in the mucous membrane of uten 
whose mucous membrane shows signs of so-called chronic 
endometritis, but not infiltration with small cells, do bacteria 
live which can be cultivated in the media commonly used. The 
external os uteri, both in pregnancy and in the non-gravida, is, 
under ordinary conditions, the boundary line between the section 
of the genital canal which contains microbes . and the section 
which is free from them. Many cases of chronic endometritis, 
especially those in Avhich the endometrium is infiltrated with 
small cells, are nevertheless of bacterial origin, most of them 
being produced by the gonococcus of Neisser. This organism 
usually diseases the whole uterus, both body and cervix. It 
invades the muscular tissue, suppuration of which, in rare 
cases, it may excite. In both acute and chronic gonoi-rhcea the 
gonococcus alone is found in the uterine cavity, no other 
microbes being present ; so that the changes produced by the 
gonococcus do not help the entry of other micro-organisms. 
Some few cases of chronic endometritis are due to infective 
organisms, which may cause puerperal endometritis ; but 
chi'onic endometritis in non-pregnant women is not due to such 
organisms. Tuberculosis of the body of the uterus generally 
has descended from the tubes. If the uterine cavity contains 
suitable food for bacteria, in the shape of retained secretions, 
dead pieces of new growth, retained secundines, or discharge 
from a w^ound of the uterus, bacterial grow^th may go on in it, 
if anaerobic saprophytes can get past the cervical canal. The 
bactericidal power of the cervix may be destroyed by secretions 
))assing down it — as in cancer and senile endometritis — or by 
the enlargement of its canal by new^ grow^ths or products of 
conception ; and if so, the passage of bacteria from vagina to 
uterus will be allowed. The bactericidal power of the cervix is 
in like manner destroyed by its dilatation during labour ; but 
it is then replaced by the increased bactericidal power of the 
vaginal secretion. 

The next part of the genital track investigated is the Fallopian 
tubes. Menge's result can be briefly told. The healthy tubes 
are absolutely free from micro-organisms, unless the peritoneum 
contains the tubercle bacillus. Menge draws an important and. 



282 TIIK YRAR-BOOK OP TREATMKNT. 

I ])(>lu!ve, real distiiictioM between two flitterent kinds of hydro- 
salpinx. One has a very thin wall, with a smooth seions 
covering, and containing c]e;ir, wat(;ry, colourless fluid. The 
folds of tlu! tube are smoothed out; the muscular and connective 
wall thinned, tiie nuiscular bundles pressed a])art. Tli(;re is no 
infiltration with, small cells, nor hyperj)lasia, nor hypertr<)]iliy of 
the muscular or connective tissue. Jn short, there ai(; no 
appearances of either acute or chronic inflammation, but only 
changes due to mechanical distension. The second kiiid of 
hydrosalpinx has a thickened and stiffened wall, which on micro- 
scopical examination shows signs of chronic inflammation ; tliere 
is small-celled irdiltration, hyperplasia of connective tissue and 
muscle ; the mucous mendjrane is thickened, folded, and often 
adjacent folds are adherent. Cases of the first kind form the 
majority. Menge has only seen two of the latter kind. In all 
there is closure of the abdominal ostium, which implies past 
peri-salpingitis ; ])ut adhesions are, as a rule, limited to the 
o.stium. .Such peri-salpingitis is presumably in some cases of 
bacterial origin ; in others microbes have certainly nothing to do 
with it. Slight or even extensive adhesions may come from 
intra-peritoneal effusions of blood from which bacteria are absent. 
Such effusions of blood may come from ovulation or from tubal 
abortions. When lapai'otomy is performed on account of rupture 
of a tubal pregnancy, the tube opposite to the pregnant one is 
often found closed by adhesions about its ostium and filled with 
serous or sanguinolent fluid. With uterine fibroids hydro- 
salpinx, with adhesions closing the ostium, is often found when 
there is no reason to think that the inflammation has been 
caused by the invasion of bacteria. The same may be said of 
tubo-ovarian cysts. Menge considers that the gonococcus of 
Neisser plays no part in the production of hydrosalpinx ; the in- 
flammation it provokes is purulent. He does not believe that 
genuine hydrosalpinx is ever produced out of pyosaljjinx. Long 
retained pus undergoes change, but is not converted into serous 
fluid. The only conditions under which hydi'osalpinx can result 
from gonorrhoea is when the ostium is not occluded until the 
acute stage of salpingitis is over. If then the fimbriae become 
sealed, hydrosalpinx may result ; but it is a hydrosalpinx with a 
thickened wall. The streptococci and staphylococci which 
pi'oduce purulent inflammation do not, so far as we know, 
produce hydrosalpinx. Perhaps late in the course of such 
inflammation, when the virulence of the microbes has become 
weakened, it may extend to the tubes, and produce closure of their 
ends and serous exudation. These are only hypotheses; the fact 



THE DISEASES OP WOMEN. 283 

is that in most specimens of hydrosalpinx the tuhe shows no 
e^i(lenee whatever of inflammation. Streptococci may get to the 
l)eritoneum, not by way of the tuhes but by way of the 
lymphatics from the uterus. Thus they may lead to closure of 
the tube and serous exudation into it, although the tul)e is 
anatomically unaltered, and microl)es are not present within it. 
This explanation INlenge thinks is not forced, and is in harmony 
with facts. No organism does so much harm to the female 
genitalia as the gonococcus, the maleiicent effect of which Menge 
tliinks is even yet under-estimated; but it has been unjustly 
blamed for hydrosalpinx. If Menge's views are correct, it follows 
that when the belly is opened and hydrosalpinx discovered, with 
thin walls and clear contents, the surgeon need not remove it ; it 
will be enough to let out the fluid by reopening the end of the 
tube, and leave the tube. 

The bacteriology of pyosalpinx is the next subject. Fallojiian 
tubes may get inflamed without the influence of microbes, 
although, as their position protects them from mechanical, 
thermic, and chemical injury, this seldom hapi)ens. Sal- 
pingitis may possibly result from prematurely interrupted 
tubal pregnancy, which is now known to be far commoner than 
used to be thought ; possibly also from pressure, or pulling, or 
disturbance of the circulation by ovarian or uterine tumours. 
Some think that a chronic hyperplastic endometritis may be set 
up by ovarian influence ; and if so, salpingitis also may be caused 
in the same way. In animals inflammation can be set up by the 
injection of sterile fluids, such as oil of turpentine. We must, 
therefore, recognise the possibility of non-bacterial salpingitis ; 
but we must also admit that we know nothing about its etiology, 
its development, its frequency, its course, or the importance of its 
effects upon the organism. Such causes probably produce thicken- 
ing and infiltration of small cells without suppuration. Suppura- 
tive salpingitis is indisputably of bacterial origin ; and Neisser's 
gonococcus is, without doubt, the most frequent cause of suppura- 
tive salpingitis. Bacteria may get to the tubes in different ways : 
(1) They may enter the tube from a diseased peritoneum ; (2) 
they may reach it from an organ which contains bacteria and 
has become adherent to the tube ; (3) they may get to the tube 
by w-ay of the blood and lymph channels ; (i) they may invade the 
tube from a diseased uterus. 

(1) The tubercle bacilli are those which most frequently enter 
the tube fi'om the peritoneum. Occasionally autopsies of patients 
dead from puerperal fever have shown suppurative peritonitis with 
less advanced and evidently secondary inflammation of the tubes. 



284 THK YRAU-nOOK OP TREATMENT. 

Such iiinainmutiou is usually tlie work of tlie stroptococcus 
pyogenes. Such Siilpiugitis is for the gynecologist of tlieorotical 
interest only, as it is only foun<l out in the (l(^acl Ijody. Possiljjy 
such cocci of attenuated virulence may set up a localised al>scess, 
IVoiu uliicli inllaiiiination may extend to the tube by its ahdominal 
ostium. I Jut invasion of the tuV)e l)y these cocci is much less 
common than that by tubercle bacilli, Irecauso the latter do nob 
till late excite intlanmiation, such as to close the fimbriated ends. 

(2) The ])ossibility of infective bacteria getting to the tube 
from the bowel camiot be denied. The l)owel may be pei-forated 
so that microbes get into the peritoneum, and thence to the tubes. 
The necessar}' condition for this is that the inliammation cau.sed 
by the jieritonitis shall be local and not (juickly close the tul)es. 
If it be not local, the patient dies too soon for .salpingitis ; and if 
the tubes are quickly closed by adhesions, they are protected. 
Bacteria may also get from the bowel through the peiitoneuui 
into the mucous membrane of the tubes. Saprophytes from the 
bowel can only flourish in the tube if they find in it suitable 
nutriment, such as serous or sanguineous fluid ; and thjs is only 
present when the fimbriated ends are closed. Saprophytes may 
get into the tube from the bowel either through a perforation or 
by traversing adherent surfaces. They may also get into it from 
the uterus. 

(3) It is possible for bacteria to get into the tul)e from the 
blood. The tubercle bacillus is almost the only one that is thus 
conveyed to the tube. The presence of the pneumonia bacillus of 
Friinkel, which has been asserted, is very doubtful. The lymph 
channels are more often the road by which bacilli reach the tubes, 
travelling by this route from the mucous membrane of the uterus 
to that of the tubes. 

(4-) Lastly, bacteria get to the tubes from the uterus, travelling 
either in the mucous membrane or in the secretions. The com- 
monest are the gonococcus of Neisser and the streptococcus 
pyogenes ; more seldom the staphylococcus albus and aureus, the 
bacterium coli commune, and the bacillus tuberculosis. The 
gonococcus outweighs them all in importance. It may excite 
endometritis in a woman not pregnant, or a puerperal 
endometritis in a lying-in woman. The streptococcus pyo- 
genes is practically unknown as a cause of salpingitis in 
a woman not pregnant. When it enters the uterus of a 
recently delivered woman it does not connnonly spread super- 
ficially, because the endometrium is far less rich in lymphatic 
■vessels than the muscular tissue ; but it spreads along the 
lymphatics in the uterine wall to the peritoneum, and pr-oduces 



TUK DISKASKS OF WOMEN. 285 

|H'ritoiiitis instead of Siiljniigitis. Tlie other bacteria wliich have 
been mentioned are only seldom found in the uterus. The 
tubercle bacillus hardly ever passes from the uterus to the tubes — 
its usual course is in the reverse direction. Hence tuberculous 
tubes are more common than tuberculosis of the uterus. Possibly 
the tubercle bacillus sometimes travels from the healthy uterus 
into the tube. Sapropliytes are very rarely found in the uterus 
of a non-pregnant woman, but more commonly in the puerperal 
uterus. 'J'hese may travel into the tube, but cannot flourish 
there unless they find a suitable food, such as retained serum or 
blood. Complete closui'e of the uterine end is not essential for 
the retention of serous or sanguinolent fluid. 

In brief, the gonococcus is by far the commonest organism in 
the tube ; next come the pyogenic streptococcus and the tubercle 
bacillus ; yet more seldom the staphylococcus pyogenes and the 
bacterium coli commune ; occasionally saprophytes. 

Menge then discusses the meaning of the term " mixed 
hifection." He thinks this is used too loosely, and should be 
defined. He distinguishes three things to which it has been 
applied : First, two organisms — e.g. the gonococcus and the 
streptococcus — may simultaneously enter the uterus ; say the 
gonococcus from the cervix, the streptococcus from an examining 
finger. They may both enter the tissues and flourish there. 
This Menge calls infective, pai'asitic, or tissue symbiosis. 
Secondly, two or more kinds of bacteria may live in the same 
secretion, which is fit food for both, without entering the tissues. 
This ]Menge terms sapropliytic or secretion symbiosis. Thirdly, 
a tissue may have been infected by the gonococcus, and subse- 
quently some other bacterium may enter the tissue. This Menge 
calls secondary tissue symbiosis. It is possible that sometimes one 
organism may prepare the way for another ; thus the gonococcus 
may destroy the epithelium, and so enable one of the wound in- 
fective microbes to enter, or the discharge produced by gonorrhoea 
may prove a fit food for saprophytes. With gonorrhoea a further 
modification of mixed infection is possible. With tissue symbiosis 
of the gonococcus and the streptococcus, the latter may get into 
the blood or lymph channels, and so set up a metastatic infection 
elsewhere. The question is. Do these kinds of symbiosis really 
occur with gonorrhcea 1 Menge holds that the gonococcus of 
Neisser is not inclined towards symbiosis with other germs, for 
the secretions from surfaces inflamed Ijy gonorrhcea cuntaiu, as 
a rule, either the gonococcus only or no germs at all. W^hen the 
gonococc'is is inoculated along with other microbes it soon 
destroys these and reigns alone. The gonococcus has never been 



286 TIIK YKAll nOOK OK 'IHKATMKVT. 

seen uloiii,' witli Dthor or<,';\ni,sin.s in the conjunctiva, tlic urctlira, 
or tli(! uterus. Cases liave been observed in which the introduc- 
tion of the erysipelas coccus or the streptococcus pyogenes has 
cured gonorrhceal inflammation. Menge concludes that long 
continued synd)iosis of the gonococcus Avith other microbes does 
not occur in the tubes, except in the case of the tubercle bacillus. 
l>ut a transitory symbiosis, lasting until the gonococcus has 
beaten the other organisms out of the field, may occur. These 
explain tlie occasional occurrence with gonorrhrca of metastatic 
abscesses, and are the only cases of gonorrhcjoa to which Menge 
would ap[)ly the term mixed infection. Other cases in which 
mixed inf(;ction with the gonococcus is alleged arc not instances 
of true symbiosis— that is, of two organisms living and gi'owing 
in the same tissue of fluid — but of admixture from accidental 
causes. 

Menge points out that tubes containing pus are found in 
different conditions. Some have their ends open, communicating 
with the peritoneal cavity. In these inflammation is recent. 
They are swollen, red, their peritoneal surface is injected and 
connected by fresh, easily broken down adhesions to neighbouring 
parts. The mucous membrane is infiltrated with leucocytes, and 
its vessels dilated. The muscular coat may be infiltrated with 
small cells, but show neither hyperplasia nor hypertrophy. 
Others are closed at their fiml)riated ends, and dilated into sacs, 
which show the effects of pressure within. They diflfer in size. 
Some are of the thickness of the little finger, with thin soft walls, 
and little infiltration or hyperplasia. Others have hard thick 
walls, with hypertrophy of muscular tissue and iiyperplasia of 
connective tissue. Others, again, form large, thin-walled sacs, in 
which the mucous membrane is completely or almost completely 
destroyed, and by pressure from within the connective tissue and 
muscular coat are so thinned that the wall at places may be 
translucent. The two latter forms, as a rule, contain no gonococci. 

Tuberculous disease of the tubes may be either primary 
or secondary. Menge calls attention to the great clinical 
importance of primary disease of the tube, in that it is not a 
very uncommon disease, and is one in which striking benefit 
follows removal of the diseased part. One of the patients under 
INlenge's observation gained 10 \h. in weight, another 20 lb., 
and another 30 11)., within a short time after the operation. We 
undei'stand not yet how the tubercle bacillus genei-ally gets 
access to the tubes. The fact that it is commonest in women 
while the sexual organs are active, rarer in childhood and old age, 
points, in Menge's opinion, to the occasional communication 



THE DISEASES OF WOMEN. 287 

of tlio bacillus by sexual intercourse ; and he relates one case 
in which the disease became manifest six weeks after the first 
intercourse with a man suffering from genital tuberculosis. On 
the otlier hand, as the disease does sometimes occur in virgins 
and in children, we are driven in them to accept the possibility 
of its getting to the tubes by the blood or lymph channels. The 
production of secondary tuberculous disease of the tubes is easy to 
explain, the bacilli entering from the peritoneal cavity. 

The bacterium coli commune does not travei"se the wall of 
healthy bowel, but inflammatory changes, which lead to adhesion 
between bowel and Fallopian tube, so alter the walls of both 
structures that they may become unable to resist the passage of 
this microbe. 

Menge estimates that about 25 per cent, of cases of sup- 
purative salpingitis are due to the gonococcus of Neisser, and 
about 10 per cent, are due to the tuljercle bacillus. [Whitridge 
Williams* found 8 per cent, from this cause, so that he and 
Menge closely agree.] Other bacteria are far less common. In 
I'are cases the gonococcus and the tubercle bacillus may exist 
together. Menge criticises the evidence of salpingitis caused by 
the pneumococcus of FrankeJ, and shows that we have no certain 
knowledge as to the role played by this organism. The one case 
of Zemann shows that actinomycosis must be admitted as a 
possible cause of salpingitis. Menge refers to statements often 
made as to the importance of the presence or absence of fever in 
the diagnosis of the cause of sali)ingitis. His observations show 
that in salpingitis from the gonococcus, the streptococcus, or the 
staphylococcus, or in salpingitis with sterile pus, fever may be 
present or maybe absent ; so that from temperature no conclusion 
can be drawn as to the cause of salpingitis. 

Menge concludes his report on the bacteriology of the- 
Fallopian tubes with some paragraphs on treatment, which 
his laborious researches entitle to respect. He thinks treat- 
ment should be as conservative as possible, and for this reason 
prefers abdominal section. He approves neither of the o])ening 
of pus sacs by the vagina nor of the vaginal extirpation of 
the uterus and its appendages. He disapproves the former 
because in suppurated tubes and ovaries thei'e are often several 
suppurated cavities, and these cannot all Ije with certainty opened 
up. He looks upon the vaginal extirpation of the uterus and tubes 
as a mutilation inconsistent with the conservative principles which 
should guide surgery. He thinks the parts should be examined by 
abdominal section. Sometimes what is thought to be a pyosalpinx 
* " Year-Book," 1894, p. 325. 



288 THK YKAU-UOOK DK TItKATMKNT. 

will provo to b(! a liydros.ilpiiix, and the tube can be opened 
and left in its place. Jf p}'osal})inx be pn^sent, a more per- 
manent result will Ije gained by cutting out the part of the 
tube which traverses the uterine wall, carefully sewing up the 
uterine lioi'n, and leaving the ovary, if healthy, behind. 

The last section of the work is devoted to the bacteriology of 
the ovary and iw.ritoneMin. Moiige points out that the ovary 
differs in three ways from the other genitalia: (1) It has no 
direct connection with the genital canal. (2) It is a gland which 
has no excretory duct, its products being liberated by a periodical 
laceration of its tissue. (.'3) It oftener than other parts undergoes 
changes — viz. the different kinds of cystic degeneration — which 
make it furnish abundance of nutritive material for microbes. 
From these peculiarities it results that microbes comparatively 
seldom enter the ovary from the Fallopian tube, but that the ovary 
is more liable than other parts of the genital system to be invaded 
by microbes reaching it by blood or lymph channels. The organ- 
isms which i-eacli the ovary may Ije divided into two classes : (1) 
The gonococcus and the tuljercle l)acillus, which cause a peri- 
tonitis which is not quickly fatal. (2) The streptococcus pyogenes, 
staphylococcus pyogenes, and bacterium coli commune, which when 
they reach the peritonenm cause quickly fatal peritonitis. These 
probably invade the ovary oftener than is thought, but as tlie 
patients soon die, their effects on the ovary have no clinical 
importance. The gonococcus and the tubercle bacillus, when they 
reach the surface of the ovary, lead to the production of false 
membranes covering it, and this leads to cystic oophoritis with 
infiltration of small cells. The microbes do not penetrate the 
ovary unless their advent should coincide in time with ovulation. 
If they do penetrate the ovary, they cause suppuration. Tliey 
find excellent nutriment in tlie corpus luteura. The suppuration 
may take the form of a true abscess, with breaking down of the 
ovarian tissue, or it may be limited to a cyst, a condition which 
Menge calls a pseudo-alDscess. Ovarian abscesses are sometimes 
found with healthy tubes ; in these the infection must have 
i-eached the ovary in some other way than by the tubes. The 
streptococcus pyogenes may set up puerperal endometritis, and 
travel from the endometrium to the ovary by the lymphatics ; or 
from septic thrombi in the uterine vessels microbes may travel 
in the blood stream to the ovary. Saprophytes may thus get to 
the contents of an ovarian cyst. The tubercle bacillus may also 
travel in this way. JNIicrobes may enter an ovarian cyst from 
adherent bowel. Out of 37 cases of ovarian supj)uration Menge 
was able to detect the causing microbe in 19. Of these in 9 it 



THE DISEASES OF WOMEN. 289 

was tlie goiiococcils, in i the tuberclu bacillus, in 4 the bacterium 
coli coninnine, in 1 a sapio])hyte, and in 1 the streptococcus 
pyogenes. In 90 per cent, the suppuration AVas unilatei'al only. 
Alenge agrees with Olshausen that the bacterium coli commune is 
the commonest cause of suppuration of cystic ovaries. Gonorrhoeal 
ovarian abscesses are generally puerperal. Menge tinds ovarian 
suppuration present in about 25 per cent, of cases of suppurative 
salpingitis ; but as the ovarian suppuration is generally one-sided, 
it will be possible in most cases to preserve one ovary ; and in 
young subjects this, if possiljle, should Vje done. Clinical experi- 
ence has yet to show the results of partial resection of ovaries. 

Lastly, Menge speaks of the peritoneum. No organisms are 
found in a healthy peritoneum. Menge has examined 32 cases of 
peritonitis in women. Fifteen of these were tuberculous ; in 4 it 
was probably gonorrhtieal, but the gonococcus could not be found ; 
in 8 the streptococcus pyogenes was present (in 5 after opex'ation, 
in 3 after childbirth) ; twice the gonococcus of Neisser was found ; 
twice the bacterium coli commune (both operation cases) ; and once 
a saprophyte. Menge holds that his own observations and those of 
Wertheim show indisputably that the gonococcus alone, without 
other organisms, can set up peritonitis. 

His general conclusion is that in the non- pregnant female the 
gonococcus and the tubercle bacillus overshadow every other 
micro-organism as the most common and the most serious pro- 
ducers of disease ; the reason being that these organisms can 
penetrate the uninjured epithelium and maintain themselves in 
the tissues. In the puerperal woman the streptococcus and the 
staphylococcus have a lai'ger role, because here there are large 
wounds through which they can enter. Having entered, they 
either kill the woman quickly or produce disease from which she 
completely recovers. They seldom produce chronic disease, and 
therefore are rare in the genitalia of non-pregnant women. 

The next paper which I refer to contains instructive facts 
bearing on the prognosis after the removal of tumours which 
show, or are attended with, the histological or clinical evidence of 
malignancy. 

"i. The results of operations on malignant tninours 
of the ovary. 

Kratzenstein has written a useful paper on this important 
subject {Zeit.fLlr Geh. und Gyn., Bd. xxxvi.), which may help the 
practitioner in advising about, and in prognosis after, operation. 

The death-rate after removal of benign ovarian tumours 
Kratzenstein puts at 5 per cent. But with malignant tumours the 
case is different. The most important statement of the operative 

T 



200 THE YKAIMiOOK OF TUEATMKNT. 

rosults in cases of nialigiiaiit tumour puI>lisliod hofoie Krat- 
zeiistein's paper was that of Cohn (Zeit. fur dub. uud G'yn., lid. 
xii.). His collection of cases showed an immediate mortality of 
20 per cent., recurrence in 15 per cent., cure in 19-5 per cent. 

Kratzenstein has analysed 100 cases of removal of malignant 
ovarian tumours in the clinic of Prof. Olshausen. The death-rate 
was 28 per cent. Of the.se 2 were cases in which it was 
impossible to complete the operation. Eleven died from septic 
infection. In 5 the patients died from metastatic or generalised 
growths of the tumour. Four died from shock — it is supposed 
from atrophy of the heart muscle, although this was not proved. 
One died from the effects of pedicle twisting on a sarcomatous 
tumour, 1 from bleeding, and 4 from intercurrent disease. 
As to the kinds of tumour, 5 were fibro-sarcoma, 2 sarcoma, 
6 carcinomatous papillary cysts, 7 carcinomatous multilocular 
cysts, 8 pure carcinoma. 

There remain 72 cases which recovered from the operation. 
In 34 of these the gi'owth recurred. These were : Two sarcomata, 
12 carcinomatous multilocular cysts, eleven carcinomatous 
papillary cysts, and 9 carcinomata. Sixteen cases of fibro- 
sarcoma which were operated upon remained free from recur- 
rence ; they were mostly small and free from adhesions ; only 
4 were larger than a child's head, and in 4 only there were 
easily broken down ac^esions. There were 18 cases of pure 
carcinoma; 8 of these died from the operation, and in 9 
recurrence took place, or in 90 per cent. Of carcinomatous 
multilocular cysts there were 27 ; 7 died from the operation, 
and in 12 recurrence took place, or 60 per cent. Of 24 
carcinomatous papillary cysts 6 died from the operation, and 
in 11 recurrence of growth took place, or 61 per cent. 

Thirty-one patients remained alive and well at least five 
years after the operation. Five others have since died from 
intercurrent disease of a different kind, and therefore may be 
regarded as cures so far as their ovarian disease is concerned. 
These figures are better than the results shown by Cohn's 
collection of cases, and therefore indicate advance, and justify 
us in holding out greater hope than we were formerly able 
to do. 

The modes of recurrent growth are four : (1) Local or wound 
recurrence — that is, cancer growths in the wound, due, as some 
would say (of whom I am one), to accidental inoculation of the 
cancer protozoon on the wound surface. Of these there were 
12. (2) Recurrence in lymphatic glands, which occurred in 
3 cases. (3) Metastatic growth in distant parts, which were 



THE DISEASES OF WOMEN. 291 

observed in 9. (4) Continuous growth of the original tuuioui', 
which took place in 8 cases. 

I next quote a paper on some minor changes in the ovar}^, 
which are important as causes of pain. The paper shows us how 
we may in many such cases remove pain. 

3. The ig^iiipuiicttire of painful ovaries. 

Pozzi lias published a statement of the results of this practice 
— one which he initiated (7?eV«e de Gynecoloyie, Jan.-Feb., 1897). 
This operation is done for two purposes: (1) To prevent cystic 
growth by destroying small cysts ; (2) to cure ovarian pain. The 
resection of ovaries — that is, the removal of the diseased part of 
an ovary, leaving the healthy fragment behind — was first 
deliberately practised by Schroeder in 1884. Since then 
Schroeder's example has been followed by others ; and it is now 
established that such an operation is safe, and that if only a 
small j^iece of ovarian tissue is left the patient may menstruate 
regularly and become ])regnant. 

Pozzi first examines the different cases in which an operator 
may find himself tempted to resect a diseased o\ary. The cases 
are those in which one ovary has been removed and the other is 
found partially diseased. Such cases may be divided into four 
categories : 

1. Benign growths, such as ovarian dermoids and cysts 
which have neither colloid nor papillary contents. 

2. GroAvths of doubtful prognosis, such as glandular multi- 
locular cysts. 

3. Growths, probably malignant, including all papillary 
tumours and solid tumours the nature of which is rendered 
suspicious by their rapid growth and the presence of ascites. 

4. Chronic ovaritis. 

As to the first group, it is impossible to say with certainty 
that an ovarian tumour is benign, for carcinomatous growth mcui 
take place in any ovarian tumour-. Nevertheless, Pozzi holds that 
with tumours of this group, if the patient is young, the attempt 
should be made, by resecting the ovary, to preserve ovarian 
function. 

In the second group Pozzi holds that the less as well as the 
more diseased ovary should be removed. 

In the third group both ovaries should always be removed 
whether the other ovary is diseased or not. 

In chi-onic ovaritis the first condition for the conservative 

treatment is that the tube be healthy. An operation is dano-erous 

which leaves an infected tube opening into the peritoneal cavity. 

If the only disease about the tube is the closure of its fimbriated 

t2 



292 TIIK YEAB-nOOK OF TRKATMEXT. 

cikI l»y soft and weak adlicsioiis, so its fringes c;iii easily b(^ opencMl 
out and its canal made patient, Pozzi thinks this may he done. 

]\)zzi dciscribcs what Ik; uieans by "chronic ovaritis." In 
some cases the lesion is an advanced sclerosis without notable 
cystic disease. Sometimes the ovary is enlarged, but usually 
small and, as it -were, dried up. Such ovaries are often seen in 
women long past the menopause, and then the change is .senile 
rather than pathological. But this change is not always present 
in old women, and when it is pre.sent we know not what the 
menstrual history has been. Whatever it ))e, it clinically goes 
in young women with dysmenorrhtea, sometimes intolerable. 
Such ovaries are ordinarily degenerated throughout their whole 
extent, and their removal is the only thing that can efiect a cure. 

