After reading the paper the subject was thrown open for discussion. DR. CHARLES FAYETTE TAYLOR said: This is a subject with which I have considerable familiarity, as all persons who are extensively engaged in the treatment of joint affections must have, but it is too large to even touch upon in many of its aspects, in the limited time at my disposal to-night, even if I had prepared myself for such a discussion by having previous intimation of the direction it would take. I should prefer to have the subject arranged before speaking of it, especially as I shall be obliged to differ from the essayist, both as to the pathology and treatment of the neurotic disturbances attending or following joint diseases of the character which he has set forth in the paper. In regard to the pathogenesis, I do not think it is necessary to adopt any peculiar theory, or to assume that even any special deviation from the ordinary course of nerve function takes place in order to account for all the facts observed in these cases. The difference is one of degree only. A person is attacked with inflammation of the knee-joint, for instance; this is rapidly followed by diminished size of the muscles controlling the action of that joint, with diminished and sometimes even with entire loss of muscular action. But loss of muscular action is by no means evidence of loss of muscular power. The nerve centres are unquestionably affected; but, most of all, the cerebral nerve centres are the seat of the greatest disturbance. No theory can be adequate which leaves the cerebral nerve centres out of the account, and the consequent mental element which plays, in my opinion, so important a part in these cases. The simple loss of muscular action, consequent on an attack of inflammation of the knee-joint, is sufficient to account for an immediate diminution of the size of the muscles whose freedom is curtailed. This is the certain result from mechanical restraint alone. But if, besides the mechanical restraint of position or retaining apparatus, there is added the mental restraint of fear, the difference in the rate and amount of muscular atrophy is enormously increased. Mental restraint acts similarly to an Esmarch's bandage; it squeezes the very life out of a muscle. As a very simple proof of the remarkable effect of mental restraint in causing muscular atrophy, let me mention those frequent instances accompanying disease of the hip-joint. These cases often apply with limbs attenuated to the last degree. That a large portion of the muscular attenuation, accompanying somewhat long standing hip-joint disease, is due to the mental restraint of motion, which might cause suffering, is proven by the fact that the application of proper mechanical protection, by which the mind is relieved of the fear of pain, is followed by immediate increase of muscular growth. This is so common and well-known a fact that advantage is constantly taken of it in the management of cases. My observation of the effects on the muscles of joint diseases must amount to some thousands of cases, and I never saw a case of atrophy which, in my opinion, could not be perfectly explained by non-use and mental restraint.

In regard to the therapeutics of muscular atrophy and loss of action following joint disease, I fear I must differ from the essayist quite as widely as in its pathogenesis. So far as the muscular wasting has been caused by non-use, during the progress of the arthritis, it is sufficient to set them to work again, after the inflammation has subsided. And, I may say, in passing, that muscles stubbornly refuse to act, or if forced to

