you to lend a helping hand in the youngest branch of the young science of prophylaxis. I appeal for the prophylaxis of venereal disease. Inasmuch as this subject must be entirely new to a great number among you, I take the liberty of treating the elements of the question, with due apology to those who already know. In the first place, let me assure you of the importance of the venereal peril. On syphilis I need scarcely insist, for you surely appreciate not only the lesions of bone and brain produced by that disease, but also the tragic horror which so often afflicts the patient who is told-as he must be told that he never can be absolutely and infallibly assured that his disease is ended. Yet the frequency of syphilis perhaps you do not all appreciate. What has impressed me most is, not the statistics that tell how one in ten New Yorkers, or one in four unmarried males aged 30 in Berlin, is syphilitic. Such estimates are large Such estimates are large and vague and doubtless inaccurate; they do not grip one. But consider rather the fact that very many of our more aristocratic patients acquire their disease from what one might term an unimpeachable source. Tell them they have chancre, and they retort, "It is impossible." They do not deny sexual contact, but they do deny the possibility of contamination from so unsullied a source. They would deny that one who is kind to two may be generous to twenty; they maintain an exception to the law that "No woman, however beautiful, can give what she has not got." Such fatuousness may make you smile, gentlemen; but 'tis no joke for a' that. Another proof, perhaps even more forceful, of the frequency of syphilis has been often called to my attention by my associate, Dr. Chetwood. It is his custom to read the riot act to those casual youths who return again and again suffering from gonorrhea, telling them: "Young man, if you keep on, in less than three years you will be back here with syphilis!" And, sure enough, in the great majority of cases, three years do not roll by ere they prove the prophecy correct. From these facts one may conclude that illicit intercourse is never safe from the danger of syphilis, while promiscuity invites it almost to a certainty. But gonorrhea is the rock upon which we split. Its frequency we all admit, but its importanceits great importance-as a destroyer of health and home is not appreciated as it should be. But to discuss this subject, which has been often and ably discussed already, would lead us too far afield. Let us only paraphrase the saying of Ricord: "A clap begins and God only knows when and where it will end." They wreck many lives, do these venereal diseases. Think of the tabetics in our streets, the paretics in our asylums, the dead or disfigured children; think of the laparotomies for pus tube that occur daily in our hospitals; think of the impotence, the sterility, the sexual neurasthenia that fill our offices with vagrants wandering from physician to quack and back again in the vain hope of a cure! Think of all this, and tell me why this suffering, why these loathsome diseases. The answer is easy because of promiscuous sexual congress. And why promiscuous sexual congress? Listen well to the answer, for I expect many of you to disagree with me. I suppose many of you believe in your hearts that old, old fable about the adult male needing intercourse for his health. Indeed, I fear that many of you are listening with cynicism in your hearts; that you are thinking, "Oh, well, it's largely a matter of taste; some prefer one way and some another; those who don't have intercourse probably do worse." Well, gentlemen, that's true. It's perfectly true; but it ought not to be true. I wish you had heard all the discussion on the subject the other night. But since you have not, I commend to you for my present purpose a paper, entitled "The Sexual Necessity," which will soon appear in the Medical News. But I haven't answered my own question yet. I haven't told you what I consider the reason for promiscuous sexual intercourse. It is habit; just the same sort of habit as smoking or drinking; a habit, tolerated if not encouraged; a habit, like smoking or drinking, though far easier to begin and far harder to break. Just stop and ask yourselves what prompts a boy to his first illicit intercourse. Let us suppose, of course, that he has not grown up in the habit; that he has escaped seduction by nursemaids, and has not been taught to masturbate by his companions until, reaching the years of discretion, somewhere between the ages of 15 and 20, he "goes out with the boys." Why does he do it? Why does he take the first step in a habit which may last his whole life long? Often enough because he is just drunk enough to follow where others lead; oftener still because he is afraid to refuse, because he thinks it's manly, because he knows the other fellows do; rarely, very rarely, I believe, does a young man open his sexual life in this way solely under the impulse of his passions. The sexual impulse, be it ever so strong, is like the impulse of the drunkard-feeble enough so long as he has never touched his liquor; but let him once get the taste in his mouth, let him run his lips warm and wet along the edge of the glass, let him smell the aroma after he has acquired the taste-ah, there is passion full-blown, if you will! And just here is where practice grapples theory. Can't we get at that young man to prevent his initial debauch? Perhaps yes; perhaps no. I am not at all sure but that, if every boy in this world were given the best possible chance of avoiding