DISCUSSION. somewhat similiar. Much albumen was found and he had at the time much Dr. James Carey Thomas asked if Dr. | headache and was declined by an insurMiles made such examinations for life ance company, although apparently in insurance. health. A second examination later Dr. Miles said the retina showed us showed same results, but no other unsigns of nephritis, but that the renal favorable symptoms. No microscopic changes might have been caused by a examination was made. A third case reflected effect upon the kidney without showed 50 per cent. of albumen with no retinal change. tube casts present and yet he had many symptoms of renal disease. At present he is much better, but his urine still showed albumen. He gave Basham's Dr. F. T. Miles said that the watery mixture and Buffalo Lithia water. He parts and the salts of the urine were thought that Dr. Miles, point was a good secreted by the epithelium which covers one and that the time would come when the glomeruli and that the other many life insurance companies would ingredients of the urine were supplied accept cases with albuminuria. by the tubular parts. Injury of the Pavy had reported a number of cases of glomeruli would allow albumen to cyclic albuminuria. Dr. T. A. Ashby asked how the absence of albumen without tube casts could be explained in this case. Dr. cases he thought did not go on to the further development of renal disease. It was not always easy to distinguish it from renal diseases, for tube casts did not seem to be always pathognomonic. escape in the urine and yet no epithe- Dr. James Carey Thomas spoke of lium would pass. He did not think the the albuminuria of adolescence which presence of albumen in the urine a he considered very interesting. Such matter of grave importance, but on the contrary thought that any one of the members present could find albumen in their urine at some time in the day. He said that lead, mercury or a slight congestion of the kidney were often suf- Dr. Miles said that this albuminuria ficient to produce it. He mentioned might come from some poison in the Heidenhain's theory of balance. Heid- blood (He remarked that a specimen enhain clamped the renal artery in a dog of urine containing tube casts might be for a moment only and then let it go kept a long time by adding a small to allow the blood to rush back into the amount of carbolic acid to it). He kidney. This happened, but the urine was secreted at first only in very small quantities and was albuminous. He thought this argued against the filtration theory of urinary secretion. He referred to a case in a medical student of cyclic albuminuria. He did not look for tube casts. He said that in one-half of all cases of albuminuria there was not disease of the kidney and in all cases of the socalled albuminuria of adolescence. showed a specimen of urine from a patient who had had capillary bronchitis, which went on to catarrhal pneumonia, coma and death. He passed much urine up to forty-eight hours before death and in it was found a large amount of epithelium and epithelial casts which Dr. Miles stained with fuchsin. He could not say here what was the primary cause of death. His urine had been examined shortly before his death and he had had his life insured. He thought the kidney might take on disease at the end of life from other causes. Dr. T. A. Ashby had seen several similar cases of albuminuria. He mentioned three. The first was a case of cyclic albuminuria where at times 30 Dr. John Uhler said this was an imto 50 per cent. of albumen was found and portant subject and required great care. no tube casts. The man had repeatedly He invariably took three specimens been turned down by an insurance com- from each patient. He let the patient pany but was finally accepted for a pass the urine in three different chamsmall amount and was at last accounts bers. The first chamber contained what living and well. The second case was was passed from the urethra, the second that from the bladder and the third from chancroidal ulceration. The woman the urine in the middle chamber and the disease from her husband. She also thought that with care he avoided many had secondary syphilis. The entire doubtful cases. He thought we should urethra and portion of the bladder had depend on the concomitant symptoms as sloughed away leaving a large opening well as on the presence of albumen and into the viscus and total destruction of tube casts. He wondered that there its function. The parts had cicatrized were no retinal changes found in the and the vagina was a mass of cicatricial case mentioned by Dr. Miles. bands and adhesions. The woman denied that she had had any trouble in childbearing. At first it was thought the ulceration had been the result of malig nant disease, but the condition of the parts and other evidences of specific disease negatived this view. The case was considered hopelessly incurable so far as a plastic operation was concerned. the parts higher up. He then examined was 50 years of age and had contracted Dr. J. J. Chisolm said the evidences of retinitis were very marked and could easily be detected at once, but that they did not occur with every case, that diagnosis from the retina alone was often made, but that many died without retinal changes. Dr. Uhler asked it were not difficult to diagnose the dotted condition of the retina at the end of Bright's dis ease. Dr. Chisolm said it was, that there might be many complications with glaucoma, and that a person with, as well as without renal disease might have a glaucoma. Dr. Uhler thought that glaucoma was present in Dr. Miles' case. AN OPENING IN THE TRACHEA. DEATH FROM OBSCURE BRAIN TROUBLE. Dr. F. T. Miles was called in by Dr. Billingslea to see a lady who was lying in a semi-comatose condition in which she had lain for three weeks. She was 50 years old, well-nourished, looked normal, could be aroused, but took no notice of those about her, would get up to attend to the calls of nature or eat when aroused. There was no emaciation and she gave the idea of hysteria except that Dr. J. J. Chisolm related the case of she was too old. The family did not a patient who came to the