act, they as stubbornly refuse to develop during the progress of an arthritis. You must wait until the joint is well before you can expect the muscles to act readily enough, after there is no longer any joint affection, except for the restraint which is often maintained for a long time by mental impressions formed during the progress of the arthritis. It is astonishing to notice how deep and lasting the impressions made on the cerebral nerve centres may sometimes be. Whatever the treatment may be, I do not believe it can be of any direct service so long as there continues a mental restraint over the muscles; and it is equally true that whatever will remove such mental restraint will cure the atrophy. So important do we, in our practice, consider the mental influence over the muscles, attending and following joint diseases, that we take special pains to get and to keep the direction of that influence, for the very purpose of hastening the recovery of the muscular power, after curing the joint disease. But the object of treatment should be to divert the mind from the affected member rather than to keep up attention to it by local treatment. It is true that massage will sometimes seem to do much good to the atrophied muscles; but this is apparent and indirect rather than real and direct. Massage has elements of mental diversion and control, which may be properly and usefully employed. But, with a large experience in its use, I am free to say that I think it is very much overestimated as a direct therapeutic agency. Its direct effect on the muscles is very slight, and what there is is not exercise. Exercise involves nerve action as the initial force. Massage merely assumes to promote the forward displacement of a certain small portion of the tissue fluids. But such propulsion of the fluids contained in the soft parts, even if effected, is not exercise nor a rational substitute for exercise. Only by the legitimate use of the nerve centres, especially of the cerebral nerve centres, can there be any action deserving the name of exercise. To regulate such nerve centre function, when disturbed by the strong impressions made by joint inflammation, is the indication presented in the cases under discussion. In most cases time alone is sufficient. In others, any means which effects a diversion of attention, whether done to the affected member or at a distance from it (which is the safer plan), will effect a cure. Incidentally, massage, electricity, the manipulations of the so-called "bonesetters," as well as the "animal magnetism" of the more arrant quacks, all do appear to produce wonderful results in a certain number of cases. The results are real, but are not produced through any direct effect on the parts, but through the incidental impressions made on the cerebral nerve centres; that is, on the mind. The worst of it is that in a large number of these cases direct treatment to the part affected by the mental restraint tends to increase the mental impressions, and to indefinitely postpone that unrestrained action of the muscles by which alone they can regain their power. The most difficult cases within my experience have been those who have had their attention to the affected member kept up by too much local treatment after the joint inflammation had passed away.

DR. L. WEBER has seen some cases of muscular atrophy following joint disease, and remembers one in particular which may be of interest to the Society.

Mr. J. W., age thirty-two, merchant, of nervous temperament, but strong and active, made a tour through

Before concluding my remarks I wish to speak of an interesting class of cases alluded to by Dr. Gibney, the pseudarthroses. We have in these cases nearly or quite all the symptoms enumerated by Dr. Jacoby in his paper, atrophy, hyperesthesia or anaesthesia, etc., following mental restraint, there being no affections of the joints. I regard the trouble as functional, and seated mainly in the brain, and not in the spinal cord as Dr. Gibney believes, if I understand him. Almost anything calculated to make a profound impression on the higher nerve centres will often prove curative in these cases. This is, in my opinion, one of the most important effects of massage.

I have in mind three cases of ankle trouble following sprains, seen three to five months after injury. The acute symptoms had subsided, but pain, tenderness, and such impaired function as to cause limping persisted. These patients had been treated with supports, etc., for several months. Physical examination showed no local trouble not readily explained by mental condition. There had been recovery from the sprain without a corresponding readjustment of the nerve centres to the new condition. The patients were perfectly and rapidly cured by purely psychical treatment. I do not doubt that massage often accomplishes the same result through its psychical effects in similar cases, but it is an empirical method as generally employed.

DR. GARRIGUES said: What little experience I have had with massage is in its favor, but that is almost nothing compared with that of Dr. Taylor. Nevertheless I have used massage for ten or twelve years. I became acquainted with it when quite new, and have found it most excellent for secondary conditions and for treatment to which Dr. Jacoby alludes.

DR. MORTON said a few words upon the subject of the continuous body battery and its use. The battery consists of a simple pair of elements. I well recollect a case in which I used this with good effect. A gentleman came to me with chronic arthritis. Associated with it was paralysis of the extensor group of muscles; the foot was dropped and the toe dragged. He said no form of electricity that he had tried had done him any good. I told him that I would give him a battery which he could wear all the time, which consisted of pieces of silver and zinc connected by copper wire. The zinc was shifted about upon different parts of the body; a constant current was kept up, which could be tested at any time with ordinary litmus paper. While under alkaline treatment the battery worked with better results, the excretions being saline.

This battery is also useful in the treatment of chronic ulcers; the granulations formed will be found much more healthy. It is also beneficial in chronic eczema. This much he would add to the practical part of the paper, since the main question after all was

treatment.

The atrophy, he further stated, is confined to the muscles and not to the bony tissue. For it is a rule that in chronic epiphysitis, about the knee for instance, the epiphysis is actually elongated. He, in common with many other orthopædists, has long since regarded acute atrophy as one of the most constant signs of chronic articular ostitis, and he believed the atrophy to be purely reflex, and not the result of disease or of the pressure from apparatus or bandages.