venereal disease, more than half of them might not go ahead and get infected anyhow. But the point is, they don't get the chance; your boys don't get the chance; you yourselves didn't get the chance when you were boys. Just hark back and call to mind how sexual matters were first explained to you. For my part, I can well remember, the pair of rabbits that constituted the physiologic clinic upon which my young instructors lectured. And all those smutty tales, magnified by the groping imagination of youth! What a distorting, debasing influence they have! How they prepare the mind to take a low, vulgar, shameless view of the sexual life that is just dawning! And to these influences we oppose what? Absolutely nothing. We read our boy the Ten Commandments, and he nudges his companion and chuckles as we reach the sixth-aye, even delves into the Bible for those passages, the memory of which is handed down among the boys from generation to generation. But we endeavor to forget the seriousness of these things when we grow up. We make no effort to keep our own boys out of the same old, muddy rut. But, if you ask me to quit this theorizing, to come down to hard facts, to tell you how to approach the boy, how to get him into a clean way of thinking, I must confess I do not fully know. A lot of disconnected points I have picked up. I know that you can't teach a boy morals out of a book-he will take it into a corner and make fun of it with his friends; you can't teach him out of the mouth of a woman, his innate sense of decency rebels at that; you can't lie to him, he will find you out; you can't scare him much-he won't stay scared. On the other hand, there are a lot of things you can do. You can appeal to his manliness, to his inborn sense of decency; even, in some cases, to his sense of physical cleanliness or of religion. But the appeal must reach him with authority and with dignity. It must be directed, as much as possible, to that particular boy rather than to boys in general. These are vague points that I allude to. In some of them I may be mistaken. Indeed, I am only the veriest student of these matters. I have been thinking them over seriously only since I became interested in the Society of Moral and Social Prophylaxis. And the more I study the matter, the more it appeals to me-the more real, practical good I can see will come out of it. I have covered only one side of the vast subject which the Society of Moral and Social Prophylaxis aims to attack. Its object is to clear up ignorance of every shade, the ignorance of the prostitute who thinks the way to rid herself of venereal disease is by intercourse with a virgin, as well as the ignorance of the young lad who knows not how to interpret the first stirrings of sexual life; the ignorance of the man who thinks he can marry within one year of his chancre, as well as the ignorance of the boy who looks forward to his first gonorrhea as the portal to true manhood. The time is rive for these things. Twenty years ago the discussion of matters sexual was too filthy for a medical society; to-day even the laity can take part in such discussions with an in telligent, clean interest; the clergy of every denomination are in sympathy with the movement. But it is for the medical profession to take the lead. Without you to keep the Society correct in its physiology and in its psychology, it could not discuss correctly the straight path of its best endeavor. That is why Dr. Morrow and I are here to-night, to enlighten you a little, to interest you. much in a work rather moral than medical, in a work which, if energetically conducted, cannot fail to produce great good in the souls as well as the bodies of our fellow men. Perhaps some of you are still skeptical. You think the old Adam will be too strong for us. Indeed, I confess to such skepticism, in some degree, myself. I have no idea that the Society of Social and Moral Prophylaxis, or any other society, will turn us out a race of passionless seraphs. But I do believe, with all my soul, that we are not giving our children or our fellows a fair share of the enlightenment which we possess, or ought to possess. They have a right to freedom and all means necessary to its attainment; they have a right to virtue and health and all means necessary to their attainment. practical difficulties in the way of imparting this necessary knowledge in such a way as to produce a good moral effect are great, but not insuperable. And to present the evidence is about all we can do. Then, if the man wills with his eyes open to go the old evil way, he will, at least, have had an opportunity for enlightened choice not afforded by our present system. The The results of such a propaganda will be slow to show themselves; of that we may be sure. Perhaps the Society for Social and Moral Prophylaxis itself may wither under public indifference or contempt before its mission is fulfilled. But its spirit will not die. The rumor must spread; it must interest brother and son as well as mother and wife, prelate, and physician, and father of family. I cannot doubt that, in the end, it will produce a marvelous change in public spirit, that, as it was the triumph of the eighteenth century to make seduction unfashionable and of the nineteenth to make drunkenness unfashionable, so it may be the glory of the twentieth to make the law of public opinion the same for man as for woman. I think that all of us laymen, men and women, have a peculiar appreciation of what a doctor means, for I do not suppose there is one of us who does not feel that the family doctor stands in a