ized that this system was adopted for the city, the eminent Virchow working heartily in its favor. At the present time 1067 acres suffice to purify 15,060,000 gallons per day, the drainage of four fifths of the city, containing a population of over 600,000. There is some odor at the opening of the large sewer, but in the fields there is no smell, and the sanitary condition is all that could be desired. There never has been any complaint from the numerous adjoining habitations, and the effluent drain water of the farms is pure and clear, it being impossible to recognize by microscopy or chemistry any influences of the sewage. Vegetables and fruit trees grow luxuriantly on the land, and their roots make a perfect filter. Thirteen and one quarter tons of hay has been cut per hectare (a little less than two and one half acres).

(To be concluded.)

CASE IN PRACTICE. CHRONIC PLEURITIS WITH EXCESSIVE SANGUINOLENT EFFUSION.1

BY CHARLES R. CRANDALL, M. D., PORTLAND, MAINE.

MRS. S., aged fifty-eight, of large stature and scrofulous temperament, always had good health until the present illness. When I was first called to see her, which was several weeks prior to the attack now referred to, she complained of difficulty with her breathing accompanied by a cough. Making physical examination of the organs of the thorax I found a localized bronchitis in the posterior lobe of the left lung, in the region of the lower part of the scapula. I noted also that she showed symptoms of marked prostration, and that her digestion was impaired. She was benefited by the treatment instituted, and soon after passed from observation.

In about three weeks I was again summoned, and was informed that she had never fully recovered her strength, although she had followed a course of tonic treatment which I had suggested. She was perceptibly weaker than when I first saw her, and her daughter complained that she was restless, irritable, wakeful, and suffered some from pain apparently due to flatulence. Despite supporting treatment and medication as indicated, she steadily declined in general health for a week or so longer. Finally her daughter informed me that at times her mother seemed a little short of breath, and especially so at night and during the day when she changed her position from the bed to her chair in an adjoining room. Again making a thorough examination I found the kidneys to be normal, but that the quantity of urine was scanty. The liver was also normal so far as could be ascertained. The heart was in a healthy state, but its action was feeble and slightly irregular. The left lung remained in good condition, although the respiratory murmurs were abnormally distinct and percussion resonance intensified. Upon examining the right lung a wonderful revelation was met in the form of an excessive pleuritic effusion, which evidently nearly filled the entire pleural cavity. On auscultation the respiratory murmur was nearly absent in every part of the lung, save some bronchial respiration in the upper portion. On percussion, with the patient in a sitting posture, dullness and flatness were elicited all over the posterior, lateral, and ante

1 Read before the Portland Medical Club, April 24, 1884.

rior surfaces of the right lung, excepting a small area on the anterior surface above the mammary gland. Vocal fremitus was greatly diminished. The chest was dilated over an inch, but the condition of the intercostal spaces could not be inspected owing to the presence of a thick layer of fat. But the most remarkable feature regarding the excessive effusion thus discovered was the fact of its rapid accumulation without one solitary symptom of chill, fever, pain, or distress calculated to call the attention of either the patient or the physician to the process taking place. The only symptom of a nature to attract attention to the chest at all was some difficulty in breathing, but this was so slight that it resembled the disturbance often noticed in cases of debility, and accompanied by a moderate degree of heart failure.

On the same day that I made the above diagnosis I performed the operation of thoracentesis, assisted by Dr. S. H. Weeks, and removed one hundred and fifty ounces (or over four quarts and a half) of fluid, the color of which was about the shade of a dark, thick port wine. The patient bore the operation without any untoward symptoms, and as the fluid escaped confessed to feeling a sense of relief. Air immediately refilled the entire lung, causing a little pain and slight cough. The respiratory murmur soon became quite normal, while the percussion note was greatly im proved.

The fluid proved to be highly albuminous, and when tested by heat it so solidified in the test tube that it had to be broken up to favor removal. Examining the effused fluid under the microscope it was found to contain an abundance of fresh, red blood corpuscles, many of which arranged themselves in rows like rouleaux of coin, while others existed separately, and were shrunken and contracted into angular and starlike shapes. There were also numerous leucocytes having normal characteristics, and a few endothelial cells. Pus was not present, nor were there any indications of an attempt towards organization. The spe cific gravity was 1022.

REMARKS.

Two months have now passed since I performed thoracentesis upon this patient, and the results have been most gratifying. Effusion recurred slowly to a moderate extent, not sufficient, however, to justify a repetition of the operation. The condition of the lung has remained good, and the general health of the patient has steadily improved. For several weeks she has been dressed and about her house, and of late has done a little work, and gone out of doors.