One argument brought against mechanical treatment, namely, that atrophy was produced, is fallacious. The clinical history of these bone lesions proves this conclusively.

He was not sure whether chronic synovitis induced atrophy, but he was very positive in stating that in acute synovitis atrophy was rather the exception than the rule.

A class of cases presented certain neuroses which were very valuable in excluding bone or joint disease. These are known as spinal pseudo-arthropthy, and known furthermore as neurosis of the joint, neuro-mimosis, hysterical joints, Brodie-joints, etc. The neuroses referred to were neuralgia, hyperæsthesia, anæsthesia, but rarely any atrophy. He believed that they had their origin in the spinal cord and the meninges, and the readiness with which they responded to spinal treatment confirmed him in his belief.

Furthermore, the neuralgia of chronic articular ostitis of the hip is well known, and the knee branch of the obturator is never affected early, and very often late in the disease, although this is denied by some writers, and especially a recent writer, Dr. Clippingdale.

In some of the most advanced cases of caries of the hip this obturator neuralgia is very distressing. Very frequently the sciatic nerve is involved, and in some cases narrated, especially one in a young lady with old disease at the hip, the sciatica was most distressing, and yielded very poorly to drugs and electricity.

The question of paralysis and degenerative nerve changes being sequences of chronic arthritis was one about which he did not feel fully convinced.

He referred to a case of chronic arthritis of the knee in an old woman who had paralysis of most of the muscles of the thigh and leg, and it was thought by some who saw the case that the paralysis was dependent on the joint lesions, but the proof was not by any means conclusive.

DR. JACOBY said: The first point to which I desire to reply is that brought forward by Dr. Taylor. He said that he believed these nervous changes, particularly the paralysis and atrophy, were produced by psychical or mental influence, and that they might be relieved by attention to this point. I am at considerable variance with him as regards the effect that mental in

fluence has in the production of these disturbances. I for my part cannot understand how mental uneasiness can produce an atrophy, which is easily diagnosticated by the tape, of a certain muscle, and that in the short time of three days. But, as the doctor has promised us a paper upon this subject, perhaps that will succeed in convincing me.

As regards the opposition which the massage treatment has received, I expected it would receive more. Massage has, especially in the United States, been very much in the hands of non-professional men, and consequently has been greatly abused and misapplied. But I hardly think there can be any question as to its efficacy in suitable cases and when properly applied. The theory advanced by Dr. Heitzman is very similar to that of Professor Charcot, who, as I mentioned in the paper, believes that certain parts of the cord are in a state of inertia or stupor.

In the first place: he divided the hospital into two departments: one for the well, and the other for the sick, with separate physicians, nurses, and instruments. He employed rapid alternation in the use of the wards, and each patient was allowed to remain eight days in the pavilion where she was confined, when she was removed to the convalescent ward. The doors between the wards were kept locked, all chinks were filled up, springs were placed on the doors of the waterclosets, and solution of bichloride of mercury used freely everywhere. As soon as a ward was vacated it was fumigated; twenty pounds of sulphur being burned for this purpose in the larger wards, and fifteen pounds in the smaller. When it was again occupied every piece of furniture was washed with a solution of the bichloride of mercury (one to 1000), and fresh bedclothes and new straw for the beds were provided. Large demijohns of the solution were kept standing in all the wards, and for the hands of the physicians and attendants it was used undiluted, except in cold weather, when a small quantity of warm water was added to it.

YORK.

PREVENTION OF PUERPERAL INFECTION.

half, very hot water being employed for this purpose in cases of post-partum hæmorrhage.

