phthisis, and not of congenital or hereditary. As well may we say that a man has a typhoid diathesis, if he takes typhoid fever after being exposed to its poison, as to say that he has a tubercular diathesis because he takes phthisis after exposure to its germ.

LOUISVILLE.

TREATMENT OF TRICHOPHYTOSIS.*

BY J. CLARK M'GUIRE, M. D.

Dermatologist to the Louisville City Hospital.

Such a vast number of external remedies have been advised for the cure of this disease that even mention of the different plans of treatment so highly extolled by writers in dermatology would be out of place in this paper. Some cases may be cured by the simplest remedies, but there are many that persist for a long period and resist treatment most annoyingly.

To test the efficiency of the different remedies advised, I have tried a variety of methods in the last twelve cases which have come under my observation. Referring to my case book, I find, on February 16th, in five cases tar and iodine in the form of Coster's paste were first used. This was reapplied every five days till March 3d. On March 17th two of these cases were pronounced cured. In the remaining three cases bichloride mercury in alcohol, gr. i to 3i, was substituted. One of these was cured by April 3d. The other two cases were then treated with the chrysarobin pigment. Cured May 5th.

On March 17th a boy twelve years of age presented himself with a ringworm of the scalp, about the size of a fifty-cent piece. It had resisted treatment for several years. In this case I used croton oil, 1 in 3. In a few days the patch was converted into an elevated suppurating mass, from which he suffered great pain. He was subsequently cured by means of chrysarobin. March 16th three cases were treated by the method recommended by J. F. Payne (Brit. Med. Journal, May 23, 1885). The scalp was saturated during the day with the following lotion:

*Read before the Louisville Medico-Chirurgical Society, August 27, 1886.

These cases being no better, on April 5th I substituted chrysarobin. Cured May 3d. February 16th, three cases treated by means of a lotion composed of bichloride mercury, gr. i to 3i alcohol, alternating with Payne's method. Two were cured by April 5th. The remaining case was cured with chrysarobin by May 3d. In examining the report of these cases, it is noted that two cases were cured with Coster's paste; one by means of Coster's paste, alternating with the bichloride lotion; two by Payne's method, alternating with the bichloride lotion; and seven by means of chrysarobin pigment.

As relapses are extremely liable to recur in all these cases, the hairs have been repeatedly examined with the microscope without finding any evidence of the parasite.

Chrysarobin was first introduced to the profession as a parasiticide, and was used in the form of an ointment. Alder Smith subsequently advised its exhibition in chloroform. In the above cases I used it dissolved in liquor gutta perchæ (ten per cent), as first recommended by Dr. W. T. Alexander (Journal Cut. and Ven. Diseases, February, 1885). The liquor gutta perchæ has the property of forming an artificial cuticle which does not become brittle -remains intact for several days-and is impermeable to water. In consequence of this quality it deprives the parasites of air (oxygen) and moisture, elements essential to their growth. Dr. Alexander's method of using it was as follows: The hair was closely cut, the scalp cleaned, and epilation practiced. ease was then covered with a applied with a stiff brush. was renewed twice a week. this treatment may possibly not cure all cases, but he recommends it for trial, as a sound therapeutic measure. My experience leads me to second the author in this statement. LOUISVILLE.

The area of dislayer of pigment, The application The author says

Societics.

CHICAGO MEDICAL SOCIETY.

Stated Meeting, August 16, 1886, E. J. Doering, M. D., President, in the chair.

Dr. F. E. Waxham presented a membranous cast of the trachea and larynx. The specimen presented was removed from a child nine years old. This cast had remained in the larynx and trachea for several months. The history is as follows: The child claims that in April she swallowed a hedge thorn while away from home. She was at once taken with suffocation, and twenty-four hours afterward was operated upon, when at the point of death, by Dr. McDavitt, of Winona, Minn., who performed tracheotomy. The child was unable to breathe through the natural passages after the introduction of the tracheotomy tube, although many attempts were made to remove it. It seemed impossible for her to get a breath through the natural passages when she was brought to me. Upon laryngoscopic examination, the larynx seemed to be closed, but dig ital examination revealed a very small opening into the larynx. In this opening a small sound was passed, and this was followed by one of the smallest size intubation tubes, this by a larger one, and finally the largest size tube was introduced. It could not be passed on account of the tracheotomy tube, and, violent vomiting ensuing, the tube and this cast were ejected. After the rejection of this membrane a large size tube was introduced, and pressed down into position as the tracheotomy tube was removed, which gave the child perfect comfort. She remained comfortable after the introduction of the tube, took several glasses of milk during the afternoon, and in the evening was taken to the train and returned to Minnesota, the intubation tube remaining in the larynx, to be removed by the doctor in the course of a few days.

