« ForrigeFortsett »
the wound was closed in forty-eight hours; in 17 later. Society Reports.
The former were termed early secondary suture, the latter late secondary suture. In none of the 37 had
there been death ; primary union in 17, or forty-five NEW YORK ACADEMY OF MEDICINE. per cent. Seventy-eight per cent. united ; twenty-two
per cent. did not. Late secondary suture had not Stated Meeting February 21, 1895.
given as good results as early secondary suture, for Joseph D. BRYANT, M.D., PRESIDENT, IN THE CHAIR. reasons not far to see. Primary union depended
mainly on two factors-proper adaptation of the parts Discussion on Amputations : A Statistical Study of and asepsis.
and asepsis. When the flaps had granulated for some Seven Hundred Cases from Eight Hospitals of New time, they were not so likely to be aseptic nor to perYork City. Topics : Mortality, Gangrene of Flaps, mit of accurate adaptation. While the ideal method Secondary Suture, Drainage, Dressings, etc.--The dis- would be immediate adaptation of the flaps without cussion was introduced by short papers upon the sev- drainage, yet where the chances of primary union were eral topics named, by Drs. J. F. Erdmann, H. Lilien- in the least degree doubtful, Dr. Torek thought better thal, F. Torek, P. R. Bolton, C. C. Carmalt, and S. results would be obtained by secondary suture. Tousey.
Dr. P. R. BOLTON, writing of drainage and dressDr. B. F. Curtis, Chairman of the Section on Sur. ings, said that the only purpose which drainage could gery, under whose auspices the meeting was held, said serve in an aseptic wound was to remove serum and that the subject of amputations had been chosen for blood. It seemed that this purpose could be served discussion in preference to abdominal surgery and by proper suture and dressing. Where, however, there some other topics, because of its more general practical was infection, drainage would continue to serve an imimportance. The original object had been to collect portant purpose. In the statistics given, of 490 cases statistics of the city hospitals in their bearing upon treated by suture and drainage, 167 healed by primary primary union of amputation wounds, and union with union ; 128 by primary union with sinus; 195 by or without sinus, and only incidentally upon the mor- granulation with more or less suppuration of the flap. tality-rate, etc.
Of 142 amputations of the upper extremities, 72.5 per DR. ERDMANN's paper showed that of 703 amputa- cent. healed by first intention; of 348 of the lower extions in eight city hospitals, forming the basis of his tremities, fifty-five per cent. healed by primary union ; and the other papers, there had been a total mortality seventy per cent of those of the hip ; sixty per cent. of 109, or 15.5 per cent. These were divided as fol- of those of the thigh ; forty-three per cent. of those of lows: Of the wrist, 7 cases, no deaths ; of the fore- the knee and leg ; forty-six per cent. of those of the arm, 74, with 1 death ; of the elbow, 6, no deaths ; of foot. Of 56 cases treated with suture without drainarm, 88, with 16 deaths ; of the shoulder, 24, with 6 age, 34 healed by first intention, 8 by first intention deaths; of the foot, 64, with 5 deaths ; of the leg, 156, with sinus, and 14 with granulation. with 19 deaths ; of the knee, 46, with 6 deaths ; of the The question of whether drainage should or should thigh, 223, with 48 deaths ; of the hip, 18, with 8 not be employed must be decided in most cases by the deaths. The general mortality, therefore, was 15.5 disease or injury for which amputation was performed. per cent. In 31 cases death was due to general shock; It could be dispensed with in many cases of amputa51, to septicæmia existing previous to the operation ; tion for tumor, also in some cases of joint disease, 18, to constitutional causes ; 27, to operative shock ; 1, trauma, etc. to secondary hemorrhage ; 3, to sepsis following the Dr. C. C. CARMALT had found details with regard operation ; 3, to complicating nephritis or pneumonia ; to the duration of the treatment in only sixty of the 1, to poisoning with bichloride. Under fresh or pri- cases. The average stay in the hospital had been fortymary cases there were 270, with a mortality of 21.4 per two days. But this was of little significance without cent. ; non-primary or old injuries and disease, 433 taking into consideration the environments, general cases, mortality of 11.7 per cent.
