January, 1910

sire to keep in touch with all the best local measures which seem to us to offer a means of bringing about an improvement in the condition of our patients.

In the treatment of the joint conditions we have always used plaster of paris where possible in preference to braces, because, in the first place, with the careful and proper application of the plaster of paris bandages we feel that we have provided the most effective means of immobilization and support to the affected joints. And in the second place, in a hospital where the funds are naturally limited as at Sea Breeze Hospital, the great expense incurred by the extensive use of braces would be a serious consideration.

Cases of tuberculosis of the elbow are immobilized flexed beyond a rt. a. by a circular plaster paris bandage. Those of the wrist in the extended position. For the ankle joint, plaster of paris from below the knee to the toes with the foot at right angles and a Thomas splint. In cases of knee joint disease plaster of paris from the groin to the ankle or with a Thomas knee brace. In hip joint disease the Lorenz short plaster paris spica extending from just below the umbilicus to the knee joint, with the thigh in abduction and full extension. The child is allowed to walk upon the foot with the hip thus immobilized, and it is a source of great satisfaction to see these cases running and jumping about with this means of treatment and go on steadily to a permanent cure, suffering no pain or discomfort from the constant use of the affected limb in weight bearing.

Up to one year ago the routine of treatment of tuberculosis of the vertebrae was by means of the ordinary plaster paris jacket, or the Bradford frame, depending upon the condition and age of the patient. For cases over 4 or 5 years of age with the disease in the lumbar or dorsal regions the jacket, and in the upper dorsal or cervical region, the jury mast incorporated into the jacket. For cases under the above age, the Bradford jacket was used. If during the treatment with the jacket, muscular weakness or paraplegia developed, those cases were at once placed on the Bradford frame and kept there until the condition improved sufficiently to warrant their return to the erect posture when a jacket was reapplied. It seemed advisable also to keep on the frames those cases which developed Psoas abscesses of a large size in the hope that the abscesses might diminish without rupture.

These forms of treatment were in many instances more or less unsatisfactory and a year ago the Calot jacket was introduced into the treatment of these cases.

The Calot jacket in our opinion fills the required needs in the support of the spine in cases of Pott's disease better than any form of treatment so far put forward, for it offers the best means of immobilization of the spine, no matter

where the seat of disease may be, and also allows us to place upon their feet many cases which formerly were compelled to remain on their backs for reasons before mentioned.

The two forms of Calot jacket, the military and the grand, we have used in the particular cases to which they are suited. The military in all cases of disease below the upper dorsal region and the grand jacket for those above, namely, the upper dorsal and the cervical regions. The results from this form of treatment have been most gratifying.

The following will illustrate the beneficial results:

Florence W., age 10, was admitted to Sea Breeze January 25, 1906, suffering from the disease of the dorso-lumbar region. For some time before admission child was suffering from paraplegia and incontinence of urine with increasing severity. Child was wearing ordinary plaster paris jacket on admission. She was placed on a Bradford frame, but although the general condition slowly improved the incontinuance and paraplegia continued and was a constant source of trouble. The skin was in a bad condition most of the time.

On December 1, 1907, a Calot grand jacket was applied and the kyphosis pushed forward by packing.

On January 12, 1908, the child was walking about, incontinence markedly improved.

May 31, 1908, child walking fairly well, though thighs still flexed-knee jerks slightly diminished; incontinence very slight.

Jackets were reapplied at intervals until November 8th, when the child was given ether, and legs straightened and put up in a double spica extending from axillæ to toes.

Child kept in bed. Incontinence which had nearly stopped returned. Two months ago spica removed and grand Calot jacket applied and child is now walking again and incontinence diminished decidedly.

This case was very intractable and gave no promise of cure until the use of the Calot jacket was instituted.

Abscesses developing during the course tuberculosis of the bones and joints and the sinuses which so frequently persist after the opening spontaneous or otherwise of these abscesses have been of great interest to us at the Sea Breeze Hospital.