In other ca.ses there is cystic degeneration of Graafian 
follicles. These ovaries may be divided into three classes : 
(1) Cystic follicles ; and (2) cysts of the corpus luteum. These 
cysts vary in size from that of a small nut to that of a walnut ; 
their contents are serum or blood. The ovary may be so invaded 
by such cystic degeneration that there remains hardly any 
healthy tissue. (3) Sclero-cystic ovaritis. The characteristic of 
this form is the smallness and multiplicity of the cysts. They 
are scattered through the ovary, and are from the size of a millet 
seed to that of a pea. Pozzi remarks that some persons do not 
regard this change as pathological, and admits that it is met 
with in ovaries that have never given any trouble. But it is 
certain, he states, that in a great number of women suffering 
from troubles of ovarian origin, the only lesion found when the 
belly is opened is " sclero-microcystic ovaritis '' ; and that cure 
follows the complete or partial removal of the organs thus 
altered. He makes two varieties of the disease : The sclero- 
microcystic, and the cedematous microcystic, terms which siiifi- 
ciently explain themselves. When these conditions are found, it 
has been the practice of most operators to remove the organs. 
Routier has maintained that the process is a progressive one, and 
that, therefore, a conservative operation is doomed to failure. 
Pozzi, on the contrary, treats such cases by removing or destroy- 
ing the diseased parts of the organ, and preserving the healthy 
part. Spencer Wells and others have treated small cysts of the 
ovary by opening them with a bistoury. But if only this is done, 
Pozzi thinks it certain that the cySts will refill. He therefore, 
if cysts are crowded together at one part of the way, cuts out the 
diseased part, and then sews together the cut surfaces of ovary 
left. If the situation of the cysts is not such that it is con- 
venient to do this, Pozzi punctures and destroys the wall of each 



THK DISEASES OF WOMEN. 293 

cyst with the actual cautery. In the oedeniatous form Pozzi 
often lays open the ovary along its whole length with the cautery 
knife, and tlien more thoroughly cauterises tlie cysts thus laid 
open. After discussing some theoretical objections, Pozzi states 
his results. He has done these conservative operations in 
62 cases. In 8 the operation was so far a failure tliat a subse- 
quent I'adical operation had to be done ; but in some the recur- 
rence of pain was due to infection after the j)artial operation. 
This leaves 54. In 4 of these the operation has Ijeen done too 
recently to permit of judgnient as to its effiects. Pozzi has been 
unable to watch the after course of 10. Of the remaining 40, 33 
have been either entirely cured or much amelioratcid, and 7 say 
that their condition is about the same as before the operation. 
Twelve of them have become pregnant since the operation. 

I think that this operation, introduced by Pozzi, of the igni- 
puncture of painful ovaries, promises to be a distinct addition to 
our therapeutic resources. I have in several cases performed the 
operation, and the i)atients have afterwards said they were better. 
But I have not yet watched the patients long enough to satisfy 
myself that the relief to pain was due directly and entirely to the 
operation, and was not due to rest in bed or to suggestion. It 
must be admitted that we know nothing as to why these ovaries 
are painful, for similar changes are often seen dui-ing al)dominal 
section, and after death, in the ovaries of women-who did not 
suffer pain. 

When a movable ovary is so painful that the patient is urgent 
for relief, even though it be by operation, I think the best way of 
getting at the ovary is by anterior colpotoniy. Pozzi relates a case 
in which he attributes death to anterior colpotoniy. The case was 
one in which he had i-emoved one ovary, and igni])unctured the 
other. On the twelfth day after operation pelvic pain led to examin- 
ation, and a mass of effusion was felt round the pedicle of the 
ovary which had been removed. Pozzi inferred that there was an 
abscess, and tried to get at it by anterior colpotoniy. He found 
no abscess, but his exploration resulted in tearing a piece of 
bowel which was adherent to the pedicle. Tliis was a disastrous 
event ; but I think it should not be put down to anterior 
colpotoniy, for the accident would have been as likely to happen 
if Pozzi had explored by the abdomen. 

The next paper relates to a modification of the operation for 
the removal of incui-ably diseased uterine appendages. This modifi- 
cation its author regards as an improvement, although, as will be 
seen, it is too soon to say this. It has been made possible by the 
introduction of the raised pelvis position for laparotomy. 



294 THIC YP:AIt-I{OOK 01' TREATMENT. 

'I. Tlic :ilMloiiiiii:il i-4>iii<>\ :il of tli<' iit<>i-iii<' :i|»- 
|»cii(l:i«^4'<s w'illioiil pri'liiiiiiiary li^:atlll-4'^. 

The French scliool of gynoBcology are applying to intra- 
l)(^ritoneal surgery the metliofls which are used in the surgery of 
other parts. Doyen and Richelot, in hysterectomy, aim at tying the 
vessels separately, inst(!ad of in a buncli with other tissues. 
Delbet {Revue de Gynecologie, Mai-Juin, 1897, p. 562) has applied 
tliis principle to the operation for the removal of di.seased uterine 
appendages. He says that the shadow upon all operations for 
the removal of diseased uterine appendages is the persistence of 
pain after operation. He is convinced that the continuanc*; of 
jiain is due to the following causes : (1) The constriction of and 
dragging upon the pedicle hy the " ligature en masse." (2) Infec- 
tion of the ligatures, not virulent enough to bring about grave 
accidents, but sufficient to cause inflaminatory exudation. 
(3) Leaving behind a stump of the tube, which is alway.s done 
when the ligature ew masse is used. (4) Adhesion of the pedicle 
to bowel or bladder. (5) Abnormal position of the uterus. 
Holding these views, Delbet performs the operation in a way 
different from that generally practised. Having broken down 
adhesions and brought the appendages outside the belly, his pro- 
ceeding differs according to whether the pus sac has been ruptured 
or not. If not, he considers that his hands and sutures are 
surgically clean. He puts a ligature through the broad ligament, 
and ties in one bundle the utero-ovarian pedicle. Then he cuts 
through the V)road ligament and treats it in the way to be pres- 
ently described. If the appendage has been torn in extracting it, so 
that the operator's hands are soiled with the contents, and a ligature 
will also be infected if applied, Delbet cuts through the broad 
ligament without any preliminary ligature. He begins at the 
external border, and as vessels bleed they are caught up by his 
assistant with pressure forceps. (This is only possible if the 
patient is in the raised pelvis ])Osition.) The uterine artery is 
the important one ; the ovarian artery is only important during 
pregnancy. Delbet takes care to cut away the ovary completely, 
but avoids the round ligament. The jet of the uterine artery is 
seen when the operator cuts near the uterus. Four or five 
vessels generally have to be tied. Delbet cuts away the tube as 
close as possible to the uterus, so that, as he says, he almost cutfi 
away a uterine cornu. Having cut away the diseased parts and 
secured all the vessels with forceps, Delltet carefully purities his 
hands and the field of operation. Then he cauterises the uterine 
end of the tube, and ties the cut vessels. There is left a long- 
wound in the peritoneum, extending from the uterine cornu to 



THE DISEASES OF WOMEN. 295 

the pelvic brim. This he carefully closes with Lerabert's suture, 
using the round ligament to cover its inner part. Thus all 
ligatures are buried under the peritoneuni, and no bleeding 
surface is exposed. By this method there is none of the dragging 
produced by ligatures en masse ; the stump is not infected by 
hands or ligatures ; the tube is removed without the smallest 
nodule being left, and as no bleeding surface is left ti'e probability 
of subsequent adhesions is diminished. Delbet at the same time 
corrects by ventral tixation any abnoi'mal position of the uterus. 
Delbet has not practised this operation long enough to be able to 
give information as to the remote eflects, but he finds that this 
new technique almost completely suppresses pain immediately 
following the operation. 

The untoward results which sometimes follow abdominal 
section are also the subject of the next paper I quote. 

5. On adliesioiis aii<l intestinal obstruction after 
abdominal section. 

Intestinal obstrviction is a possible cause of death after 
abdomina,l section which at present cannot be said to be 
entirely under the surgeon's control. Many causes have been 
assigned for it, and preventive measures recommended. These 
are the subject of a careful paper by Dr. Uhlmann,* who has 
studied the subject with the help of the records of Prof. Zweifel's 
clinic at Leipzig. Uhlmann gives a summary of the work of 
those who have preceded him in the study of this subject. As 
causes assigned for it we have the pi'esence of dead tissue ; the 
pedicle and wound ligatures ; adhesion of bowel to stump, to 
injured pai'ietal peritoneum, or to omentum, pieces of which have 
been tied and cut ofi\; adhesion of coils of inflamed bowel to one 
another ; incarceration of boM-el by bands or sacs formed in the 
peritoneum after operation. It is clear that obstruction comes 
from adhesions of bowel, and the problem is how to prevent their 
formation. The latest and most plausible theory is that bowel 
becomes adherent whenever its epithelium is damaged and it 
comes into contact with the abdominal wound. Walthard, who 
studied the subject by experiments on animals, came to the con- 
clusion that when a healthy serous membrane is long exposed to 
the atmosphere the uppermost cells of its epithelium die. If two 
sui-faces of peritoneum so affected are brought into contact they 
adhere. Walthard ascribed this death of epithelium to drying. 
He found that a fatal peritonitis could be produced in a peri- 
toneum dried by exposure by a one-thousandth part of the dose 
of microbes which would set it up in a healthy peritoneum. The 

* Arch, fiir fi'ijii., Bd. liv. 



296 



TIIK YEAR-HOOK OF TKKATMKNT. 



j>ractical coiiclusioii from Waltliard's cxpcriiiKMital re.soarcli was 
that it is essential to keep the peritoneum moist — not to sponge 
out fluid but to wash it out. Waltliard had better results witii 
this "moist asepsis" than he had previously had with "dry 
asepsis." Sanger, in the year following, also chamjiioned " moist 
asepsis" against "dry asepsis." Out of 132 cases operated on by 
the "dry" method, Hangei- had 10 dc^aths, 5 of tht^ni from 
intestinal obstruction; while among 70 in which " moist asepsis" 
was used there was no case of ileus, and recovery was smoother. 

Uhlinann's paper is to t(!st these methods by the results of 
Zweifel's })ractice. That surgeon's abdominal operations are 
divided into three groups, (1) 240 cases treated by "dry anti- 
sepsis " ; (2) 481 cases by " dry asepsis." [The difference 
between antisepsis and asepsis is that in the former germicide 
solutions were used, in asepsis sterilisation by heat.] (3) Eighty 
cases by "moist asepsis." In testing the results Uhhnann first 
eliminates those causes of death which are independent of 
septic causes — such as haemorrhage, cardiac disease, cancer, and 
peritonitis depending upon suppuration present before the 
operation. The deaths that seemed connected with defective 
methods of attaining asepsis were in the antiseptic period 2 '44 
per cent, in the "dry asepsis" period 0"6 per cent., and in the 
"moist asepsis" period 1-25 per cent. Zweifel's experience 
therefore goes to show that asepsis is better than antisepsis, and 
that "dry asepsis" is better than "moist asepsis." Turning 
next to th<> question of intestinal obstruction, the percentage of 
intestinal troubles following the three ditferent series of opera- 
tions was, in the antiseptic period 3'56 per cent., under " di-y 
asepsis " 3-3 per cent., under " moist asepsis " 5 per cent. 
Zweifel's experience therefore goes to show that it is better 
to leave the peritoneum dry than to pour in fluid ; although the 
difference is so slight as to show that the matter is not one 
of great importance. 

The remaining question is the prevention of adhesions. In 
last year's "Year- Book" I referred to a recent law suit, in 
which it was strongly urged that when one ovary was found 
much diseased and the other only slightly diseased, it was proper 
to leave the less diseased ovary, in the hope that the disease 
might not progress ; for that if the disease did advance, the 
second ovary could be removed at a second operation, with no 
greater risk than that attending the first oi)eration. The 
question arises, Is this so? Uhlmann records 23 cases in which 
a second operation had to be done soon after the first. In every 
case adhesions were found of bowel or omentum to tlie stump, 



THK DISEASES OF WOMKN. 297 

the abdominal scar, and to places in which the peritoneinu had 
been injured, either by breaking through adhesions or applying 
ligatures. But lie never found adhesions between two surfaces 
of peritoneum both of which had been left uninjured at the first 
operation, however much the peritoneum may have been exposed 
to the air. 

The next paper is a small contril)ution to a great subject, but 
it is one which helps to make our knowledge more definite and 
more correct. 

<>. Tlie eliolog^y nii<I troatnioiit of uterine cancel'. 
Backer I^Arcli. fiir Gijn., Bil. liii. ) analyses 705 cases of uterine 
cancer occurring in the clinic of Prof. Kezmarszky at Buda-Pesth 
His paper does not contain any novel opinion, but is valuable as 
bringing the support of large numbers to opinions sometimes 
advanced without enough evidence. Backer shows that the years 
of life in which uterine cancer is most prevalent are the later 
years of sexual life — viz. from forty- one to forty-five. That women 
who suffer from cancer have, as a rule, had larger families than the 
average. That it is only in a very small minority that the cancer 
rapidly follows delivery ; in most an interval of years elapses 
after child-bearing before cancer growth begins. Backer sees in 
this an argu)nent harmonising with the observations of Sir John 
Williams and Fehling, who failed to discover that lacerations of 
the cervix had any etiological bearing upon cancer. Backer asks, 
How is it, if cervical lacerations cause cancer, that ten or twenty 
years often elapse after the laceration befoie the cancer begins"? 
He refers to the rarity of cancer with prolapse as a fact telling 
against the influence of irritation of tlie cervix. Backer thinks 
the relationship between cancer and the having had many children 
is best explained by su})posing that puerperal cervical endo- 
nietritis predisposes to cancer ; but I cannot say that I think his 
argument very cogent. He does not attribute a similar eftect to 
gonorrheal inflammation on the ground that cancer is compara- 
tively rare in prostitutes. He finds that cancer of the vaginal 
l^ortion occurs in younger subjects than other forms, being coni- 
parati\ely most frequent from thirty-one to forty ; cancer of the 
cervix Ijeing, as compared with other forms, more frequent from 
fifty-one to sixty, and cancer of the body after sixty. He, like 
Prof. Sinclair, of Manchester (in Allbutt and Play fair's "System 
of GynaBCology "), lays gi'eat stress on the friability of the growth as 
a means of diagnosis; and in this I agree with him. Lastly, 
Backer gives statistics of the operation results. The cancerous 
uterus was extirpated seventy times in the Buda-Pesth clinic, 
with eight deaths, or 11 "6 per cent. In eight a vesico-vaginal 



298 TlIK YEAU-nOOK OF TREATMENT. 

fistula followed the operation, and in one the rectum was opened* 
These results are not brilliant ; Vjut as a candid statement of 
what may happen after the operation done by experienced liands 
they may be a useful warning to any who will lightly undertake 
it without experience. Among those who recovered 33 per cent, 
were cured, meaning by cure that they lived three or more years 
without recurrence. The best results so far attained after this 
operation are those of Kaltenbach, whose mortality was 3'9 
per cent. 

The operation performed by Ke'zniarszky has always been the 
removal of the uterus, not amputation of the cervix, for three 
reasons: (1) That the disease is more completely removed; (2) 
that amputation of the cervix leads to stenosis and dysmenorrh(ea, 
and, if pregnancy follow, to abortion ; (3) that I'ecurrence is less 
frequent after extirpation than after amputation. I doubt the 
assertion implied in the first and third of these reasons ; the 
second is a valid and, in my opinion, sufficient reason for pre- 
ferring total extirpation. 

7. Hysterectomy. 

The questions that at present occupy chiefly the attention of 
gynfecologists are those connected with hysterectomy. These 
questions refer to two things : (1) The technique of the operation, 
and (2) the cases for which it should be advised. 

(1) As to the technique. Up to 1889 every method of inti-a- 
peritoneal treatment of the stump left after removing a fibroid 
had proved a failure. [" Intra-peritoneal treatment" means 
suturing or in some way securing the stump, di'opping it, and 
closing the abdominal wound.] The only method which was at 
that time safe was securing the stump in the abdominal wound 
outside the peritoneum by a clamp that could be tightened up if 
necessary. The disadvantage of this method is that the part of 
the stump beyond the pedicle has to be separated as a slough, 
either by the natural process or by the surgeon cutting it away 
ten days or so after the operation. After this is done, the surface 
of the stump left has to heal by granulation. Convalescence is 
therefore slower. To wait for a part to be cast off by gangrene 
is a practice which in other departments of surgery has been long 
superseded by quicker methods, and therefore the oi)ponents of 
the clamp are not without theoretical justification in calling 
it " unsurgical." But, nevei'theless, to call the clamp 
"horrid," "barbarous," "unsurgical," etc., is a question-begging 
objection. If the clamp gets the patients well more surely 
than any other way of treating the stump, it is the surgical 
method. At a discussion of the subject by the Obstetrical 



THE DISEASES OF WOMEN. 299 

Society of London in November, 1897, so experienced a 
surgeon as Meredith stated that he was not prepared to give 
up the clamp. The long convalescence is not so weighty 
an argument as it may at first appear ; for operators very 
fond of surgery seem to forget what a grave nervous shock to a 
patient a severe operation is, and this is the san)e whatever the 
method used. If tlie clamp is used, the patient will have to keep 
her bed two or three weeks longer than if it had not been used ; 
but the length of time that will elapse before she regains her 
former nervous tone will be much the same whatever the metliod 
by which the pedicle is treated. 

In 1889 Stimson introduced the ligature of the uterine arteries 
as a part of the operation, and this has made it possible to drop 
the pedicle, close the abdominal wound, and disj^ense with the 
clamj\ Since then discussion has mainly turned on the method 
of ligature. The earliest proceeding was to tie the broad ligament 
in masses as thick as it was safe to trust in the grasp of one 
ligature, and either tie a similar bunch, including the uterine 
ai'tery, or else by dissection more or less isolate the uterine 
arteiy so as to include in the ligature little beside it. This was 
done on both sides, and then the body of the iiterus was cut away 
at or near the level of the internal os. This has been modified 
in two ways : (a) By cutting away the cervix also ; (h) by tying 
the vessels after cutting through them, not before, (a) If the 
cervix is to be i-emoved, the ligatures on the uterine artery must 
be put farther from the cervix. This brings with it danger of 
including the ui-eter, and the uterine artery must therefore be 
more carefully isolated. When the cervix has been cut away the 
ligatures may either be cut short or brought down through the 
vagina, so as to bi-ing down and oppose to one another peritoneal 
surfaces, (b) Doyen, of Rheims, first pushes up by the vagina its 
anterior and posterior fornices and opens them, thus more exten- 
sively and surely separating the bladder and ureter from the 
uterus. Thus he cuts through the broad ligaments from above 
downwards, picking up the bleeding points as he goes. Richelot 
{Revue de Gynecologies 1897) does the whole tiling from above. 
He has the wound held open by a broad retractor, and cuts 
through the lateral attachments of the uterus from above down- 
wards, an assistant being ready with forceps to catch every 
bleeding point as it spurts. When the vaginal attachment is 
reached, Richelot cuts round close to the cervix with scissors. 
Then, having removed the uterus, the vessels grasped with forceps 
are tied in turn. 

The latest American modification of the operation is to tie 



300 TIIK yKAIMi()(»K OF TKKATMKNT. 

and cut thioiij^li the Inroad lij^aiiKMit on one sido from above 
downwards ; then tlie uterine artery ; then to cut hoiizontally 
tliiough the uterus, and tie and sever its attachments on the 
opposite side from l)eknv upwards. This method and that of 
Doyen are tliose which find favour in the eyes of Segond [Revue cle 
Gynecolo(jie, 1897). 

The operation in wliich the cervix is removed differs from 
that in wliich it is left lioliind, in that (1) the [)elvic floor is 
weakened l»y cutting a part out of the middle of it. This, one 
would think, might produce a tendency to vaginal prolapse. I 
liave known such prolapse follow vaginal hysterectomy, and 
therefore believi; it may follow al)dominal ; Vjut I know of no 
operator who has published any repoi-t of the after well-being of 
his patients. (2) It is, as I have pointed out, more difficult from 
the necessity for tying the uterine artery farther away from the 
cervix. (3) The latest German bacteriological researches go to 
show that one function of the cervix is a bactericidal action — that 
it keeps bacteria from ascending from the vagina into the body 
of the uterus. From these two latter featui'es one would expect 
the mortality of this so-called " pan-hysterectomy " to be higlier 
than that of hysterectomy. It is not surprising, therefore, to find 
that Olshausen, who has collected ("Handbuch der Clynakologie," 
herausgegeben von J. Veit, 1897) 806 cases of amputation of the 
body of the uterus, treated by the intra-peritoneal method, the 
cervix being left, and 520 cases of total extirpation of the uterus, 
the so-called "pan-hysterectomy," finds that the mortality of the 
former openition was 5'6 per cent., of the latter 9-6 per cent., or 
nearl}- double. One would think that it was safer to tie vessels 
before cutting through them than afterwards ; at least, the patient 
by the former plan loses less blood. These seem to me the great 
points in the comparison of the difierent methods of operating ; 
all others are comparatively unimportant. 

(2) The other question which is now being much discussed is 
much more important. In the "Year-Book" for 1895 I quoted 
American surgeons who have gravely urged that all fibroids 
should be removed, on the ground that if they are not causing 
trouble now they will at some future time. At a recent meeting 
of the Obstetrical Society {Brit. Med. Journ., Nov. 13, 1897) 
Mr. Bland Sutton read a paper, in which he said " it was becoming 
a plain duty to point out to patients with uterine myomata, as 
was done with those who had ovarian tumoiirs, that the earlier 
the tumours were removed the less the operative dangers." It 
ought to be borne in mind that the prognosis of a fibroid is not 
like that of an ovarian cyst. The ovarian cyst will grow, the 



THE DISEASES OP WOMEN. 301 

fiUroid will not. True, tht'ie are ;i few tumoura cliuically iiulis- 
tinguishable from ovarian cysts (parovarian, simple cysts, der- 
nioiils) which may remain stationary a long time, and even 
undergo natural cure. There are also fibroids which grow to 
a great size, or degenerate and cause great trouble. But these 
are exceptions. When the presence of an ovarian cyst has been 
diagnosed by a competent surgeon, the rule is that it will go on 
growing until it kills the patient. But when a small fibroid that 
is causing no trouble is accidentally discovered, the probability is 
that it never will cause trouble. I therefore cannot agree with 
what Bland Sutton implies — viz. that the advice given to patients 
with small fibroids should resemble that given to patients with 
ovarian tumours. At the same meeting (and at former meetings) 
small batches of extirpated fibroids have been exhibited, ap- 
parently to show that patients might survive the operation. One 
of them was a small submucous fibroid, about the size of an 
orange, which, in the opinion of many present, could have been 
easily and safely removed by the vagina, a mode of treatment 
which would have left the patient unmutilated, and have spared 
her the risk of abdominal section. 

In deciding whether or not a fibroid should be removed, the 
ultimate judge is, of course, the patient. But she will l^e influenced 
by what she is told of the consequences of the alternative courses 
before her. Wliat are these 1 Take the case of a woman who 
has a fibroid which has attracted attention by its size, but which 
is not large enough to cause distress. Suppose she lets it alone. 
What will happen 1 Her belly will remain big, and may get 
a little bigger. It is possible that it may get very big. It is 
also possible that degeneration of the tumour may set up in- 
flammation, or that it may get incarcerated or adherent in such 
a way as to interfere with other organs by its pressure. But 
these things are very unlikely. The probability is that an 
increase of an inch or two in her waist measurement will be all 
the trouble that her tumour will give her. Suppose that the 
tumour is removed. Some mishap during the operation may kill 
her in a few days, and the cause of death may be one, such as 
intestinal obstruction or tetanus, beyoiid the operator's control. 
This is unlikely, because, while the tumour is small and the 
peritoneum healthy, the operation is easy and tolerably safe, but 
it is possil)le. The mortality of these operations is not less than 
one in twenty. If she recovers, she will have three weeks in bed, 
and it will be months before she regains the tone of her nervous 
system. The days following the operation will be very un- 
pleasant ones, mai'ked by vomiting, thirst, pain, and anxiety. 



302 THE YEAR-BOOK OP TREATMENT. 

After she gets up she will have a scar, a weak place in tin; Ijcily 
wall, wliicli even years afterwards may give; way and allow a 
hernia to protrude and possibly get strangulated. If she he 
young and the ovaries have been removed, the menopause, with 
atrophy of the remaiiung genitalia, will come on prematurely. 
None of these things are desirable. What does she gain by 
submitting to all this ? Nothing but a slightly smalhsr wai.st, 
and s(!cui'ity against some contingent but improljable dangers. 
I think a sane woman will prefer to wait as she is. 

I have referred above to a case in which a patient was 
deprived of her uterus as a cure for a fibroid which some thought 
could safely and easily have been removed l)y enucleation, while 
others at the meeting spoke of enucleation as being more dangerous 
than hysterectomy. The apparent conflict of opinion is (^xphiined 
by the different proceedings to which the term enucleation is 
applied. Thus I find a case reported in which first of all five 
laminaria tents were inserted, and tlien, under ether, the lower 
portion of the tumour was separated from the uterine -wall, 
A week afterwards, laminaria tents were again inserted, and 
attempts made with the finger, volsella, cephalotriVje, and mid- 
wifery forceps (!) to remove the tumour, but in vain. Lastly, 
the operator cut away as much as he could with scissors. The 
patient died. I quite agree that this sort of thing is uiore 
dangerous than hysterectomy. But I do not call this the proper 
way of enucleating a fibroid. The essential features of enuclea- 
tion are (1) dilatation of the cervix till it will admit two fingers ; 
(2) cutting up the tumour into little bits, and removing a bit at 
a time ; (3) strict antisepsis throughout. In this way a sub- 
mucous fibroid as big as a foetal head can be easily and safely 
removed. The mortality of attempts such as I have quoted is 
not the mortality of enucleation but the mortality of bad 
surgery. 

The above remarks do not apply to hysterectomy for tumours 
so large as to destroy the patient's health or comfort, or in 
situations such that any increase in size will bring about dangei'ous 
pressure effects, nor to rapidly growing tumours, nor to bleeding 
fibroids too large to be dealt with by the vagina. But the per- 
formance of hysterectomy as the routine treatment for all fibroids 
is not, in my opinion, good surgery. I have put the mortality 
of hysterectomy as being at least 5 per cent. This, I think, is an 
under-estimate. It is the lowest shown in Olshausen's collection 
of cases from various sources {vide supra). Such compilations 
generally understate mortality, for successful cases find their way 
more easily into print. Mr. Sutton's mortality was two out of 



THE DISEASES OF WOMEN. 303 

28, or 7"7f) per cent. Polk (^Anieriraa Gy)ia'cological and Obstet- 
rical Journal, Sept., 1897) has published his M^iole experience, 
extending over fourteen years, and it shows a mortality of 12-98 
per cent. How diHerent the views taken by ditferent operators 
as to the necessity for operation may be is shown by the fact that 
Mr. Sutton in eighteen months met with 28 cases calling for 
hysterectomy ; while Dr. Lusk at the Bellevue Hospital, New 
York (^American Gyiuecoloyical and Obstetrical Joiwnal, Sept., 
1897), in thi-ee years only met with live. Lusk's views on the 
treatment of fibroids will be found in the " Year-Book " for 1896. 
I next quote an account of a mode of treatment which may be 
found useful in the case of patients who object to radical treat- 
ment. I should have thought that a collateral circulation would 
so soon be established that the operation would prove useless, 
but a priori prejudices must give way to facts. 

§. The ligature of the uterine arteries as a means 
of stopping: iiceniorriiag^e from fibroids. 