condition of the patient, condition of field of operation, Dr. Erdmann then divided the cases into those and the after-treatment. In two of the sixty the duraoperated upon between 1884 and 1889, and those oper- tion in the hospital after amputation had been one ated upon between 1889 and 1894. The fresh trau- hundred days. In none of the sixty cases had there matic cases showed an improvement in the mortality been primary union. The younger subjects went out during the last period of five per cent.
earlier. Hemorrhage and shock had apparently had These statistics were then compared with
no influence on the duration of treatment.
There was given in The Lancet and with those reported in the delay in all cases where there had been other diseases MEDICAL RECORD recently by Dr. Estes. The great or exhaustion. This remark did not apply to disease superiority of the latter was to be accounted for in part of the heart or kidneys, syphilis, or vascular changes, by the fact that they were in a degree select, and also except thrombosis in one instance. by the younger age of the patients.
Dr. S. Toussy read regarding shock and other Dr. Howard LILIENTHAL stated the results as to points, basing his remarks upon 181 of the cases gangrene of the flap, by which was meant extensive which were observed at Roosevelt Hospital.
In ampusloughing or marginal necrosis. The latter, marginal tations for traumatism, in cases in which the primary necrosis, was not opposed to good surgery. Of 367
shock was marked, the mortality had been forty per cases where the flaps consisted of skin alone, 69, or cent. ; where it was absent, the mortality had been only nineteen per cent., sloughed in whole or in part, while five per cent. The inference was that the shock from of 216 cases of musculo- cutaneous fap, only 41 the injury killed the patient. If the shock were slight sloughed, or nineteen per cent.--showing the compara- or absent, the condition of the nerves of the limb from tive advantage of the musculo-cutaneous flap as to vi- the traumatism was one of paralysis, and amputation tality. The skin flap was also found to be more easily did not act to produce more shock, as was seen where killed by sepsis. The statistics showed further that con- the shock of the operation alone had added to the morstitutional disease was a frequent cause of flap necrosis. tality only five per cent., whereas the original shock inGreat judgment was required in deciding as to the creased by the shock of the operation increased the viability of tissues through which amputation was mortality very greatly. Dr. Tousey thought the operadone. The tendency to fap gangrene was greatest
tion should be done before this paralysis of the nerves below the knee. Musculo-cutaneous flap was to be se- had been recovered from. The statistics showed that lected wherever possible.
where the shock had been treated more than twelve DR. TOREK had found that out of the 703 cases sec- hours prior to amputation there had been sixty-six per ondary suture had been employed in 37 ; in 20 of them cent. of deaths, against twenty-two per cent of deaths
in cases with shock of like degree, but treated only its removal there would be a blush in the blanched three or four hours before amputating.
skin not seen in the diseased or non-vital porThe other subject which he had studied at Roosevelt tion. Follow the outline of the parts which had been was the circumstances affecting the frequency and du- white. The knife should be carried down close to the ration of sinuses. Age had little to do with it, while fascia in all skin flaps, as it increased the chances of the site of the amputation had a great deal to do with
survival of the flap. Loose suture and snug bandage it. Sinuses occurred oftenest in amputations of the would give all drainage required in most cases, thus upper extremities, especially at the shoulder, but the doing away with the drainage-tube and with the necesduration was greater in the case of the lower extremi- sity for change of dressing called for by other plans. ties, and greatest of all in the foot. It made little dif- Dr. Robert Abbe emphasized a few points, the first ference in the duration whether bone-tube or rubber- being the importance of using muscle and skin flaps intube were used for drainage, the advantage being a stead of skin alone wherever possible. The skin flap little on the side of rubber. The age of the patient sloughed because of tendency to fall in folds and behad much to do with the mortality.