We have always recognized that as a rule a cold abscess is better left unopened unless so large as to interfere in some way with the treatment or the comfort of the patient. Recently, however, we have introduced, in the treatment of the abscesses, that method employed by Prof. Calot, of aspiration of the contents of the abscess under strict aseptic precautions and injection into the abscess cavity of a solution of 7/8 cc of the following:

Agnes C., aged 6, was admitted to Sea Breeze Hospital, April, 1907, suffering from tuberculous disease of the 1st L. vertebra. She had been

under our care at the Roose. Disp. since April, 1906, treated with an ordinary jacket. She presented a large right psoas abscess at the time of her coming to R. H. and a moderate sized left abscess. A short time before her admission

to Sea Breeze she developed signs of paraplegia; the knee jerks became exaggerated, gait weak and unsteady and she was emaciated, nervous and fretful. She was placed on a Bradford frame and from that time on the condition improved steadily. The abscesses, however, still remained and showed no tendency to diminish, and in fact the left one had decidedly increased in size.

On September 10, 1908, over two years after the abscesses were first recognized, they were aspirated under cocaine just below int. to ant. Sup. spine and 100 cc thick pus was removed from the right abscess and 50 cc removed from left abscess and 8 cc of Calot fluid injected into

each.

September 19, 1908, 65 cc of pus withdrawn from the right abscess and 8 cc of fluid injected. October 18, 1908, 175 cc. of pus withdrawn from right abscess and 75 cc of pus withdrawn from the left and 7 cc of fluid injected into each. November 8, 1908, 275 cc of pus removed from right abscess and 7 cc of fluid injected.

November 25, 1908, left abscess aspirated and small amount of dark brown fluid removed.

November 29, 1908, practically nothing could be felt except a slight thickening in either iliac fossa, and therefore a Calot jacket, military form, was applied.

December 20, 1908. Child walking quite well. Left abscess barely palpable in this region; no signs of paraplegia. At present child fat and happy and has grown a good deal in height since admission.

The change in 18 months has been remarkable. Harry S., aged 5, admitted April 1, 1908, suffering with tuberculosis of spine in the middorsal region, wearing poorly fitted jacket.

Shortly after admission he developed an abscess in the right gluteal region; placed on Bradford frame. In May the abscess had increased considerably in size and its surface became red. Inflammation subsided under wet dressings.

In July abscess near rupture; was aspirated and 50 cc of pus removed and 8 cc of Calot fluid injected.

July 18, 1908, abscess ruptured spontaneously

and discharged about 2 oz. of greenish fluid through very small hole and treated with rigorous asepsis, then closed spontaneously.

July 20, 1908, opened again and discharged 3 cc of yellowish fluid; then was aspirated and. 30 cc of pus removed and 7 cc of fluid injected.

July 27, 1908, abscess still discharging intermittently through small hole. During this time removed from frame and kept as much as possible on his face in bed.

August 17, 1908. For 12 days abscess has not discharged; it is closed and flat, apparently empty. General condition of child markedly improved since admission.

November 17, 1908, child has been on Bradjacket applied. ford frame since abscess healed, military Calot

The abscess has never reappeared and the boy is now wearing the jacket with comfort and is in excellent condition.

The importance of these cases can be realized if the fact is borne in mind that an infected abscess of the spine almost invariably is fatal.

We no longer hesitate to attack a presenting abscess and thereby shorten the duration of the treatment of the disease quite materially.

No condition in the course of a tuberculous process is more to be dreaded, if we set aside amyloid degeneration and pulmonary complications, than the occurrence of a tuberculous sinus. We all know full well the months and even years of constant drainage that usually results and the tedious dressings which must be applied indefinitely. It is these particular cases, more than any others, which have put the Sea Breeze Hospital, as a representative of the fresh air treatment, to a severe test and it has not been found wanting.

There are several elements which have had to do with successful treatment of these cases. We have not resorted to operative methods except where the drainage of abscesses proved insufficient and there resulted a damming back of the discharge.

We regard the curettement of the sinuses and diseased bony area as useless. The focus in the walls of the sinuses is not superficial, but extends deep into the adjacent tissues, where it cannot be reached by a curette.