When labor was coming on the patient was given an enema and bath at first, after which at least two quarts of the bichloride solution were injected into the vagina by means of a fountain syringe. There was a large glass vessel, with which was connected a long rubber tube, at whose extremity was a straight glass tube for the vagina. When it was necessary to use intra-uterine injections a curved glass tube was employed. In tedious labors the vaginal injections were

In this year the number of confinements was 515, and the deaths, fifteen, a mortality of 2.67. In 1876 there were 536 confinements and twenty deaths, a mortality of 3.73. In 1877 there were 480 confinements and thirty-two deaths a mortality, of 6.67. In 1878 there were 225 confinements and seven deaths, a mortality of 3.11. In 1879 there were 254 confinements and eleven deaths, a mortality of 4.40. In 1880 there were 149 confinements and eight deaths, a mortality of 5.37. In 1881 there were 382 confinements and nine deaths, a mortality of 2.31. In 1882 there were 439 confinements and fourteen deaths, a mortality of 3.25. While some of these deaths were attributable to other causes, the great majority of them were due directly to hospitalism. For a few years past separate pavilions had been used for the lying-in patients, but the mortality had still continued large.

In the first three months of 1883, when Dr. Garrigues was himself in charge of the wards, there had been 108 confinements and no less than eleven deaths. During the six months of his service, from October 1, 1882, to the end of March, 1883, 192 women were confined, and of these forty-six, or about one in four, were seriously sick. Thirty-nine of the number, or about one in five, suffered from inflammatory puerperal disease. On the 1st of October, 1883, he again came on duty, and found the condition of the hospital much the same-nine patients having died within the past month, and several of the women being still very ill. In the meanwhile bichloride of mercury had come into notice as an antiseptic, and he resolved to give it a full trial; but at the same time he thought it well to adopt other precautionary measures in addition.

the physician and nurse were both required to wash their hands thoroughly with soap and water by means of a large nail-brush, after which they were to allow their hands to remain in the bichloride solution for a minute or more. In case of more than one patient being taken in labor at the same time, the hands were to be treated in the same manner before passing from one patient to another. No other lubricant than the bichloride solution was employed, except in case of operation, when glycerine was used with the solution; glycerine itself being a good antiseptic. When the child's head appeared at the vulva it was covered with lint wet with the solution, and after the expulsion of its body the genitals were kept carefully covered. The placenta was expelled by Crede's method. Intra-uterine injections were resorted to only in cases where it had been necessary to introduce the hand or instruments into the cavity of the uterus. No portion of the placenta or membranes was ever allowed to remain in the uterus, as it was considered safer to introduce the whole hand into the uterus, if necessary, than to run the risk of hæmorrhage or septicemia from this cause. curved glass tube used for intra-uterine injections was fifteen inches in length, and had a large opening at the end, while there were eight smaller holes at the side. It differed from the Chamberlain tube in having the orifice at the extremity and a greater number of holes at the side, while its calibre (a quarter of an inch in diameter) was considerably smaller. On account of its small size it could be used at a comparatively late period, when the os uteri had become considerably contracted. The opening at the end permitted the stream from the syringe to impinge directly against the fundus, and by means of the numerous holes at the side,

The

which were all within a distance of four inches from the extremity, the walls of the uterine cavity were thoroughly washed with the antiseptic solution. When used directly after labor it was held in position by means of the fingers; but if at a later period, and there were any signs of inflammation present, a Cusco speculum was first introduced into the vagina. If there were any diphtheritic deposit (which had hitherto been found very likely to occur at the Maternity Hospital), it could be thus seen to advantage, and the tube could be introduced into the uterus through the speculum.

After every labor the vulva was covered with a piece of lint six by eight inches folded lengthwise, so as to make its width three inches, and over this was placed a piece of oiled muslin nine by four inches. Over this again was placed a large pad of oakum; the whole dressing being kept in position by means of a piece of muslin eighteen inches square, with all its sides folded over, so as to form a kind of boat, which was then pinned securely to the binder in front and behind. This dressing was put on with the same special care that would be used in dressing a wound after a capital operation, and it was changed four times in each twenty-four hours. Before making the change the nurse was always required to use the precautions in regard to her hands alluded to above. When this plan was pursued preventive injections were unnecessary, and thus one of the greatest dangers from infection was avoided. During the eight days that the patient was in the lying-in pavilion no visitors were permitted to see her, and this rule extended even to clergymen, unless the patient were seriously ill.