cause of pressure on harder parts. Another point was General Discussion.—Dr. Charles McBurney was the value of deep-buried suture in muscle over the end asked to open the general discussion. The subject, he of the bone. Regarding drainage, he had been sursaid, was too vast to attempt to cover it in a systematic prised that so much had been said about sinuses resultmanner. Therefore, he would refer only to a few ing. There might be a little sinus for a while, but this points suggested by the papers. He thought the mor- was unimportant, while drainage was very essential. tality at present would be much smaller compared with As to gangrene, it was apt to occur in amputations that of ten years ago, if amputation were done as fre- through the foot, because bone immediately underlay quently. With improved antisepsis
, etc., surgeons now skin, whereas, in amputations where muscle as well as tried to save many limbs severely injured, which some skin and subcutaneous tissue overlay the bone, there years ago would have been sacrificed at once.
was better nutrition. Besides, amputations through The speaker seldom saw gangrene of the flap. It the middle of the foot did not leave a serviceable limb was not infrequently due to bruising and injury in- because of painful scars, etc., and it was better to cut flicted by the operator, especially when the flap con- through the lower third of the leg if possible, or sisted of skin alone. Particular attention should be through the lower third of the thigh, points at which given to the condition of the circulation at the proposed instrument-makers found it possible to apply the most point of amputation. If it were in a doubtful state, serviceable artificial limb. Amputation through the amputate higher. If the foot were gangrenous one lower third of the leg was to be preferred even to could easily tell whether it were safe to amputate at a Symes's amputation, although this gave an admirably given point by making a transverse incision and ob- bearing stump. He thought shock was due largely to serving whether hemorrhage followed. If not, the cir- hemorrhage. culation at that point was poor, and one should go DR. F. H. MARKOE thought the cases divided themhigher.
selves into two classes naturally-amputation for traumaDr. McBurney was in accord with what had been tism and amputation for disease ; again, into amputasaid with regard to the value of secondary suture in de- tion for septic conditions and for non-septic conditions. creasing the mortality. He would include it under the In non-septic conditions amputation should be done head of drainage. The only objection to drainage con- through healthy tissues and the wound closed. By sisted in leaving it too long. If the wound were asep- using buried suture, accurate apposition, and careful tic, the tube ought certainly not to be left in longer dressing, he had had no occasion to regret omitting than forty-eight hours, probably not longer than twenty- drainage. In traumatic cases he agreed with Dr. Mcfour hours. Much could be said with regard to shock. . Burney that we should cut away waste tissue and wait A loosely attached limb could be snipped off with the until after shock had passed before amputating: In scissors, the wound treated by open tampon, the patient certain of the remaining cases gauze drainage might be allowed to go without further traumatism until shock used twelve to thirty-six hours, and in the others secwas recovered from, secondary amputation being done ondary suture and tamponade. later. He had saved several patients by pursuing this Dr. F. W. Murray thought it had been definitely course when primary amputation would probably have shown that since the introduction of antiseptic surgery ended fatally
the mortality from amputations had been decreased, In the speaker's opinion, many cases of shock, so and it was destined to be decreased still further. He called, were cases of hemorrhage. The amount of always drained the first twenty-four or forty-eight hours. blood lost was a matter of very great importance, and He had great faith in secondary suture in certain cases. one should, at a very early period, make use of active He, too, had had opportunity io save the lives of sevmeasures to overcome its bad effect. For this purpose eral patients by hot saline infusion. It was very neceshe had found of greatest value hot saline solution thrown sary in amputations to shorten anesthesia as much as into the blood-vessels. The infusion might be made be- possible, and this was one important reason for using fore, during, or after amputation. A quart or quart and tamponade and secondary suture. a half of normal salt solution could thus be injected. Drainage or no Drainage.DR. B. F. Curtis said it
