Special Notices. ARTICULAR RHEUMATISM OF INFECTIOUS ORIGIN.-Dr. L. T. Riesmeyer, of St. Louis (Medical Review, October 22, 1898), calls attention to the growing tendency to attribute articular rheumatism to an infection with pyogenic micro-organisms. He reports in detail three cases in which a demonstrable primary inflammatory focus preceded the attack, the first patient having suffered from a purulent catarrh of the cervix uteri, the second from a parametric suppuration, and the third from follicular tonsillitis before the occurrence of the rheumatism. The author believes that the prompt action of Salophen in the treatment of these cases also speaks in favor of the microbic etiology of rheumatism. He regards salicylic acid, of which Salophen is a derivative, as one of the few true specifics in medicine. Its administration in the pure form is objectionable, however, on account of its irritation of the stomach. The salicylates, too, have irritating properties and produce disturbances of digestion, anorexia, nausea, and a heavily coated tongue; they also have a depressing effect upon the heart and irritate the kidneys. These disadvantages are overcome by the administration of Salophen, which passes through the stomach unaltered and separates in the intestine, on account of the alkaline contents, into salicylic acid and acetyl-paramidophenol. It produces no heart depression nor any other untoward symptoms, and may be advantageously administered in all cases where salicylic acid is indicated, that is, for the purpose of diminishing the activity of micro-organisms which produce inflammation, fermentation, and putrefaction. SECONDARY ANEMIA.-Dr. Milton P. Creel, of Central City, Ky., in his capacity as a railway surgeon and general surgical consultant, finds the most intractable forms of secondary anemia are those which follow upon severe injury, where amputation is necessary. In these cases he has failed altogether with the more common iron preparations, they producing biliousness and often severe constipation. To obtain the best results he has now accustomed himself to the employment of Henry's Three Chlorides, in doses of one to two fluid drachms three times daily after eating. The small amounts of bichloride mercury and chloride arsenic add, he holds, to the efficiency of the protochloride of iron which the preparation contains, besides it is most grateful to the palate of adults and children. F. E. HARRISON, M. D., Abbeville, S. C., says: I have used Celerina in appropriate cases, and can heartily recommend it to all who wish an elegant preparation, combined with undiminished therapeutic activity. It is peculiarly fitted to such cases as delirium tremens, headache from debauch or excessive mental or physical exertion. LABOR SAVING: The American Medical Publishers' Association is prepared to furnish carefully revised lists, set by the Mergenthaler Linotype Machine, as follows: List No. I contains the name and address of all reputable advertisers in the United States who use medical and pharmaceutical publications, including many new customers just entering the field. In book form, 50 cents. List No. 2 contains the address of all publications devoted to Medicine, Surgery, Pharmacy, Microscopy, and allied sciences, throughout the United States and Canada, revised and corrected to date. Price, $1.25 per dozen gummed sheets. List No. 2 is furnished in gummed sheets, for use on your mailer, and will be found a great convenience in sending out reprints and exchanges. If you do not use a mailing machine, these lists can readily be cut apart and applied as quickly as postage stamps, insuring accuracy in delivery and saving your office help valuable time. These lists are furnished free of charge to members of the Association. Address CHARLES WOOD FASSETT, Secretary, cor. Sixth and Charles streets, St. Joseph, Mo. AMERICAN PRACTITIONER AND NEWS. News. VOL. XXVI. “NEC TENUI PENNÂ.” LOUISVILLE, KY., DECEMBER 15, 1898. No. 12 Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN. Original Articles. SOME DESULTORY REMARKS ON RETINAL HEMORRHAGES IN CERTAIN BLOOD CONDITIONS.* BY J. MORRISON RAY, M. D. Clinical Professor of Ophthalmology, University of Louisville. Extravasations of blood into the retinal tissue from the bloodvessels therein contained is a condition frequently found by those accustomed to the use of the ophthalmoscope. The blood may come from either an artery or a vein. It is most often found in connection with an inflammation involving the optic nerve and retina. Under such conditions the inflammatory process precedes the retinal extravasations, and is the predominating local change. Often we find cases in which blood is poured out in the different planes of the fundus without local inflammation, showing that diseased conditions in remote parts may be a factor in their etiology. These hemorrhages may be single or multiple, abundant or consist of one small hemorrhage directly in the macular region. Their influence on vision will depend principally on their location. If central, they interfere seriously with visal acuteness. If eccentric, they may be abundant and yet interfere but little with normal vision, and their discovery accidental. Their prognostic importance is of the greatest significance. The late Dr. Agnew once stated to the writer that whenever he encountered a case of simple retinal hemorrhage in a person after sixty years of age, he expected death would take place inside of three years, usually from cerebral hemorrhage. Where they occur earlier in life, * Read before the Louisville Medico-Chirurgical Society, December 16, 1898. For discussion see p. 459. their portent is not so serious, yet they are the local expressions of a general vascular disease, the discovery of which might not have been made without the presence of the eye changes. Uncomplicated retinal hemorrhages, exclusive of those due to trauma, are produced by agents conveyed to the eye by the circulating blood. Von Amman divides them into those due to, first, primary blood changes with secondary vessel changes; second, those with primary circulatory changes with secondary vessel wall changes. In the former class would be included blood dyscrasia, such as anemia, malaria, leucocythemia, and all toxemias. The latter class would consist of diseases of the heart and blood-vessels (including arterio-sclerosis). The intimate connection between retinal hemorrhages and conditions of the general health led me to draw your attention to this subject, since most works on eye diseases, and also those dealing with the general practice of medicine, while mentioning them casually, do not indicate their possible significance. The relation of a few clinical cases