When a main artery is tied in a limb we know that an 
anastomotic circulation is very quickly established. The tem- 
porary arrest of the blood current to an aneurysm a little way 
below the ligature lasts long enough for the coagulation of 
enough fibrin to fill up the aneurysm ; but the nutrition of parts 
situated farther away from the ligature of the artery is hardly 
aftected at all. With this fact in mind, it does not seem to me 
that on a priori grounds much is to be expected from cutting off 
part of the blood supply of a uterine fibroid. For this reason, 
although this treatment was proposed five years ago and has 
frequently been the subject of comment since, I have not pre- 
viously thought it worth while to take up space in the " Year- 
Book " by a reference to it. But a jjriori opinions must always 
yield to observed facts. Franklin H. Martin, of Chicago, who in 
1892 originally proposed this therapeutic measure, put before the 
meeting of the British Medical Association at Montreal his 
experience of its results, and his views as to the cases for which 
it is specially suitable. 

Martin defines the aim of the operation as being both to cut 
off a large part of the blood supply of the utervis and to change 
the nutrition of the uterus by interfering with its nerve supply. 
He does it by tying the base of the broad ligaments ; and it is 
obvious that it could be also eflected by compressing them with 
forceps. He also speaks of tying the whole of one broad ligament 
and the base of the other ; but if so extensive an operation as 
this is done, it seems to me that it is but a very small step farther 
to remove the uterus. He precedes the opei'ation by curetting, 



304 THE YKAR-nOOK OP TREATMENT. 

iii-i^iitiu;!^, iiiid packing witli ;^au/c the iiteiiiin cavity. This 
seems to nic a c(^inplication wliich makes it <litticult to jurlf^e 
which is the henelieial agent, the curetting or the ligatui'c. But 
I pass tliis point and go on to the results. 

Tlie following are the advantages which Martin claims for 
this new treatment : (1) From the standpoint of mortality it is a 
minor op(!ration. There is no shock nor long convalesc(;nce. In 
case the operation should prove a complete failure it can do no 
harm. (2) It does not unsex the woman. One of Martin's patients 
bore a child after it. (3) The operation is applicaV>le in those 
desperate luemorrhagic cases where the depletion is such that 
more radical measures are prohibited. It provides a means of 
instantly depriving these tumours of two-thirds of their l)lood 
supply. Afterwards, when recuperation has occurred, more 
radical measui'cs become safe, should they be deemed necessary. 
Martin relates six cases of this kind. Four were cured ; haemor- 
rhage ceased immediately, and the tumour was reduced in size 
and "practically disappeared." In the two others there was 
immediate improvement, but one relapsed ; and in the other 
severe neuralgic pains persisted, so that hysterectomy was done. 
(4) This operation can be resorted to in cases of fibroids in which 
the mechanical difficulties in the way of a radical operation are so 
great as materially to increase the risk of such operation. These 
are few, but Martin has had one. In it "the cure was magical." 
He thinks there are many similar cases, and that the more fre- 
quent ajDplication of this operation would lessen the death-rate of 
hysterectomy. (5) Martin thinks that this operation should be 
given preference in all interstitial bleeding fibroids which are 
discovered by their ra}>id growth and increased haemorrhage just 
as the menopause is approaching. In such cases a surgeon will 
hesitate before advising a woman to submit to hysterectomy when 
he is reasonably certain that nature, after a year or so, " will be 
able to do a better job." (6) This oiJeration may be employed as 
a substitute in all cases of growing and bleeding fibroids where 
patients a):)solutely object to radical operations. Martin's final 
limiting word is that this operation is not applicable in cases of 
pedieulated submucous or subperitoneal tumours. 

In the discussion which followed Vineberg, of New York, said 
he had performed the operation in five cases of bleeding inter- 
stitial fibroids, and the results were either temporary or entirely 
nil. Extensive sloughing of the cervix took place afterwards, 
showing that the uterine arteries w^ere completely tied off. 
Professor Skene, of Brooklyn, favoured the operation in young 
women with 1 deeding fibroids, for if the operation fail the uterus 



THE DISEASES OF WOMExX. 305 

can afterwards be removed. He tlioiiglit that about one case in 
tivp could be benefited in this way. 

9. The ««urg^ioai ti'ontiiient of retroflexion. 

In last year's "'Year-Book" I referred to this subject. I 
then expressed the opinion that in certain cases of retro- 
flexion, in which other means of relief fail, we have in vaginal 
fixation a means of cure. I mentioned that it had been urged 
against the opeiation that if the patient subsequently should 
become pregnant, the fixation of the uterus would lead to disas- 
trous consequences. I quoted, among others, a brief abstract of a 
paper read before the Geneva Congress of Obstetrics and 
Gynaecology by Professor Kiistner, of Breslau. Quoting only from 
an abstract, it was impossible to do justice to Kiistner's thought- 
ful, dispassionate, and laborious sumn)ary of the questions at 
issue. The paper has since been published as one of Volkmann's 
series of clinical lectures, and I think that it may interest and, 
perhaps, instruct the readers of the " Year-Book." 

After remarking on the differences of opinion that exist as to the 
pathological effects of uterine displacements, Kiistner thus defines 
his own position. He thinks that " every movable retroversion 
and flexion occurring in a woman of child-bearing age requires 
tieatment, even if, as some say, it is causing no symptoms ; or if, 
as it is more coriect to say, the subject of it either is not aware 
of any symptoms (which is not connnon), or (which is frequent) 
the patient or her doctor has not recognised the causal relation- 
ship of the uterine displacement to the symptoms. Now were 
there a method of operative treatment as safe and as free from 
undesirable effects as a well-fitting pessary, it would have the 
advantage that the correction of the displacement would be 
permanent, and would therefore generally be preferred to treat- 
ment with a pessary." Fi'om this general proposition Kiistner 
excepts retroversion of the gravid iitei'us and of the puerperal 
uterus. 

I may say, in passing, that if a patient has no symptoms I 
see no reason why she should be treated either by a pessary or an 
operation. But as what concerns us here is the effect of the 
operations, I argue not this point. 

In the opinion of Kiistner none of the operations, even when 
performed in the best possible way, restores a normal state of 
things. But the result of each one is preferable to the condition 
of retroversion or flexion of the uterus. 

(1) Alexander's operation in its original form, in which the 
ligament was sought for in the inguinal canal, was not certain 
enough. Often, especially in virgins, the distal end of the round 
U 



306 THK YKAH-HOOK OK TKKATMENT. 

ligament is Uiiii, hard to (iiid, (!asy to mistake, easy to tear. 
TIk! operation lias been greatly improved hy Edebohls, Werth, and 
Kocher, who have lengthened the incision, and so rendered it 
possible to find the ligament with certainty. Greater certainty 
ill tiiiding the ligament means more accurate stitching, and there- 
f(ne more permanent results. 

(2) Veidral fixation. — Kiistner thinks that fixation of the 
uterus I)}'' sewing it to the abdominal wall is easy and certain. 
He thinks the permanency of the results of other methods than 
this of fixing the uterus after opening tlie belly is doubtful. I 
think it not worth while to describe these. 

(.3) Vaginal fixation. — Kiistner, in his remarks upon the 
therapeutic v.due of this operation, takes together all the ditlerent 
methods of doing it, and consequently thinks that relajjse 
frequently follows. I am not surprised that relapse should 
follow operations by some of the metliods proposed ; for I think 
the ditferent methods are of very uneipial value. Kiistner after 
this refers, but not with approval, to certain proposals to fix the 
uterus to the back of the pelvis. I share his opinion of these, 
and therefore mention them not. 

Next in importance to the permanency of the result, says 
Kiistner, comes the question how far the function of the uterus 
is influenced by the operation. 

Kiistner quotes all the evidence that has been published to 
show that labour is apt to be difficult after ventral fixation. He 
holds it as to-day certain that ventral fixation of the uterus 
little, and only in exceptional cases, influences the function of the 
uterus. These exceptional cases are those in which the operation 
has been performed in an exceptional way. The closer operators 
keep to the advice of Olshausen the rarer will be these cases. 
Disturbance of labour follows not the operation but wrong per- 
formance of the operation. 

Vaginal fixation of the uterus has been in some cases followed 
by ill consequences in pregnancy and labour. The root of these, 
in Kiistner's opinion, is overdoing the operation, fixing the whole 
of the anterior surface of the uterus instead of being content 
with fixing the lower half only. This is enough to give a 
permanent result, and not enough to produce any serious conse- 
quences in the event of pregnancy. But there is an increased 
tendency to abortion after this operation, and this is the sole 
objection to it. Were pregnancy afterwards negatived, then 
this operation would be a valuable and indispensable addition to 
gynaecological surgery. No ill effects have in the event of 
pregnancy ever followed Alexander's operation. 



THE DISEASES OF WOMEN. 307 

Kiistner then considers the treatment of fixed, adherent retro- 
flexion. Here, he points out, operation consists of two things : 
First, separation of adhesions ; second, fixation of the uterus in a 
proper position. Attempts to fix the utei-us in a normal position 
before separating adhesions are alisolutely irrational, always have 
failed, and always will fail. In considering the treatment of 
adbesious the cause of the adhesions is important. The adhe- 
sions result from inflammation set up by microbes. The 
microbes are of two kinds : the gonococcus and the ]>yogenic 
organisms that infect wounds. The adhesions produced by these 
two agents present important differences, to which enough 
attention has not hitherto been paid. In ascending gonorrhoea the 
tubes sufter most ; the inflammation reaches the peritoneum by 
travelling along the tubes and not by s])reading through the 
uterus. Hence, with adhesions from this cause thei'e are also 
changes due to old salpingitis. But septic inflammation, on the 
contrary, extends through the wall of the uterus to the peri- 
toneum before it has reached the tubal mucous membrane ; and, 
therefore, with adhesions from this cause tubal inflammation is 
generally absent. Kiistner thinks that although adhesive 
inflammation is generally caused by microbes, it is yet not 
improbable that, when the uterus has lain long in an abnormal 
position, the continued pressure upon parts which ought not to 
be pressed on may lead to destruction of epithelium and adhesion ; 
for occasionally the retroverted uterus is found adherent in 
^^rgins. 

The proper treatment depends upon the nature of the 
adhesions. With acute inflammation of the tubes or pelvic 
peritoneum retroversion is an insignificant factor in the case ; the 
acute inflammation dominates treatment. When acute inflam- 
mation has subsided the proper treatment depends upon the 
condition of the tubes. It is only in cases in which they can be 
preserved that it is worth while to alter the position of the 
uterus. If the tubes are so diseased as to require removal, 
the fixation of the uterus is an unnecessary complication of the 
operation. Removal of the uterus along with the tubes is the 
best thing, and as a rule this should be done by the vagina. 
'But cure without mutilation is the highest aim of treatment. 

Assuming that the case is one in which the rectification of 
the position of an adherent and retroverted uterus is desirable, 
the next question is how to do it. The author fii'st considers the 
methods, recommended by Schultz and others, of breaking down 
adhesions by pressure through the vagina and by massage. The 
latter process he condemns as too slow for practice, and too 
U2 



308 THE YKAK-BOOK OF TUEATMKNT. 

uncertain for science. Schultz's nietliod lie iilso rejects because, 
first, it often fails, and secondly, because if the tulies are diseased 
it is dangerous. Great force slioidd not be used except under 
ocular control. [I agree with Kiistner's condemnation of both 
these proceeedings. I do not Vjelieve that a uterus adherent in 
Douglas's pouch can Ije separated from the adh(;rent peritoneum 
by any manipulation outside the ]jeritoneal cavity. It may be 
pushed up, but will then carry the adherent peritoneum with it, 
and fall back when the pushing is withdrawn. If there be an 
abscess in tube or ovary, this may l>e Imrst by such manipulations 
with fatal consequences.] Nor does Kiistner approve of separating 
adhesions in Douglas's pouch through an opening in the anterior 
vaginal wall. He has known such a proceeding followed Vjy 
hsemorrhage so great that the operator was obliged to go on to 
extirpation of the uterus. The proper mode of liberating an 
adherent utei'us is, in Kiistner's opinion, abdominal section in the 
raised pelvis position. The operator can then see what he is 
doing, ascertain the condition of the a})pendages, and control 
hsemorrhage. When the uterus has been freed, it is best fixed 
by suture to the abdominal wall. 

Kiistner has collected statistics of their operations in cases of 
retroflexion from 71 operators. He has got together 1,120 cases 
of ventral fixation. In 637 of these the uterus was fixed, in 443 
not fixed. I presume that in the remainder information was not 
given. There were 7 deaths — 2 of them from intestinal obstruc- 
tion — a mortality of "6 per cent. It is not stated in what pro- 
portions the deaths occurred in the non-adherent and adherent 
cases respectively. Relapse occurred in at least 44 cases, or 3 '9 
per cent. In many the result was simply stated to be " good " — 
an adjective which in this case is meaningless. Subsequent 
pregnancy was observed in 122. Delivery was noi-mal in 74. 
In 15 abortion or premature labour occurred (a proportion rather 
below the average, which is 1 to 5). There were 1 tubal 
pregnancy, 3 transverse presentations, 1 case of retention of 
placenta, and 2 cases of Csesarean section, for what reason is not 
stated. 

Kiistner has collected 376 cases of vaginal fixation without 
opening the peritoneum, and 410 in which it was opened ; 786 in 
all. In 514 the utex'us was movable, in 163 fixed. I presume 
that in the remainder information on this point was not given. 
There were 3 deaths ; their causes and the class of cases in 
which they occurred are not stated. In 72 the retroflexion was 
reproduced either before or soon after the discharge of the 
patient. In 92 there wei-e subsequently functional ill results, 



THE DISEASES OF WOMEN. 309 

details not given. In 23 subsequent pregnancy ran a normal 
course. Besides these there were 13 abortions, and one case of 
placental retention, and 5 complications iii labour, transverse 
presentations, and eclampsia. Lastly, in 5 cases the retroversion 
recurred in childbed. 

Kiistner's own results are the following : — Out of 687 cases 
of retroflexion he has treated 292 by operation. In 140 cases 
the operation was ventral fixation. There were 2 deaths, 1 
from diabetic coma, and the other from a peritoneal abscess 
opened during the operation. The result as to function was 
without drawback in any case. Nine pregnancies were observed 
with 2 abortions, 2 still births, 1 case of turning. Kustner 
treated 81 cases by vaginal fixation. In nearly all the uterus 
was movable. Out of 42 cases subsequently examined, in 12 the 
displacement was found to have returned. Subsequent preg- 
nancy was observed in 9 cases. Four ended in abortion, 2 
in dead-born children ; in 1 forceps delivery was requii-ed. In 
2 the displacement returned in the puerperium. Kustner treated 
71 by Alexander's operation. Twice he failed to find the liga- 
ments, and once he did the operation only on one side. No 
harm followed in either. Out of 65 subsequently examined, 
relapse occurred in 8. Five subsequent labours were observed, 
all of them natural. 

I think these figures will materially help the profession to 
form a judgment on these opei-atious, first on account of the lai-ge 
number of cases they comprise, and, secondly, because I think 
they show tlie worst eflects that are ever likely to follow these 
operations. Adhesions in the pelvis cannot be broken down 
without some risk, either immediately from hifimorrhage or later 
from the multiplication of microbes in blood which has oozed. 
Hence I think that a collection of cases in which this is done 
will always show a mortality great enough to deter many from 
the operation. But when the uterus is not adherent its suture to 
the abdominal wall is so simi)le and easy a thing that, if done 
with clean hands and instruments, there ought to be no mortality. 
I regard Kiistner's collection of cases as showing a mortality 
higher than that which belongs to fixation of the uterus, because 
it includes cases in which adhesions were broken down. Then 
with regard to the further question of the permanence of the 
result. It is certain that peritoneal adhesions may be absorbed, 
and therefore that, among cases in which peritoneum is sewn to 
peritoneum, in some the adhesions will be absorbed. But when 
peritoneum is sewn to muscle there is no reason, from experience, 
to expect absorption of adhesions. Kiistner's statistics do not 



310 THR YEAll-IiOOK OF TREATMENT. 

tell US in how many cases peritoneum was sewn to peritoneum, 
in liow many peiitoneum sewn to muscle. I think it probably 
iiiclutles many in which peritoneum was sewn to peritoneum, and 
therefore shows more relapses than need have occurred. The 
tables of vaginal fixation include cases in which the operation 
was done without opening the peritoneum — a l)lind proceeding in 
wliich tlie operator cannot tell what he is doing, and after which 
it is not surprising that relaj)ses should occur. 

The ligures show plainly enough that ventral fixation done in 
a proper way does not inteifere with pregnancy and labour, but 
that it is possible to do vaginal fixation in such a way as to 
cause a tendency to miscarriage. This efiect is not inevitable, 
and only follows in a minority of cases. Alexander's operation 
is without any effect on pregnancy or labour. I have not quoted 
the figures Kiistner gives as to Alexander's operation, because 
this operation is difficult, not free from danger, and sometimes 
followed by relapse. By vaginal fixation the uterus can be 
stitched in a position of such anteversion that relapse is scarcely 
possible. My impression is, although I cannot adduce proof, 
that the better the uterus is secured in anteversion the more 
surely are symptoms permanently relieverl, and also the more 
likely is pregnancy to end in miscarriage ; that if only one 
or two stitches are put in near the os internum, preg- 
nancy will not be interfered with but the displacement may 
return. 

I do not recommend any of these operations for patients in 
whom the uterus can be kept in a natural position by a vaginal 
pessary, and therefore I do not find cases calling for such opera- 
tions in anything like the numbers that Kiistner finds them. 
But I am sure that there are cases in which retroflexion causes 
enough local suffering to spoil the comfort of a woman's life, and 
for various reasons vaginal pessaries are ineft'ective. Some of 
these occur in parous women, and are associated with distinct 
though slight prolapse. For them I think ventral fixation is the 
best remedy. Others occur in the sterile without appreciable 
prolapse. For them I prefer vaginal fixation. Most patients 
will prefer freedom from local pain and pregnancy, even with 
a possibility of abortion, to suffering and sterility. 

10. Oil lia;iiiatos»lpiiix with nicnstriial retention. 

Meyer (^Zeit. far Geh. und Gyn., Bd. xxxiv. and xxxvi.) has 
written important papers in which he, as I think successfully, 
impugns the current teaching that the blood in the Fallopian 
tubes which often accompanies retention of menses has arrived 
in the tube by regurgitation from the uterus in consequence of 



THE DISEASES OP WOMEN. 



311 



obstruction to its normal outflow. This is the teaching of ahnost 
every textbook, including the great clinical lectures of Matthews 
Duncan. 

Meyer has pointed out that if blood did flow back into 
liealthy tubes it woukl run into the peritoneum and be there 
absorbed. Its retention in the tubes is because their peritoneal 
extremities are closed, and were closed before menstruation 
began. Their closure points to the past existence of salpingitis 
and perimetritis. It is known that luematosalpinx does not 
always accompany menstrual retention, and the current doctrine 
has been that the higher up atresia occurs the less room is there 
to accommodate the retained menstrual blood, and thei-efore the 
greater is the probability that some of it will flow back into the 
tubes. Meyer shows that this is not so. He says that luemato- 
salpinx is not found with atresia due to a congenital defect— a 
vaginal septum. But it is found with a broad atresia; whether 
this be higli up or low down. The reason is that a broad atresia 
is of inflammatory origin. The same inflammation that sealed the 
tubes also led to adhesion of vaginal wall. The blood in the 
tubes comes from the diseased tubes themselves. 

In tlie second paper Meyer considers cases of unilateral 
atresia with retention of blood in the vagina, uterus, or Fallopian 
tubes. He shows reason for thinking that many cases of uni- 
lateral atresia are due to infective disease acquired after liirth by 
the possessors of a double genital canal. In them the hiemato- 
salpinx is explained also as being due to bleeding from a diseased 
tube sealed up by inflammation. Some are, however, congenital ; 
notably those cases of bicorned uterus in which one horn joins the 
other at about the situation of the os internum. In these cases 
Meyer holds that hfematosalpinx is due to an infective process. 
The closed half of the genital canal may be infected from the open 
half, either by the gonococcus or other infective organism. 
Menge quotes cases in which the closed half of the canal showed 
such clear evidence of inflammation as ulceration, destruction of 
mucous membrane, and suppuration. In these cases there is 
great danger from rupture of diseased tubes. In ha^matometra or 
hpematocolpos the fluid can be liberated with safety by the vagina, 
but tubal distension can only be dealt with by laparotomy. If 
there is good reason to believe that hsematosalpinx is present, 
laparotomy should not be postponed, for to postpone it is to 
expose the patient to much risk of rupture. 

Meyer's valuable paper concludes with a tabulated summary of 
112 cases of unilateral atresia and a full bibliography of the 
subject. 



312 THE YEAR-HOOK OP TKEATMKNT. 

II. I\:is:il 4l,vsiii4'iioi-iii4i':i. 

Wilhelm Fliess lias made, a uomiiiuiiifaUoii lu tin; Ijcrliii 
01jsU;trical Society {Zed. J'ilr (Jejj. mid (/ifn., Bd. xxxvi.) of so 
novel a character that I quote it, although I have not yet had 
opportunity of testing it in practice, and my kno\v](;dg(! of the 
nose is not enough to enable nie to appraise as an expert the 
value of tlie autlior's statements. 

According to him, there is a part of the nose which, by njeans 
of the sympathetic nerve, is so closely connected with the genital 
organs that it should in future be known as tlie genital area 
[Ut'.nital stall e). At this [)lace capillaries do not enter directly 
into the veins, but pass first through a number of anastomosing 
convoluted cavernous blood spaces. At the time of menstruation 
these cavernous places swell, beconu; cyanotic in colour, and are 
easily made to bleed. 

Fliess divides cases of painful menstruation into two groups. 
In the first the pain ceases when the flow is established. In the 
second the pain continues although the uterus is bleeding. For 
the occurrence of this pain a certain abnormal condition of the 
nose is a necessary condition. This pain promptly diminishes 
when the genital ax'ea (which, if I understand the author idghtly, 
is over the inferior turbinated bone) is swabbed with a 20 per 
cent, solution of cocaine. Not all cases of such menstrual pain are 
cured in this way, for some are hysterical — that is, of psycliical 
origin — and not dependent upon any local change, but the 
majority are thus cured. Cocaine injected subcutaneously does 
not relieve the pain ; the reli^■f comes from the ansesthetisation of 
the genital sphei'e of the nose. If the genital area of one side only 
o.' the nose is anaesthetised, the pelvic pain on the opposite side of 
the body is relieved. The relief is not due to suggestion, for it 
takes from five to seven minutes to bring it about ; and it does 
not follow antesthetisation of any part of the nose except the 
genital area. 

The disease in the nose, Fliess thinks, is of infective origin, a 
legacy from measles, scarlatina, influenza, or some rarer disease. 

Fliess also finds that by anajsthetisation of the genital area of 
the nose labour pains can be much diminished. The only pain so 
diminished is that of uterine contraction ; continuous local pain 
from pressure is unatlected by it. 

Tiiere is at least this to be said for Fliess's recommendation, 
that if he be in error and his treatment useless, it will do 
no great harm, and in that respect it contrasts favoural)ly with 
many modes of treatment which have been and are practised for 
dysmenorrhoea. 



MIDWIFERY. 

By M. Han dfiki.u- Jones, M.D. Lond., 

Ohstelric Physician to St. Mar\j's HospiloJ, and Lecturer on Midn-ifery and Diseases 

of Women to St. Mary's Medical School. 



During the past twelve months no work lias been done in the 
department of obstetric medicine and surgery which can be said 
to have marked any detinite advance in our knowledge. Evidence 
has been slowly accumulated to show that the operation of ventri- 
fixation for prolapsus or })Osterior displacement has a definite 
tendency to raise difficulties in consequent deliveries, and must be 
unhesitatingly condemned. The operation of vaginal fixation is 
certainly open to less serious objections, but, at the same time, on 
the score of utility as well as on the question of its bearing on 
later pregnancies, must be considered as being still sub j^idice. 

Evidence regarding the use of the antistreptococcus antitoxin 
has been again brought forward, not that the utility of the treat- 
ment can at present be regarded as assured in all cases of puerperal 
intoxication, but rather because it seems to be more and more 
apparent that no detinite bad result can be attributed to the use 
of this antitoxin, while in a fair percentage of the cases quoted 
it is abundantly proved that some manifestations of s^^ecial 
poisoning are undoubtedly removed by free and early use of 
this treatment. 

I.— PHYSIOLOGY. 

1. Deflection aii<l rotation of the preg^nnnt and 
puerperal uterus. 

Milne Murray (Edln. Med. Journ., Feb., 1897) discusses the 
various views that have been put forward to explain this condition. 
He considers that it is to the construction of the muscular wall of 
the uterus that we must look for the explanation of the tendency 
to rotation. The rotation and deflection persist for a few days 
after the expulsion of the child. He notes the curious fact that in 
occipito-posterior cases the deflection of the uterus is nearly always 
to the left instead of to the right, and it is an interesting fact 
that there is a fairly close numerical relationship l)etween the 



314 THR YEAK-nOOK OF TRKATMFNT. 

l)r()poition of cases of occipito-posterior position and cases of left 
lateral (leviatioii. 

Out of twenty-six cases of occipito-postei-ioi- position observed 
by Milne Murray, eighteen showed definite leftr-sided deviation 
after labour. In the other cases the uterus lay in the middle line, 
and in none of them was the ordinary right-sided deviation 
observed. Schroder and Stratz have noticed the same thing, Ijut 
no satisfactory explanation has been given. It is a matter of 
some doubt whether the position causes the deviation or the 
deviation the position. 

'i. "Is tliere a Positive Pressure in flie Grouiiiu: 
Pi'e^iiniit Ulei-HS?" is another physiological subject discu.ssed 
by Milne Murray at the Edinburgh Obstetrical Society on Feb. 10. 
He said that the physical relations of the growing pregnant uterus 
might be best realised Ijy regai'ding it as a sac enclosed witliin a 
distensible capsule, which was composed of the abdominal walls, 
the diaphragm, and the pelvic floor. Assuming the intra-abdominal 
pressure to be neutral at the beginning of pregnancy, the uterus 
as it grew would require to push aside or lift up the viscera, and 
a gradual increase of the intra-abdominal pressure would result. 
This increase of pressure could be obviated only if the alxlominal 
muscles underwent physiological enlargement to the same extent 
as the enlargement of the uterus. The anterior walls bulged 
obviously, and the question was : Did this bulging occur with the 
same tension as in ordinary circumstances, or during pregnancy 
was this bulging attended with increase of tension due to increased 
pressure behind them 1 That this tension was increased was 
evident by different facts : the fo-tal head in all primiparaj and 
in many multiparfe was kept in position in the pelvis by the 
tension of the resisting abdominal muscles ; the walls in the 
majority of cases became thinner as pregnancy advanced ; the 
]3resence of striae gravidarum or cracks ; the discomfort due to 
even slight degrees of flatulence in the compressed intestines , the 
shallowness of the respiration showing that the diaphragm is 
impeded in its action ; and the projection of the jjelvic floor. 
Separation of the walls of the uterus could only be effected hj a 
pressure on the part of the ovum greater than that of the extra- 
uterine region. 

II.— PATHOLOGY. 

1. Placenta prsevia. 

Heil (^L'Obstetrique, January 15, 1897) describes the practice 
now adopted at the Heidelberg Maternity in dealing with 
placenta praevia. The membranes are first ruptured so as to 



MIDWIFERY. 315 

bring down the liead. When dilatation is complete there is no 
doubt what ought to be done. But if the os remains small, and 
in cases where the haemorrhage begins befwe labour, antiseptic 
plugging of the vagina and cervix is indicated. Braxton Hicks's 
method is dangerous for the child, but quite allowable if it be 
dead or hardly viable, or if the mother be in immediate danger. 
Heil notes 28 placenta prjevia labours, 29 children being l^orn ; 
4 mothers died (1-1 '28 per cent.) ; 14 had high temperatures ; in 
10 of these the tampon had been employed ; out of the remaining 
14, where there was no fever, the tampon had been inserted in 6. 
Out of the 29 children, 19 (65 "5 per cent.) were at full term, 9 
delivered dead, 4 died within twenty-four hours of birth, and 16 
(55 -1 per cent.) survived. In 2 cases admitted with complete 
dilatation both mother and child were saved. Out of 19 children 
at term that were living when labour began, 11 were deliveied 
alive by turning, whilst in 8 eases the tampon was applied till 
dilatation was complete, only 1 child being lost, and in that 
instance the pelvis was rachitic ; all 8 mothers were saved. These 
statistics are favourable to the tampon. 