Point for Amputation Determined by Esmarch's Band- had been hoped to show the comparative advantage of age.—Dr. L. A. Stimson thought it not unlikely that drainage and no drainage in amputations, but a fair the greater mortality attributed by one of the speakers conclusion could hardly be drawn from the statistics to waiting twelve hours or longer on account of shock given, since drainage had been practised in over five was due, not to the waiting, but rather to presumably hundred cases and omitted in only about fifty. With greater severity of the injury in those cases. He had drainage there had been absolute primary union in been taught by Dr. Van Buren not to amputate during thirty-seven per cent of the cases of amputation of the shock ; that amputation would be safe as soon as the
upper extremity, thirty-three per cent of the inferior temperature began to rise again from subnormal. We extremity, or thirty-four per cent. altogether; and owed much to Dr. McBurney for calling attention to primary union including sinus in seventy-two per cent. the value of injections of saline solution. Regarding of the upper extremity, fifty-five per cent of the lower necrosis of flaps, he had seen many cases at the Cham- extremity, or sixty per cent. altogether. Against this
, bers Street Hospital and elsewhere in which doubt
without drainage there had been absolute primary union existed as to the vitality of parts through which it was in sixty per cent. of amputations of the upper extremity, proposed to amputate, and he had found the best
seventy-one per cent of the lower extremity, altogether means for determining that point to be the application sixty-seven per cent.; and primary union including of the Esmarch bandage three to five minutes. After sinus, in seventy-three per cent. of amputations of the
upper extremity, seventy-seven per cent. of the lower really precursors of conditions of a most serious nature. extremity, or seventy-six per cent. altogether.
But calling them minor ailments, there was still every Dr. Curtis thought New York surgeons did not ap- reason to investigate them, because of their great frepreciate as much as they should the advantage of get- quency and the important bearing which they had ting rid of drainage, since it would exclude danger of upon our success as practitioners. Our first duty was introducing sepsis with the drain, and again with the that of healing, and not altogether that of trying to second dressing. While a sinus, usually due to the solve scientific problems. old ladies and lay persons drain, might not be serious, yet it was very disagreeable, generally were loud in their praises of irregular practiand kept the patient in the hospital for days when the tioners, simply because they had given attention to space was desired for new patients.
One cause of gan
their minor ailments. grene of the flaps had been cutting them too short, so Among the more important of these lesser derangethat there was tension on the sutures which held them ments were the reflex neuroses. Some seemed to conover the ends of bones. He did not think all would sider them insignificant, and some even appeared to agree with Dr. Abbe in his condemnation of amputa- doubt their actual existence. By the generic term tions through the foot, especially in workingmen, who neurosis was meant a hyperästhesia or disturbance of could not meet the expense of renewing costly artificial the nervous system which simulated disease in an legs.
organ that was healthy, or without evident lesion of There should be improved methods of keeping any of its parts. It might be general or local. The records of cases in our hospitals. Some important de- specialist who saw such patients must have the knowltails were lacking in these statistics.
edge of the general practitioner, otherwise many mistakes would be made in diagnosis and treatment of chronic ailments. If the confiding and unsuspecting
patient with a run-down constitution, the result of NEW YORK COUNTY MEDICAL ASSOCIA- anxiety, bad air, and a worse diet, and with a headache TION.
and some abdominal or uterine symptoms, should stray
into the office of an enthusiast in ocular tenotomy, he Stated Meeting, February 18, 1895.
would probably want to relieve her distress by dividS. B. W. McLEOD, M.D., PRESIDENT, IN THE CHAIR.