The foregoing case affords many points of practical clinical interest, but I will avoid trespassing upon the valuable time of the meeting longer than to touch upon a few of the most important.

(1.) It illustrates the inestimable value of thorough investigation. This patient did not have a single sign or symptom well calculated to call attention to the diseased pleura. There had not been any pain, chills, fever, sweats, lividity, or acceleration of pulse. True she had been annoyed by slight failure of breathing upon exertion, but no more than we often see in debilitated patients whose respiration and circulation are practically normal. When I informed her that there was a collection of water in her pleural cavity she ridiculed the idea. Had I taken her word regarding the condition of her thorax, I should have been misled

in a woful manner. The condition verified the observation of Flint, that chronic pleuritis is often developed imperceptibly, and that it is likely to be overlooked by those who do not employ the physical methods of examination.

(2.) The diagnosis of uncomplicated latent or chronic pleural effusion is easily made when it exists to any extent. The history of the case often aids materially, and especially so if it discloses difficult breathing, insufficiency of breath, a dry, hacking cough, and illdefined pain or uneasiness in the lower lateral portion of the thorax. Now if to this be added a high-pitched percussion note at the apex of the lung with decided dullness or flatness at the base, feeble, or inaudible vesicular murmur over the portion of the lung, where dullness is most marked, decreased vocal fremitus where the effusion is greatest, and increased percussion resonance on the healthy side, accompanied by a marked accentuated vesicular murmur, a group of ordinary signs and symptoms are met with which are characteristic and unmistakable. Hydrothorax is to be excluded by the absence of cardiac and renal disease, and by the fact that the accumulation is unilateral instead of bilateral; but if doubt exists the introduction of a large-sized hypodermic-syringe needle, or one of the small aspiratory needles, will quickly clear up any obscurity. Exploratory punctures are easily made, and are of great service, for they aid in diagnosticating, convince both the physician and the patient, and display the character of the fluid if any be present.

(3.) Another practical point is that diagnosis should be made early, for the presence of a pleural effusion of any extent is always prejudicial. It deprives the patient of the necessary amount of oxygen, burdens the heart by interfering with the pulmonary circulation, and impairs digestion and nutrition by inducing secondary congestion of the liver and stomach. Moreover, the longer an excess of effusion remains in the pleural cavity the greater the danger of its undergoing degenerative changes and giving rise to empyema. Prognosis is rendered much more favorable by an early detection of the effusion, and a correspondingly prompt treatment. It is the neglected cases which more often give rise to malnutrition and tuberculosis.

(4.) Again this case displays in an impressive manner the great value of thoracentesis or paracentesis as a therapeutical agent. Here was a condition where, in all probability, ordinary absorbent and alterative remedies would have been powerless, owing to the enormous quantity of fluid present, or had they by chance afforded relief it would at best have been a long and wearisome process. On the contrary, this valuable method at once reëstablished normal respiration, and also favored circulation and general nutrition to an extent which soon became very evident. In addition to prompt relief, it promoted the action of remedies to such a degree that permanent improvement rapidly ensued, and reaccumulation was largely prevented.

(5.) In regard to the extreme bloody color of the effusion, it was, to say the least, very suspicious and suggestive. As it began to flow, the first thought was that the aspirator needle had punctured a large blood

vessel or else had wounded the structure of the liver or lung. Immediate examination, however, showed that the needle was properly entered, and that the peculiar fluid was only a highly tinged specimen, and by no means pure blood. The presence of blood under such conditions is ever suggestive of hæmor

rhagic effusion due to malignant or tuberculous disease, but the history and symptoms in this instance were not of a character to sustain either theory. On the contrary, it was the opinion of both Dr. Weeks and myself that the presence of blood was due to the state of the patient's system, and to the high degree of congestion of the pleural surfaces. It is not at all impossible that the distention and weight of so much dense liquid favored exosmosis of the blood corpuscles, and ruptured some of the smaller vessels. The remarkable recovery of the patient is confirmatory of the view that the blood effusion did not originate in either tuberculosis or malignant disease.

(6.) Lastly I will say a few words regarding the treatment instituted and carried out after thoracentesis had been performed. As I estimated the case I saw three chief indications for medicinal remedies: (1.) To improve digestion and nutrition.

(2.) To promote the action of the heart and kidneys.