Carbolic acid was used only for instruments, the solution of bichloride of mercury corroding the metal, and also becoming weaker itself in consequence. In two or three instances the bichloride had produced slight eruptions upon the skin, but in no case had the drug been abandoned on this account, and in no case had it produced any general symptoms. Some of the nurses complained of sore hands caused by it at first, but the difficulty was quickly remedied by the use of glycerine. The lochia were kept entirely sweet by it, and the use of the drug was always continued as long as the patient remained in bed.

As to the results obtained by the plan of treatment thus described, from the 1st of October up to the present time there had been ninety-seven women confined, and not a single one had died. Six had been more or less sick, but only one had been seriously ill. This was a case of eclampsia. Three cases of metritis and two of perimetritis made up the six. In two only had there been any rise of temperature, although some of the labors had been severe, including two versions and one craniotomy. Formerly, on the other hand, there had been more or less rise of temperature in from one third to two thirds of all the cases of confinement. In short the pavilions were scarcely recognizable now by those who had previously been familiar with them. Instead of being filled with foul air the wards were pure and sweet, the physicians and nurses were no longer overworked and anxious, and the patients were bright and cheerful instead of despondent and foreboding.

Bichloride of mercury possessed several advantages over carbolic acid, among which were the facts that it was a much more efficient antiseptic, and that it was an excellent deodorizer while being free from odor

itself. It also affected the hands much less unpleasantly than carbolic acid. It might be objected to the paper, Dr. Garrigues continued, that the time during which the plan of treatment described had been tried had been too short to prove anything. But the change in the condition of the patients and the wards had been so sudden and so remarkable that he thought it could be attributable to nothing but this, and he believed that the same results could be continued indefinitely if the same attention to detail was maintained. The great factors in the success, in addition to this careful attention to detail, were the use of the bichloride of mercury and the exclusion of air.

DR. MURRAY was the first speaker who took part in the discussion which followed the reading of the paper. The latter had been especially interesting to him, he said, because he had been Dr. Garrigues' immediate successor as visiting physician to the Maternity Hospital. During the three months of his service there had been ninety-six confinements with fourteen deaths. Four of the fatal cases, however, were not due to the results of labor, so that the mortality from hospitalism was eight out of the ninety-six. The form of puerperal fever which had prevailed was very similar to that which had been met with in Bellevue Hospital about ten years ago, and was frequently characterized by diphtheritis. Puerperal peritonitis was very seldom seen. The diphtheritic deposits would commence at the vulva and gradually extend up the vagina, but rarely into the interior of the uterus unless the case were protracted as long as two weeks, when this result was liable to occur. The symptoms were not very well marked at the commencement of the attack, and the pulse did not often run above 100 during the first few days. Afterwards it was very apt to be intermittent. With the appearance of the diphtheritic deposit typhoid symptoms usually became developed, and in some cases the patients sank into a semi-comatose condition. In a certain ward the women almost invariably had diphtheria, and notwithstanding that it was disinfected as perfectly as possible the same result was noticed afterwards when it was reoccupied. When Dr. Garrigues came on duty he had the advantage of a new ward, which had not been used for a year, and this he thought might have had something to do with the results shown. When the lying-in wards had been in Charity Hospital it was always noticed that when a new ward was taken possession of there was a marked improvement for about a week. Still he questioned very much whether the immunity from mortality was due to this cause alone, and was disposed to give Dr. Garrigues full credit for the efficient system for the prevention of infection which he had inaugurated. In private practice he thought all this minute attention to detail was unnecessary, though the main features of the treatment might be carried out with advantage. Before concluding, Dr. Murray spoke of the inefficiency of carbolic acid in the treatment of puerperal diphtheria. As soon as the slight slough which was caused by its application had come away he had often noticed the diphtheritic deposit to spread to all the points which the acid had touched, and he had seen the patches appear just the same after patients had been actually cauterized with it.

DR. WYLIE referred to a paper which he had read before the County Society about six months ago, and said that he commenced to use antiseptics in midwifery when an interne of Bellevue Hospital in the year