ing the rectus muscle for eye-strain. If, however, she
should strike a surgical gynecologist of a certain class, Annual Address by the President. - DR. MCLEOD a symptomatic uterine catarrh, an unoffending lacerachose for the subject of his address, “The Place and tion, or a harmless, retiring cystic ovary would be Influence of the Medical Profession in the Progress of pounced upon by this enlightened specialist
, and reCivilization." His remarks referred not alone to mem- ceive most vigorous treatment; and if he did not always bers of the profession, but equally to many outside carefully sterilize his instruments he would probably the profession who had done much to further its efforts succeed in sterilizing his patient. Or her destiny in elevating the human race. Among these were might lead her into the office of a digestive specialist, Benjamin Franklin, Stephen Girard, the Vanderbilts, who, of course, would diagnose stomach trouble as the and many others. It was not easy to define the word cause of all her ills, and proceed to lower several feet civilization. While in its full sense it meant advance- of rubber hose into her surprised stomach and treat ment, yet it was attended by certain disadvantages un- that organ to a wholesome bath. If our specialism known in the savage or uncivilized state. Some of was allowed to run into exclusivism, very shortly the these were the accidents attending the introduction of only safe man for a patient to consult would be the the industrial arts. The profession was called upon old-fashioned general practitioner, with all his faults to treat the injuries resulting from railway travel, to and deficiencies. cope with the spread of contagious diseases through There was much difference of opinion with regard modern facilities for travel. The organization of a to the causation of the various neuroses, but many meteorological bureau and the establishing of boards cases had been recorded illustrating the fact that periphof health were features of modern civilization, and eral irritation was a very decided factor in their propromised much for the promotion of human health duction. Irritation might be set up in any part of the and happiness. The question might well be asked, body, and result in a reflex disorder in a distant organ. what next should engage our attention, and how with Some of the sources of irritation which might be noted our improved means were we to meet our present were : The digestive organs-indigestion ; a, stomach responsibilities?
-gastric catarrh ; b, intestines-parasites, ulcers ; c, A few of the many questions of lively interest were, rectum hæmorrhoids, thread worms, pruritus ani. the eradication of tuberculosis; prevention of spread The genito-urinary organs-inflammations, internal; a, of disease in schools ; greater widening of the field kidneys-calculus; b, bladder — calculus, catarrhal of usefulness of orthopedics; the further perfection states; c, ovaries-inflammation, morbid growths ; d, of electro-therapeutics; prevention and treatment of uterus-inflammation, morbid growths. External; a,
ophthalmia neonatorum; should criminals by heredity vulva--pruritus, herpes; b, clitoris-adhesions. The be unsexed; improvement in relation to expert testi- respiratory organs-inflammation, irritation (catarrh), mony.
new-growths--the eyes--eye-strain, errors of refraction Dr. McLeod referred also to the prosperous condi
and accommodation. The ears — abscess, impacted tion of the Association, and said it was a duty and a cerumen. pleasure to enter upon the new year with energy and This, the author said, was by no means a complete determination in the purpose to consider such sub- summary of the causative factors which operated in the jects as were practical and calculated to improve the production of reflex disturbances, yet they were fair profession and promote the public health. The great examples of what we should look for when searching work accomplished by the late Dr. William Detmold, for some peripheral irritation to assist us in the diagthe first president of the Association, was placed be- nosis and treatment of disease. fore the members, young and old, as a most worthy Strong mental impressions stimulated the vesical and example.
rectal nerves of the young soldier when going to battle The Neuroses of Women.—DR. T. J. McGilliCUDDY
for the first time ; the uterine nerves in the young feread a portion of a long paper which he had prepared male emigrant produced amenorrhæa, from the exciteon this subject
. Every woman, he said, suffered more ment incident to leaving home and going to a new or less, and many almost constantly, from functional country.
The differential diagnosis between a severe derangements of some of the organic structures of the reflex headache depending upon uterine or digestive body.
Many simple deviations from the normal were trouble, and beginning exophthalmic goître where a
rapid pulse and swollen thyroid were among the ear- production of neuroses or psychoses. For instance, he liest manifestations, was often exceedingly difficult, as believed that in connection with gynecology there had the mere fact of entering a physician's office for exam- been a tendency to attach too much importance to conination would often produce in nervous young women ditions of the uterus and ovaries in the causation of a great amount of excitability, giving rise not only to neuroses. An experience of two or three years in an a rapid pulse, but also globus hystericus and temporary asylum had convinced him of the correctness of this congestion of the thyroid.