(3.) To further absorption by counter-irritation. In order to meet the first I kept her upon a tonic composed of the fluid extract of cascara sagrada and the tincture of nux vomica given in the elixir of calisaya. I believed that more would be accomplished by stimulating the power and function of her bloodmaking organs and combating a condition of habitual constipation than by acting more directly upon the entire volume of blood with iron, as is generally advised. Conjoined with these remedies I advised a substantial albuminous diet of milk, eggs, beef, stale bread, and coffee of moderate strength. It is to be ever borne in mind in the treatment of this class of cases that the effusion is highly albuminous, and the demand for a restoration of this vital material to the economy is very great. Excessive waste needs to be counteracted by a corresponding supply.

With a view of stimulating the action of her heart and kidneys, and thereby promoting absorption, I have from first to last maintained the action of carbonate of ammonia given in Trousseau's diuretic wine. Regarding carbonate of ammonia in cases of pleural effusion, Bartholow says that "when an effusion is poured out the only agents which possess the property of resolving it are alkalies, and the most efficient of these is ammonia." The diuretic wine, containing as it does digitalis, acetate of potash, squills, and a mild stimulant, afforded a combination which met well the indication for a heart tonic, diuretic, and alterative.

For counter-irritation, employed with a view of modifying diseased action and furthering absorption, I used a succession of cantharidal blisters over the lower portion of the thorax on the affected side, and also the tincture of iodine. All and all the case is a most satisfactory illustration of the great value of surgical and medical therapeutics.

In his investigations he took as a guide this rule: "Whenever a nerve passes through a bone it marks the confluence of two or more ossific centres." Applying this to the lower jaw, we have to deal with three nerves inferior dental, mental, mylohyoid. The inferior dental enters the bone by a foramen formed by the union of five ossific plates, the coronoid, condyloid, dentary, angular, and splenial; the nerve then travels in a tunnel formed on the outside by the dentary, and by the splenial on the inner side. The branches which go to the teeth pass up the foramina left between the splenial and dentary plates.

The mylo-hyoid runs in the groove which once lodged Meckel's cartilage.

The mental passes out of the bone through a fenestra formed by the dentary and mento-meckelian ossifications. The paper is too long to give more than a very brief abstract, though it is one of the most interesting investigations of the year.

Dr. N. Meyer 2 reports a case in a first-born child of healthy parents. At birth there was a swelling about the size of a walnut on the left and outside the normal jaw. As the lower lip was large, a piece was removed eighteen months after birth. The first deutition did not begin till the fifteenth month, but was otherwise normal. At seven years a tooth erupted from the tumor; this was followed by nine others. At the age of fourteen the jaws presented the following appearance: In the upper jaw the teeth were normal. In the normal lower jaw there were four incisors, one canine, two bicuspids, and three molars. The supplementary jaw contained two molars, one bicuspid, two incisors, the other teeth having been extracted.

3.

DOUBLE CLEFT IN PALATE.3

The child was four months old. Instead of the ordinary medial fissure there was one on each side. The part between these clefts was one quarter of an inch wide, and extended into the posterior wall of the pharynx, with which it was continuous. The bony septum completely separated the pharynx into two parts. The most probable explanation of this peculiar condition is that the notochord, instead of ceasing at the pituitary fossa, extended further forward, the blastema surrounding it uniting with the plate descending from

1 British Journal of Dental Science, May 15, 1883.

2 Archiv für klinische Chirurgie.

8 Dr. Maylard, in Brit. Jour. Dental Science, page 1144, 1883.

6.

SPONTANEOUS FRACTURE OF THE TEETH.

Several cases have been reported during the year. In each the symptoms have been alike. The patient heard a loud report, as though a gun were fired near the ear. The fractures did not come when the teeth were in use, so that they could not be traced to any hard substance. Various explanations have been given. One writer in describing his case suggests that the explosion was caused by the pressure of gas in the pulp chamber. Colman denies this, as he has seen a fracture of this kind in a tooth with a living pulp. He thinks the cause is calcification in an inflamed pulp. He believes such a pulp is in a condition of tension; when this reaches a point greater than the resistance of the dentine fracture must result.

6

weeks later, while eating, he felt as if struck by a blow. An examination revealed a fracture.

4.

NEURECTOMY OF INFERIOR DENTAL.

Dr. Sonnenberg1 describes a new operation. The patient's head is held firmly back. An incision is begun one centimetre in front of the angle of the jaw. This is carried forward along the edge of the body for four centimetres. The inner surface of the bone is cleaned up to the internal lateral ligament. The insertion of the internal pterygoid is cut; a blunt hook is passed around the nerve, which can then easily be brought to the external opening, and a piece removed. The advantages are: a small wound; the operation is an easy one; there is little bleeding; the capsule of the submaxillary gland is not cut; the wound is a favorable one for healing; and, lastly, the scar is small and not conspicuous.