Dr. John B. Hamilton, of Washington, D. C., read a paper on the Radical Cure of Inguinal Hernia, in which he said that the ablest surgeons, from the earliest times to our day, have given much attention to this subject. Dr. Baxter's tables show that out of 334,321

recruits and substitutes examined by the recruiting officers during the war of the rebellion, more than 17,000 were rejected on account of hernia. The London Truss Society, during the first twenty-eight years of its existence, issued over 83,000 trusses. Two factories in Philadelphia manufacture and sell from 216,000 to 250,000 per annum. Celsus was the first surgeon to have definite ideas about the operation for the cure of hernia; he used cauterization and a bandage. Ligature of the sac has been practiced from an early day. Maupas performed gastrorraphy. Lanfranc, in 1296, favored castration, Ambrose Pare was the first to absolutely abandon castration; he employed astringents. Freytag was the first to practice dilatation of the rings in strangulated hernia. Nicholas le Quin, of Paris, introduced the truss about the year 1660, but it was not until the middle of the eighteenth century that surgeons began to cut off the gangrenous portion of intestine in cases of strangulated hernia. The galvano-cautery was proposed by Dr. John C. Minor, of New York. Galaud, in 1878, favored the elastic ligature. The practice of scarification is a very ancient one, and has been brought down to recent date with excellent results. Guerin was probably the first to practice subcutaneous scarification. Invagination has for its object the occlusion of the inguinal ring. by the fascia, and sometimes by the integu ments. The late Dr. George Allen, of Springfield, Ill., reported fifty cases cured by Gerdy's method. Wood's method not only invaginates the fascia, but draws together the pillars. All of these methods have their greatest successes in small hernias and buboroceles, and are absolutely valueless in those which are so large that ordinary invagination will not occlude the opening. Dr. Alexander stated, in 1883, that he had performed the radical cure thirty times without any deaths. Wood reports 339 cases without special antiseptic precautions; ninetysix were cured, seven died, and fifty-nine failed; in the remainder the result could not be ascertained. Accidents may follow Wood's operation as well as others, such as sloughing, peritonitis, and tetanus. From official reports on file in the Marine Hospital Bureau at Washington, it appears that in Calcutta, India, in

1884, out of a total number of deaths from all causes of 1,293, nearly nine per cent were due to tetanus. Dr. Hamilton favored an operation in all cases affording a reasonable prospect of cure, and thought all cases of bubonocele should be operated upon.

Dr. D. W. Graham said: I think I express the sentiments of every member present when I say that it is probably not possible to find in the English language as complete and satisfactory a review of the history of the various operations for the radical cure of hernia as Dr. Hamilton has given us in this paper. Certainly it has been gratifying and instructive to us all to listen to it. Some of the figures which the Doctor quotes gives us an idea of the great prevalence of hernia. I believe reliable statistics show that on an average about every fifteenth or sixteenth individual in civilized communities suffers from some form of it. When we remember its great prevalence, and when we remember that every subject of a hernia sustains thereby a certain amount of disability, and that very many are entirely disabled by it, the subject of the radical cure of hernia assumes an importance not always accorded to it. I think the author of the paper takes rather a highly colored view of the future of these operations. It is not probable that this generation, at least, will be able to use the expressions he thinks surgeons will be using some day in Chicago. However, this degree of success is to be looked forward to and attained if possible. In regard to the modern methods of operating, I understand the distinctive features of Wood's method to be that it is almost entirely subcutaneous, that he uses wire, and that he allows the sac to remain in the canal as a kind of plug. So far as I know, this method is not practiced in this part of the country to any extent. In Mr. Wood's hands it seems to be successful in permanently curing a considerable majority of those operated upon, and in decidedly benefiting a good many who are not permanently cured. His statistics show that there is almost no danger to life from the operation itself, at least in his hands. Any method which will give such results, and at the same time involves so little risk to life, must be a good operation.