Presbyterian seem anxious about her. He recomEye and Ear Charity Hospital with an mended the battery. A week later he incision is his throat about the size of found she was dying, much emaciated, the finger nail. It looked very much comatose, passed her evacuation s in bed like a wound after tracheotomy. He and finally died. He wanted a postsaid he had had no such operation per-mortein and mentioned what he expected formed, but had had some time ago a to find. He made the examination. swelling there which a country physician There was not much emaciation about had opened and had evidently cut into the body. No escape of blood and the the trachea as he could blow air through it. Dr. J. C. Thomas asked if there was anything to prevent its healing. Dr. Chisolm said it had not healed, but why, he did not know, there was no specific history. tissues were very dry. The skull was not thick, dura mater not inflamed, no enlarged pacchionian glands. He cut into it and found the watery, 'sobby' look of the pia mater so often observed after congestion. This he stripped off very easily. The brain seemed to be normal. He could find nothing but VESICO-VAGINAL FISTULA DUE TO CHAN- some congestion in the corpus striatum CROIDAL ULCERATION. Dr. T. A. Ashby related a case in which the urethro-vaginal septum of the bladder had been entirely destroyed by and was about to put the brain back when he noticed a trickling of blood by the sella turcica. He felt around the pituitary gland which he had not removed and found this black mass (showing specimen) which ran down to the jugu-[patient under in one half a minute and lar foramen, a little fibromous melanotic and in many cases if continued a half deposit, but there was nothing further minute longer than absolutely necesand he did not know the cause of death. sary, it could kill the patient. When There was evidently a melanotic degen- used too long ashiness of the face occureration of the pitiutary gland. There red and the heart's action stopped. He had been no hemiplegia, no paralysis, had never had a death from it. It was no congestion of the head and face. not given in New York and PhiladelShe looked natural. He also remarked phia. His inhaler was a closed tin cone that in spite of an exact knowledge of absolutely tight, lined with flannel and any given bone of the head, the position rim covered with padding to fit the face; of the dura mater made a great differ- 3 ss to 3i of the bromide of ethyl was ence in its appearance, especially in the sufficient. It was very volatile, so that dim light of a dark room that it was the cone should be inverted at once. He difficult to define the exact location of a made the patient blow out forcibly before lesion. the cone was applied. The patient was under it in a half to one minute and had a natural appearance unless the anæsthesia continued over one to two minutes when the ashy skin would denote danger. The oculist probably had better results with chloroform because the DISCUSSION. Dr. G. L. Taneyhill asked if there was no cause outside of the brain which might have caused death. Dr. Miles said there was none. Dr. Hiram Woods asked if the ears eye was so near the nose that the inhaler had been affected. Dr. Miles said no. was removed during a part of the operation and if respiration became difficult Dr. John Uhler asked if the mucous the chin was elevated which had the membrane of the stomach had been ex-same effect as drawing out the tongue. amined. Dr. Miles said he had not examined the stomach. Dr. Hiram Woods read a paper on CHLOROFORM AND ETHER.* DISCUSSION. Dr. J. J. Chisolm had had little exderience with ether. Bromide of ethyl had with him supplanted the use of chloroform to a large extent. It enabled him to operate in the primary anæsthesia, i. e., before the patient wakes up from the first sleep. He had had thirtyfive years in surgery and had given chloroform every day with no death, i.e. about 15,000 cases and no death. He thought it was hardly right to take the percentage of deaths, as in one case, a physician whom he knew had administered chloroform once and the case died, so that he had a mortality of 100 per cent. Bromide of ethyl would bring a *See MARYLAND MEDICAL JOURNAL (May 14th and 21st, 1887. He al Had never had heart arrested. Dr. P. C. Williams asked Dr. Chisolm why he preferred bromide of ethyl. Dr. J. J. Chisolm said for short operations the patient could be brought under anesthesia at once, had no nausea afterwards and could get up and go home. He thought too much could be given just as one might give too much morphia. Dr. Bombaugh asked if he used nitrous oxide gas. Dr. Chisolm said it was too bulky and difficult to prepare and patients resisted it and patient might wake up too soon. He thought the careful administration of chloroform free from danger. He knew little about ether. Had prob ably used two quarts in his life and Dr. Chisolm thought chloroform rewas ashamed to say how many hundred quired skill, the blunderer could use gallons of chloroform. Ether was too ether. Ether he thought was like a dull uncomfortable. knife for the boy, and chloroform the THE CLINICAL SOCIETY OF STATED MEETING HELD APRIL 15, 1887. The 192nd meeting was called to order by the President RANDOLPH WINSLOW, M.D., in the chair. Dr. William B. Canfield read a paper entitled SOME REMARKS ON PULMONARY PHTHISIS. Dr. T. A. Ashby said that for sever-sharp razor for the man. al years, during his service as resident physician to the Maryland University Hospital, it was his almost daily duty to administer anæsthetics. In this way he had enjoyed a very large experience. He had never witnessed trouble from the use of chloroform and preferred this agent to ether. During the past few years he had yielded somewhat to the prejudice against chloroform. He was now in the habit of giving chloroform in short operations. When the patient was kept under an anæsthetic for any great length of time, an hour or longer, he continued the anesthesia with ether. He prefers chloroform in all cases where He reviewed the different theories exthe patient bears it well. He once kept plaining why the first physical signs of a patient under the