5.

TRANSFUSION FOR HÆMORRHAGE FOLLOWING
EXTRACTION OF A TOOTH.

The patient, a soldier, aged twenty-two. The bleeding was at first slight, but continued all night. Plugging the alveolus, cautery, ergotin, perchloride of iron, ice, and various other things were tried. Ten days after the operation, the patient being almost dead, four after the operation, the patient being almost dead, four ounces of blood were injected into the cephalic vein. The patient rallied, but the bleeding increased. A second transfusion was tried next day. During the operation the heart stopped. The length of time the heart remained quiet is not given. It began again, and from that time the patient made a rapid recovery.

6. - UNITED FRACTURE OF TEETH.

Dr. Van Horne reports 2 a case of fracture of an upper lateral, near the alveolus. A year after the accident the tooth was alive and firmly united. (To be concluded.)

Keports of Societies.

ONE HUNDRED AND THIRD ANNUAL MEETING OF THE MASSACHUSETTS MEDICAL SOCIETY.

PRELIMINARY DAY.

ON Tuesday, June 10th, as is the custom, the Fellows of the Massachusetts Medical Society were entertained after the manner common to the day preceding that of the annual meeting of the Society.

AT THE HOSPITALS.

At ten o'clock A. M. the Fellows responded to invitations from the Massachusetts General, the City, the new Children's, and the Lying-in Hospitals, at each of which they visited the wards and witnessed certain operative procedures.

At the City Hospital the visitors were shown through the surgical wards, which presented a very attractive appearance. and where were found many cases of unusual interest. The plaster posterior splint so generally used here in treatment of fractures of the leg, and which was the subject of a paper during the afternoon, was found in the various wards in its different plications. One of the cases of interest was a congenital dislocation of the hip in which an attempt is being made

1 Medical Times and Gazette.

2 Items of Interest, February, 1884.

ap

to restore the head of the femur to its proper position. At the rear of the main buildings could be seen the tents in process of erection for summer use. In the operating room the femoral was tied for aneurism of the calf by Dr. Homans. Several cataracts were removed by Dr. Wadsworth. Other operations of everyday occurrence were also done. The traumatic surgery of the hospital was exemplified by the case of a boy who had shattered his hand by a cartridge which he had exploded by a hammer. The boy was brought into the hospital during the visit. The application of plaster of Paris to the treatment of club-foot was also shown.

AT THE NEW MEDICAL BUILDING.

At twelve o'clock M., and at the new Harvard Medical building, the Fellows listened to an address by PROF. H. P. BOWDITCH on Methods of Instruction and Research in Physiology, with Demonstrations. Professor Bowditch received the Fellows in the lower lecture room, and there explained the arrangements which adapted the room for experimental lecture

courses. Also described the lecture table with its mov

able central portion which can be wheeled into the physiological laboratory for the preparation of an experiment and be brought into place again for demonstration in the lecture room. tion is similarly used in the chemical laboratory, the A duplicate central porlecture room being common to both departments. The fixed portion of the table contains at one end a pneumatic trough, at the other a sink, and is also supplied with gas, water, electricity, and compressed air. The convenience of the blackboards serving also for suspension of diagrams by means of a brass rod at the top and being movable by weight and pulley was explained. A hood revealed by pushing up the black boards, and useful in experiments which develop unpleasant odors, was shown.

The Fellows being then invited into the physiological laboratory, witnessed experiments connected with original work now in progress and examined the ap paratus, which had been arranged for their inspection. The demonstrations were the following:

(1.) Blood pressure experiment on dog under ether and morphia. Effect of irritation of vagus nerve on

rate of heart beat.

(2.) Study of the vaso-motor nerves of cat under ether and curare. Effect of irritation of sciatic nerve on size of leg recorded by means of the plethysmograph.

(3.) The same experiment with frog's legs. (4.) Demonstration of the action of the semilunar valves of the ox.

(5.) Demonstration of the force of ciliary motion on the mucous membrane of the frog's mouth.

(6.) The effect of changes of temperature on the rate of beat of the frog's heart.

(7.) The phenomenon of subjective complementary motion shown in the after-image of a revolving spiral figure.

(8.) Reaction time studied by means of the pendulum myograph.

(9.) The development of the eggs of the snail studied under the microscope.

(10.) The methods of studying the bacillus of tubercle, with microscopic demonstrations.

(11.) Apparatus for artificial digestion with automatic regulation of temperature.