JHyhoS (Jlonats. /. Geburtsh. u. Gyndk., Nov., 1896) strongly 
objects to tlie routine treatment of placenta prsevia centralis by 
the same method as is right \i\ placenta prtevia lateralis, namely, 
rupture of the membranes and turning. He carefully breaks 
through the middle of the- presenting placenta and separates it 
from the amnion ; this manoeuvre is easy when the amnion is 
tough and not adherent to the placental tissue. The labour can 
then continue as in normal cases, the bag of waters dilates the os, 
and the "chances are better for the child. No chloroform is 
needed, and an antiseptic tampon can be readily applied to the 
vagina. In lateral placenta prjevia this manoeuvre is not 
advisable, since the amnion and placenta adhere too firmly in 
such a case. NyhofF also warns the obstetrician not to employ 
his method when pains are absent or weak, and when the amnion 
is closely adherent to the placenta, or gets torn during separation. 
Turning and bringing down the leg are needed at once in the latter 
condition. When pains are weak the tampon may be tried for a 
short time. 

la. The ti'eatiiieiit of placenta praBvia by Cliaiii- 
petier de Ribes's bag:. 

Blacker, at the Obstetrical Society of London, April 7, 1897, 
in his jjaper, said that in the more severe cases of hfemorrhage 
from placenta prtevia Charapetier de Ribes's bag might be 
employed in place of version by introducing it into the amniotic 
cavity after rupture of the membranes. Used in this way the 



316 TUB YEAR-IJOOK OP TREATMKNT. 

bag acted l)oth as a tampon in arn^sting the liaMiioriliage by 
pressing the separated poition of ])lacenta firmly against tlie 
uterine wall, and also as a dilator of the cervical canal and a very 
powerful stinndus to uterine contractions. The use of the bag 
was tlierefore advocated in grave cases of ha'niorrhage from 
placenta pneviaas an easy method of arresting the ha-morrhage, 
and at the same time as likely to I'educe the heavy ftetal mortality 
which usually occurred in these cases after the performance of 
version. Blacker had treated five cases of placenta prsevia in 
this way, and had collected seventeen others similarly treated. 
He gave an analysis of the chief features of interest in the cases 
detailed, showing that only in one case did severe luemorrhage 
occur after the intr-oduction of the bag ; that such luemorrhage 
might as a rule be readily controlled by traction on the bag ; that 
in none of the cases was any dithculty experienced in introducing 
the bag, or was preliminary dilatation of the cervix necessary ; 
and that the average length of time required for the complete 
dilatation of the cervix after the introduction of the bag was five 
hours and ten minutes. 

Of the mothers, 1 died from septictemia — probably present 
on her admission to the hospital — before the introduction of the 
bag. Of the others, 5 had a slight rise of temperature during the 
puerperium, the highest point reached being lOO'G" F., while in 
the remainder recovery was perfect and the pvierperium afebrile. 
Of the 22 children, 14 were born alive, and 8, or 36-3 per cent., 
dead. Of the 14, 4 subsequently died, giving a total mortality 
of 54-5 per cent. The advantages claimed for the bag were : 
(1) Ease and facility of introduction ; (2) the certain arrest of 
the haemorrhage ; (3) any further hiemorrhage was controllable 
by traction upon the bag ; (4) the bag, and not the child's body, 
dilated the cervical canal ; (5) the ease of delivery after expulsion 
of the bag ; (6) the fact tliat the bag was a powerful stimulus of 
uterine contraction ; and (7) the lessened foetal mortality as 
compared with the results obtained after version. The objections 
that the bag was difficult to introduce, and that preliminary 
dilatation of the cervix was required, were shown to be ground- 
less. Even in cases of central placenta prpevia the use of the bag 
was practicable and likely to give results just as good if not 
better than the performance of version. 

Herman said that he thought the bag was a better plug than 
tlie half breech because it pressed on the whole circumference of 
the lower uterine segment, while the half breech did not. The 
haemorrhage in placenta prajvia was produced by dilatation of 
the cervix, hence the bag could always be introduced when 



MIDWIFERY. 317 

considerable hfemorrliage liud occurred. His own experience of 
the use of Cliampetier de Ribes's bag in placenta prjevia was 
altogether favourable. 

Horrocks said that for some years he had used Chanipetier de 
Ribes's bag not only in cases of placenta previa, but also in all 
cases where formerly Barnes's hydrostatic dilators had been used. 
In cases of placenta praevia, the bag had been placed in the 
amniotic cavity only when the membranes had been ruptured. 
In cases where they had been intact, care had been taken to 
avoid rupture. The presenting portion of the placenta had been 
detached by sweeping the finger round the lower zone, and then 
the bag had been passed into the uterus so as to lie below the 
membranes. 

2. Aiite-parttiin lia;inorrhag'e. 

Budin (Z/rt Presse Medicnle, No. 64, 1896) relates the history 
of two cases of ante-partiun hojinorrhage in which the blood came 
from a rupture in the circular siinis of the placenta. In neither 
case was the placenta situated in the lower uterine segment, nor 
was there any reason to believe as the result of careful examina- 
tion of the surface that any separation had occurred before the 
child was expelled. A black clot in each instance was traced 
directly up to and into the interior of the ruptured circular sinus. 
The possibility of ante-pm-tum hfemorrhage being sometimes due 
to this accident had formerly been suggested by Jacquemier and 
Matthews Duncan, but no clinical facts were brought forward to 
support the hypothesis until quite lately. At the present moment 
there are twenty-two cases on record of haemorrhage due to the 
rupture of the circular sinus. The so-called circular sinus of the 
placenta is situated at the periphery of the placenta, and does 
not generally form a complete circle, but is interrupted at various 
points. In calibre it is about equal to the little linger, but in 
some cases it is imperfectly developed. The walls of the sinus 
are very thin, which may explain the fact that rupture sometimes 
occurs. The blood may accumulate in the uterus between the 
membranes and the uterine wall, or it may escape externally — 
more often, perhaps, some escapes and some is retained. It is 
only after the labour is over and the placenta is examined that 
the cause of the haemorrhage can be definitely ascertained. The 
])rognosis and treatment are much the same as in cases of hjemoi'- 
rhage due to partial detachment of a normally implanted placenta. 

3. Parturition during: parapleg'ia. 

Amand Routh, at a meeting of the Obstetrical Society of London 
on June 2, 1897, related the case of a multipara who was ad- 
mitted into hospital with complete pai*aplegia below the level of 



318 THK YKAU-UOOK OF 'J'RKATMKNT. 

the sixtli dorsal vertebra, the result of an accident. She was 
then nearly seven months pregnant. For eiglit days intcu-niittent 
contractions of the uterus were absouit, and then became more 
and more perceptible. After over two niontlis labour came on 
261 days after th(! hist menstruation without tlie patient feeling 
any pain. The first stage lasted Um hours, the second two and 
a. quarter hours. The placenta followed, aided by slight 
" expression," in five minutes. The patient's only sensation 
during a " pain ' was a " tight feeling " at the epigastrium, 
giving her an inclination to hold her breath ; but this tightness 
was in no sense painful. As the head was passing the vulva the 
patient cried out, but this also seemed a reflex act, and was 
unaccompanied with sensation of pain. The " pains " were not 
as well defined as in a normal case, the intermissions being often 
absent, as judged by the vaginal touch and the hand on the 
uterus. In fact the " pains " rather remitted than intermitted. 
Retraction was not good for some hours, but there was no undue 
Iniemorrhage. Uterine involution and lactation were quite 
normal. Death occurred six months later. 

Routh then discussed the views held at dift'erent times as 
regards the physiology of parturition, and cases described by 
Ollivier (1827), Nasse (183.5), Benicke (1874), Scanzoni (1848), 
Paget, and Brachet (1837) were given. Experiments by Sir 
James Simpson (1849), von Rohrig (1879), Serres (1824), Langley 
and Anderson (1895-96), Riemann (1871), Goltz (1874 and 1893), 
Dembo (1884), and others were summarised. The evidence 
afforded by cases of j^ost-partum parturition was also reviewed. 
Finally, the secondary questions of conception and lactation 
during paraplegia were mentioned, and the following views were 
given as being borne out by the facts stated : — 

In pregnant women affected with paraplegia, from injury or 
disease of the spinal cord in the dorsal region, labour might 
commence at the normal period of gestation and progress in an 
approximately normal manner, but without sensation of pain. 
Involution and lactation were also normal. It was proved also 
from both cases and experiments that conception might take 
place during paraplegia. Further experiments as well as clinical 
facts were required before the physiology of parturition could be 
known, and much would be done when it was discovered with 
certainty what was the force by which the process of labour was 
initiated at the end of gestation. Meanwhile the following views 
seemed to be fairly established : — (1) The act of parturition is 
partly automatic and partly reflex, these actions corresponding in 
the main to the first and second stages of labour respectively. 



MIDWIFEUY. 319 

(2) Direct communication with the l)rain is not essential to co- 
ordinate uterine action, though the brain seems to have a 
controlling intluence upon the "pains," helping to make them 
regular with well-detined inteiinissions. (3) Direct communica- 
tion between the uterus and the lumbar enlargement of the cord, 
through the medium of the sympathetic ganglia between the first 
and third lumbar, is probably essential to the regular and co- 
ordinate contraction and retraction of the uterus, as occurs in 
normal parturition. (4) It seems also probable that the uterus 
is able automatically to expel its contents as far as the relaxed 
part of the genital canal, even when deprived absolutely of spinal 
intluence, spinal reflexes being then necessarily absent. But in 
the absence of reflex action tlie entire process of parturition 
■would be irregularly, and probably incompletely, performed, as 
in Sir James Simpson's experiments and Brachet's case. (5) Lacta- 
tion is not solely due to nervous influence, but partly to chemical 
changes in the blood, which afiect secondarily the mammary 
glands and other tissues of the body. The chemical change in 
the blood is not of ovarian origin, but is probably due to the 
metabolism of the pregnant uterus. 

4. Fatty (leg:eiiei'atiuii of the iitci'iis diiriiig^ l»'cg:- 
iiancy. 

L. M. Bossi (^Annali di Ohstet. e Ginec, December, 1896), in the 
examination of thi'ee uteri, one removed at the eighth month of 
pregnancy and the other two at full term, found fatty degenera- 
tion of the muscular fibres in active progress. He asks whether 
this is a physiological condition ; and if it be so, whether it may 
not explain the wonderful rapidity with which involution of the 
uterus after labour normally takes place. Further, it may be 
asked whether in this fatty degeneration there exists an explana- 
tion of some cases of inertia uteri in labour. 

5. The nature and diag^nosis of the so-called 
fleshy mole. 

Berry Hart {Brit. Med. Journ., Oct. 24, 1896) writes :—" By 
fleshy mole we understand a form of abortion where part of the 
aborting ovum, usually at or about the second month, is retained 
for many months, and ultimately discharged in a much altered 
condition. The most marked change consists in haemorrhages 
beneath the chorion which give a characteristic series of multiple 
elevations on the amniotic surface of the mass. Fleshy mole is 
not by any means a common condition, and its diagnosis is 
usually attended with great difficulty, and is very often not made 
until the actual mass is expelled. The mass thrown ofl" how- 
ever, is quite characteristic, and the specimens all resemble one 



320 TIIK YEAR-noOK OF TKKATMKN'T. 

another very much." LittUj has been written on the Kulijcct, 
althougli GranviUe, of London, fij^urefl a very fine sjx^cirnen in liis 
" Atlas of Ahoftion," The fullest accoujit has been given by 
Breus ill his abh; monograph, " Das tub(!rose sultchoriale Htimatom 
der Decudua," published in 1892. Hart (juotes two cases. (1) The 
patient was married in May, 1H91, ceased to menstruate in the 
following July,and had a threatened miscarriage; onOctoljer 1 8, but 
the hicmorrhage and the pains were slight. On December 2 the 
uterus was the size of a two months' pregnancy, the cervix was 
undilated, and the patient's general condition was good : expect- 
ant treatment was advised. A few months after, the size of the 
litems was the same ; the amenorrhea had continued, and the patient 
had no com})laint to make except that she wished to know more 
definitely when to expect the bal>y. On June 20 the uterus was 
about the size of a four months' [)regnancy, although not so 
broad. There had been some haemorrhage, but the i-eal condition 
was not evident until two days after, when the fieshy mole was 
expelled. It was an oval, thickened, fleshy mass 3 inches in 
diameter, ~ inch thick, and with many characteristic elevations 
on the amniotic surface. It was quite free from odour, was, in 
fact, perfectly fresh, and covered with recent blood. From her 
last menstruation to the complete expulsion was eleven months. 

(2) The second case presented much the same clinical history, 
and what came away eight and a half months after the cessation 
of menstruation was the same as in the previous case. A careful 
microscopical examination of the specimen showed that the 
amnion, and the chorion immediately underlying it,, wei-e quite 
normal, and there were here and there a few villi projecting from 
the chorion, which were, however, almost entirely degenerated. 
The main mass of the sections was taken up by liiemori'hages, 
some old, some recent, those furthest from the amniotic surface 
being evidently the oldest. Beneath these was a small portion 
of tissue, very much degenerated, which appeared to represent 
part of the decidua serotina, and scattered among the strands of 
fibrin on its upper surface were a number of villi in the most 
various stages of preservation, some almost normal, some with 
their structure almost obliterated. The only common character 
which they presented was the fact that, in all, the mucoid matrix 
of their connective tissue was greatly increased in amount. 

Hart continues : — " The fleshy mole is expelled in two forms. 
It may come away as a piece of fleshy-looking tissue, with its 
amniotic surface studded with prominences the size of the finger 
tip ; this is really the altered early placenta. The second variety 
takes the form of a sac, which, on examination, is made up of 



MIDWIFERY. 321 

reflexa and placenta, and usually contains a little liquor auinii 
and a shrivelled fretus. In the firist variety the ftetus may not 
be i)reseat, and there is usually no decidua'vera except a few 
shreds. This condition is essentially a ftetus change. There is 
death of the ftetal elements of the pregnancy, but the maternal 
portion of the pregnancy, the decidua, remains at first unaltered. 
The amnion is the ftetal membrane which changes least, and even 
in the eleven months' case the cellular elements are well preserved. 
The ftetus is, as we know, a maternal parasite, and thus the Heshy 
mole is an encysted dead parasite, aseptic, which the uterus 
tolerates long and only sluggishly expels. The sequence of events 
is, therefore, death of the foetus — that is, of the chorion and its 
derivatives — shrinking of the chorionic sac with wrinkling of 
the amnion and chorion, and ultimately blood extravasation 
from the intervillous circulation into the protuberances. The 
decidua vera shrivels, but the exact changes are not known. 
Some of these moles are expelled in their typical conditions at 
the fourth-antl-a-half month ; others are retained until apparently 
the ele\-enth period after conception. 

" These abnormal points must be kept carefully in mind. We 
may have a patient with a threatenetl abortion continue amenor- 
rhceic for many months, the uterus remaining about the size of a 
two months' pregnancy during that time. Ultimately some 
increase in uterine size takes place, and the characteristic fleshy 
mole is expelled. The medico-legal importance of such cases is 
evident. Apparently no case recorded has gone beyond eleven 
months. 

" When the condition is diagnosed, the cervix should be dilated 
and the uterus cleaned out." 

In discussing the above paper, Fothergill said that the two 
terms, " blighted ovum " and " fleshy mole," might be applied to 
two varieties of missed abortion, between which there is one 
difference. Blighted ovum results from tleatli of the ovum, with 
little or no effusion of blood into it. If, however, blootl infiltrates 
the dead ovum, blood clot is formed, which is gradually organised, 
and forms a fleshy mole. Placental polypi are identical in 
structure with fleshy moles, being caused by the retention of a 
portion, large or small, of placenta ; while the fleshy mole results 
from the retention of an almost complete ovum. 

6. Albiiiiiiniiria in preg^nancy. 

Clifford Allbutt {^Lancet, Feb. 27, 1897) expresses his opinion 

that the belief that the renal complications of pregnancy are due 

merely to mechanical pi-essure is erroneous. He thinks that the 

evidence in favour of this theory, whether clinical or anatomical, 

V 



322 THE YEAR-BOOK OP TREATMENT. 

is very weak, although it represents the current pathological 
teaching on the subject. 

He points out that thrombosis of the renal veins is not followed 
by renal symptoms ; that swelling of the legs and other signs of 
venous obstruction occur more and more as pregnancies increa.se 
in number, wliereas albuminuria and eclampsia are evils of the 
primipara ; that pressure from other tumours, such as large fibroid 
tumours of the uterus, does not produce serious kidney disorder ; 
that frecjuently in heart disease there is increased venous blood 
pressure in the kidneys, but that the resulting pathological con- 
dition is by no means the same as is found in the renal disturbance 
of pregnancy. 

In contrasting the "cardiac" with the '^' puei'peral " kidney, 
Clifibrd Allbutt says of the latter that, "so far from being a 
mei'e congestion, there are signs of acute degenerative processes 
penetrating the organ in all its tissues. It is not hard as is the 
cardiac kidney, and it is often pale. Scattered throughout 
it are points, or more than points, of broken-down structure, 
and the anatomical elements throughout are blurred and de- 
teriorated. Many vessels are plugged. The kidney looks as if it 
had been subjected rather to some more intimately mischievous — 
I had almost said corrosive — action than to a mere mechanical 
interference." In considering the vomiting of pregnancy, the 
headaches, faints, and even eclampsia, the question arises. Can 
there be any agent more directly concerned in these phenomena 
than "the heightened reflex excitability" so easily assigned? 
Clifford Allbutt draws attention to some of the symptoms of the 
infections, and says that if in scarlet fever we see, first, vomiting, 
then nervous disturbances, then albuminuria, then enlargement 
of the heart, we conclude that there is some toxin circulating in 
the body. Can it be in pregnancy that there is some circulating 
poison which sets up vomiting, albuminuria (which we know that 
other poisons do), and ultimately even eclampsia? Clifford 
Allbutt then reviews the evidence of the existence of such a poison, 
and he comes to the conclusion that the toxin does exist. The 
presence of a toxin, or toxins, he continues, in normal urine has^ 
been demonstrated, although the poison itself has defied detectiojx.. 
The kidney, therefore, is a channel for its escape, and so long as 
the renal functions are intact, the toxin can, and usually does, 
escape without doing any harm. It is not known whei'e the 
toxin or toxins are found, but we can show that the liver is at 
fault. The toxins may be absorbed direct from the bowel, but at 
any i"ate the liver perfox'ms the function of neutralising the 
toxins which find their way into the circulation. The tendency 



MIDWIFERY. 323 

to acute atrophy of the liver in pregnant women is well established. 
If for any reason the liver is unable to deal with the toxin turned 
into the blood, the excess will fall directly upon the kidney, and 
probably will so injure its finer structures that albumin can leak 
tiirough, and perhaps inflict serious and permanent damage on 
the kidney itself. A careful necropsy by Lindemann, of Moscow, 
in 1892 {C entralblatt far allgemeine Fatliulogie, Jena, Aug. 20, 
1892), of a case of albuminuria in pregnancy clearly showed acute 
degenerative changes in liver and kidneys chai-acteristic of toxic 
influence ; the spleen also was enlarged, .ind neuritis was well 
marked in several tracts. Albumin in the urine, an early sign 
of a toxic condition of the system, is frequently found in pregnant 
women showing no other departure from health. In primiparte 
the percentage is as high as Ave or six. As a rule, this albumin 
disappears within a day or two of delivery. The origin of this 
toxin is obscure ; the toxicity of the blood in fatal cases has been 
found to be very high, but the evidence of the presence of a 
microbe is very small. 

Referring to the abnormal excitability of the nervous system 
in pregnant women, Cliflbrd Allbutt points out that toxins tend to 
expend their malignant power lai-gely upon the nervous system, 
and in proportion as the nervous system is developed their effects 
become the more perilous. This is the case in all infections. 
Other symptoms which may well be due to a toxin in the blood 
are phlebitis and thrombosis of vessels, and the terrible sus- 
ceptibility of pregnant or recently delivered women to septic 
poisoning. Finall}^ as in lead-poisoning and in Bright's disease, 
we find the red cells diminished both in number and luemoglobin 
value. 

The writer fears that he can advance no definite and immediate 
advantages from this toxin point of view, but he says we are 
enabled to see more distinctly the reasonableness of certain 
measures which we have empirically learned to take in cases of 
danger. Especially does this theory of a circulating toxin in all 
pregnancies assure us of the usefulness of the precaution of 
promotijig early delivery in cases which lend themselves to this 
treatment. Even in dangerous and persistent vomiting, if the 
mother's life be in danger we mast bring about expulsion of the 
fojtus. In eclampsia this is a still more pressing step. We 
shall most carefully keep an eye on albuminuria, not regarding it 
as a mere mechanical accident, but as the signal of a danger 
essentially implicated in the process of pregnancy itself. Any 
other signs of a toxic state must be minutely observed with a 
view to the pz'evention, if possible, of further mischief. As the 
V 2 



324 THE YEAR-BOOK OP TREATMENT. 

toxin may, in part at any rate, ho alj.sorljeil from the Vjowel, a 
patient should 1)0 carefully dieted from the time of any suspicious 
symptoms, such as Chaussier's symptom of violent pains in the 
stomach — always a precui'sor of eclampsia. All sultstances likely 
to promote i^astro-intestiiial catarrh- -that mother of poisons- 
should be forbidden. It may indeed be 7iecessary to reduce the 
diet to milk, which we tind to be the diet which lends itself least 
to the generation of toxins in the body. At the same time, by 
the admini.itration of antiseptics we shall try to keep the bowel 
as clean as possible. Again, knowing now the important part of 
the liver in neutralising toxins, we shall jealously watch the con- 
dition of this precious organ ; and, if necessary, by estimating tlio 
excretion of urea and so forth, we shall keep ourselves informed 
of its activity. The presence of albumin will not be overlooked, 
but rather we shall be diligent in search for it from early periods 
of pregnancy, especially in primipara? ; if we have the opportunity 
we may test the toxicity of the urine on rabbits ; but this is not 
of much direct help, as a free exci-etion of toxin is consistent with 
the retention of much more in a case in which the poison is very 
actively formed. 

To account for the more frequent occurrence of toxic symptoms 
in primiparie than in multiparie, Clifibrd AUbutt advances the 
theory that immunity is gained against the poison of pregnancy 
as it is against so many other toxins. Olshausen has reported 
that of 200 consecutive cases of eclampsia, 74 per cent, were in 
primipar;>5. 

In connection with the theory of the " toxic " origin of 
albuminuria in pregnancy, Christian Simpson [Lancet, July 10, 
1897) publishes a note on Auto-intoxication during Pregnancy, 
especially referring to two conditions — viz. salivation and 
eclampsia. He says the amount of saliva secreted by some 
pregnant women may amount to many quarts in the twenty- 
four hours. This usually persists during the months of pregnancy 
only, but in some cases lasts up to the confinement, and usually 
disappears in a few days, though it has lasted two weeks. The 
saliva contains no ptyalin and less sodium salts than is normal. 
Bouchard has discovered a sialagogue in normal urine which he 
defines as "a stable organic substance not fixed by charcoal, 
soluble in alcohol, and distinct from the diuretic (urea) or the 
narcotic toxin." It is found in much greater amount in the 
blood, liver, and muscles than in the urine. In the case of 
eclampsia it must be noted that two convulsive principles are 
found in normal urine. Van der Velde has recently i-ecorded 
experiments in which he found that pregnant rabbits are much 



MIDWIFERY. 325 

more sensitive to the action of noi'mal urine than non-pregnant 
animals. He also found tl.at blood from a pregnant rabbit 
induced convulsions with a less quantity than blood from a non- 
jjregnant rabbit. He concludes that there is not only ;in increased 
production of toxin, but also an increased susceptibility to its 
influence in pregnancy. 

7. Tlic treatnioiit of oclaiiipsia. 

This was one of the subjects under discussion at the Inter- 
national Congress of Gynaecology held at Geneva According 
to the statistics of N. Charles, of Liege, eclampsia occurs once in 
every 151 deliveries, and is about four times as common in 
primipane as it is in multiparas Among every fuur women who 
suffer from albuminuria during pregnancy, one gets eclampsia. 
He teaches that it is most desirable to terminate delivery in all 
cases as speedily as possible when eclamptic convulsions set in, 
and, with this object in view, labour should be induced or 
accelerated as the case may be. In urgent cases the cervix must 
be dilated by the hand, or by hydrostatic bags ; and if that is 
impossible, Ciesarian section should be performed. 

Charpentier, claiming to represent the French school, said that 
when the patient was seized with eclampsia, and labour appeared 
spontaneously, all were agreed that the right treatment was to 
terminate labour as quickly as possible. But when eclampsia set 
in before labour a distinction must be made between cases at or 
nearly at full term and those earlier in pregnancy. The German 
school consider the induction of premature labour, or even aboi'- 
tion or forced delivery, the only treatment. Diihrssen incises the 
cervix deejjly, and if necessary the vulva and perineum. Bossi 
uses instrumental, others manual, dilatation ; others again would 
perform Caesarian section. Charpentier is convinced that induc- 
tion of laV)Our is useless and forced deliv^ery dangerous. He 
concludes that: (1) The ui-ine of every pregnant woman should be 
examined. (2) If the least trace of albumin is found she must be 
put on a strict milk diet, which prevents the production of toxins : 
this must be continued till after labour and till no albumin is 
present. (3) When oedema without albuminuria is found, the 
milk diet is indicated. (4) Whenever eclampsia occurs with 
cyanosis in a strong woman, bleeding up to half a litre must be 
perfoi'med. (5) Chloral should be given. (6) When convulsions 
have set in, milk should be given by the mouth, or, if necessar}', 
by the oesophageal tube ; this alone sometimes causes cessation of 
the convulsions. Besides this, the fits should be treated with 
chloroform inhalations, and diuresis induced by subcutaneous 
injections of saline solution. One must then wait till normal 



326 THE YEAR-BOOK OF TREATMENT. 

labour sets in. If there is inertia uteri, labour must be termi- 
nated ])y forceps or version if the child is alive, by hasiotripsy if 
dead. Induced labour is only exceptionally necessary, and forced 
delivery never. 

Halbertsma, Bossi, Pasqualini, and others spoke on the other or 
" German ' side, and advocated early emptying of the uterus. 

Kelt, of Leyden, draws attention to the fact that many cases 
of eclampsia get well whatever the treatment may he, and states 
that there is no direct evidence that forced delivery improves the 
prognosis. He does not rely on any one method of treatment, 
but considers that the systematic use of large doses of niorj^hia 
administered subciitaneously seems to give the best results. 

Byers, of Belfast, pointed out that the most pi'obable hypothesis 
was that the convulsions were caused by a poison elaborated by 
the mother, or by the foetus, which accumulated in the blood 
owing to some failure in the normal process of elimination. He 
advised the subcutaneous administration of morphia, the woman 
being kept upon her side, and all liquids by the mouth being 
withheld. Hot water or vapour baths, if obtainable, should be 
used. If labour has not begun, the convulsions should be treated 
with morphia, but the uterus should not be excited, and no 
attempt should be made to bring on labour. In the first stage of 
labour, when convulsions supervene, hydrostatic bags may be 
employed if the cervix is soft and dilatable ; but if it is rigid, no 
local measures should be used. In the second stage of labour 
he advises delivery with forceps after the patient has been first 
ana?sthetised. 

Mangiagalli says that preventive therapeutics are very bene- 
ficial in removing the conditions which are the expression 
probably of the auto-intoxication, and consist in milk and in- 
testinal disinfectants, diuretics, etc. The medical treatment 
(bleeding, purgation, morphine, chloral, chloroform, veratrura 
viride, or diaphoretics) is purely symptomatic, but is the only one 
possible in post-partuni eclampsia, and in other conditions is 
a valuable aid to the obstetric intervention. Bleeding, followed 
by the subcutaneous or endovenous injection of normal saline 
solution, has much to recommend it, but it has not been employed 
Kufiiciently often to enable us to form a just estimate of its value. 
The speedy evacuation of the uterus constitutes the most im- 
portant means of treating eclampsia. In intra-partum eclampsia 
it is a good rule to terminate labour when the conditions permit, 
and even to anticipate these by means of multiple incisions of 
the cervix. In eclampsia in jiregnancy the induction of labour 
by rupture of the membranes is indicated along with the use of 



MIDWIFERY. 327 

moi'phine or chloral, or veratrum viride, in large doses. If these 
means fail, then forced dilatation of the cervix is to be preferred 
to the deep incisions of Diihrssen. In some, very bad cases even 
Ciesarian section may be a justitiable operation, especially if the 
fcetus be full-time and alive. Every operative intervention must 
take place with the patient deeply aniesthetised. 