view. The following classification of the neuroses suggested DR. NATHAN G. BOZEMAN mentioned a case of enuitself : The neuroses of the nervous system ; of the cir- resis in which it was possible to make very accurate culatory system ; the respiratory system ; the genito- observations, since the woman had a vesico-vaginal fisurinary system ; the glandular system ; the cutaneous tula. She was suffering from an irritable condition of system. The spinal and cerebral centres were not the organs of the pelvis, which was not relieved by the alone implicated, but the ganglionic and vasomotor treatment which a physician, who had previously seen nerves probably even more. The cardiac and solar her, had directed to the uterus. On one occasion the plexuses in particular, took an important part. A urine was collected every hour for thirteen hours. further division of the neuroses with regard to the During the first twelve hours she passed only one parts affected might be made as follows: cerebral, ounce of urine, while the next hour she passed fifteen spinal, cardiac, vascular, pharyngeal, laryngeal, bron- ounces. chial, gastric, intestinal, renal, vesical, genital, glandu- DR. ACHILLES Rose mentioned as an example of lar, ophthalmic, aural, lingual, articular, dermal. Many the influence of emotion on the gastro-intestinal funcof these were combined, as in the cerebro-spinal, gas- tions, the fact that, as Napoleon's army was going tro-intestinal ; while two or more might exist at the through Poland in 1812, all the soldiers had dysentery same time, as vascular and glandular.
from drinking stagnant water, but the dysentery ceased The author had time to read further only about the during a battle of three days' duration, and returned at cerebral neuroses or psychoses. Among peculiar men
its close. tal conditions depending upon morbid conditions of Dr. J. BLAKE White emphasized the statement that the abdominal and pelvic viscera, were : mental depres- one should practice general medicine before entering sion ; loss of memory; excessive irritability ; wakeful- upon a specialty. ness ; intense lethargy and drowsiness during the day ; DR. LEONARD LANDES pointed out the difference bemorbid fears, as of death. Under the head of cerebral tween exophthalmic goitre and myxcedema as described psychoses fell catalepsy, trance, hypnotism, somnambu- by German and French writers, having mistakenly unlism, neurasthenia, anæsthesias, amenorrhæa, enuresis, derstood the reader of the paper to say they did not dyspepsia, and diarrhæa coming on from bad news or differ. "hard times.” Also all the hysterical symptoms de
DR. BROTHERS said a word as to the treatment of pending upon the emotions, such as hysterical aphonia, neuroses, and particularly of the necessity for checking hysterical apnæa, hysterical laryngismus, hysterical sexual excesses and errors of diet, which were among suffocation and strangulation. More severe types were the most potent causes.
Calisthenics should be pracmelancholia, mania, and convulsions.
tised. Arsenic occupied about the first place among The cerebral neuroses often occurred in neurotics drugs. from the mind being directed to a particular part. DR. FRANK VAN FLEET thought there had to be an This was seen in patients who were familiarly known idiosyncrasy, else patients with uterine disease, ocular
"womb cranks," who imagined they had uterine trouble, etc., would not suffer from reflex neuroses. disease, and were sometimes readily cured by almost When that idiosyncrasy did exist, he thought the excitany simple manipulation of the uterus.
ing cause was no more likely to be in the uterus than The author related a case of migraine, hemiplegia, in the eye or other organs, and it might be necessary and chorea depending upon uterine irritation. The to send the patient to several specialists before relief symptoms came on after an attack of diphtheria, but as
could be given. she had suffered from disordered menstruation and Dr. MCGILLICUDDY, in some concluding remarks, hysterical symptoms, and the hemiplegia disappeared said he thought general practitioners should know from the left side and later appeared on the right, it enough about medicine to treat the neuroses without was evidently of a hysterical nature, starting, with her sending the patients to specialists. other hysterical symptoms, from pelvic disturbance. Paroxysmal Hæmoglobinuria.—Dr. Bishop reported Like chorea—which was also present in this case-func- a case in which the urine on certain occasions contained tional hemiplegia was found during periods of develop- blood-pigment, but which upon careful and repeated ment.
examination had not been found to contain blood. Diagrams were shown.