The marked improvement in the constitutional condition of our cases has played a large part in the healing of these sinuses. As a rule the improvement in the condition of the sinuses. is not noted until the patients have already reached a decidedly good physical state, but from that time on as a rule the diminishing of the discharge and the closing of the sinuses progress steadily. Thus we have put before us the great cause of the persistency of the sinuses in the city. cases, for this persistence represents a continuance of the diseased focus, and as long as the patients continue to live that city life, with insufficient pure air and bad food; with the fondling

January, 1910

and nervous life of the home, so long will the sinuses persist. Thus the great need of the outdoor life and good food in the treatment of these

cases.

The beneficial effect upon the sinuses of their direct contact with the salt water was learned the first summer of the existence of the hospital. Considering that the daily baths would have a tonic effect upon the patients all those not wearing plaster paris were allowed to go into the ocean. It was then noticed that those children with discharging sinuses showed a marked improvement and that the sinuses steadily and rapidly healed.

The following case will illustrate:

Marvino A., aged 13 was admitted to the hospital among the first patients in June 1904. In 1898, in Italy he first showed symptoms of tuberculosis of the left ankle joint. Soon after a sinus formed on either side of the joint and several operations were performed to no avail, in Italy and in New York. When admitted to the Sea Breeze Hospital he presented two sinuses discharging freely, one on either side of the joint. He was allowed to take his daily bath and like the others come out each day with the dressings filled with sand. Far from doing harm this exposure was a decided benefit and the discharge diminished so that by October it had. ceased. Two months later the sinuses were entirely closed and the ankle joint was ankylosed at an angle of 95 degrees and the boy walked and ran with only a slightly perceptible lameness.

This is only one of a number of similar cases of sinuses connected with the hip, knee, wrist, elbow, acting in the same favorable way.

It is interesting that three cases which started the sea bathing for their sinuses last summer have continued to take their baths during the fall, and on a vists of the writer just before Christmas, they had only then discontinued their full baths, the water being a little too cold. They still wade in to the hips each day, however.

Since the presentation, last October, in Washington, by Dr. Emil Beck of Chicago, of his paper on the treatment of tuberculous sinuses by the injection of Bismuth subnitrate, we have recently inaugurated the same treatment in certain of our cases at Sea Breeze..

The injections have been made twice a week and the sinuses have been filled at each sitting by means of a cone-shaped syringe.

The formula which Dr. Beck used at first was:

We began with No. 2 and the discharge of pus diminished rapidly and the sinuses were healed permanently in two cases after three and four injections respectively. Three other cases showed marked improvement after several injections but suddenly all three developed nausea and vomiting and fever and were quite sick for four days. At this time the pus also had decidedly diminished in amount. We stopped the injections and after several days the discharge became quite free and with it considerable of the Bismuth mixture before injected. We waited some time and then commenced injections recently with formula No. 1. The discharge in the cases is now rapidly diminishing with no tendency to blocking up. Two cases of advanced amyloid degeneration, complicating Pott's disease and hip disease respectively showed decided diminution in the discharge, but the disease progressed to a fatal termination in one and the other was so ill that she was discharged as incurable. One other case showed an apparent poisoning from the Bismuth after the first injection and we have discontinued the treatment.

The results have been promising and warrant our continuation of the treatment in appropriate cases. We are keeping notes and shall at a future date report our results.

There is another class of cases which has shown the good effect of a life in the open air, namely, that of tuberculous adenitis. It is a matter of routine practice with us to remove the adenoids and enlarged tonsils, when existing and if the diseased glands are considerably enlarged and softened, to send the patient to one of the city hospitals for removal of these glands, as we feel that we thus avoid the possible formation of sinuses as the result of the broken down condition which has already taken place. These patients then return and remain until cured. The cases of moderate severity undergo the usual constitutional upbuilding by means of the fresh air and good food and improvement has taken. place from the first, the glands have steadily diminished in size until the patients have been discharged cured. In those cases presenting discharging sinuses as the result of broken down glands, there has been no decided improvement until the adenoids and tonsils are removed, when the discharge rapidly diminishes and in a few months the sinuses are healed.