Ferr^ (L'Obsfetriqtie, November 15, 1896), after a clinical 
review of the treatment of puerperal convulsions, insists that the 
milk treatment is most efficient from a prophylactic point of 
view, though it does not necessarily cause the other alarming 
symptoms besides the fits to vanish. He has never seen fits in a 
patient subjected for over a week to milk diet, nor any other 
trouble of a toxic origin. The alleged disappearance of albu- 
minuria, on the other hand, does not necessarily occur. He 
speaks with equal decision on this point, declaring that he has 
never seen so much as an appreciable diminution of all^umin, 
even after prolonged treatment by milk diet. Ferre says the 
same of oedema ; this treatment seems to have no effect on it. 
He emphasises the above facts because he is aware how some 
obstetricians have very naturally given up milk diet on account 
of the persistence of albuminuria and cederaa. Such a step is 
a mistake, for if the treatment be continued, labour will proceed 
without any fits coming on, though the legs remain swollen and 
the urine albuminous. 

Halbertsma [Nederlands Tijdschrift van Verlosk. en Gynaeh., 
1897, No. 2) gives an account of 109 cases of eclampsia, 49 being 
closely analysed. Of these latter, 31 suffered during pregnancy, 
and 18 at the beginning of labour. In 7 eclampsia set in before 
the eighth month of pregnancy — all mothers saved, but six children 
lost. In the case whei'e the child was saved, incision of the os 
was undertaken. Of eclampsia later in pregnancy, Halbertsma 
classes 5 as "light" cases, 1 "moderately severe," and 17 as 
" heavy " cases. Out of the 17, 2 are rejected on account of some 
uncertainty as to the treatment, whilst in 7 neither Cfesarian 
section nor Duhrssen's incision was practised, and all died ; whilst in 
8, where one or other of these procedures was adopted, 6 were saved. 

Of the 18 cases beginning with labour, 6 are classified as 
"light," 12 as " severe," no less than three-quarters being lost. 
Of the 3 severe cases that were saved, in 2 incision of the cervix 
was practised, while in the third chloroform and morphine were 
administered, and when the os was completely dilated, forceps 
were applied. Halbertsma favours this last line of treatment, 
but states that, should it fail, the continuance of the fits will be 
more deadly to mother and child than Csesarian section. 



328 TIIK YKAK-BOOK OF TKKATMKNT. 

M. Daii^j^ei-*!) of iiieiubiaiioiis inseition of the cord. 

Lef^vre [These de Paris, 1896) has collected 151 cases where 
the cord lost itself on the membranes some distance from the 
edge of the placenta. This condition is most frequent in twin 
pregnancy. It exposes the fd'tus to dangers during pregnancy 
as vvell as in lal)our. iJnring gestation it may involve premature 
rupture of the membi-anes ; in six cases at least no other reason 
could be found. Prematun; labour may be caused Ity mem- 
branous insertion of the coid, and J^efevre believes that this 
anomaly of the funis explains certain cases of hydranmion and 
ffctal dropsy. In labour some cases of jtremature rupture of the 
membranes are due to membranous insertion, but it appears not 
to be so frequent a cause of that accident in labour as in preg- 
nancy. It is also a predisposing cause of prolapse of the funis. 

9. Pei-i|>licral iiotii-iti)s connected witli pre^:nancy 
and the puerperal state. 

Reynolds (^Brit. Med. Journ., Oct. 16, 1897) writes that 
paralyses due to lesion in the nerve trunks may be divided into 
two classes : (1) those due to injury or disease of the nerve trunks 
as they pass through the pelvis ; and (2) those due to neuritis 
occurring at the periphery of the nerves, and in which the nerves 
affected do not necessarily pass through the pelvic cavity. It is 
of this second variety that he deals more particularly. Relying 
upon the evidence of 49 cases which have been reported, Reynolds 
finds that the disease is more common in multi[)ara}. In 12 
cases the onset occurred during pregnancy. Of the others, in 16 
the symptoms appeared within the first week after delivery, in 
7 during the second week, in 6 during the third and fourth 
weeks, in 2 within the second month ; in the remaining 5 the 
time of onset is not mentioned. In 15 cases there was a dis- 
tinct history of some form of sepsis, with shivering and fever ; 
in 11 cases there was marked and incessant vomiting of preg- 
nancy, and in 2 of these the symptoms of neuritis did not 
come on until about three weeks afterwards. In 4 of the cases 
there v/as a history of alcoholism, rendering the etiology of those 
cases doubtful. 

Reynolds looks upon sepsis, or on incessant vomiting setting 
up a condition of acetonannia, as the most potent factors in 
jjroducing the neuritis, but it seems more probable that tlie 
vomiting, as well as the neuritis, is due to the toxin. 

In 14 cases there was either no recoveiy or only a partial 
recovery, some of the most severely affected muscles reinain- 
iijg permanently paralysed. In 22 cases I'ecovery was com[ilete ; 
while in 13 cases there is no mention of the termination. It 



MIDWIFERY. 329 

would seem that years may elapse before recovery takes place, 
so that treatment in some cases must be kept up for long periods. 

10. Tliroo iioi'inal pre^iiaiirios after iicplirectoiiiy. 

E. Tx-idondani {^Aidi. di Obstetricia e GhiecoJogia, July, 189G) 
adds to the cases ali-eady recorded by Schramm, Fritsch, and Israel 
an interesting instance of the reproductive history of a woman 
who had had a kidney removed. A patient aged twenty-nine 
came into the TNIaternity at Pavia, suflering from symptoms 
resembling those of intestinal obstruction, accompanied by pain 
on micturition and scanty urine. She was in the eighth month 
of pregnancy, and to the left side of the uterus was a fluctuating 
tumour. Under treatment the woman improved and was 
spontaneously delivered of a male infant. Three months later 
the abdomen was opened and a cystic kidney remo\'ed: recovery 
was complete. Since then the patient has had three pregnancies. 
In none of the three were there any abnormal symptoms. The 
labours were at full term and natural. The infants were healthy 
and had a weight and size above the average. The author concludes, 
from the study of this and the three other reported cases, that 
pregnancy occuning in a woman with one kidney does not inter- 
fere with her health ; that the progress of the pregnancy is not 
disturbed, and that the product of conception does not suffer. 
He does not, therefore, agree with Schramm, who advises a 
Avoman with a single kidney not to marry. It is noteworthy that 
in the above case the liquor amnii was increased in amount, but 
it is doubtful whether this was a consequence of the absence of 
one of the mother's kidneys. 

11. Hypereiiiesis g:ravidai-uni. 

At the 1897 meeting of the British Medical Association, 
held in Montreal, there was an interesting discussion on hyper- 
emesis gravidarum. Temple, of Toronto, opened the discussion. 
He said it is generally admitted that the pernicious vomiting of 
pregnancy is more common in primse gravidse. He also believed 
that it is much more frequently fatal than some authorities 
stated. The ordinary morning sickness may be looked upon as 
physiological and purely sympathetic, but he believes, in the 
pernicious form, it is invariably accompanied by some pathological 
condition. Robert Barnes reports 9 fatal cases ; Gueniot out of 
110 cases reports 46 deaths; Howitz, 13 cases and 5 deaths; 
Joulin reports 121 cases and 49 deaths; McClintock reports 50 
fatal cases; Doe, 48 cases and 18 deaths; M'hile on the other hand 
Carl Braun, with an experience of 150,000 obstetrical cases, has 
never known a single fatal case of hyperemesis. 

Of the theories regarding the etiology the large majority 



330 TIIS YEAR-BOOK OF TREATMENT. 

ascribe the malady to reflex plienomena originating in conditions 

])resent in conTicction with the pregnant uterus, Init the exphina- 
tions are various. 

Graily Hewitt laid great .stress on tUixions and versions in the 
growing uterus originating the peripheral impulses. 

J. H. Bennett laid special stress on the inflammatory con- 
ditions of the cervix. 

Howitz draws attention to the frequency of metritis and 
cellulitis. 

F. Veit has drawn attention to the frequency of endometritis 
as a factor. Ehell agrees with Veit. 

Bretonneau and others suggest that the ])eripheral irritation 
originates in the stretching of the fibres of the growing uterus, 
and stretching of the external and internal os has been practised 
with relief in certain cases. 

Gi^andin suggests ovarian irritation as a cause, due to pressure 
on super-sensitive ovaries by the growing uterus. Disease of the 
gastro-intestinal canal is insisted on by other writers. 

Hadra's toxic theoi-y has many adherents. 

Giles (London) said that among piimiparje there is a close and 
constant relation between sickness of pregnancy and previous 
dysmenorrhcea. Vomiting during the later months is frequently 
associated with hydramnion, twins, or an unusually large child. 
He has come to the conclusion that the vomiting is due to three 
factors: (1) exalted nervous tension, (2) a source of peripheral 
irritation, the enlarging uterus ; (3) an easy outlet for this exalted 
tension — viz. the vagus. He could not agree with Horrocks that 
a j^ost-mortem examination was necessary to establish the diagnosis 
of hyperemesis gravidarum, when patients going rapidly down hill 
recover completely on the termination of pregnancy. 

Gardner (Montreal) had seen dilatation of the cervix relieve 
symptoms — in some cases promptly, in others within a few days. 

Maury (Memphis), in his experience, had failed to find any 
])athological condition in the pelvis to explain the vomiting. 
When he found it necessary to induce labour he dilated the 
cervix and, after removal of the ovum by curette and forceps, 
tamponned the lower part of the uterus and the vagina. On the 
day following he completely cleansed the uterus with a dull 
curette. 

Jewett (Brooklyn) found chloral and the liromides useful 
administered by the bowel. Locally he had found satisfaction in 
the use of cocaine, but of late had also dilated the cervix. 

All the speakers agreed that operative interference must not 
be too long delayed. 



MIDWIFERY. 331 

A. Pozzi (Archivto di Ohstet. e Ginecol., May and June, 1897) 
has treated successfully 5 cases of severe vomiting in pregnancy 
by the method proposed by Professor Tibone. In 4 of these 
pregnancy had reached two and a half months, in 1 only one 
month and a half. The method referred to is the subcutaneous 
injection in the hypogastrium of a solution of hydrochlorate of 
cocaine (1 eg. to 1 g. of distilled water). In 2 of the cases 
treatment was begun in the second stage of the vomiting, when 
there was fever, and when cerebral phenomena had begun to 
manifest themselves. In 2 cases the cocaine was administered 
when the vomiting was still in the first stage, and in the fifth 
patient the author had to do rather with an exaggerated form of 
simple vomiting than with the grave incoercible type. In all the 
cases a great number of other means of treatment — in- 
cluding in some replacement of the uterus — had been pre- 
viously tried. 

13. Spurious abortion. 

Eden ^Lancet, Sept. 25, 1897) gives an account of thi-ee cases 
of spurious abortion. It is an account of a class of cases in which 
a mimicry of early pregnancy and of abortion occurred, quite 
difiei-ent in its characters from the condition known as spurious 
])regnancy. They were not associated with hysteria, and the 
usual functional disturbances of pregnancy were not exaggerated. 
They differed from pseudocyesis in the existence of definite 
changes in the uterus, and from pregnancy, topic or ectopic, in 
the essential point of the absence of an ovum either within 
or without the icterus. They mimicked abortion in the occur- 
rence of amenorrhoea with enlargement of the uterus, and the 
formation within it of a body the detachment and expulsion of 
which were followed by a return to menstrual regularity. The 
body expelled was not an ovum, but was formed entirely from 
maternal structui'es. Three cases only have been recorded, and 
Eden gives an account of each of the specimens. In each case 
there was the same history of amenorrhcea and morning sickness, 
terminating after eleven weeks in hremovrhage and the discharge 
of a fieshy mass, presenting certain points of resemblance to the 
decidua of pregnancy, with certain well-marked points of differ- 
ence ; in all of them the microscope alone did not sutti^ce to dis- 
tinguish these casts from those often met with in extra uterine 
pregnancy. 

Eden would formulate the condition as follows : "The develop- 
ment within the uterus, in the absence of uterine or extra-uterine 
gestation, of a memVn-ane having the essential characters of the 
decidua of pregnancy and accompanied by the signs of early 



332 THE YEAR-BOOK OF TREATMENT. 

pregnancy ; and its separation and expnlsion from the uterus with 
hcHeniorrhage, tlius simulating abortion." 

Diagnosis was itiipossible until aftor the discharge of the cast; 
it then consisted of two distinct steps : ( 1 ) Tlie exclusion of uterine 
pregnancy by careful microscopic examination of the cast, which 
demonstrated the absence of chorionic tissues ; and (2) the exchi- 
sion of extra-uterine pregnancy. In two of tlie three cases this 
was possible by the direct inspection of the tubes and ovaries, as 
in each case abdominal section was performed under the impression 
that the case was one of extra-uterine gestation. 

Two explanations of the condition were possible : (1) Tliat an 
ovum was actually fertilised, l)ut perished at a very early period 
without leaving traces of its presence, while the "genetic re- 
action " in the uterus and in the general organism progressed as 
in pregnancy ; and (2) that some stimulus other than the presence 
of a fertilised ovum in the genital tract might lead to the forma- 
tion within the uterus of a complete decidiia, and might hold the 
menstrual functions in abeyance. Provisionally, Eden adopts the 
first explanation. 

13. Tlic iiso of injections of saline fluid in rases 
of severe uterine liseniorrliag^e after delivery or during; 
preg^nancy. 

Olivier (Journ. de Med. de Paris, March 28, 1897) asserts 
that injection of saline fluid has a distinct hfemostatic action, and 
quotes Hayem in support of this view. The same authority states 
that of all the fluids used the least harmful is one containing 
chloride of sodium in the proportion of 10 in 1,000 parts of 
water. In cases where the haemorrhage has been severe, Olivier 
thinks it best to inject large quantities of this fluid directly into 
the veins, but in less urgent cases injection into the loose cellular 
tissue will suffice. He insists on the importance of the water 
used being properly sterilised, and suggests that a supply of sterile 
salt solution should be carried by the accoucheur, together with 
the necessary af)paratus. Although the amount of fluid carried 
may be insufficient, it will be enough to tide over the patient till 
a further supply be prepared. The only contra-indication to 
the use of large venous injections of saline fluid is renal disease. 
In such cases, if used at all, only small quantities should be 
injected. 

14. Dia;(nosis and treatiiieiit of rupture of the 
uterus. 

H. Ludwig records ( Wien. klin. iroc/;., 1897, Nos. 11,12) nine cases 
of rupture of the uterus. In the first the rupture occurred during 
the exti'action of the decapitated breech ; the head was subse- 



MIDWIFERY. 333 

quently removed by laparotomy. In tlie second the rupture was 
diagnosed before deli\ery and Caisarian section performed. In 
the third a rupture arose during version ; the child was extracted, 
and the after-coming head perforated. The fourth was a case of 
craniotomy, which terminated the labour, after which the rupture 
was discovered. In the liftli, also, craniotomy was})erformed, tlie 
rupture not being diagnosed with certainty before birth. In the 
sixth there was again uncertainty ; delivery was efrected after 
decapitation. The last three were all diagnosed ; they were 
delivered by craniotomy, perforation, and cutting through the 
cervical vertebrae respectively. With regard to diagnosis, Ludwig 
in.sists on the valuelessness of individual symptoms, such as 
collapse, bleeding, sudden and severe pain, recession of the 
formerly fixed presentiiig part, cessation of pains, etc. He has 
found the best diagnostic signs to be : (1) in lateral rupture the in- 
terruption of the natural contour of the uterine quadrant, either 
a projection or a nodule being formed ; (2) abnormal mobility 
of the uterus ; and (3) em phy.se matous crackling at the seat of 
rupture. If the head presents and can be pushed back, bimanual 
examination under deep narcosis should lead to a certain 
diagnosis. 

With regard to treatment, delivery may be effected per vias 
naturales, or by laparotomy. The former is indicated when a large 
part of the child is already fixed in the pelvis, and also when the 
diagnosis of uterine rupture cannot be made before delivery. In 
cases in which the child remains in the uterus after the rupture, 
or has only partly passed into the abdominal cavity, delivery ^:»er 
vaginam is only to be preferred when it can be carried out without 
losing time or increasing or complicating the tear — for instance, 
in head presentations and the absence of contraction of the pelvis, 
also where a rupture takes place during an operation. Laparotomy 
is indicated when the whole child has passed into the abdominal 
cavity, when the passages are not fully dilated, in contracted 
pelves, in severe htemorrhages, and in injuries to the neighbouring 
organs. In partial passage of the cldld into the abdomen, or with 
a living child still in the uterus, Ciesarian section is the correct 
procedure when natural delivery would take too long, and be 
fraught with danger to the mother. As regards treatment after 
delivery, of Ludwig's 9 cases, 3 came into the hospital and 
were operated on — 2 by supravaginal amputation and 1 ])y 
abdominal hysterectomy ; all 3 recovered. The remaining 
6 were treated outside : 5 were operated on — -4 by supra- 
vaginal amputation, 1 by abdominal hysterectomy, of whicli 1 
recovered and 4 died of sepsis. There was no death from 



334 THE YEAR-BOOK OF TREATMENT. 

liiBinorrhage, except in the reinaininf^ case, which was not sub- 
jected to oj)erative interference. 

Cullingwortli (Lancet, Sept. 26, 1896) reports two ca.ses of 
rupture of the uterus. Tn the first case, before delivery, a rent 
.'> inclu's iu extent in the posterior vaginal wall was discovered, 
through which the intestines could be felt ; the posterior wall of 
the uterus was very thin. It was a breech pre.sentation. Labour 
was completed under chloroform by bringing down the half breech 
and extracting. The rent was then found to extend upwards, and 
was 10 inches in length. After removal to the hospital the rent 
was sewn up for 6 inches ; the remainder, about 4 inches, Ijeing 
out of reach, the vagina was plugged. The patient recovered com- 
pletely. In the second the patient died before delivery and before 
any treatment could be applied ; it was found that the uterus, 
which at its lower part was only ^ inch in thickness, was ruptured 
for a length of 6 inches into tlie left broad ligament. In both 
these cases the rupture occurred in the lower part, and in the 
second case the part in which the I'ent was placed was the thinnest 
of the whole uterine wall ; while in the first, examination showed 
great thinning of the uterus before the laceration had extended 
into it. This is to be noted, because Dr. Blind, from twenty-four 
cases, states that the rupture is always at the fundus. In 
neither case was there any evident obstruction at the outlet. 

Cullingworth quotes the statistics of Merz. He gives a list 
of 230 cases ; of these 94 were untreated, 54 wei'e subjected to 
abdominal section, and the rest treated in various ways. Of 
the untreated cases, 70 had complete rupture, of which 10 
recovered, and 21 incomplete rupture, of which 4 recovei'ed ; 
3 were doubtful cases, and all died. The treatment varied con- 
siderably. Compression of the abdomen by liandage was employed 
in 5 cases, with 3 recoveries. Intra-uterine tampons w-ere inserted 
in 25 cases ; 9 of these patients recovered. Tube drainage in 
19 cases gave 12 recoveries. Drainage by an iodised skein of 
thread in 8 cases gave 7 recoveries. Drainage, washing out, 
and irrigation was the treatment in 7 cases ; 5 recovered. 
Suture of the rent after abdominal section in 24 cases gave 10 
recoveries; without suture in 15 cases gave 8 i-ecoveries ; with 
amputation of the uterus in 15 cases gave 8 i-ecoveries. 

15. J\crvotis (liarrhoea. in prei^iiaiicy. 

Condio {Centralbl. f. Gyndk., No. 29, 1897) has published a 
monograph on an interesting complication which he considers to 
be related to hyperemesis gravidarum. Whilst the latter is more 
frequent in the higher ranks of life, diarrhoja seems commoner 
amongst poor pregnant women. Obstetricians note its occurrence 



MIDWIFERY. 335 

in lying-in hospitals in cities where it is hardly ever seen in 
private practice. Out of 3,674 pregnant women in the Turin 
Maternity, nervous diarrhoea was observed in 35. No fewer than 
21 of these cases occurred in priniipara?. Temperature has little 
influence on this affection, but errors of diet are more probably 
among its causes. Nervous diarrhoea begins about the fifth 
month, and may become formidable ; it has been found to con- 
tinue even in child-bed. Nerve tonics are indicated, and, as in 
hyperemesis, premature labour must be induced if the diarrhrea 
persists and the patient becomes seriously debilitated. 

16. Etiolog:y of innstitis. 

Rudolf Kostlin (Arc/i.f. G'l/ndk., Bd. liii., Hft. 2, 1897) dis- 
cusses the question of the relation between the germs contained 
in human milk and the production of mastitis. He has in- 
vestigated bacteriologically the milk from the breasts of 100 
pregnant women, of 137 in the puerperium, and of GO children. 
Micro organisms were found in the milk in these groups of cases 
in the proportion of 86, 91, and 75 per cent. With few excep- 
•tions these were of the nature of staphylococci, and especially the 
staphylococcus albus. The immigration of bacteria takes place 
from the outside from the mammary areola ; their entrance along 
the line of the blood current has not yet been satisfactorily 
established. The entering germs ai-e relatively innocuous ; they 
injure neither the mother nor the infant ; mastitis without micro- 
organisms does not occur. The infection in mastitis takes place 
from the outside, along the line of lymphatic vessels, from injuries 
in the skin. The result is the development either of the ordinary 
form of mastitis due to the invasion of staphylococci, especially 
the staphylococcus aureus, or of the much rarer form of pseudo- 
erysipelas and of retro-mammary abscesses caused by streptococci. 
These conclusions are supported by bacteriological, clinical, and 
pathologico-auatomical evidence. Mixed infections are, of course, 
quite possible. A metastatic mastitis developed along the line 
of the blood current has not yet been certainly established. 

17. Paralysis of child's arm after delivery by feet. 

Guillemot (^Annales cle Gynec. et cVOhstet., January, 1897) pub- 
lishes a report of a large number of cases of paralysis of the arm, 
where all the infants were extracted by the feet and all by the 
same midwife. Proufl", of Morlaix, detected nearly 30 of these 
cases. Guillemot publishing clinical notes on 12 out of the same 
series. Most of the patients were about twenty years old, for 
the cases have been most carefully watched. In many the 
shoulder-joint, elbow-joint, or wrist was the seat of the disease — 
not neuropathic, but, like the nerve lesion, caused by damage 



336 THE YEAR-BOOK OF TREATMENT. 

during delivery. Tlie midwife must have pulled with great 
foice and irregularity, knowing nothing about axes. (Juillemot 
suspects tliat she in several instances turned, piohahly when 
quite unnecessary, and extracted hciore complete dilatation of the 
OS. He gives reasons to .show that the paralysis was not due to 
myelitis. Torticollis was present in some cases, but (Juillemot 
admits that it might be a complication cau.sed by laceration of 
the sterno-mastoid muscle and hiematoma, or by articular disease 
in the cervical spine. In nearly all, the scapula on the affected 
side was elevated, indicating paralysis of the lower part of the 
trapezius. The branch of the cervical plexus which supplies 
this part must manifestly be stretched by the great depression of 
the .shovdder caused by firm and long traction on the arm. 
These tractions appear to damage the fifth and sixth cervical 
•nerves most severely, judging fi-om the lesions .seen in the ann. 
When the cervical spine is torn through or the head torn off in 
delivery, the separation occurs at the level of the third, fourth, 
and fifth cervical vertebrae. Thus at this level the tissues are 
least resistant and allow of the greatest amount of traction. In 
these cases sensation is usually preserved more or less, for during 
these violent and clumsy tractions on the aim the head is 
deflected and the neck forms a concavity backwards, so that the 
posterior and sensory roots of the cervical nerves suffer the least 
traction. 

Fieux (ibid.) publishes an independent communication on the 
pathogeny of paralyses of the arm in newly-born children. In 
this paper valuable neurological observations will be found. 
Fieux directs attention to the law of Forgues, of Montpellier, that 
when a group of muscles I'eceive their nerves from a plexus, the 
highest muscles are supplied from the highest filaments in the 
plexus. The deltoid, according to that law, should be supplied 
from the highest filaments of the brachial plexus. The highest 
cords of that plexus suffer most from the traction on the arm 
during delivery, and therefore it is not surprising, in Fieux's 
opinion, that the deltoid is the most gi'avely affected of all the 
muscles in obstetric paralysis. 

18. Labour complicated by abiioriiialilies of the 
cervix uteri and vagina. 

John Campbell, at the annual meeting of the British Medical 
Association (Brit. Med. Journ., Oct. 23, 1897), drew attention 
to these serious, if rare, complications of child-birth. (1) Atresia 
of the cervix may occur in primipava? or multipara?. In all cases 
it is due to inflammation of the cervix, which, in the early stages 
of pregnancy, leads to adhesion of the granulating surfaces of the 



MIDWIFERY. 337 

lower end of the cervical canal. As labour advances the cervix 
descends and ap[iears at the vulva, or e\en protrudes beyond, as 
a dark-red, thick-walled, fluctuating tumour, 'becoming tense at 
every jiain. The os is concealed by the perina'um, and is to be 
sought for on the posterior asjject of the presenting mass. 

Pains of great force and frequency are present in these cases, 
and there is considerable risk of injury to the uterus. The fii'st 
thing is to determine exactly, by palpation or inspection, the 
site of the occluded os, if necessaiy drawing the cervix forward 
or to one or other side with a volsella. When this is found, 
scratching with the finger-nail is all that is required to define its 
margin. The membranes can then be seen, but are usually very 
adherent to the margin of the os, and must be separated by 
steadjdng the cervix with the volsella and sweeping the finger 
round. Dilatation will be continued by the mendiranes, puncture, 
incision, or the use of dilators being very seldom required. 

(2) Septa in the vagina, (a) Strong transverse septa are 
occasionally found, usually having a central aperture requiring 
dilatation or incision. (6) Longitudinal septa are more common. 
These septa can hardly interfere with the progress of labour, but 
are important to the obstetrician, because they may puzzle him 
when making examination. 

(3) Abnormalities of the hymen as a rule cause no serious 
obstacle to deliveiy, but may lead to difficulties in diagnosis, and 
to a certain amount of hai*m to the patient. Examination should 
be carefully made ; dilatation with the finger is all that is 
required. 

19. Tlie influence of siispensio uteri on |>i'eg:nancy 
nud labour. 

There is an important and interesting paper on this subject 
in the August number of the American Journal of Obstetrics ly 
C. P. Noble, of Philadeli>hia. He relates two cases in his own 
practice in which suspensio uteri had been performed, and the 
uterus firmly fixed to the anterior abdominal wall by buried silk- 
worm-gut sutures, in which pregnancy subsequently occurred. 
In Case 1, when labour came on, the pains continued for several 
hours without effect. On examination a tumour was felt resem- 
bling a uterii^e fibroid resting above the symphysis, and causing 
a serious obstruction at the pelvic inlet. The sutures used could 
lie distinctly felt through the abdominal wall at the upper maro-in 
of the mass. No presentation was felt through the cervix. In 
a more thorough examination it was found that the posterior wall 
of the uterus w-as extremely thin, and almost the whole cavity 
in which the child lay was bounded by the posterior wall. The 
w 



33.S THE YKAU-nOOK OF TREATMENT. 

brooch lay just above tlie upper limit of the obstructing mass, 
aud the child's head Avas hi«fh up on the left; the feet and legs 
lay to the front. Cepludie version was performed, and delivery 
was effected by a very high application of Tarnier's forceps. The 
undjilical cord had been compressed between the mass of muscle 
above the symphysis and the chihl's head, and the child was 
stillborn. The mother made a good recovery. In Case 2 the 
membranes were ruptured at the beginning of labour. The 
cervi.K uteri could not be felt on ordinary vaginal examination, 
and the anterior lip could only be I'eached when half the hand 
was introduced into the vagina. Under an an;esthetic the os was 
found to be very high up opposite the sacral j)i-ominence, and 
undilated. A large tumour, which was evidently the hyper- 
trophied fundus and anterior abdominal wall held down by the 
sutures, obstructed the inlet of the pelvis, and on this mass the 
breech rested. It was impossible to get the feet down, and 
delivery was effected by Porro's operation. The patient died 
afterwards from septicajmia. Noble has collected 808 Americau 
cases of ventrifixation in which at least one ovary was left. 
Among these there have been 56 pregnancies. Six ended in 
abortion, and 7 were not* delivered at the time of writing. 
Among the remaining 43 cases in which labour occurred at or 
near full term thei'e were 3 deaths, in only one of which cases 
Noble considered the operation had any influence, and the 
mortality therefore traceable to it is about 2 per cent. 