position of close intimacy, in a position of obligation under which one is happy to rest to an extent that hardly any one else can stand, and those of us-I think most of us who are fortunate enough to have a family doctor who is a beloved and intimate friend, realize that there can be few closer ties of intimacy and affection in the world. -THEODORE ROOSEVELT. A DISLOCATION OF THE FOOT BACKWARD, BY GUY CARLETON BAYLEY, M.D., HE patient whose misfortune was my opportunity was Emil Holmes, aet. 30; native of Norway; a farm hand, strong and healthy. He was admitted to Vassar Hospital February 2, 1903. Diagnosis, dislocation of foot backward. History: On November 20, 1902, while attempting to separate two men who were fighting, one of them kicked him on the instep placed under the leg. This was done to take the tension off the gastrocnemius and soleus muscles. Strong extension was made by two men with a strip of unbleached muslin around the heel and instep; reduction attempted, failed. February 10th, under ether, with Drs. Tuthill and Poucher in consultation, reduction attempted, failed. Dr. William T. Bull being the consulting surgeon of the staff residing in New York City, he was written to about the case, and asked to see the case in consultation. In his reply accepting he suggested that probably the only thing to do would be to open the joint and remove the head of the astragalus. while his foot was suspended in the air. Two doctors had made various attempts to reduce the dislocation, but had failed. Examination: Foot slightly everted, toe pointing downward; unable to get heel to the floor. No pain, except when weight of body is put on the toes, when pain is intense in the ankle. No heat or swelling. X-ray showed dislocation of the foot backward. February 3, 1903, patient taken to operating room, etherized fully, attempted reduction, while two men made extension and counter extension. Attempt failed. February 7th, taken to operating room, etherized deeply, patient laid on the floor and a box 1Read before the Fifth District Branch of The New York State Medical Association, at the Twenty-first Annual Meeting, at Poughkeepsie, N. Y., May 2, 1905. On February 23d Dr. Bull, in consultation, satisfied himself that the dislocation could not be reduced, and agreed with me that cutting the tendo Achillis and putting the foot in plaster, with the foot forcibly put at a right angle to the leg, might give a better result than the major operation of opening the joint, which could be done later if found necessary. I then cut the tendo Achillis subcutaneously, and applied a plaster dressing, the foot being held in place carefully until the plaster dried. On March 3d the patient was allowed to walk about the ward, the heel coming on the floor nicely and the patient having no pain. On April 2d the plaster was removed, and the man walked freely with no pain, and about as much disability as is ordinarily seen in a case where the arch of the instep has given way, and no more. The X-ray examination showed the dislocation unreduced. The man has reported since that he is working as usual, perfectly satisfied with the condition of his ankle, which gives him no pain or inconvenience. SECOND CASE. Isabel Frazier (colored), aet. 65; native of U. S.; a heavy woman; general health good. On December 25, 1904, fell from the porch of her house, striking her foot. The foot shortened, the heel lengthened, much swelling, great tenderness, skin much blistered from tension. X-ray shows complete dislocation of the foot backward, with fracture of tibia and rupture of ligaments. December 27th, under ether, the frac ary 10, 1905, fell from ladder, striking on his foot, and injured ankle. Examination: Heel raised, toe pointing downward, ankle swollen, tender and painful. X-ray examination showed dislocation backward, no fracture, probable rupture of ligaments, slight rotation of astragalus outward. January 12th, under ether, dislocation easily reduced, Day's splints applied, progress uneventful. February 2d, splints removed, ankle found strong, free from pain or swelling. February 6th, patient walking about ward with crutches. February 8th, walks without cane, and with no inconvenience. X-ray shows joint in normal condition. Being 'baffled in my first effort to reduce the dislocation in Case 1, I turned to the books, and ture and the dislocation were reduced easily. Day's splints were applied. X-ray taken December 29th shows fracture and joint in excellent position. Patient very restless, moving foot about continually in the bed. January 24, 1905, the splints were removed, union firm, ankle joint movable, blistered skin dressed with benzoated oxide of zinc. February 15th, patient walking about. February 25th, patient discharged; has no pain or swelling, with good motion in the ankle joint. THIRD CASE. George F. Skinner, aet. 75; Native of U. S.; remarkably well preserved and healthy. On Janu was surprised to find how little was said about what seemed to be an important matter. The leading practitioners of surgery, the teachers, and even those who have made a specialty of fractures and dislocations, only mention the four dislocations in their direction-outward, inward, backward and forward-in all my search I found no account of a case similar to the first one mentioned. In fact, Gross, in his "System of Surgery," says: After a very careful examination of the records of surgery I find that the simple displacement of this bone in any direction is an occurrence of such extreme infrequency as hardly to deserve mention. He had evidently never seen a case. Sir