The patient was a sailor, and had begun to pass colMelancholia due to Uterine Retroflexion.—Dr. H. J. ored urine from the time of great exposure on shipBoldt thought the paper was so complete that nothing board. He could bring on an attack at will by exposremained to do but relate cases in corroboration. Heing himself to the cold, and it was only after exposure recalled the case of a woman who had suffered from to cold that the urine was colored. In the summer he profound melancholia with suicidal tendency, due en- had attacks apparently replacing the paroxysmal attirely to retro-displacement of the uterus.
tacks of hæmoglobinuria-of cerebral symptoms coming relief after replacement of the womb, but subsequently on at night, during which there was fright, especially it again became displaced, melancholia returned, and fear of being enclosed in a small space, as a barrel. again disappeared on the insertion of a pessary. Tachy- Dr. Bishop had advised the patient to take up his resicardia was common in backward displacements of the dence in a warm climate, but such advice, he said, uterus.
might prove disastrous should the cerebral symptoms Dr. Boldt, and some of the speakers who followed become more frequent in the absence of attacks of him, emphasized the author's remarks upon the neces- hæmoglobinuria. sity for a knowledge of general medicine before practising a specialty, and cautioned against the recognition of but one part of the human frame, that which A New Diagnostic Sign of Carcinoma of the Stomach happened to correspond to one's speciality.
consists, according to Boas, confirmed by Dr. D. Stewart Dr. FREDERICK Peterson, having arrived in time (Medical News) in the presence of lactic acid. By to hear only the latter part of the paper
, remarked sim- giving a test-meal (flour soup) quite free from any lacply upon a study of the entire system, and cautioned
tic acid this acid was never found in any conditions exagainst unduly magnifying any of the organs in the cept those of carcinoma.
THE NEW YORK PATHOLOGICAL SOCIETY.
any ulceration in the trigone. If we were
to hold to the theory that tuberculosis of the bladder Stated Meeting, January 23, 1895.
was due to an extension from the urinary tract below, GEORGE P. Biggs, M.D., PRESIDENT.
usually beginning in the seminal vesicles or the pros
tate, it would seem strange that the bladder should esPrimary Tuberculosis.—Dr. E. HODENPYL presented capé so completely. Such a condition, he thought, three specimens of tuberculosis, illustrating some rare was almost unknown among clinicians. conditions. The first one was from a case of primary DR. HODENPYL asked if Dr. Alexander had found tuberculosis, with volvulus and perforation of the in- in his experience that tuberculosis of the bladder was testine. He was indebted for this specimen to Dr. usually attended with great pain. Sanger, house physician of St. Francis Hospital. The DR. ALEXANDER replied in the affirmative. patient was a fairly nourished man, forty-five years of
Urethral Stricture, Cystitis, Suppurative Nephritis. age, a baker by occupation, who gave a history of the - DR. FARQUHAR FERGUSON presented the bladder, bowels not having moved for two weeks previous to urethra, and kidneys from a male, fifty-six years of age, his coming to the hospital. On admission, the abdo- who was admitted to the service of Dr. L. A. Stimson men was distended, and his temperature was 99o. A on January 17th. He had had gonorrhea twelve large dose of calomel failed to relieve the constipation, years before. During the past five years there had and on the following day several enemata were given been difficult micturition ; the stream of urine had without result. After this he was given a large dose of been small, and the urine had contained mucus and croton oil with negative result. The temperature then pus. He had been obliged to get up several times rose, an intense peritonitis developed, and he finally died. during the night, the pain being greater at night and The autopsy showed a general peritonitis, and at about when the bladder was full. During the three weeks two feet from the ileo-cæcal valve a volvulus which prior to his admission to the hospital he had had more completely constricted the intestine. Above this point pain, micturition had been more frequent and difficult, the intestines were considerably distended. Here there and the urine had contained both blood and pus. At were also two perforations of the intestine, and another the time of his entering the hospital the urine was perforation was found below the point of constriction. dribbling away constantly. Dr. Stimson performed The intestines were covered with a rather large number supra-pubic cystotomy under cocaine anæsthesia, and of tubercular ulcers. Microscopical examination con- the bladder was continuously irrigated. After the firmed the diagnosis of tuberculosis of the intestine. operation the urine had a specific gravity of 1.010,
The speaker said that this was the first case of pri- contained five per cent. of albumin, and the micromary intestinal tuberculosis he had met with, and so scope showed numerous pus-cells. Although the far as he could ascertain none of his medical friends bladder was constantly irrigated, the patient's condihad seen such a case. There was nothing in the his- tion steadily grew worse, and he finally died on Janutory to give a clew as to how he had contracted the ary 21st. At the autopsy, the supra-pubic incision was disease, and there were no evidences of tuberculosis in found to communicate with the bladder through an other parts of the body than the intestine.