His conclusions are : (1) That women subjected to ventri- 
fixation are less likely to become pregnant than other women; 
(2) that pregnancy and labour are generally uncomplicated ; (3) 
that inertia uteri is not unfrequently met with ; and (4) that 
serious or insuperable obstruction to labour may be produced if 
the fundus and anterior wall of the uterus are fixed below the 
point where the uterus has been attached to the abdominal wall. 
He believes that the sutures should be passed through the 
anterior aspect of the fundus, and not too deeply into the uterine 
wall, and that as regards the abdominal wall they should only 
include the peritoneum. 

Noble alludes to the difficulties in deliveiy which he has 
met with after vaginal fixation of the uterus, and states that in 
cases where pregnancy follows the o])eration, abortion has occurred 
in 25 jjer cent. He considers that from an obstetrical standpoint 
the results have been disastrous, but he gives no statistics. His 
results do not agree with other authorities as to the relative 
\alue of the two operations. 

Grusdew (i/iincA. med. Woch., Nov. 17, 1896) gives an account 



MIDWIFERY. 339 

of the results of vaginal fixation as performed at the hospital 
for women in Riel. In 4 cases pregnancy occurred — 1 aborted, 
and 3 were delivered of living children/ In one of these 
cases the child presented by the shoulder, but in the other two 
spontaneous delivery took place without any difficulty. 

20. Po«iit-|>artiiin liaeinorrliag^c. 

Lombe Atthill [Brit. Med. JoitTU., March 6, 1897) makes 
some observations on the Anticipation of Post-partum Haemorrhage. 
As the result of his experience of the administration of ergot, or, 
as was usually given, ergot in combination with strychnine, for 
not less than three weeks prior to labour, he comes to the follow- 
ing conclusions: (1) That when administered previous to the 
termination of pregnancy in women in whom a tendency to j^ost- 
jmrtmn haemori'hage is known to exist, ergot in combination with 
strychnine tends in a marked manner to prevent the occurrence 
of lijemorrhage. (2) That when so administered in ordinaiy doses, 
it does not produce any injurious effect on either mother or child, 
and that its exhibition seems to delay the commencement of 
labour in svxch a case. (3) It tends to make the involution of the 
uterus more perfect, and lessens the chance of the occurrence of 
subsequent uterine troubles, many of which depend for their 
cause on imperfect involution of that organ. (4) It will not 
bring on premature labour or induce abortion unless uterine 
action has previously been set going. (5) In cases of threatened 
abortion its administration frequently seems to act as a uterine 
tonic, and in some cases tends to avert the danger of a mis- 
carriage, provided the ovum be not blighted. (6) That if the 
ovum be blighted, and especially if it be detached, ergot usually 
hastens its expulsion. 

It was the unexpected immunity from post-partum hiemor- 
i-hage in a patient to whom he had administered quinine for 
neuralgia prior to labour that induced Dr. Atthill to caiTy out 
the preventive treatment he advocates, and it was quinine that he 
first administered for this purpose. 

III.— EXTRA-UTERINE FCETATION. 

1. Siniiiltaiieoiis ovarian and nterine progfnancy. 

H. Ludwig, of Chrobak's clinic {Wien. klin. Woch., July 2, 
189G), records a case exceptional in its nature and unique in its 
event. The patient, aged thirty-five, had previously Ijeen delivered 
at term of five healthy cliildren. She became pregnant for the sixth 
time in April, 1895, and complained, from the third month, of 
considerable pain in the abdomen, which increased during the 
second half of gestation, and was accompanied by unusually 
w 2 



340 THE YKAR-nOOK OF TREATMENT. 

vif,'orons fcctal moveirieiits. On Feln-uaiy 20, 1896, slio was 
d(iliv(!recl naturally of a mature and liealLliy girl. The midwife 
discovered that another child remained, and called a doctor; both 
he and anothcsr medical man waited for the second birth, which 
they expected to be natural. As this did not occur, they gave 
the patient the choice of waiting till the death of the f(i;tus and 
then undergoing laparotomy, or of being operated on at once. She 
came to no definite decision, but went on perfectly well for four 
days, the movements of the child being still vigorous. On the 
fifth day she made up her mind to go to Vienna for an operation, 
and arrived there after a seventeen-hours' journey. On examina- 
tion a living child could be felt in the abdomen. The normal 
puerperal uterus was about the size of a man's fist, and the 
appendages on the right side were natural, but on the left side a 
short thick cord could l)e felt, extending into a tumour, filling up 
the left iliac fossa. Per vaglnam. this tumour could be felt 
pressing down into Douglas's pouch, and the child's head could be 
made out entering the pelvis ; the lochia were normal. The 
diagnosis of a left extra-uterine gestation with a living mature 
child having been made, laparotomy was immediately perfonned. 
The ovum was found attached to the left side of the uterus, from 
which the placenta appeared to grow. The vascular relations 
were so intimate that the idea of i-emoving the gestation sac and 
sparing the uterus was at once abandoned. The sac was there- 
fore opened and a healthy, well-developed boy extracted, who 
began at once to scream lustily ; the cord having been tied, the 
uterus and appendages were removed. The stump was treated 
extra-peritoneally. The recovery was somewhat delayed by a 
right-sided pneumonia, but the mother and child left the hospital 
well on March 22. The specimen removed consisted of the uterus 
and the appendages of the right side, which were normal, and 
those of the left, which were converted into the sac of the ovum. 
The left tube could be distinctly traced into a tubo-ovarian liga- 
ment about half an inch broad, while the ovarian ligament proper 
was seen to lose itself in the upper part of the sac ; from the free 
end of the tube an ovarian fimbria led into the sac, of which the 
outer layers appeared to be formed by the remains of the ovary. 
The sac itself consisted of two parts, one of which, closely attached 
to the side of the uterus, was solid, while the other, situated more 
externally, was membranous and had contained the ovum. The 
former consisted mainly of a normal placenta, into which two 
large vessels, artery and vein, ran from the uterus ; the latter 
corresponded in its relations to a greatly enlarged ovary, and 
showed on its surface a number of cystic piotrusions, which were 



MIDWIFERY. 341 

obviously ovarian follicles. INIicroscopical examination revealed 
the |iresence of a layer of ovarian tissue covering the whole of the 
membranous portion of the sac ; the placentaj tissue was normal 
in structure. 'J'he essential points in the pathological diagnosis 
of ovai-iau pregnancy have been laid down by Veit as complete 
presence of both tubes and one ovary, the other ovary either being 
absent or forming part of the sac wall, while at the same time one 
ovarian ligament must open into the sac. All these requirements 
are satisfied by this case, and the diagnosis is clinched by the 
microscope. Ludwig gives a full bibliography and a classified 
table of resiilts, from which it appears that this case is the first of 
its kind which resulted favourably both to the mother and to two 
healthy children. 

*i. F\ti-a-|)eritoiical iiirisioii. 

Berry Hart, at a meeting of the Edinburgh Obstetrical Society 
on March 10, 1897, read a paper on the Extra-peritoneal 
Incision in Extra-uterine Gestation, Intact and at Mid-term. 
While the conditions of an extra-uterine gestation may be very 
varied, there are practically three possibilities in intact forms. In 
the first two months the gestation is in the Fallopian tube, and 
intact or ruptured. At the third month it begins to develop 
between the layers of the broad ligament and lose its pediculated 
characteristic. In the fourth and fifth months it is usually 
embedded in the pelvic connective tissue and the broad ligament, 
and may go on developing extra-peritoneally ; but, as a rule, the 
ftetus escapes into the peritoneal cavity, and the placenta remains 
extra-peritoneal or tubal. He specially referred to the second 
variety, having o]:ierated on five such Qases. The first case 
had ruptured before operation, and the patient died subse- 
quently ; the others recovered. The treatment should be wholly 
operative. In this class of case — mid-term and intact — the gesta- 
tion is extra-peritoneal ; the possibility of its being an ovarian 
pregnancy is most remote, and primary intra-peritoneal gestation is 
a myth. Hart advocates extraperitoneal incision where possible, 
immediate removal of the fffitus, and, to avoid bleeding, the 
taraponnade of the sac till the placenta be thrombosed, if it cannot 
be easily separated. He thinks it better to open the abdomen 
in the middle-line fii'st, and thus to find the relations of the 
gestation and the refiections of the peritoneum. The vaginal route 
for operation is more difficult if the fcetus and placenta are present, 
and control of hsemorrhage is very difficult, as the tampon cannot 
be so efiectively applied. 

3. Operation for full term ventral preg^nancy. 
John W. Taylor, at the Obstetrical Society of London, May 5, 



342 THE YEAR-BOOK OF TREATMENT. 

1897, re;i(l a pajKT on "A Second Case illustrating the Treatment 
of (so-called) Aljd(jminal or Ventral Pregnancy at Full Term by 
tlie Op(;rative Removal of Child and Placenta ; Operation at the 
Twelfth Month ; Recovery." The patient believed she became 
pregnant twelve months before the operation. Except for an 
attack of luemateniesis she was up and about the whole time. At 
no period was there any acute pain, sudden illness or fainting. 
A description was given of the operation. The placenta was of 
the ordinary size, and covered the pelvic inlet " like the lid of a 
saucepan incompletely closed," the edge of the placenta being 
exposed and free on the left side of the pelvis, but closely applied 
to the a])dominal wall on the right side, where the cord was 
situated. Its attachments were, first, a thick band or rope of 
omentum firmly attached to the upper or serous edge of a placenta 
on the left side ; secondly, several thin attachments or adhesions 
of small intestine and cjecum to the same sui'face ; thirdly, the 
deep pelvic attachments of the under surface of the placenta. 
The author described his bloodless method of removing the 
placenta. He said that the attachments were very vascular, and 
tliat tlie vessels could be felt pulsating before the forceps were 
applied. The main point, however, was that as each va.scular 
connection was controlled before separation, the same operation 
might have been performed at any previous period of the preg- 
nancy ; and it might have been possible to save the child 
as well as the mother if the patient had come to the hospital at 
the time of the supposed labour. He said that he would always 
prefer to operate at term, and under no circumstances would he 
purposely wait for the death of the child before opening the 
abdomen. 

IV.— OPERATIVE DELIVERY. 

" The Relative Advantages of Forceps and Version as a Means 
of Extraction in Cases of Moderate Pelvic Deformity" was the sub- 
ject of a discussion opened at the meeting of the British Medical 
Association, 1896 {Brit. Med. Jo2irn., Oct. 31, 1896), by Milne 
Murray. He points out that obvious advantages to the mother of 
delivery by forceps ai-e : (1) avoidance of risk of uterine rupture ; 
(2) avoidance of intra-uterine manipulation ; (3) diminished risk 
of infection ; and to the foetus : (1) avoidance of traction on the 
neck ; (2) avoidance of compression of the cord. The group of 
cases in which version competes with forceps is that occurring in 
flat pelvis, where delay is due to shortness of the conjugate 
diameter, and in which the transverse is in no degree, or only 
to a small extent, diminished. In cases of the justo-minor type 



MIDWIFERY. 343 

the question of turning cannot arise. Experience has certainly 
shown that the use of ordinary forceps in cases of minor degrees 
of pelvic tiatness was associated either with failure in delivery, or 
else delivery was accomplished by the expehditure of enormous 
force, generally resulting in a dead child and lacerated maternal 
passages. By version a living child is often obtained with the 
expenditure of comparatively little force. Authorities explain 
this disadvantage of forceps thus : — (a) The forceps must he 
applied to the antero-posterior diameter of the fcetal head ; 
(6) this grasp of the head is associated with a bulging of tlie 
transverse diameter ; (c) that by version, on the other hand, a 
shorter diameter than the bi-parietal is introduced into the conju- 
gate at the brim ; and (d) that when the head is dragged through, 
base first, the bi-parietal diameter is compressed. 

Milne Murray, however, denies that the forceps causes the 
bi-parietal diameter to bulge. He has shown that it is possible to 
compress the occipito-frontal diameter to the extent of li inches 
without producing the slightest increase in the bi-parietal 
diameter, the expansion being a vertical and not a ti*ansverse one. 
This is explained by the cranial shell being made up of three 
segments — frontal, parietal, and occipital — and the effect of 
antero-posterior compression is to force the occipital and frontal 
bones under the edges of the parietals. The ditiiculty of forceps 
extraction is caused, he thinks, by the exaggeration of the 
mechanical defects of the ordinary forceps as a tractor when 
applied in flat pelves, the axis of the brim being inclined farther 
backward and so making it practically impossible for traction to 
be employed in that axis, and rendering the effective force of tlie 
traction less and less. The solution of the problem of econo- 
mising the force used is in a great measure found in the axis- 
traction forceps of Tarnier ; but Milne Murray has introduced a 
most important modification of the instrument which will permit 
the line of traction to be altered to suit any given case of i)elvic 
deformity, the ordinary axis-traction forceps only allowing 
traction to be made in the pelvic axis when the pelvis is normal. 
In his instrument the traction rods run down the back of tlie 
handles, and at a point half way down turn backwards at a right 
angle, forming two horizontal bars with graduations J inch apart. 
Against one of these marks is placed the word " normal," and 
when the movable handle is adjusted to it the instrument is for 
use in a normal pelvis. To adapt it to a pelvis whose axis is 
inclined less than normal it is only necessary to shift the handle 
one or more divisions nearer the a])plication handles, and vice 
versd when the axial inclination is greater than normal. 



344 THE YEAR-BOOK OP TREATMENT. 

The advantages claimed for the use of tlie axis-traction forceps 
ill Hat pelves are : (1) tlie forceps can Ix; ap|)lied without dilHculty 
to the aut(!ro-posterior diameter of the head, ajid in tin; transverse 
or roomy diamcjter of the pelvis ; (2) the grasp of the head does 
not materially compress it ; (3) no amount of practical )le com- 
pression of the head in this direction is capable of causnig the least 
expansion of the hi-parietal diameter; (4) the mode of grasp 
favours the development of the Naegele obliquity, and this follows 
the natural mechanism of delivery in these cases; (5) as compared 
with version, forceps avoids intrauterine manipulation. 

v.— THE PUERPERAL STATE. 

I. Di«>tiii'l>:iii<-<> of lai'tatioii. 

Angel Money (Australasian Med. Gaz., Jan. 20, 1897) says that 
the custom of weaning newly born children is too prevalent, and 
too few attempts are made to correct the milk when at fault. A 
thorough investigation of mother and milk should be made, and 
the quantity and ({uality of the latter determined, and the per- 
centage of fat and proteid, which are the only variable factors, 
ascertained. Bad milk contains toxic matters, albumoses, and 
leucomaines, all)umin being plentiful, but of the wrong kind, 
while the percentage of fat is deficient ; colostrum corpuscles are 
present and may be numerous. The most successful milk is that 
of mothers desirous, and confident of ability, to nurse. Exercise 
can diminish percentage of proteids, and a modei'ate amount of 
beef or mutton can increase percentage of fats ; these facts are 
seldom acted upon. A poor milk may be enriched by improving 
the maternal dietary, giving more meat and more milk, diminish- 
ing exercise, shortening intervals of nursing, and diuiinishing 
amount of liquids imbibed. Rich milk may be diluted by 
lengthening intervals of nursing, decreasing the amount of meat 
eaten, increasing exercise, augmenting fluid drunk ; drinking 
distilled water, Helitlon or Vichy water, midway between the 
nursings is an excellent practice. Colostrum corpuscles present 
after the first fortnight signify defective formation of milk. It is 
unjustifiable to diminish the water in poor milk by purgation, which 
may stop milk flow or may even cause the milk to contain toxic 
substances. The breast pump is not sufticieatly used to improve 
the function of lactation ; it should replace the baby while attempts 
are being made to improve the milk. The more perfectly formed 
the milk is, the more caseinogen and less albumin it contains ; 
however great the percentage of caseinogen, it never in the 
stomach forms dense clots as formed by cow's milk. It is a 



MIDWIFERY. 345 

mistake to suppose that stout or porter improves m'lk. Another 
error is the belief that beef-tea and chicken broth are good for 
nursing mothers. Excitement, fatigue, and overfeeding should 
be avoided ; also highly spiced, rich, or stim'ulating foods. The 
bowels should be regulated by proper dieting and massage or 
exercise rather than by laxatives, and it is highly desiral)le that 
there should be at night uninterrupted sleep for six hours for 
mother and child. 

'2. PiK'i'poral biliary colic. 

Eiermami (Miinch. med. Wocli., Jan. 12, 1897) says that the 
records of cases of biliary colic occurring after labour are few. 
He relates the case of a primipara wdio suffered from albuminuria 
during pregnancy and who had an attack of biliary colic five 
days after delivery. There had been no previous history of gall- 
stones. Gottschalk has seen nine or ten cases in ten years. In 
one case the colic reappeared after a subsequent pregnancy, the 
patient having been free from it in the meantime. Praus has 
stated that the first attack of colic occurs in a large number of 
cases during pregnancy or after parturition. 

3. Puerperal fever. (The use of antistreptococcic serum 
in the treatment of jnierperal fever.) 

John D. Williams (Brit. Med. Joiirn., Oct. 31, 1896) reports 6 
cases with 5 recoveries, and notes 8 cases collected from litera- 
ture. On 10 of them which were fully reported he makes the 
following remarks : 

(a) Nature of the cases. — In every case a previous thorough 
trial had been made of the usual constitutional and local i-emedies. 
The state of the pelvic organs was ascertained in 9 cases, and, 
with two exceptions, where there was uterine tenderness, were 
apparently normal. The cases were characterised by sevei'e 
febrile symptoms, and in some there were diarrhoea and vomiting. 
In 2 cases only was bacteriological confirmation of streptococci 
obtained. 

{b) General effect of the serum. — Following each injection, the 
previously hot, dry, and inactive skin passed into a state of 
moisture and active perspiration, the parched lips and dry tongue 
became moistened, and other distressing symptoms were relieved. 
In three eases, however, no benefit resulted from the treatment. 

(c) Effect on temperature and pulse. —In all the cases except 
the three just mentioned the degree of temperature and the 
frequency of pulse w^ere reduced after each dose of the serum. 
This reduction took place in from six to twenty-four hours. 

(d) ComjjUcaiions and fatalities. — Two of the cases proved 
fatal. 



346 THE YEAR-BOOK OF TUKATMENT. 

(e) Mode of admiuiHlraiwu. — -'The serum was injected into the 
areolar tissue of the abdominal wall. 

{/) DoHfKje.- — The largest dose administered was 45 c.c. 
(Kuffer's). Better results were found after a, large than after 
a small initial dose. The Brit. Inst, of Preventive Medicine 
fixes the initial dose at 20 c.cm., but Bullock states that much 
larger dos(!S can be given with safety. 

Haultain (Lnncet, June 2G, 18!)7), at tlie Edin])urg]i Obste- 
trical Society, gives a detailed account of three cases. In the 
first, symptoms began late — on the 2f)tli day, Vjeing the first on 
which any severe symptoms appeared. A culture then showed 
typical Loeffler bacilli, and the patient was treated with anti- 
diphtheria serum with very marked success. In the second case, 
the onset was forty-eight hours after delivery, and bacteriological 
examination showed a growth of streptococcus and bacillus coli. 
The patient died a week aftei-vvards, and apparently she derived no 
benefit from the antistreptococcic serum. In the third case, the 
onset of symptoms was on the third day, and a culture showed 
many streptococci. Antistreptococcic serum was injected on the 
ninth day. Haultain says that the three cases showed three 
distinct varieties of infection : (1) an intra-uterine diphtheria, 
probably localised to the placental site, giving rise to a dangerous 
state without external evidence of its true character, or evidence 
deducible from ordinary clinical signs. The second was a mixed 
infection, and shovved the virulence of the bacillus coli communis, 
and the absolute inefficacy of the antistreptococcic serum in these 
cases. The third case was of less value, since it was probably 
a simple toxin poisoning or saprgemia such as generally yields to 
antiseptic uterine donching. It must be noted, however, that 
improvement only set in after the douching was combined with 
the serum treatment. The culture method was the most effective 
diagnostic yet advanced. Even the microscope gave no idea of 
the vitality or virulence of the oi-ganism. In Case 3, for 
example, streptococci were found in the dischai-ge after the 
disappearance of symptoms. Probably they were tlien either 
dead or so crippled as to be innocuous. It was to be ho[)ed that 
the close observation of a number of cases would lead to the 
association of clinical symptoms with each variety of infection. 
Diarrhoea and erythematous patches seemed more or less charac- 
teristic of infection with bacillus coli communis. From a prog- 
nostic point of view the culture method was invaluable, because 
the prognosis varied greatly, according to the organisms present. 
Thus Marmorek has shown that of 15 cases of puerperal fever in 
which the serum method was employed, 7 were due to pure 



MIDWIFERY. 347 

streptococcus infection, and these all recovered ; 5 were due to 
a mixed infection of streptococcus and staphylococcus, of which 
'2 died ; 3 cases were due to a mixed infection of streptococcus 
and bacillus coli communis, and all died. The prognosis is 
distinctly more favourable when the case is one of simple strep- 
tococcus infection. All other methods should be used conjointly 
with the serum treatment. Packing with gauze soaked in anti- 
toxin seemed worthy of trial, since the serum was said to be 
bactericidal as well as antitoxic. Haultain's method of obtaining 
cultures is to jiass a Fergusson's speculum and expose the os. A 
})latinum wire, previously rendered aseptic by lieating in a flame, 
is passed into the cervical canal and some discharge obtained on 
it. This is then dipped into agar in a prepared test tube, the 
tube at the time being held bottom upwards to ])revent dust and 
germs from falling into it. A plug is then inserted and the tube 
sent to the laboratory. 

Several isolated cases have been reported in the medical 
joiTrnals. Edmunds (American Joitrn. Med. Sci., April, 1897) 
records a case in which no other ti-eatment was adopted, and 
which was shown, by the examination of pus from an abscess 
near the knee, to be a case of genuine streptococcus infection. 
The patient made a complete recovery, which Edmunds thinks 
was entirely due to the antitoxin. Cummins {Brit. Med. Journ., 
Feb. 13, 1897) had a case admitted under his care on the ninth day 
after her continement, who on the sixteenth day, with a pulse of 
132, rigors, and a very high temperature, was apparently sinking. 
There were constant vomiting, hiccough, and involuntary evacua- 
tions. Under the intiuence of the serum injections the general 
symptoms disai)peared rapidly, but the temperature continued 
high for some days. 

Steele {Brit. Med. Journ., Oct. 2, 1897) gives a table of the 
cases I'eported in 189G. Those cases in which the serum was 
injected soon after the onset of symptoms appear to have done 
best. "When the treatment has been delayed convalescence has 
been more protracted. The earlier the onset the more sevei'e 
were the symptoms, and in all the fatal cases the symptoms 
began early. 

In a recent work by Pinard and Wallich (Paris, 1896) the 
subject of the treatment of puerperal infection has been very 
fully dealt with. They emphasise the importance of beginning- 
treatment early, and state that, if the temperature reaches 102^ F., 
whether the pulse be above or below 100, an intra-uterine douche 
should be given. If the temperature does not fall to normal, 
or if the pulse remains above 100 although the temperature has 



348 TIIK YKAIMK)OK OP TRRATMENT. 

goiif down, tli(! JoucIk! iiiust he. repeateil. If, in spite of treat- 
inont, (lie triiiporaturc I'ciniiins liigli, and the patient lias Ijeon 
dc.livcM'cd tlii-(!(> or niofo days, curettaj^e is advised. If, in spito 
of cui-ettaife foUowtMl by intrauterine douclies, the teniporatiire 
still continues to rise and a second cui-ettiif^e is not successful in 
reducini^ it, continuous uterine ii-rigation should be employed. 
The fluid us(h1 for the first half-hour is biniodide of mercury 
1 in 4,000, and then this is replaced by a 1 per cent, solution of 
carbolic acid. Later a still more dilute solution may be used. 
If relief is not obtained in from twenty-four to forty-eight houus, 
the irrigation may be discontinued. Pinard considers it dangerous 
to use a curette on the first or second day of the puerperium, 
and advises that, if an intia-uterine douche does not lead to a 
speedy fall in temperature, continuous irrigation should be 
resorted to. 



VL— MECHANISINl OF DELIVERY. 

I. Breerh presentation with exteiKied legs was tlie 
subject of a ])aper read by Griffith and Lea at the Obstetrical Society 
of London on January G, 1S97. This paper was based on 
seventeen cases, which were briefly descril)e'd, and the following 
conclusions were arrived at : — (1) The extension of the legs in in- 
complete breech presentations may be either primary or secondary. 
(2) In the primary variety, which occurs before labour has begun, 
the breech engages readily in the brim, and the diagnosis can be 
made. (3) In the secondary variety the extension occurs during 
labour. This form is more frequent than the primary. (4) This 
complication is more frequent in primipara? — viz., 70 per cent of 
the cases. (5) The prognosis as regards the child is not worse 
than in pelvic pi-esentations in general. (6) Cephalic version 
is advantageous before labour is advanced. It is not usually 
possible in the primary, but may be so in the secondary variety. 
(7) Most cases are delivered naturally. (8) Prophylactic reduc- 
tion of the leg is only required in exceptional cases. (9) It is 
probable that flexion of the leg on the thigh is preferaljle to 
pulling down the leg into the vagina. (10) If aid is required in 
the lower part of the pelvis the soft fillet will usually eftect 
delivei'y. 

In discussing the paper, Amand Routli doubted whether the 
statement that the prognosis as regards the cliild was no worse 
when the legs were extended than in ordinary breech-presentation 
eases was correct ; in general practice, at any rate, he believed 
the result was very different. 



SIIDWIFERY. 349 

Champneys said that he had seen a case of primary extension 
of the legs in vertex presentation lead to ditticult delivery. A 
patient with a normal pelvis and a small child fell in lahovir 
which could not be terminated by natural efforts. On examina- 
tion a presentation of the vertex in the first pcjsition was found, 
together with presentation of the left arm and left foot. He 
suspected twins, and thought that the foot at least was conti'ibuted 
by a second fcetus. The child was delivered by forceps, and no 
twin was present. The legs after birth lay on each side of the 
neck. The newness of the subject might be illustrated by the 
fact that so careful and learned an observer as Matthews 
Duncan told him he had never seen a case of primary extension 
of the legs. As to the question when to interfere, interference 
should always be resorted to when in a case of breech presenta- 
tion delay took ])lace at any stage, even in the first stage. The 
paper illustiated the fact that the subject is not yet thoroughly 
understood. It might be thought that the cases of difficulty 
would be those of large children, contracted pelves, and primi- 
para?. But, on the one hand, many large children were delivered 
easily, many pi^imiparjie even witli large children experienced no 
difficulty, and contracted pelves accounted for a very small 
number of difficult cases. On the other hand, difficulties not 
infrequently occurred with normal pelves and small cliildren. 
One mode of delivery was not insisted upon in any book that he 
knew, though it might be mentioned casually, and that was 
pressure from above. 

Herbert Spencer read a paper at the Harveian Society on 
Feb. IS, 1S97, on the Dangers and Diagnosis of Breech Presenta- 
tions, and advocated the examination of all patients at the seventh 
month of pregnancy, and the ti'eatment of breech presentations 
by external version at seven and a half months, followed by the 
wearing of an abdominal belt. He mentioned 6 cases which he 
had treated in this way, and in which the children were born as 
vertex presentations and survived, and 26 cases similarly treated 
in Pinard's clinic, with 1 immediate infantile death, 2 other 
children subsequently succumbing. 