In examining cases sent to us for admission to the Hospital we must determine whether each case is a suitable one. Certain patients present who give a history of a long and tedious course, numerous operations performed, and a very unsatisfactory response to treatment. They present discharging sinuses which have remained about the same for possibly several years. This of course is the history of a large number of cases which are unquestionably tuberculous. But a certain number of these cases present a somewhat different picture. The sinuses, although

perhaps near a joint, appear to lead us away from the joint towards the shaft of the bone. The joints themselves are not much limited in motion. Moreover the sinuses are of a punched-out appearance and are surrounded by a copper colored areola. Usually multiple joints are apparently affected and the sinuses have formed in rapid succession. The teeth of the patients are often bad and frequently notched. They present a more or less general moderate adenitis. In these cases we reserve our decision until we have put them through a course of mixed treatment, KI in increasing doses and ung. Hydrarg. to the sinuses for at least three or four weeks, for we are inclined to believe that a mistaken diagnosis has been made, and whereas they have been treated for a period of years for tuberculosis they are in reality cases of hereditary syphilis.

Our observations in a goodly number of these cases have met with success and the patients have been restored to health in a comparatively short space of time under treatment at the city dispensary. We do not send these patients back whence they came, but keep them under our own care until cured.

A few such cases were found already in the hospital when the present staff took up its work two years ago, and we also admitted a few before we came to observe them carefully and these patients were apparently cured at the hospital before discharge with a proper diagnosis. In the first cases, however, their condition recurred beIcause we lost track of them and their medication was discontinued, so that now we insist on the patients coming to us regularly for at least 18 months after discharge in order that we may continue the appropriate treatment. Latterly there have been no recurrences.

The writer lays great stress upon these cases, as it appears that hereditary syphilis is not carefully considered in a number of instances and the mistakes are thus too common. The patients are thereby put unnecessarily to years of suffering and ultimate deformity.

Medicines do not occupy a prominent place in our methods of treatment. We have no recourse to such tonics as cod liver oil and the like. Simple laxatives are sometimes indicated.

Several cases have improved under the use of the syrup of the iodide of iron when indicated, and the writer feels that it is a very valuable tonic in cases which seem to need a lifting up to that point where the body is able to assimilate the food given. It does not upset the stomach and is usually not constipating.

The results obtained of the Sea Breeze Hospital as a permanent institution, open winter and summer, have shown the necessity of long continued life in a hospital of that nature. Several summer hospitals and homes have been established along the eastern sea coast and in the country, such as the country branch of the N. Y. Orthopedic Hospital at White Plains, the

Daisy Fields Home and Hospital for Crippled Children, at Englewood, N. J., the Southampton Home on Long Island, the Hospital at New Dorp, Staten Island, and others near New York, one at Providence, R. I. and those at Marblehead and Wellesley, Mass., most of which are open from June to October, and the patients admitted to these institutions have shown gratifying improvement. However, this improvement has been in the majority of instances but temporary, because, naturally, a cure has not been affected in the four short months of their sojourn, and the return to the poor surroundings of the cities from whence they came, has resulted in a speedy loss of the ground gained. This is the experience of the various surgeons who have charge of these institutions and the universal hope exists that in the future greater financial support may make it possible to establish their hospitals on a permanent basis.

The Sea Breeze Hospital was established at Coney Island because it was urged abroad that the sea shore was the best place for such a sanitorium, and that it was desired to try the experiment in America.

There are certain elements which suggest themselves as reasons why the seashore may be preferable to any inland location for a hospital. The balmy air and more even temperature without the sudden changes which are apt to take place in our inland States, the sea bathing and the observation that children are happier on the sand and near the water than in the fields. We also feel that there may be something about the air off the ocean which is more beneficial than the inland atmosphere. This has been claimed. by writers abroad.

However, it is the writer's desire at this time to emphasize certain salient facts which above all else present themselves in the successful treatment of surgical tuberculosis.

1. That the patients should as far as possible live in the fresh air all of the twenty-four hours, day and night, winter and summer. That they should never be indoors except at necessary periods and that the windows of the house should always be open.

2. That this is best brought about by the establishment of sanitoria in the country or at the seashore, away from the city, thereby removing the patient from the worries of home life crippled condition, and from the dirt and vitiated where they are too frequently made to feel their

air of the city.

3. That they should be supplied with good simple food in abundance.

4. That the surroundings of the sanitoria should be made as attractive as possible, including good education, kind treatment and attention.

5. That, with the constitutional, the best possible orthopedic, treatment should be offered, bringing into use every means whereby the patients