complete influence pulmonary phthisis are generally obof chloroform for four hours and a half served at the apex. He laid_particular in an operation for vesico-vaginal fis-stress upon the views of Dr. Athur tula. The case bore it well. He substi- Hanan as being the most satisfactory extutes ether for chloroform in long opera-planation. Dr. Hanan's conclusions are: tions when the latter depresses the The apices take an active part in inspiheart's action. He thinks the anaesthetic ration and are therefore in an especishould be selected for the case just as we ally favorable condition to receive all select the operation. He thinks the dust and micro-organisms mixed with merits of these two agents should not be this dust; the apices expire badly and judged in a partisan way. They both hence the inspired particles find the best have their special advantages and should opportunity to remain where they are be employed with the same intelligence or by a retrogade current of air to be and care that we employ other narcotic driven still deeper into the lungs to the and dangerous drugs. Dr. Canfield said he had seen stated in a foreign work that ether was universally used in America, the use of chloroform being prohibited by law. He knew of no such law. Dr. Chisolm said if a death from chloroform should occur in Boston, it would be unpleasant for the surgeon. He mentioned a case related in Pancoast's Surgery in which apparently not enough chloroform had been given. He thought the verdict should have been "death from want of chloroform" rather than "death from chloroform. Dr. Woods thought the last point was a good one. Thought partial anesthesia very dangerons and quoted from Bartholow and Lister in Holmes' Surgery to prove his point. inner surface of alveoli. DISCUSSION. Dr. 1. E. Atkinson said the points brought forth by Dr. Canfield were very interesting, but the views regarding the cause were so various, that he felt unable to express any positive ideas on the subject. Dr. J. H. Branham said he knew that the parts of the lung at the apices were not so active as the lower part and that foreign substances would remain there longer, but he could not see how infection through the blood could be explained in the same way. Dr. F. C. Bressler then read notes on and exhibited a specimen of ANEURISM OF THE ABDOMINAL AORTA. The report of the following case is interesting in that it is, as far as known, the youngest patient in whom aneurism has occurred in this city. immediately purged and mustard applied to various parts of his body with the result of so modifying the number as to have but two during the day following the one on which he had the 12. From this day on he had no more, but in place of convulsions delirium set in; at the same time he became blind in both eyes. He remained in this delirious condition up to a few days before death, when he again became rational, while his eyes never improved. His urine was diminished in quantity and actually suppressed the last two days before death. The night ere he died, had a stool mixed with blood. Throughout all this time, his only complaint would be that of intense pain in his back and stomach. Geo. W. Smith, colored, æt. 25, occupation oyster shucking, lately employed in a lumber yard, gave the following history: Contracted syphilis 4 years ago. He was placed on the usual treat ment and responded quickly to treat ment. Suffered occasionally with headache. Last May, 1886, while employed in the country, began to suffer with pain in the stomach, which was of a paroxysmal character. Leaving this place, got a situation in a lumbar yard; this was in September. The work was hard, requiring considerable lifting of heavy lumber. While thus employed, one day The temperature varied slightly, three lifted a piece of timber heavier than he days before death it reached 101°, while had been accustomed to, he immedi- the night before he died it reached only ately afterwards complained of severe 98°. pain in his stomach and back. He ap- Heretofore no cedema was observed but plied to one of our city dispensaries, two days before death found both feet was told that he had Bright's disease, moderately swollen. while his abdominal pains were treated with electricity. The electricity seemed to increase his pain and had to be stopped. He found no relief under this plan of treatment, gave up his position and remained as quiet as possible. His pains varied, sometimes so severe as to compel him to remain in bed for some days; again his pains eased up so as to be free altogether from them for days, still no matter how mild, they were always localized in the stomach and back. Death took place suddenly, the result of internal hæmorrhage, due to bursting of the aneurismal sac. One thing attracted my attention rather forcibly, a full and incompressible pulse. This peculiarity was so marked as to cause me to think that there certainly must exist something which impeded the free passage of the blood onwards through the blood vessels. I compared the femorals with each other, likewise comparing the femoral with the radials, but could find no markOccasionally he would vomit, and ed difference as to the filling of the just before death-a few days-his stom-blood vessels or their time of pulsation. ach was so irritable as to reject the Suspecting some deeper seated lesion I smallest quantity of anything taken. began a close physical examination with Paroxysmal pains, vomiting and consti- the following results: pation were his symptoms up to three weeks before death. Now other symptoms made their appearance. One morning he was taken without premonitory symptoms with a convulsion, the same day had another; six days elapsed without having any more convulsions, when he again had one in the morning, which was followed by 11 during the balance of the day. He was Lungs normal. Heart area of dullness increased with an impossibility to locate apex. Abruit accompanied the first sound and heard best at apex. Contour of abdomen normal, but palpation elicited an apparent tumor, situated midway between ensiform appendix and umbilicus about two inches to the left of the median line. Pressure on it |