2. Ti-oatBii4'»t of breocli preseBitatioii!^. 

Achsharumoff (JlomUi^. /. Geburl. u. (Jyndk., Jan., 1897) has 
adopted the practice of bringing down a foot as a prophylactic 
measure successfully in forty-two cases of breech presentation. 
He says that this procedure has no unfavourable influence on the 
course of labour ; indeed pains weak before the manoeuvre become 
strong after it. The chance of spontaneous delivery of the lower 
part of the trunk becomes greater, and if the labour lingers, the 



350 TIIK YKAU-nOOK OF TKKATMENT. 

trunk can all the more ea.sily be oxtractcfl. Tlie child is more 
likely to be saved wlum the foot has been brought down. 



VTL— THE NEW-])ORN INFANT. 

1. OI>sti'ii«*tioii of the Iniliryiiinl <1iirt in new-born 
<-liil4li-<'ii. 

Landolt (Amiales de Gyiirc. et d'Obsfei., Jan., 1897) finds that 
this condition is not rare, and is often overlooked till much harm 
is done. The aflection should be suspected whenever there 
appears to be conjunctivitis in one eye only a day or two after 
birth. The conjunctiva itself is not infrequently cured, so to 
speak, by appropi'iate lotions. The ol)stetrician, mistaking a 
complication, or result, for a primary disease, finds to his sur])rise 
that the eye continues to water, the lids becoming glued together, 
and a drop of pus often exudes from the injier canthus. This con- 
dition is yet more alarming in certain cases where no conjunctivitis 
has been observed. It looks like the beginning of purulent 
ophthalmia. Landolt lays down as a rule that obstinate uni- 
lateral lachrymation in a new-born child usually signifies obstruc- 
tion of the tear-duct. As an ophthalmic surgeon he advocates 
sounding of the duct with a fine probe ; on no account should the 
canaliculus be slit up. Afterwards weak antiseptic lotions must be 
injected into the duct by means of a Euel's syringe ; the infant 
must be turned on its face directly afterwards, lest any of the 
lotion be swallowed. 

2. Sypliilis in |>re$;^nancy. 

Murray (i\''e((; York Med. Hews, June 19, 1897) first cjuotes 
Fournier and Le Pileur as to the results of pregnancy in syphilitic 
mothers. Fournier's figures are 167 pregnancies, of which only 
22 infants survived, the rest being either abortions, stillbirths, 
or early deaths. Le Pileur quotes 414 pregnancies with 295 
deaths. Murray divides syphilis in pregnant women thus : (1) 
That acquired before pregnancy, in which there is nothing 
abnormal ; (2) infection from the primary chancre of the father at 
a fruitful coitus, in which the primary sore in the mother appears 
earlier than in unimpregnated women and is more severe, this 
form of infection being most fatal to the child ; (3) infection from 
a secondary lesion in the father, which, if it occurs in the earlier 
months of pregnancy, usually kills the child ; if in the later 
months, is less dangei'ous to the child ; (4) syphilis in both 
parents, when the efi'ect on the child is the woi'st. With regard 
to the diagnosis, this is often diflicult, since the primary sore is 



MIDWIFERY. 351 

not often seen. An examination of the husband should be made 
whenever possible. If the husband, thinking he is cured, having 
had no symptoms for some time, impregnates his wife, the disease 
usually appears in the third month. As regards treatment, 
Muri'ay jtrefers inunction combined with tonics sucli as iron, 
arsenic, and strychnine. After birth the child should be treated 
through the milk by administering mercury to the mother. As 
the child grows older it is sufficient to place mercury ointment on 
a flannel binder. If the mother is too weak to suckle, the child 
must be fed by hand, no wet-nurse being admissible. 



DISEASES OF THE SKIN. 

By Malcolm Moukis, F.R.C.S.En., 

Surgeon to the S/cin Dcimrlment, St. Mary's Uosjiital. 



During the past year two important medical gatherings have 
been held — namely, the annual meeting of the British Medical 
Association at Montreal, and that of the Jnternational Medical 
Congress at Moscow. At each of these dermatology had a 
section assigned to it, and at each good work was done. As 
usual, however, the work was mainly pathological in character, 
treatment occupying a c^uite subordinate position. This circum- 
stance indicates the direction in which dermatology is at present 
making most decided progress ; and although the " practical 
man" may feel some impatience at the relatively slow advance 
of therapeutics, the scientific dermatologist sees in the increase 
of knowledge as to the causes and processes of disease the best 
hope of acquiring the power of effectively conti'olling them. 
The pathologist, in fact, must prepare the way for the therapeutist, 
unless the latter is content to be a mere empiric. Hence, although 
there is no definite advance in the treatment of skin diseases to 
record since the last edition of the "Year-Book" was published, 
the pathologists have made some progress in the making of roads 
along which we shall doubtless be able to move forward in the 
not distant future. But dermatologists during the past twelve 
months have done moi'e than merely mark time ; they have 
worked on their own account to improve the methods of dealing 
with the diseases that fall within their special province, and in 
some directions not altogether without result. 

As in former issues of this work, I propose to consider first 
the new methods of treatment that have been adopted in various 
diseases ; and, secondly, the new drugs, or novel uses of drugs 
already known, that have been introduced. 

LUPUS VULGARIS. 

Tlio itew tuberculin. 

In each successive issue of the " Year-Book " I have to record 
the birth — or resurrection — of one or more methods of dealing 



DISEASES OF THE SKIN. OOO 

with lupus vulgaris. For every one of them more or less brilliant 
results are claimed. Unhappily, however, their efficacy w^ould 
seem to be mostly due to some subtle factor inseparable from the 
personality of their inventors ; the remedy is like the bow of 
Ulysses, which could be draw'n by him alone. But in the case of 
so intractable a disease as luj^us, it is the duty of the dermatologist 
to try every method of treatment that comes before the medical 
w^orld with anything in the nature of a guarantee of scientific 
genuineness. For this reason, as soon as Koch published his 
account of his new tuberculin or T.R. (see p. 31), I lost no timt 
in putting it to the test in cases of lupus vulgaris. Koch, in his 
paper (published in the De'iot. vied. Woch. of April 1, 1897) 
containing the description of his new " Mittel," stated that in 
several cases of that affection in which it had been used he had 
"invai'iably seen a considerable improvement take place," Ijut 
he expressly refrained from speaking of any case as cured, 
" although in a number of observations one would be warranted 
in speaking of a cure in the current sense of the w^ord." I had 
used Koch's oi'iginal tuberculin in a number of eases of lupus 
vulgaris with only temporary benefit as far as the immediate 
effect was concexned. It is true that in certain cases the remedy 
appeared to exert a modifying influence on the process, so that 
subsequently surgical procedures were more lasting in effect than 
they had been before (see Brit. Med. Journ., June 3, 1893, 
p. 1154); but after all, the measure of success obtained in that 
way, though real as far as it w^ent, was far from fulfilling the 
expectations which one had been led to form by the exaggerated 
accounts that filled the medical journals in the first enthusiasm 
of the announcement of a " cure for tuberculosis." 

My mental attitude in regard to the new tuberculin was, 
therefore, one more of scepticism than of even " benevolent 
neutrality." In conjunction with Dr. Arthur Whitfield I tried 
it in six cases of lujms vulgaris, following with scrupulous fidelity 
Koch's directions as to the mode in which the remedy should be 
used. The initial dose of the injection was -^^ of a milligramme ; 
this was raised rapidly, care being taken not to excite con- 
stitutional disturbance, to 1 — 10 milligrammes. A detailed 
report of the cases was published in the Brit. Med. Journ. of 
July 24, 1897, p. 207 et seq. The improvement in all the cases 
was at first veiy marked. On the patients themselves the effect 
was to produce a sense of satisfaction almost amounting to elation. 
As for myself, I have never seen any treatment do anything 
like so much good. The change for the better in the affected 
parts was, in most cases, a veritable transformation. 

X 



354 THE YEARBOOK OF TREATMKNT. 

Summarising the effects oi tlie new tuberculin in the 
order in whicli tliey were oVj.s(;rve(i there was : (1) A diminu- 
tion of tlie surrounding h.do of rechiess in those cases in 
which this had been present to a marked degree before the 
commencement of the treatment ; in cases in wliich there were 
only yellowish brown nodules in a white scar the injV-ctions pro- 
duced no visible effect at this stage. (2) The next cliange noticed 
was a slight depression in the centre of the nodules, leading to 
wriidding, and later to desquamation of the cuticle. Then there 
occurred (3) steady healing of all ulcerated surfaces ; and (4) 
slow subsidence of the previously permanent (ledema of the lips, 
ears, etc. In two cases actual disappearance of the characteristic 
lupus nodules was noticed ; in others, there was distinct shrinkage 
of nodules, with diminution in the scaling of the surface. Another 
marked effect of the injections was the softening and flattening of 
pre-existing scars. 

At first, when only small doses were being given, there was 
little or no reaction, although in some cases a feeling of heaviness 
and drowsiness was complained of. When the larger doses (from 
1 milligramme upw^ards) are reached, there is considerable febrile 
disturbance, sometimes with headache and pains in the limbs, 
some trouble in breathing, and a general feeling of depression 
with broken sleep. Locally, the erythema was generally in- 
creased, and the whole affected area, including even old-standing 
cicatricial tissue, was swollen. The phenomena of reaction quickly 
disappeared. On the whole we felt warranted at that time in 
affirming that the local effects of the new tuberculin in the cases 
here referred to had been uniformly good, and "in some cases 
distinctly brilliant." The constitutional disturbance had in no 
case been severe, and was always of a very transitory character. 
We were emphatic, however, in stating that the results then 
reported were not "cures." 

For some weeks after the date of the report here summarised 
the lupus remained stationary ; fresh nodules developed, but, 
on the other hand, none of those which remained at the end of 
the treatment disappeared, nor was there any further retro- 
cession of the disease. Recently (November) in all the cases 
but one the good effect seems to have become exhausted. 
But the improvement which follows the injections, even if 
it be only temporary, is so great that I am still disposed to 
have recourse to the treatment in cases where the constitution is 
not broken down. One objection to the free use of the remedy is 
its cost, which for hospitals is almost prohibitive, and in private 
practice is burdensome to all but wealthy patients. 



DISEASES OF THE SKIX. 355 

0x1 July 6th 0. Lassar showed at the Berlin Derniatological 
Society [Separat-Abdruck aus Denfiatologische Zeitschrifl) five 
cases in which he had used the new tuberculin with striking 
immediate results — absorption of iufiltratin* material, decrease 
in size of nodules, and healing of ulcerated surfaces. He considers 
that the cases show that the injections paralyse " the local 
}»oisonous etfect of the lupus nodules on the surrounding tissues," 
adding that one would not be warranted either in generalising as 
to the beneficial effects of the treatment from these few cases, or 
in excluding the possibility of a cure being effected by means of 
the remedy. 

Seeligman (^Deutsche med. Wochenschri/t, No. 30, 1897) records 
his experience of the method in the case of a woman suffering from 
lupous ulcei-ation of the nose and hand, together with erosions 
of the cervix uteri, with a purulent discharge containing a few 
tubercle bacilli, and tuberculous pyosalpinx and endometritis. 
After forty injections, which were borne with great difficulty, 
there was marked improvement in the general condition and in 
the lupous ulcerations of the nose and hand, as well as in the 
condition of the genital organs. 

Doutrelepont (ibid., No. 34) obtained good results in fifteen cases 
of lupus, although he complains of the general and local reactions 
and the uncertainity of the preparation. The age of the 
tuberculin has, in his opinion, some effect on the febrile reaction. 
There was a relatively rapid healing of the ulcerations, the 
hypertrophy diminished, and scar tissue soon appeared. The 
swollen l}nn[)hatics decreased in size, although some suppurated 
and had to be operated upon. The new tuberculin seems to 
him to have more curative value than the old, but care must be 
exercised in the dosage. 

Van Hoorn (i6irt.) had under observation ten patients with 
lupus, all of whom impioved under the treatment ; the colour of 
the affected parts became paler, the infiltration diminished, the 
small, irregular tubercles disappeared. The weight increased in 
four patients, was stationary in five, and diminished in one. 

Gerber and Prang (ibid.) saw improvement in three out of six 
cases of lupus. They believe that in lupus, as well as in tuber- 
culosis, when the patients are in good condition, and the affection 
is not too far advanced, the remedy is of value. 

Juan L. Hohr, of Cadiz (Anales Medicos Gaditanos, July 15, 
1897), records the case of a woman, aged thirty-six, suffering from 
superficial lupus of the nose and upi)er lip, which were the seat 
of scars ; the disease was of eight years' standing. There was a 
fresh patch on the chin and another along the jaw. Injections 
X 2 



350 'I'lIK YKAU-IiOOK OF TIIKATMKNT. 

(1 and 2 c.cin.) of the ,_/,„ solutiou caused disappearance of tlie 
redness around tlie patches, but the patient complained of great 
weakness and pain in the Hmbs, and of feeHng " ill all over." 
The treatment was therefore discontinued. The author's ex- 
perience leads him to conclude that tlie new tuberculin — even in 
the highest degree of dilution — always causes reaction, though 
the intensity may vary. Koch's statements cannot, he thinks, Ijo 
reconciled with clinical facts. 

R. Campana of Home reports {// FolicHnico, (Jcto})er 1st, 1897) 
the effect of the new tuberculin in a case of nodular lupus of the 
face in a young man, which had not Vteen intluencesd in any way 
by treatment of various kinds, including the u.se of the old 
tuberculin. The T. R. was administered during two months, 
with the result that a progressive diminution of swelling and 
subsidence of the nodules took place, so that the patches were no 
longer raised, and were distinguishable from the suri'ounding 
healthy skin only by being somewhat redder and rougher. Cam- 
pana describes the effect of the new tuberculin as shov/ing itself in 
diminution of the tuberculous infiltration, this diminution being 
more evident in spots where there were small nodules, the place 
of which is taken by superficial atrophy. 

At the meeting of the German Association of Scientists 
and Physicians, held at Brunswick in the autumn of 1897, 
Sternthal {Betitsche med. Zeif/ung, October 11th) showed cases 
of lupus which had Vieen treated with the new tuberculin. In 
two of these no good result was observed, although the dose 
was inci"eased to 13 milligrammes of pure tuberculin. In one of 
the cases an old otitis media which had been cured many years 
before developed anew. In the third case (hypertrophic lupus of 
the nose) striking improvement followed the injections. On the 
same occasion Finger related three cases in which the results of 
the treatment were entirely negative. 

At a meeting of the Dermatological Society of London on 
November 10, 1897, Crocker and Fernet showed two cases — one, a 
child of ten, with the freely ulcerating form of lupus, was immensely 
improved by the treatment, which, however, was not complete ; 
the other, a young woman of twenty, with multiple nodular lujius 
of the face and ear, who had beeiT treated as an out-patient, and in 
whom " the improvement was only very moderate in degree — 
certainly not worth the time and expenditure of money on the 
treatment." It should be added that on subsequent scraping the 
lupus tissue was found to be very resistant to the curette, a 
iact which may possibl}'^ account for the slight effect of the 
tuberculin. 



DISEASES OF THE SKIN. 357 

OtiKM' iiictliods of tr<':itiii('iit. 

[jiipus has been treated by the application of tlie vapoui- 
of boiling water, but without result, penetration of the agent 
to any depth being prevented by condensation of the steam 
on the surface. Hollander (^Deutsche med. Wochenschrijt, No. 43, 
1897) reports that for two years past he has treated the 
disease by cauterisation tvifh dry hot air. The air is driven 
through a red-hot metal tube, which raises it to a tempera- 
ture of 300° C, and it is directed on to the diseased parts. 
Under the influence of the current of hot air the healthy parts 
became quite bloodless and shrunken. The lupus nodules, on 
the other hand, project so that the hot air reaches them more 
directly and causes necrosis. A few days after the application 
the circulation in the healthy parts is restored, and the necrosed 
tissues are eliminated. Cicatnsation therefore starts from islets 
of healthy tissue scattered over the whole surface of the lupus ; 
the result is a supple and non-contracting cicatrix. After the 
nse of the hot air a dressing of bora ted lanolin should be 
applied to the parts, and should be left on for three or four days. 
The stench is sickening at tirst, but this ceases when the 
necrosed tissues have separated ; after that cicatrisation can be 
quickened by painting the spots on wliich tlie disease was 
situated with a 3 per cent, solution of nitrate of silver. Of the 
cases treated in the manner described not one has relapsed. 
New foci appear from time to time, but they are always small 
and yield to one application of hot air. 

Calomel injections have been used by Asselberghs {^Presse Med., 
No. 65, 1897) with good results in fourteen cases. The dose was 
5 centigrammes of calomel in one cubic centimetre of olive oil. 
The injections were at first given every ten days, but owing to 
the pain which they caused they had to be given less frequently. 
No symi)toms of mercurial poisoning were observed. 

Dubois-Havenith has quite recently, at a meeting of the Paris 
Societe de Dermatologie et Syphilographie [Sem. iMe'd., Dec. 15th, 
1897), confirmed the statements of Asselberghs; he pointed out 
that the treatment should be used only exceptionally, and that 
it may with advantage be combined in certain cases with other 
methods. Scarenzio (Gazz. Med. Lombarda, April 19th, 1897) 
has successfully treated three cases in the same way. 

Fernianyaiiate of potassium has been used with advantage in 
eleven cases by L. Butte (^Ann. de la Polycliu. de Paris, January, 
1897). It is applied by means of compresses saturated with a 
solution at first of h per cent., gradually increased to 2 per cent. 
The application, which is made daily and continued for ten or 



35S THE YKAK-nOOK OF THKATMKNT. 

fifteen ininut(!S, causes some pain, which is speedily i-elievecl by 
the use of a cocaine ointment. Tlie effect claimed for the 
treatment is that lupus nodules disappear and the progress of the 
disease is arrested. 

The Roentgen rays have been used in cases of lupus in the 
Breslau clinic by Loewenheim, and at Hamburg by KUmmel, with 
good re^sults. Finden of ('opciihagen has also used concndr<ded 
sunlight and the electric light (G9 Versanim. Deutscher Natnr- 
forscJier nnd Aerzte, Braunschweig, 20-26 September, 1897). 

LUPUS ERYTHEiMATOSUS. 

Josef Schutz (Archiv. far Dennatologie nnd Syj/hilis, Bd. 
xxxviii., Hft. 1, 1897) uses local applications of Fowler's solu- 
tion 4 grms., distilled water 20 to 30 grms., and chloroform 
2 drops. This solution is applied morning and night, and is 
allowed to dry upon the skin. The chloroform is added to prevent 
change in the solution. The first few days there is no change in 
appearance, but about the fourth or si.xth day there is slight 
swelling, increased redness, and sensitiveness ; then a powder or 
paste is applied in the next four to eight days. The swelling 
diminishes, the surface becomes pale and exfoliates. The solution 
is again painted over the affected surface as before. In from ten 
to eleven weeks the case is cured. This treatment is not 
followed by cicatricial atrophy of the skin. The author believes 
with Binz, that the action of the remed}^ is due to reduction 
and oxidation. The arsenic becomes arsenious acid ; this, again, 
changes into the arsenical salt ; this change takes place whenever 
and wherever arsenic comes in contact with living protoplasm, 
and the amount of reaction is in direct proportion to the quantity 
of protoplasm in the cells. He has treated ten cases in this 
manner with uniform success, and so far there has been no 
relapse. 

ECZEMA. 

Picric acid. 

Aubert ("Traitement de I'Eczema par I'Acide Ficrique," These 
de Paris, 1897) says that, speaking generally, the use of picric 
acid is indicated in those forms of eczema in which the inflamma- 
tion is acute and superficial, and where the lesions are chiefly 
epidermic. The keratoplastic action of the remedy cannot l^e 
exerted in the chronic forms of eczema, which are accompanied by 
induration and thickening of the epidermis. In acute conditions 
the acid forms, on contact with the ulcerated, " weeping " surfaces, 
a protective coating composed of coagulated proteid substances 



DISEASES OF THE SKIN. 359 

ami epithelial dSris, beneath which the growth of new epidermis 
proceeils ra))itlly. When the crusts come away the underlying 
skin is found perfectly dry, without any redness, and covered 
with newly formed epidermis. The application of picric acid, 
moreover, causes almost immediate cessation of itching, and this 
effect is produced in chronic as well as in acute conditions. The 
treatment is indicated : (1) in acute vesicular " weeping" eczema ; 
^2) in acute exacerbations occurring in chronic cases ; (3) in the 
impetiginous eczema of children ; (4) in chronic eczema where 
itching is troublesome. The remedy is used in a saturated 
solution as follows : — 

Picric acid ... ... ... ... 12 grammes 

Tepid boiled water ... ... ... 1 litre 

M. Allow to cool and decant. 

This solution is easy to prepare and will keep unchanged. It is 
painted over the affected surface, care being taken to carry it a 
little beyond the limits of the disease. Then the parts are covered 
with gauze or compresses of tarlatan (a kind of open, transpax'ent 
muslin) squeezed out of the same solution ; over this is placed 
a layer of cotton wool. On no account must oil-silk, or any other 
substance that will pi-event evaporation, be placed over the dress- 
ing, otherwise cicatrisation will be hindered by maceration of 
tissues. The dressing should be renewed every two or three days. 
In changing it the gauze may be found to be adherent to the 
surface ; it should be detached carefully by wetting with tampons 
impregnated with picric or boracic acid. When healing has taken 
place the skin is sometimes harsh and hard ; it can be softened by 
a few applications of borated vaseline. Aubert gives full par- 
ticulars of twenty-three cases successfully treated by the method 
described, in the Hopital St. Antoine, under the cai'e of M. 
Gaucher. He concludes by affirming that picric acid is neither 
irritant nor caustic nor toxic, can be used in children, and can 
be applied to extensive surfaces svithout inconvenience. A cure 
is effected in ten to fifteen days. 

Gaucher himself speaks highly of the treatment (.S'oc. Jled. des 
Hopitaux, May 21, 1897). Excellent results have also been 
reported by MacLennan (Brit. Med. Journ., Dec. 27, 1896) ; 
Brousse (Nouv. Montpellier Medical, Sept. 5, 1897), who, before 
a] plying the acid, asejjticises the cutaneous surface by washing 
with a solution of boric acid ; Leredde {^Anii. de Derm, et de 
Syphiliyr., June, 1897) ; and L. Pluymers [Ann. de la Soc. Med. 
Chir. de Liege, July, 1897). On the other hand, Frangois (^An7i. 
et 'Bull, de la Soc. de Med. d'Anvers, July- August, 1897), who 



360 THE YEAR-BOOK OF TREATMENT. 

lias tried the method in two cases of acute and throe of chronic 
eczema, and in seven of artificial eczematoid d(!rmatitis in work- 
men, reports that, so far from doing any good, it caus(!d aggrava- 
tion of the conditioix at once in nine of the cases, and later in the 
remaining three. H(; therefore agrees with Besnier and Daiic^r 
that the action of picric acid cannot be depended on, l>eing 
sometimes beneficial, sometimes not, and often causing irritation. 
H. Waldo [Brit. Med. Joutji., Feb. 6, 1897) observed symptoms 
resembling carbolic poisoning in a case of eczema which he 
treated with picric acid. 

Bilberry. 

The treatment of obstinate eczema by means of a concen- 
trated decoction of vaccinium myrtilbis (r?t/(/o bilberry, blaeberry, 
or whortleberry) was (says Professor Stockman in the Edinburgh 
Medical Journal, December, 1897) tirst tried by Winternitz, who 
gives his reasons for using it in the following words : — " The 
observation that a highly concenti'ated watery decoction of the 
bil])erry not only colours intensely the epidermis and horny 
growths from it, but also overspreads the skin with an adhesive 
unirritating covering, led me to use it in cases where fatty and 
irritant applications increased the local affection." He found 
that in discharging eczemas rapid benefit was obtained ; that 
under its action "weeping" ceased in a few hours, the hyper- 
semia of the skin diminished, and normal epithelium tended to 
replace the unhealthy layer. Itching also was greatly lessened 
or entirely disappeared, much to the increased comfort of the 
patient. Fried, Utschik, and Wertheimer have recently reported 
certain cases which they treated with this })reparation (Bl. f. 
klin. Hydrotherap., Wien, October, 1897). They find that its 
action is extremely beneficial in severe cases of sycosis with 
eczema of the face. The decoction is painted over the affected 
parts and covered with a thin layer of cotton wool, when the 
whole becomes so intimately attached to the hairs that in forty- 
eight hours the dressing may be gently removed, and brings 
away with it, with little discomfort, all the hairs. They report 
at length a case of severe eczema of the face, scrotum, and 
perineum, in a man of forty- six years of age, which was healed 
completely in three weeks by this method of treatment, after 
lasting for eighteen months. Two cases of general eczema in a 
girl of seventeen and in a man of seventy-six also gave excellent 
results. K. Kraus (ibid., No. 9) has also found extract of bilberry 
useful as an application in eczema. He used it in combination 
with hydrotherapy. 



DISEASES OP THE SKIN. 361 



LICHEN PLANUS. 

Biiiiotlide of luerciiry* 

For some time past I have used biniodide of mercury as an 
internal remedy in cases of generalised lichen planus with highly 
satisfactory results. A short paper embodying my experience of 
this treatment in some twenty cases was published in the St. 
Louis Medical and Surgical Journal for October, 1896. At tirst 
I used this method of treatment as complementary to a course 
of arsenic given in the ordinary way. Afterwards I used the 
biniodide alone with equally good results. The following may be 
taken as a typical formula : — 

^7 Liq. Hydrarg. Perchlor. 5J. 

Potass. lodid gi'- xl- 

Decoct. Sarsaj Co. ad *viij. 

M. Ft. mist. Sig. Two tablesp9onfuls Ihi-ee times a day. 

I have tried this treatment in tbe chronic localised form of 
lichen planus without appreciable benefit. How the remedy acts 
is not quite clear. It is well known, however, that mercury, 
besides its parasiticide action, has valuable tonic properties. It 
neutralises the effect of toxins circulating in tlie blood, increases 
the number of red corpuscles, and quickens the activity of tissue 
changes. These properties would a prio7-i indicate that mercury 
is likely to be useful in an acute process like generalised lichen 
planus. 

J. Abbot Cantrell {Philadelphia Pohjchnic, July, 1897) reports 
a case of generalised lichen planus in a man in which one-fourth 
of a grain of mercury biniodide was given three times a day, 
with recovery after live months of treatment ; externally he 
applied liquor carbonis detergens, two drachms to the ounce of 
water. Nine years later the patient again presented himself 
with a similar eruption, which again subsided under the same 
treatment. Another case was treated with arsenious acid, one- 
thirtieth of a grain three times a day, and locally with a lotion 
containing three drachms of carbolic acid to a pint of water. A 
third was given some saline mixtiire, and locally inunctions of 
two grains of mercuric chloride to one ounce of petrolatum, which 
relieved him in about three weeks. A fourth was much relieved 
by the administration of the extract of cantharides in the dose 
of half a grain thrice daily. Cantrell believes that the biniodide 
of mercury in the first case, and the extract of canthai'ides in tlie 
fourth case, show a result as decided as that from the use of 
ai'senic, and are worthy of a further trial. 



362 THE YEAR-BOOK OF TRKATMKNT. 



1 '.SOU IAS IS. 



liili-:iV4'iioii*>> injection of ai'«4cni<>. 

Herzheimer (/ierlin. k/in. WtichauHcJir., No. 35, 181>7j has 
used tlu; intravenous method of administering arsenic in twenty- 
three cases of psoriasis, with the result that ten were cured and 
nine notably improved. The injections were made, with strict 
antist^i^tic precautions, into veins at the bend of the elbow or 
behind the knee, the dose being at first 1 milligramme of arsenious 
acid, and being increased every day till a dose of 15 milligrammes 
was reached, which was continued till the patches had completely 
disappeared. The treatment occasionally caused some secondary 
troubles — small thromboses (two cases), tiny furuncles, arsenical 
neuritis, and diarrhoea. Relapse occurred in the cases as after all 
other modes of treatment. Herzheimer recommends that psoriasis 
should be treated, as syphilis is, l)y intermittent medication, the 
intravenous administration of arsenic Ijeing supplemented l>y 
internal treatment. 

Cacodylic acid. 