The open method, the one chiefly practiced in this country, according to my observation, contemplates strict attention to antiseptic details and the avoidance of suppuration. It involves a little more risk to life from the operation per se, but to compensate for this it would seem to give, theoretically any way, a larger per centage of permanent and complete cures. The modifications or varieties consist chiefly in dealing with the sac. Although MacCormac claims that unless the rings are wide there is no advantage in attempting to close them. It seems to me, the best way to treat the sac is to excise a section of the neck between two ligatures, pushing the stump into the abdominal cavity and allowing the body of the sac to remain, unless it is small and loosely adherent, when it may be extirpated. After any of these operations there remains the funnel-like depression on the inner surface of the abdominal wall, which favors a recurrence of the hernia, however efficiently we may have obliterated the sac and closed the rings. MacEwen, of Glasgow, in a recent article describes and advocates a plan he has devised for obliterating the depression. He utilizes the sac by dissecting it from its surrounding attachments, putting a suture through it from side to side, beginning at the lower end, thus making a corrugated pad, which he pushes. through the internal ring into the cavity, after first separating the peritoneum for a little distance around the ring with the finger. This makes a convexity on the inner surface of the abdominal wall, when there would otherwise be a concavity. This modification appears to be a real improvement, but the practical value of it is as yet largely conjectural. By way of adding something from an historical standpoint, I might mention, what I think was not alluded to in the paper, that electrolysis has been used and advised to set up a plastic inflammation in the inguinal tract. I believe this suggestion comes from a Cleveland surgeon, whose name I have forgotten. This is the same in principle, of course, as the use of subcutaneous injections, and I should think would be preferable to the injections, if I were to judge of it without having tried it.

Dr. Moses Gunn said: This subject is of in

tense interest, and we are very much indebted to Dr. Hamilton for the exhaustive review he has given us. We have to consider what are the best methods for operating with the intent of effecting a radical cure. I am inclined to discard all the old invaginating processes. In the first place, the invaginated portions are always liable to subsequent prolapse; in the next place, it is always a foul mess. It won't do to simply remove the cuticle; all the organs of the skin must be destroyed. The skin contains the hair, sweat, and sebaceous follicles, and unless they are destroyed, they will continue their work, and thus accumulate material for decomposition. In order to make a success, you are obliged to do more than destroy the cuticle. You will have to destroy the skin, and that is a very slow process and exceedingly nasty. Therefore I am inclined to repudiate all invaginating processes. I repudiate, also, all of the subcutaneous processes, for they are blind procedures, and I would not adopt them where an open operation could be as well and even more advantageously and safely resorted to. I believe the best and surest method of trying to effect a radical cure of hernia is the open method. This method should be performed in every case where an operation is made for the relief of a strangulated inguinal hernia. Just as soon as the operator has opened the neck of the sac and restored the prolapsed viscera or viscus, he should close up the wound. He should begin at the topmost portion of the sac, and with a curved needle and catgut take it up and ligate it as near to the internal ring as he can. Then he should drop down about half an inch lower and ligate again, and so on down through the canal. He should then approximate the pillars at and above the external ring as closely as possible and close the outside tissues. Thus the operation which is made for the relief of the accident should be made an operation for radical It can be done more effectually at that time than any other.

cure.

Then again, the physician is called upon to make an operation for a radical cure; the patient comes to him complaining of the truss, which has become ineffectual, the hernia escaping in spite of it, and his life becoming a misery