and the comments thereon may better explain the purpose of my theme. Mrs. W. was confined in the fall of 1895 with her second child. The labor was normal. Six weeks later there began an ulcerative stomatitis, and with this a steady loss of flesh until she became profoundly anemic and greatly debilitated. In March, 1896, she became suddenly blind in the right eye. This lasted for several hours, when vision was restored sufficiently for her to see large objects. Six weeks later the left eye went through a similar process. After this both eyes gradually improved until August, 1896, when on a visit to her physician, Dr. Wakefield, I was requested by him to examine her eyes. At that time she looked pale, the conjunctivæ were blanched, and the sclerotic china white. Her vision was sufficient for her to be able to get around; the pupils responded well to light; she complained of a large spot in the center of each eye that prevented her seeing when looking directly at small objects. She was unable to read because of the presence of this spot. An examination with the ophthalmoscope was exceedingly interesting. The optic discs were pale, and the entire fundus was of a peculiar light pinkish hue. The similarity in color of the blood in the arteries and veins was so great that they could with difficulty be distinguished from each other, and the blood-vessels appeared full and in places tortuous, with very broad white streaks along their center. Directly in the macular region was a large extravasation of blood nearly circular in shape, about one-half disc diameter in its greatest width. The center of this hemorrhage was dark, and faded to a light red at its margin. The changes in the eyes were nearly symmetrical, the blood spot in the left being of a lighter hue. At the time of the sudden attack of blindness a thorough examination of the urine failed to show any evidence of organic kidney disease. Her physician, Dr. Wakefield, recognizing the profound anemia, put her on iron and blood-making tonics. One year after the trouble began the patient was much improved in general health, and she was able to read ordinary print with some difficulty. In a recent note from her physician, to whom I am indebted for the history up to the time of my eye examination, I learn that there is still some defective vision, which is most annoying when the patient is in a bright light, the contraction of the pupils shutting off the retina except in the area involved in the former hemorrhage. The fundus changes in cases of anemia, simple and pernicious, have been carefully studied by several observers. Gowers says that hemorrhages are certainly rare in simple anemia, and can probably only take place where there is a very great absolute deficiency in the number of red corpuscles. On the other hand, in progressive pernicious anemia, the characteristic feature is a tendency to retinal hemorrhages. The case I have related above was in many of its features apparently a case of simple anemia, but the eye changes were more like those found in the pernicious form. The onset of the process with an ulcerative disease of the gums would seem to place it as a case of scorbutic anemia. Gowers claims that such a condition occurs, in no way due to a deficiency of vegetable foods. Stephen Mackenzie says that the presence of retinal hemorrhages in cases of anemia is a diagnostic sign of the dangerous form of the disease, for in all such cases the corpuscular richness of the blood must fall below fifty per cent before the tendency to retinal hemorrhages is developed. He remarks that in the absence of a hemacytometer we can gauge whether the corpuscular richness is above or below this point by observing the pink color through the finger nails; as long as this is present, it will be found that the patient has above fifty per cent of red blood corpuscles. The histological appearance in these cases has been worked out by Uhthoff, Bettman, Sargent, De Schweinitz, and others, and consists of hemorrhages into the various strata of the retina, especially the nerve fiber and inner granular layers, and edema of the retinal elements, the hemorrhagic condition seeming to result from transudation through the wall of the vessel and not often from a rupture of the wall. Closely akin to cases of profound anemia are those of toxemia from chronic malarial poison. A few cases are found where this poison has spent its force on the retinal blood-vessels. While in this city on his way September 6, 1898, John Roberts, aged thirty-two, presented himself at my office with the statement that on the day before he became suddenly blind in both eyes. At first he was unable to get about, but now he can with difficulty find his way around. The history he gave me was as follows: He was until last spring a farm hand in Southern Kentucky, and had always been in good health. He left his home and sought employment in St. Louis, going to work in a foundry that was situated on the river bottom below East St. Louis, the surrounding land being low, and during the spring quite damp. Some time after he began work he suffered from chills and fever, but for the past month he had gotten so much worse and had become so weak that he determined to return to his home. He had been under the care of several physicians, and had taken much quinine. home the sight suddenly became bad. had a peculiar sallow complexion with intense pallor of the mucous membranes of the mouth, throat, and eye. His vision was: R. E., fingers at two feet; L. E., 20. The ophthalmoscope showed the most extensive retinal extravasations that I ever saw. Instead of having numerous minute punctiform hemorrhages, it seemed as if about three or four large hemorrhages encompassed the visible portion of the fundus. The hemorrhages were thick; the retinal blood-vessels passed in front of them, showing them to be in the deep layers of the retina. These changes were similar in each eye. The shape of these blood extravasations were much like those found in subhyaloid hemorrhage, but they were distributed over the entire fundus and deep in the retina. While waiting in my office he suffered from a severe chill, and I sent him to the City Hospital. For the following history I am indebted to the interne, Dr. Morrison: His family history is good. He had most of the diseases of childhood. When admitted to the City Hospital was suffering from a severe shaking chill, which lasted for an hour; after this his temperature became 104°; this fever continued for several hours, when he had a profuse sweat. He said he had been living in a swampy region where everybody suffered from chills and fever, and for three months he had been unable to rid himself of them, although he |