Danlos (^Therap. Woch., iv., p. 560) treated a long-standing 
and ol)stinate case of generalised psoriasis successfully with the 
following mixture : — 

ly Cacodj'lic acid 2*5 gmes. 

Rum 20 gmes. 

Syrup of orange peel ... ... 20 gmes. 

(Jil of peppermint ... ... 2 drops. 

Distilled water 60 gmes. 

At first six teaspoonfuls of the mixture were given daily, the 
amount being after three weeks reduced to four. Except a 
garlicky smell of the breath and slight intolerance of the stomach 
at the end of the third week, the treatment caused no discomfort. 
The disease, which had existed for eight years and had resisted 
various kinds of treatment, yielded quickly. Recurrences became 
less frequent and less severe, redness diminished, the scales fell off, 
and the thickening of the skin became visibly less. 

Testicniar extract. 

At a meeing of the Paris Academy of Sciences (Presse Me'dicale, 
July 17, 1897), Guyon reported the results obtained by Boufife 
with the use of testicle juice injected subcutaneously, in amounts 
progressively increased from ten to twenty centimetres daily, for 
periods of time averaging about three months. He had thus 



DISEASES OF THE SKIN. 363 

tfoatetl sixty-one men and twenty-two women with generalised 
psoriasis of long standing. Seventy-seven per cent, of them had 
been cured, and there had been no i-elapse. in periods varying 
from two to five years. 

ALOPECIA AREATA. 

R. Panichi, of Florence {Settimana Afedica and Monatsh. f. 
prakl. Derm., No. 4, 1S97), has treated sixteen cases of alopecia 
areata by the following method of local stimulation : — After first 
rubbing the bald patches with a 1 per cent, solution of corrcsive 
sublimate in glycerine, isolated punctures are made at the cir- 
cumference of the patch with the needle of a Pravaz syi'inge, the 
point of which has been steeped in a mixture of carbolic acid 
(3 to 4 parts) and tincture of cantharides (6 to 7 parts) ; the 
same mixture is then painted over the bald surface, and, if 
possible, injected with the syringe into the hair follicle. The 
])unctures should be repeated every four to six days, according to 
the tolerance of the patient, the affected places being painted 
with the solution on the intervening days. In all the cases the 
treatment was successful, although several of them were of old 
standing, and others very extensive and refractory to other 
treatment. 

KELOID. 

Sinclair Tousey {Xew York Med. Journ., Nov. 6, 1897) has 
found thiosinamine very useful in the treatment of keloid. He 
administers it hypodermically in a solution containing 1 part 
of the drug to 10 parts of sterilised water. The maximum dose 
of the drug is about 3 grains, which is most advantageously 
injected into the nniscular tissue. Tousey was led to investigate 
the action of thiosinamine by observation of its effect on the 
scar tissue surrounding lupus in cases in which the drug was 
being used on account of its supposed destructive effect on 
tubercle bacilli. Its hypodermic administration brings about an 
immediate disintegration and elimination of white blood cor- 
puscles. This is followed by leucocytosis lasting forty-eight 
hours. In this property of the drug, which produces an increase 
in cellular activity in the fixed connective tissue cells throughout 
the body, Tousey finds the explanation of its value in the 
treatment of keloid. 

Artificial sertini in skin <ii<»oa<$<>s. 

Tommasoli {Riforiiut Medica, July 5, 1897) has for some three 
years used injections of an artificial serum composed of chloride 



3G4 TiiR YKAn-nooK of tkratme.vt. 

of Kodium and bicarbonate of Hodiuni in certain skin affections 
which lu! believes to b(! cine to chronii; infective intoxication or 
auto-intoxication. In some cases — two of clifl'use chronic eczema, 
one of scattered folliculitis, one of senile pruritus —a cure had 
been effected ; a case of lichen planus, in which itching was very 
marked, was cured in thirty-six days. Tiie same treatment had 
also been successful in cases of psoriasis and various pruriginous 
affections. Tommasoli lias also used the artificial serum (in doses 
of 300-400 grammes) with the object of preserving life in cases 
of extensive burns, with results which he; considers sufficiently 
encouraging to warrant further trial. 

Sci'iiiii trcatiiK'iit ill leprosy. 

Juan de Dios Carrasquilla, of Bogota, has treated a number of 
cases of leprosy with serum taken from horses immunised Yty 
means of blood serum taken from lepers (Proc. x\cad. of Medicine 
of Colombia : Correio Med. de Lisboa, 1896, xxv., 122, 124). 
The results are said by him to be good, and the method has 
attracted so much attention in his own country, where leprosy is 
comiiion, that an institute for the preparation of the therapeutic 
serum and a hospital for the treatment of lepers, both under the 
direction of Carrasquilla, have been established by the Colombian 
Government. The treatment has been tried in the Saint Louis 
Hospital, Paris, under the supervision of a committee of the 
Academic de Medecine. A preliminary report which was 
presented to the Academy by this committee on Sept. 28, 1897, 
was, on the whole, unfavourable to the treatment. In a case 
treated with Carrasquilla's serum by Buzzi [Deutsche nied. 
Wochenschri/t, Oct. 14, 1897) the patient's condition markedly 
improved in every respect and the results were much better than 
any that had been obtained by other methods. 

At the International Leprosy Conference recently held in 
Berlin Arning stated that he had obtained good results by the 
serum in one case, and Neisser said he had seen im})rovement in 
sonie instances. Dehio, Barillon, Hallopeau, and Abraham have used it 
without any advantage. 

Deluca (^Giorn. Ital. d. Mai. Vener., xxxi., 2) treated a case of 
leprosy by injection of serum from a rabbit inoculated with the 
disease. The effects were analogous to those seen in cases of 
tuberculosis after the injection of tuberculin. Another case was 
treated by injection of blood serum from another leper in 
whom the disease was in a latent state, but without any result. 

Tlij^'oidiii. 

V. Zarubin, of Charkoff (^rc/m'.,/! Derm, und Syph.,Bd. xxxvii., 



DISEASES OF THE SKIN. 365 

Hefi 3, December, 1896 ; Brit. Journ. Derm., July, 1897), has used 
thyroicliu in four eases ; three of psoriasis, and one of sycosis 
idiopathica. In the cases of i)soriasis a total amount of 30 
granunes was given, the treatment extending over forty days ; 
in the case of sycosis the amount given was 11-5 grammes, in 
twenty-seven days. No other drug was given, and no change of 
diet was prescribed. In all the cases the frequency of the pulse 
was marketUy increased, in one to 130 per minute. The tempei'a- 
ture in one case rose to 39 '8° C. on the hfteenth day. Headache, 
chiefly frontal, with weakness, languor and pallor, was present in 
all the cases. 

All the patients lost weight, and in all the digestion was 
disturbed, and nervous disturbance, manifesting itself in sleepless- 
ness, fidgetiness, etc , occurred. The amount of urine was in- 
creased in all. No albumin was detected. As regards the skin 
disease, the effect of the drug was nil. Zarubin concludes that 
thyroidin is useless in cutaneous affections, and that it is so 
dangerous that its administration requires the greatest care. He 
offers no opinion as to tiie causation of thyroidism, but refers to 
the possibility of its being due to albumin compounds not 
necessary to the beneficial action of thyroidin. Bacilli, resembling 
those of malignant oedema, have been found in thyroid tablets by 
O. Lanz. The composition of the tablets used by Zarubin was as 
follows : 

ly Thyroidini exsiccati 2 grammes 

Sacchari lactis ... ... ... ... ... 15 grammes 

M. Fiant trochissi xs. 

Cui-rciit*>> or high frequency and hig^h tension. 

At the twelfth International Coagress of Medicine, held at 
Moscow, August, 1897, Oudin and Barthelemy, of Paris, claimed 
that these currents have a powerful trophoneurotic action, and may 
be employed with success in diseases of various kinds. Certain 
eczemas, psoriasis, and even lupus, are favourably influenced 
by them. They seem to have a special parasiticidal action, 
"as proved by the rapid cure of affections exclusively parasitic, 
such as molluscum contagiosum." The high frequency is obtained 
in the appai-atus of d' Arson val ; the high tension by attaching 
to it a resonator and a special electrode constituted of a metal 
wire surrounded by glass, the whole acting as a condenser, 
which attacks the disea.sed surface by numerous little sparks. 

Franklinisation. 

At the International Medical Congress at Moscow, H. Bordier, 



3GG THE YEAR-BOOK OF TREATMENT. 

of Lyons, gave an account of a new luetliod of treating a<'ii<; by 
rraiikljiii<>«»tioii. He cmijloys the procedure in tlie punctate 
and pustular forms of acne. Tiie method consists in subjecting 
the patient to tlie action of the electrostatic bath and to that of the 
electric bath. He is isolated on a stool witli glass feet, and he 
is placed in electrical communication with the negative pole of 
an electrostatic machine of high discharge. Each sitting lasts 
fifteen minutes, and the procedure is repeated every two days. 
The method is said to have a great influence on the vasomotor 
system, the effect of which is to cure the acne. 

Doumer {Bulletin ch la Soc. irEkclrothcrajne, May, 1897) 
i-eports five cases of impetigo cured by franklinisation. Often 
after the first sitting, he says, and almost always after the 
second, the erythema begins to disappear ; then in a short time 
the crusts become dry and fall off, leaving the .surface of a light- 
rose colour, which soon gives place to the normal hue. 

Static electricity. 

Schatzky (Vratch, No. 25, 1897) reports a case of psoriasis 
of four years' standing in a neurasthenic physician aged 32, 
which was cured by static electricity (three sittings of twenty 
minutes every week) combined with moderate diet and raw 
milk. Itching diminished after two or three sittings, and the 
patches gradually disappeared. 

Electrolysis. 

W. A. Hardaway (Journ. of Cutan. and Gen.-Urin. Diseases^ 
Sept., 1897) gives a general summary of twenty-four years' 
expei-ience of electi'olysis in the treatment of diseases and 
deformities of the skin. In the case of keloid he confines the 
operation to small growths. In telangiectasia, certain kinds of 
vascular nsevi, the so-called spider na;vi, etc., there is no better 
and more satisfactory agent in the hands of a judicious operator ; 
but, taking the port-wine mark as a whole, the method has not 
met with the success that he had originally anticipated from it. 
In small foci of lupus, and for separate nodules, and especially 
relapsing tubercles, electrolysis is superior to the mechanical and 
caustic methods in vogue ; but for large areas of infiltration and 
ulceration it is tedious and inferior to the other measures. In 
tuberculous infiltration of the skin, other than lupus vulgaris, 
Hardaway regards electrolysis most favourably. In lupus ery- 
thematosus, though he does not advise it in acute superficial 
forms, it has been of great service in his hands in chronic 
patches with much thickening. As regards technique, Hardaway 
has long discarded the positive sponge electrode — which, even 



DISEASES OF THE SKIN. 367 

when he used it, he never allowed the patient to grasp, but 
merely to touch with the tinger-tips. He now always places the 
positive pole electrode in a small bowl or tumbler of water, and 
the connection is established by inserting one, two, or three 
fingers, as may be required. Even triHing operations should be 
done under the strictest antiseptic precautions. Immediately 
after an electrolysis the parts should be fomented for five or ten 
minutes with very hot water, and this procedure should be 
repeated at least twice on the same day, but not afterward. In 
this way the redness and tumefaction are at once allayed, and 
subsequent inflanunatory changes are largely prevented. As a 
rule, after the iirst day, no other applications or dressings are 
required. 



DISEASES OF THE EYE. 

By Hexky Power, M.B., F.K.C.S., 

Vonsultuiij Ophthalmic Surijeon, St. BnrthoUimetc's Hosju'dU. 



1. l\c\v remedies. 

Amongst the new, or comparatively new, drugs which liave 
recently been introduced into practice, arecoline may be mentioned. 
According to INIerck, whose paper is referred to by Prof. Snellen 
(in the American " System of Diseases of the Eye,'" 181)7, p. 46) 
the hydroV)ronuc salt of this alkaloid keeps better than eserine, 
acts more powerfully than pilocarpine, and is much cheaper. It 
does not irritate the eye, and, even after repeated instillations, 
does not produce headache or other complications. A 1 per cent, 
solution induces myosis in five minutes. The maximum contrac- 
tion of the pupil (the diameter being then 1^ mm.) occurs fifteen 
minutes after the instillation and lasts for thirty minutes. After 
seventy minutes the pupil regains its original size. 

A remedy which in chemical language bears the cacophonous 
title of P. diethoxyethenyldiphenylamidine, but which will be 
more easily remembered by its therapeutic name of hofocaine, has 
been introduced by M. Gutman (Deutsche med. Wochen., 11 March, 
1897), who uses it in the form of the hydrochlorate. It is a local 
anfesthetic, and a few drops of a 1 per cent, solution, applied to 
the conjunctiva, renders it quite insensible. The efl'ect lasts 
about ten minutes, it does not affect the size of the pupil, nor 
does it modify the intra-ocular pressure. It should be borne in 
mind that holocaine is highly poisonous, the toxic dose, according 
to Heinz (Berger, Archives d'OphtalmoIogie, 1897, vol. xvii., 
p. 589), being 1 cgr. for holocaine, 5 cgr. for cocaine, and 75 mgr. 
for eucaine. 

A. Cattaneo of Bologna (Annnli di Ottalmologia, vol. xxv,, 
Fasc. 4) describes at length some experiments and clinical obser- 
vations he has made on a new mydriatic named midrol or 
iodomethylated phenilpirazol. 



DISEASES OF THE EYE. 3G9 

Lastly, Dr. B. Treutler (Klinische Monatsbldtter filr Auyenhail- 
ki'.nde, Jahrgang xxxv., September, 1897) recommends a remedy 
named euphthalmm. It has the same relation to eucaine that 
homatropin hears to tropacocaine, and it is a powerful mydriatic 
acting slowly after the lapse of ten minutes after the instillation 
of a 2 per cent, solution, producing its maximum effect in about 
one hour without pain, but with the abolition of the power of 
accommodation. The return of the pupil to the normal size and 
recovery of accommodative power take place much more quickly 
than with atropin or homatropin. 

M. Debagory-Mocrievitch has for several years employed with 
advantage a crayon or pencil of caoutchoitc for the expression 
of granulations and trachomatoiis infiltrations, and considers it to 
be superior in its effects to the nails or to forceps. The conjunc- 
tiva should be powdered with some indifferent powder, and the 
massage with the crayon is effected by placing it beneath the 
upper lid. An additional advantage is obtained if the surface 
which has been subjected to friction is cauterised with a stick 
of copper sulphate {Archives iVOjjhtalniologie, t. xvii., No. 9, 
1897, p. 569). 

Altliough not by any means a new remedy for the re- 
moval of leucomata and nebulae of the cornea, the extract 
of the chelidonium majus has been recommended by M. Krayski 
{Wiestnik 0])hthalmolog7ii, May-June, 1897) as a new means of 
treating cancer of the eyelids. He injects about 50 cgr. of the 
extract into the healthy tissue adjoining the ulcerated surface, 
and then covers the whole surface with a pad of iodoformed 
gauze dipped in the same liquid. The pain lasts for some hours, 
oi" even for a day. One or two injections are sufficient, and the 
surface is brushed over with the extract once or twice daily. A 
well-marked swelling surrounds the affected parts, and sharply 
separates them from the healthy tissue, and cicatrisation soon 
commences. 

The Electric Treatment of Painful Conditions of the Eyes, is 
the title of a paper by Prof. Benedikt, of Vienna [Arcliiv filr 
Ophtlialmologie, b. xliii., 1897, p. 683). He recommends that the 
current should be transmitted through the lids, and not, as Prof. 
V. Reuss recommends, through the conjunctiva, on account of the 
pain that is excited. The current should be applied by means of 
the finger, which enables the operator to recognise whether the 
current is too strong. He thinks the induced cun-ent possesses 
decided advantages over the constant. The induced current has 
the peculiar power of deadening the sensibility of the spot on 
which it acts, so that the strength of the current can be consider- 

Y 



•^70 TIIR YEAR-BOOK OF TKKATMKNT. 

jibly, if tfradiially, increased. Tliis renders it particularly applioahlc 
to all tonus of" co2)lialalgia — as tic douloureux, artliralgite and 
o])litlialiualgiie. Its catalytic action is also considerable, though 
])erhaps in this respojct it is inferior to the constant current. It 
nevertluihjss acts well in troj)hic distui'liances, and especially in 
inflaniniatory troul)Ies. The physiological and pathological changes 
involved are, however, very complicated, including modifications 
of the blood vessels, the quantity of blood traversing them, the 
breaking down of infiannnatory products, and neoplastic forma- 
tions, and the carrying ofi" of disintegrated material. This 
catalytic action n)ay be observed in inflammation of the sclera and 
cornea and of the conjunctiva and iris. Many of these cases, 
ordinarily termed inflammations, lie is inclined to think are really 
neuralgic, and he supports his view by referring to the benefits 
obtained from the application of heat, cold, pressui^e, and faradic 
stimulation which may act on nerve fibres and expansions. He 
quotes a case in which a man of sixty years suffered from violent 
supraorbital and ophthalmic pain, accompanied by strong injec- 
tion of the conjunctival and scleral vessels, with haziness of the 
cornea. Section of the supraorbital nerve effected a cure. The 
inflammatory symptoms in this case were, he contends, neuralgic. 
He recommends faradisation in cases of anajsthesite, in asthenopia, 
in mydriasis and in myopia, in addition to galvanisation of the parts. 

2. Aiito-liircctioii ill diseases of the eye. 

An important paper by M. Panas (^Archives tVOpldahnologie, 
March, 1897, p. 273) was read before the 15th Congress of the 
Societe Frangaise d'OphtalmoIogie, on this subject. Auto-infec- 
tion he defines to be the infection of the eye or of its annexes 
through or by means of the circulation, and it may occur as a con- 
sequence of the presence of germs and toxins introduced from with- 
out, or from the products of disintegration which are either in 
excess, or which have been imperfectly eliminated by the natural 
emunctories, as the uterus, kidneys, liver, alimentary canal, skin, 
and lungs, and to these may be added the retention of internal 
secretions of certain glands like the thyroid. In addition, the 
various forms of virus known as the syphilitic, variolous, and vac- 
cinal, as well as the virus of rabies and the miasms, may be mentioned 
as provocative agents. A subordinate but still important role is 
played by the diathesis or constitutional condition, as by arthritism, 
the lymphatic habit, alcoholism, diabetes, and albuminuria. The 
various forms of microbes and of pathogenic toxins are as yet 
but imperfectly known, Ijut even with the same species of microbe 
the virulence varies according to the conditions of the medium, 
the number of the microbes, their association, and the frequency 



DISEASES OF THE EYE. 371 

of tlieir attack, and it is particularly wortliy of notice that tliey 
may long remain quiescent, constituting what is termed latent 
microbism. The etfeets of all these agents on the tissues are 
shown by phlegmonic processes from oedema to suppui-ation, by 
hsemorrhages with or without intravenous thromboses, or lastly 
by hyper[)lastic conditions which may be either benign or malign. 
The action of microbes on the nervous system, which they excite 
or paralyse, is worthy of special attention, since the resistance of 
the organism depends upon it. It has been shown, for example, 
that if tlie nerves of the kidney be divided near the hilum, the 
subcutaneous injection of staphylococcvis or streptococcus occasions 
double nephritis, although no such localisation is observed in 
uninjured animals. So, too, if rabbits be inoculated with 
tuberculous matter and one vagus be divided, double pulmonary 
bacillosis develops, which, however, is more pronounced on the 
injured side than on the other. In applying these general 
observations to the eye in particular, Panas remarks that 
the participation of the eye in various pathological conditions 
of the system has been clearly established. Thus inflammatory 
troubles are known to be associated with variola, scarlet fever, 
and measles. Amongst the dyscrasise we find diabetes, albumin- 
uria, uraemia, oxaluria, and phosphaturia, gout and chronic 
rheumatism, leuksemia, scurvy, and the sequelae of syphilis. 
Then there is the large group of infectious diseases, some of 
which come from without, whilst others develop within the 
tissues, constituting auto-infection properly so called. In both 
of these cases we are dealing with ocular endo- infection, in 
opposition to direct exo-infection. The infective external 
agents which attack the eye by internal paths are syphilis, 
endo-ocular tuberculosis, lepra, certain manifestations of 
blennorrhagia, pysemic fevers, both puerperal and traumatic, 
typhus, cerebro-spinal meningitis, influenza, erysipelas, diphtheria, 
pernicious anajmia, paludism. Amongst chemical poisons ai-e 
alcohol, nicotine, carbon bisulphide, santonin, quinine, and 
others, which attack the eye, and, cliiefly, the optic tract, 
producing various well-known forms of amblyopia and atrophy. 
The concluding observations made by Panas in his paper are 
to the effect that every infective focus, in whatever part of the 
body it may be situated, should be investigated with the greatest 
possible care, since it may either dii-ectly or indirectly act on the 
eye. In women the utero-ovarian tract is a fertile source of 
trouble, as may be deduced from the instance of the so-called 
metastatic ophthalmia of puerperal origin, which is a typical 
example of this form of disease. 
Y 2 



372 TIIR YKAK-ROOK OF TKKATMEN'T. 

There is reason for Ijelieviiig that the aqueous humour plays 
an important part in promoting endog(!nous infections of tlie iris, 
and Dr. F. Benoit, of Liege {Archives d'Oplddlinoloyin, July, 1897, 
p. 409) has devoted much time to the; consideration of this 
sul)ject. It is generally admitted in textljooks that the aqueous 
humour is chieHy secreted by the ciliary processes, but in part 
also by the iris. Dr. Benoit, however, has satisfied himself that no 
aqueous humour is secreted by the iris, but that, on the contrary, 
the anterior surface is an absorbing surface ; indeed, Professor 
Fuchs has shown that there are here really openings, or stomata, 
on the front aspect of the iris, especially near the pupillaiy and 
ciliary margins, which establish a communication between the 
anterior chamber and the lymphatic spaces of the iris. In man 
the stomata are larger, and it is not didicult to perceive that, as 
Nuel demonstrated at Carlisle in 1896 at the British Medical 
Association, in a case of corneal ulcer with hypopyon following 
lagophthalmos, the cells make their way through the stomata 
and form small collections in the depressions and pits of the 
ii-idal tissue. Similar conditions occur in syphilitic and tuber- 
culous inflammation. Benoit, therefore, holds that in cases of 
irido-cyclitis a condition of inflanmiatory oedema is established 
at the plane of the ciliary processes which favours the entry into 
, the aqueous humour of micro-organisms and their toxins. The 
aqueous humour thus infected is absorbed by the anterior surface 
of the iris, and causes inflammation of this organ. The reason of 
the beneficial effect of atropine in these cases is manifest, for by 
dilating the pupil the iris is prevented from acting as an absorbing 
or eliminating organ, and is thus protected fi'om infection. 

3. Choroid. 

The mechanism of ruptures of the choroid has been the subject 
of a short paper by Fage of Amiens (ArcJiives d' Ophtalmologie, 
July, 1897, p. 401). The position of these ruptures, he points out, 
is usually at or near the posterior pole of the globe, and their form 
is not unfrequently crescentic. Ammon thought they were caused 
by the direct pressure of the contusing agent ; Knapp to contre- 
coup ; Bertin and Arlt, to the compression causing distension of 
the contents of the globe ; Otto Becker, to the concentric pressure 
which the optic nerve exercised at the moment of injury on the 
posterior pole. Fage himself contends that the eye, at the instant 
of contusion, is between two resistances — the wall of the orbit 
on the one hand and the insertion of the optic nerve on the 
other; the choroid stretched and but little capable of distension, 
owing to the vessels passing between it and the sclerotic, tears in 
a direction perpendicular to that of the traction. 



DISEASES OF THE EYE. 373 

Cataract. 

Tlie performance of a i)reliminary iridectomy in the extraction 
of senile cataract has been ui'ged by W. F. Coleman, of Cliicago 
(jimialsqf Ophthalmohgi/, vol vi., April, 1897, p. 218). He con- 
tends that there are many points in its favoui', as, for example, the 
opinion of many experienced operators that it is an eminently 
safe method : and he points out that the maturing of an unri[)e 
cataract is frequently hastened ; that the diagnosis of the character, 
extent and size of the cataract is facilitated ; that there is no 
haemorrhage from the iris ; that the iris is not wounded by falling 
over the knife ; that an unobstructed opening is afforded for the 
introduction of the cystitome, and for the expulsion of the lens and 
cortex ; that the wound of the iris is healed, leaving only the 
corneal incision to unite ; that the iris is not exposed to pressure 
and stretching as in the simple operation ; that the operation is 
shorter and less painful than the combined method ; that it lessens 
the danger of iritis, and allows the cataract to be removed before 
it is quite matui-e ; that it is the operation best suited to com- 
plicated cataracts, and not unsuited to any ; and, lastly, that 
preliminary iridectomy exposes the eye least to the need of 
a secondary operation. 

M. Chibret, of Clermont - Ferrand (Archives d'OpJdalmoloijie, 
t. xvii., Sept., 1897, p. 545), strongly recommends irrigation of the 
anterior chambers after extraction of the lens in hard cataract opera- 
tions, where it is difficult, or impossible, by pressure or the use of the 
curette to obtain a clear pupil. He takes advantage of a double- 
action injecting and aspirating syringe. This instrument, which 
has been constructed for him by Aubry, of Paris, requires to 
be very carefully made and kept scrupulously clean. The fluid 
he injects is a warm saturated solution of boric acid, with the 
addition of l-200()0 part of mercury cyanide, and about from 
20-30 grammes are injected. The cases in which it is especially 
valuable are soft, incomplete and ti'aumatic cataracts. He 
considers .that it diminishes the chances of infection, of prolapse of 
the iris, and of secondary cataract. 

4. Operations on the iris, 

M. Gayet, of Lyons {Seance du 3 au 6 Mai de la Societe 
FraiKjaise d''Ophtalmologie, in Recueil d' Oj^htalmoloyie, 1897, 
p. 323), having found difficulty in operations on the iris when 
made with elbowed, curved or bent instruments through the small 
wound of the coi-nea made by a keratome, recommends that an 
incision embracing one half of the peripher}^ of the cornea should 
be made, and that the large flap of cornea should be reflected, ex- 
posing the iris freely. He has practised this proceeding, and does 



371 THE YKAR-JJOOK OF TRKATMKNT 

not find that it is followed by ;iny opacity of llio cornea, nor by 
pain, whilst it enabhss the iris to b(^ dealt with much more easily. 
He has devised a special form of tooth(;d forceps, Vjy means of 
which the corm^a can be seized and iirmly held. 

.1. Ati-<»|»liy of optic <li<>«4*. 

M. Galezowski {Rpcveil dOplitdlinoUxjU',, .June, 18'J7, p. 311j) 
has endeavoured to establish a distinct class of cases of atrophy 
of the optic disc due to lymphangitis, and subdivisible into those 
that are peripheric in their origin and those that originate in the 
central lymphatic spaces. He believes them to be amenable to 
treatment. His classification of forms of optic atrophy are those 
proceeding from disease of the cortex cerebri, those which proceed 
from lesion of the central visual organs, those of glaucomatous 
origin, and those which result from changes in the nutrient fluid 
in the course of the optic nerves. 

6, Artificial oycs. 

The deformity which results from the removal of the globe of 
the eye has led to the adoption of vai-ious means for the conceal- 
ment of the defect, and the skill of the glass-worker has been 
utilised to produce a shell that imitates, in the colour of the iris 
and average size of the pupil, the characteristics of the remaining 
eye ; but in many instances great difficulty is experienced in 
adapting the artificial substitute to the form of the orbit, proving 
sometimes too large, sometimes too small ; whilst its immobility 
directs the attention of the casual observer to that which is 
desired to be concealed, as much or even more than if no attempt 
to hide the loss had been made. The proceeding termed exenter- 
ation, in which the cornea is removed, the contents of the globe 
are scooped out, and the edges of the wound brought together, 
frequently affords a good stump for an artificial eye, since the 
muscles are retained with the atrophied sclerotic, and movements 
co-ordinate with those of the opposite eye can be effected. But 
the retention of such a contracted and atrophied globe is not 
always expedient, especially in cases of threatened secondary 
glaucoma and of sympathetic ophthalmia, and the same objection 
holds in regard to Mules's operation, in which after exenteration a 
small aseptic glass globe is int