opening 1/2 ctm. in diameter. In the perinæum were Healing Tubercular Ulcers of the Colon. The sec- three sinuses leading toward the urethra. After the ond specimen presented had been removed from a man removal of the bladder it was found that the sinuses who had suffered for a number of years from pulmo- communicated directly with the membranous portion nary phthisis. In the small intestine were a moderate of the urethra. At the junction of the membranous number of small tubercular ulcers, while in the colon and penile portions of the urethra was a tight stricture. there were a number of ulcers with irregular margins
In front of the stricture the canal was narrowed and and smooth bases. Microscopical examination of these
its wall thickened for a distance of five centimetres. ulcers showed some remnants of tubercular disease, · This portion presented evidence of previous inflammabut the bases were covered with new connective tis- tion. Behind the stricture the urethra was greatly sue. It was certainly rare to find a case in which tu- dilated, dark in color, and necrotic. The wall of the bercular ulcers of the intestine were healing.
bladder was greatly thickened, and in its walls were Tuberculosis of the Bladder.-The third specimen numerous pouches containing pus. These varied in was more interesting from a clinical standpoint than capacity from one to fifty cubic centimetres. The from a pathological one. The specimen had been mucosa of the bladder was softened and discolored. taken from an old consumptive, who had been in the A probe two millimetres in diameter passed through hospital for three months before his death, and yet no
the stricture. The pelvis of each kidney was dilated. bladder symptoms had been detected.
and the left kidney contained numerous purulent foci. The autopsy showed advanced tuberculosis of the Purulent Pericarditis.—Dr. Ferguson also presented lungs and two or three small tubercular abscesses in a remarkable specimen of purulent pericarditis. The the kidney. The bladder was quite small and con- patient was a male, twenty-two years of age, who had tracted. In the fundus were a number of irregular been admitted to the hospital on January 7, 1895. He ulcers, and toward the edge a few miliary tubercles. had previously had two attacks of la grippe, and was Section of the walls of the bladder showed tuberculo- an alcoholic subject. Five days previously his illness sis and considerable round-cell infiltration.
had begun with severe pain in the right side and in DR. WILLIAM VISSMAN asked if in the second case both knees, an aching in the lumbar region posteriorly, the patient had been treated with tuberculin, as the and dyspnea. He had not had a chill or cough, nor condition in the intestine was very much like that had he been very feverish. He had had no headache, found in patients who had been treated with tubercu- and had not been aware of any heart trouble. His lin shortly after its first introduction.
dyspnea had grown steadily worse. On admission, Dr. HODENPYL said that he did not know how the his pulse was 122, respirations 48, and temperature, patient had been treated.
100.8° F. Physical examination showed friction THE PRESIDENT said that the specimen recalled to sounds in both axillæ, and abundant sibilant and sohis mind one recently added to the museum of the norous rhonchi scattered over both sides of the chest. New York Hospital, the clinical history of which he There was dulness at both bases posteriorly, and also did not for the moment recall. There were character- diminished respiratory murmur. Just below the spine istic tubercular ulcers presenting distinct evidence of of the right scapula was an area of diminished resoattempts at repair.
nance, and over this portion were distant bronchial Dr. SAMUEL ALEXANDER, referring to the third voice and breathing. Respiration was labored and specimen, said that the position of the ulcer, so high up
ulcer, so high up rapid. The cardiac area appeared to be normal. The in the fundus of the bladder, was a very unusual feat- first sound of the heart was somewhat valvular and