Astley Cooper had seen but one case of dislocation of the foot backward. Thomas Bryant, Mr. Cock, in Guy's Hospital Reports, had each seen but one case of the backward dislocation, and they mention their cases chiefly on account of the difficulty they experienced in keeping the parts in place after an easy reduction. Edmund Andrews, in "Ashhurst's Encyclopædia of Surgery," devotes some space to the difficulty of retaining the parts in position. He quotes Professor Jarjavay, of Paris, who demonstrated that this difficulty of retention was caused by the fracture of the posterior rim of the articulation, leaving the lower end of the tibia a single inclined plane working on the smoothly rounded astragalus; the muscular action invariably causes recurrence of the displacement when extension is removed. He makes no mention of the uncomplicated cases of dislocation, or of the difficulties of reduction. Stimson, the best of the later authorities on dislocations, says: In dislocation of the foot backward the astragalus, and with it the foot, is displaced backward to a variable distance, with rupture of the lateral ligaments and sometimes of other parts of the capsule, and sometimes with fracture of one or both malleoli and of the posterior edge of the lower articular surface of the tibia. Examples of pure primary dislocations are rare. Malgaigne could find only eighteen reported cases, but partial and perhaps complete dislocations occurring as a secondary result of rupture of the lateral ligaments or fracture of the fibula and internal malleolus, as in fracture by eversion of the ankle, are frequent. Reduction has always been easily obtained, etc. Hamilton, on "Fractures and Dislocations," gives the pathological anatomy of dislocations of the lower end of the tibia forward as follows: The displacement may be very slight, so that the end of the tibia is only a little advanced upon the astragalus; or it may be such that the tibia rests one-half upon the naviculare and one-half upon the astragalus, or it may even desert the astragalus entirely. The fibula may at the same time be broken at any point, but is generally broken two or three inches above its lower extremity. The malleolus internus is also sometimes broken, but more often the internal lateral ligament is torn. Still more rarely a fracture occurs through the posterior margin of the articular surface of the tibia. W. F. Clark, in his "Manual of the Practice of Surgery," says: These injuries can hardly occur without fracture of one or both malleoli. Not infrequently it will be found impossible, after all, to bring the bone back to its place. In such a case the bone may be excised at once, or left to itself. Erichsen, in his "Science and Art of Surgery," says: In the dislocation of the foot backward, the deltoid ligament is ruptured, the fibula broken in the usual place. In these cases traction on the foot in the proper direction will readily be attended by replacement of the bones. In this little country hospital in two years we have had three cases of dislocation of the foot backward, and a fourth complicated by a rotation of the astragalus on its own axis. And yet some of the most prominent surgeons of their day have seen but one case of dislocation of the foot backward, in all their lifetime, and none have seen or described a case similar to the first detailed. In backward dislocation of the foot I would note four conditions in the order of their frequency. A complete dislocation with fracture of bone and rupture of ligaments, easily reduced and kept in place. Dislocation with fracture of posterior edge of articulating surface of the tibia, and rupture of ligaments, easily reduced and difficult to keep in place. Dislocation without fracture, with rupture of ligaments, easily reduced and retained. Dislocation without fracture or rupture, impossible of reduction. In presenting these cases of the three conditions, I only regret that I could not report a case of the fourth, a fracture of the articulating surface of the tibia with difficulty of retention. I believe that this difficulty could be overcome by the use of plaster, and we should not be placed in the position of Malgaigne, whose patient died of gangrene of the parts, caused by the means used to keep the dislocated joint in position. UNILATERAL AND OTHER UNUSUAL FORMS BY ALEXANDER DUANE, M.D., ably symmetrical affection, the vibratory movements being simultaneous, parallel, and equal in the two eyes. The following forms occur as rare exceptions: 1. Disjunctive Nystagmus.-The two eyes move, not in parallel directions, but alternately toward and away from each other. The movements are symmetrical and equal in the two eyes. 2. Dissociated Nystagmus.-The movements of the two eyes are unsymmetrical and unrelated, one either moving much faster and further than the other or moving in a totally different way. 3. Unilateral Nystagmus.-This is evidently only a variety of Form 2, into which, indeed, it often passes. Mention may also be made of circumduction nystagmus, not so much because it is necessarily aberrant as because it is extremely rare. CIRCUMDUCTION NYSTAGMUS. In circumduction nystagmus the center of each cornea moves rapidly round and round in a circular or elliptical path. It obviously differs from a rotary nystagmus, in which the cornea rotates about its center, the latter remaining fixed. Circumduction nystagmus is evidently a complex form of mixed nystagmus. In ordinary mixed nystagmus two kinds of oscillation occur *Read before the Section on Ophthalmology, New York Academy of Medicine, March 20, 1905. |