to him, and he asks if something can not be done to make a radical cure. The answer is, "Yes;" but the question is, by what method shall we make it? I say by an open operation, practiced with all antiseptic precautions. Cut down upon the parts, separate and dissect out as well as you can the neck of the sac, the hernia having been reduced; ligate the sac and cut out a portion. Thrust the stump back into the canal and approximate the pillars, closing them tightly and keeping the external ring tightly closed. So much for the method; now for the prospect of success. How much right have we to expect what might justly be called a radical cure? By the term radical, I mean permanent. In what proportion of cases can we expect to have a permanent cure, so that the patient will never have hernia again? What is hernia, and who have it? I think I can safely say that the typical man never has hernia. When the true type in development has been attained and the abdominal walls closely woven together, they are proof against such accidents and there will be no hernia. Hernia is the result of the imperfect development of the abdominal muscles and aponeuroses. When that imperfect anatomical development obtains in the patient, the abdominal muscles are thin and flabby, and in such cases we get hernia. Nor can we in such a case by an operation make a man better than his Creator made him, but if we can make him as good as he was we may congratulate ourselves. After we have operated and closed up this weak point as well as possible, the very best result that we can expect is that we have made the man as good as he was before he had hernia; but if he was weak enough to have hernia from certain exciting causes, he will be weak enough to have it under similar circumstances again. If his hernia is brought on by lifting and straining, the same exciting cause will bring it on again, and under these circumstances a radical cure is only measurably radical. We should tell the patient after operation, that if he will be more careful and take no violent exercise, he may hope for exemption from hernia.

In other cases the patient has an old and immense hernia and can not wear a truss; we

operate upon him and can say to him, that if he will be more careful and wear a truss, he can be tolerably comfortable for the rest of his life. Such, I apprehend, is the true aim and scope of operations for the radical cure of hernia; such are the precautions we should give our patients, as they must become our co-operators in order to make this operation a success; and with such co-operation and conscientious efforts on our own part, radical cure of hernia becomes a standard and important operation, as important as the subject itself, which, as we have seen, is of immense importance on account of the great dissemination of the disease.

Dr. E. F. Wells said: Dr. Hamilton has certainly read a very interesting and extensive paper. There is one point in particular mentioned by the author, namely: that he advocates an operation in all suitable cases where an operation is not distinctly indicated. Every practitioner of large experience must certainly have met with many cases in which the truss has been applied, resulting in a cure, and I think the truss should not be stricken entirely from the radical cure of hernia.

Dr. Hamilton, in closing the discussion, said: I need not say that I am gratified to find such unanimity of sentiment as to the propriety of the operation-nay, as to the necessity of operation-but there can be no doubt as to the necessity of further statistics on the subject. In regard to invagination, I think a reading of the paper will not show that I advocated the method of invagination recommended by Gerdy. In the recent open method there is no invagination. Under the original Wood's method, the subcutaneous fascia only was pushed up under the ring; by the open method we cut down directly on the sac. This open method is really This open method is really a combination method, because it brings together the pillars and takes care of the sac. Statistics are necessarily unreliable as to the ultimate permanency of the cure of these cases. The best statistics are those shown by the Swedish Hospital, where out of three hundred cases a large percentage of recoveries is shown, and if statistics are worth any thing in determining the success of a method, we must place some reliance on these. It would be well to have

patients come back every year for the purpose of re-examination.

Dr. Fenger, if I correctly understood him, speaks of the influence of suppuration in curing these wounds by letting them heal from the bottom, but in the various subcutaneous operations that is exactly what it is intended to avoid. There is no doubt that suppuration will make a radical cure of hernia if the patient's strength lasts, and the suppuration does not extend into the abdominal fascia. That was the method by which the old red-hot irons accomplished their purpose. The mineral acids produced a radical cure by the destruction of the tissue and healing from the bottom. The seton also performed a cure, but it has so many disadvantages that it is not to be compared with those procedures that stop the inflammatory processes short of the decomposition or death of the exudate. In regard to operating on children, I think the argument can not be regarded as sound that we should not operate on them on account of the difficulty of keeping a bandage on, for surely if any cases are to be benefited by an operation for radical cure, they are those in which the patient is young enough to grow-in which the tissues can be brought together and retained with great hope of a permanent cure. Every body knows that cases do recover by the use of the truss, but the proportion, I believe, is less than by any other method. As stated by Prof. Gunn, it is found that a majority of operations for strangulated hernia are, in effect, really operations for the radical cure, and there are more than five cures from operations to one after-application of the truss. And when we remember that there are 250,000 trusses manufactured per annum in Philadelphia alone, I doubt very much if it can be shown that trusses have even a fair percentage of recoveries following their use.

Dr. Wm. T. Belfield reported a case of suprapubic cystotomy with extraction of large calculi and corrosive-sublimate poisoning. The patient was a feeble, emaciated man, seventyone years old, who for nine years had suffered from cystitis of steadily increasing severity, caused, as was supposed by his various physicians, by prostatic enlargement. He had been