Sleep. The patient should sleep between blankets, but not on feathers, or old moss, or old hair; a cotton mattress is the best. If a cotton mattress is not used, then a heavy cotton quilt should cover the bed mattress. It will be well to have the pillows made of cotton.

Anointing the face, neck, hands and feet with vaseline just before retiring is quite refreshing because it is cooling.

The "catarrhal season" should be slept away if possible, but it is not best to sleep so much during the day that the night will be passed in wakefulness. If the patient can not sleep sufficiently long at night, an anodyne should be given, but as a usual thing the ice and quinine produce refreshing repose.

The Diet. A good, nourishing diet is advisable. Every thing that the patient thinks may disagree with him, and all those articles known to disagree with him, should be avoided. Going to bed very hungry may prevent a good night's sleep. Drinking water is always healthful. One to two teacupfuls of hot water as soon as the patient rises from bed in the morning, or if convenient, before rising, is frequently conducive to good digestion. Milk, if taken after dinner, is liable to induce a cough by its causing the mucus in the throat to become quite thick and adherent.

Exercise. Many of these patients suffer from palpitation of the heart when they take exercise, but some gentle exertion, even to the extent of inducing a slight perspiration, is quite beneficial. As a general thing, the avoidance of sunlight, dust, smoke and other irritating agents that float in the air is the most conducive to comfort. Walking in a close, darkened room, in which a piece of ice is hung to keep the temperature fully 10° F. to 20° F. below the outside temperature, is usually quite refreshing.

To be Avoided. Sufferers from this complaint should not bathe; should not smoke, chew or snuff tobacco; should not drink beer, wine, whisky, brandy, gin or any beverage that contains alcohol; should not be out in the night air, and should not allow themselves under any circumstances to become angry. The disease has a tendency to make one irritable, but this condition of mind must be controlled. A fit

of anger will be almost certain to induce a fit of sneezing. Every victim of this complaint can, if he chooses, cultivate a habit of becoming angry, to his own discomfiture, or of exhibiting a disposition of patience. Coughing and sneezing must be avoided if possible. The former may many times be controlled to almost complete suppression. Handkerchiefs that have become wet from nasal secretions and tears should be put out of the room. If the expectorations are very profuse, a spittoon filled with dry earth should be kept in the room and new earth put in it every morning.

ST. LOUIS, MO.

A CASE OF LATENT PERICARDITIS PUR-
ULENTA, WITH FATTY DEGENERATION
OF THE HEART, AND ATHEROMA
OF THE ASCENDING

AORTA.*

M. D.

BY J. A. OUCHTERLONY, A. M., Professor of Principles and Practice of Medicine and Clinical Medicine, University of Louisville.

Henry Willis, aged forty-two, married, railroad man, was admitted to the Louisville City Hospital November 18, 1886.

Previous History. His father died, at the age of forty-five, of a destructive ulceration of the face, said to have been cancer. His mother is still alive and in good health. The patient himself generally had good health up to four months ago, when he thinks his present illness began. He has used alcoholic stimulants in moderation, but has been excessively addicted to smoking. His illness began with pain in the right epigastrium, rather constant and aggravated by the ingestion of food; he has also been much troubled with flatulence and other digestive disturbances, but had vomited only twice prior to his admission. His appetite had kept up tolerably well, but he has lost flesh steadily and in considerable amount. He had been under the care of two excellent physicians, who had suspected cancer of the stomach, and had so informed the patient. He was himself strongly impressed with this belief.

Present Condition. The patient is rather tall and gaunt, eyes somewhat sunken, but bright; color rather good, certainly not suggestive of

*Read before the Clinical Society of Louisville.

cachexia. He complains of a bad appetite and symptoms of indigestion as described above. The integument over the epigastric region is discolored over an oblong-square, which he says marks the site of blisters ordered by his former medical attendants. He complains of severe, deeply seated pain in this locality, shooting up under the sternum. There is tenderness under pressure, most marked at a point corresponding to the pylorus. Palpation reveals increased resistance, but no tumor can be detected. The liver appears somewhat enlarged. He has no cough, but vomited several times after entering the hospital. Pulse is weak and slow. Temperature is subnormal, reaching but 98°. There is nothing abnormal observed about his chest.

Progress of the Case. During the evening of the 19th of November, that is, the day after his admission, he complained of very severe pains in the epigastrium and precordia. At 3 o'clock in the morning he was breathing hard; pulse was imperceptible at the wrist; his extremities were cold. The heart sounds were barely audible. His mind, however, remained perfectly clear. At 6 o'clock A. M., on the 20th instant, he died.

Autopsy. About five hours after death rigor mortis marked. Body thin, but not emaciated, moderate amount of fat in subcutaneous areolar tissue and omentum. Liver somewhat enlarged and congested; spleen full-sized, capsule opaque and thickened at various points; kidneys congested.

The pericardium was highly injected, and its cavity contained about two drams of pus. The heart was distended and flabby, pale, fattily degenerated; left ventricle contained black, soft coagula, left auricle contained a very firm, white, fibrinous clot, entangled in the cordæ tending of mitral valve. Aorta ascendens thickened from incipient atheroma; orifices of coronary arteries almost obliterated. No disease of the stomach was found. Dr. A. LeCoq, Assistant to the Chair of Microscopy, University of Louisville, made a careful microscopical examination, which revealed that muscular structure of the heart was in a state of advanced fatty degeneration.

LOUISVILLE.

Societies.

THE LOUISVILLE CLINICAL SOCIETY. Stated Meeting, November 23, 1886, John A. Ouchterlony, A. M., M. D., President, in the chair.

The President gave a detailed report of a case of latent pericarditis purulenta, with fatty degeneration of the heart, and atheroma of the ascending aorta, which was seen recently at his clinic in the Louisville City Hospital, as reported in page 391, this issue. By way of introduction, and as bearing especially upon the case at hand, the speaker read a translation from the Nord. Med. Arkiv's account of Prof. Panum's last illness. (See page 405.)

This report was followed by an exhibition of the heart and great vessels of the subject, together with microscopic sections of these organs, prepared by Dr. A. LeCoq, Assistant to the Chair of Microscopy, University of Louisville. These specimens confirmed in every particular the statements contained in the foregoing report.

Under the order of oral reports, Dr. H. A. Cottell said that some six weeks since he had been called to see a young woman, aged twentytwo, who, while in a paroxysm of pain due to a chronic follicular gastritis, had swallowed about two ounces of a mixture of equal parts of chloroform and spiritus etheris comp.

Dr. Cottell arrived at the house about twenty minutes after the mishap. At this time the patient, though unconscious, was making feeble efforts at vomiting. The matter, which was thrown up in small quantity, consisted of semidigested food. The pulse was feeble, and respiration had well-nigh ceased. The patient being unable to swallow an emetic, a piece of rubber tubing a quarter of an inch in diameter and a Davidson's syringe were brought into requisition. The tube was passed without difficulty into the stomach, and by means of the syringe a pint of water with salt and mustard was injected, which had the effect of producing free emesis, with the tube in situ. The first injection was followed with at least another pint of the emetic, and this with water, until the stomach was thoroughly ridded of its contents, clear water only at last coming away. This measure

was supplemented by injections hypodermically of whisky and atropia, with carbonate of ammonium by rectum. In less than an hour the pulse and respirations had become normal; consciousness returned, and the patient made good her recovery.

She has since shown no symptom of her former gastric trouble.

In the management of the case Dr. Cottell had the able assistance of Dr. D. T. Smith.

Dr. P. Guntermann: I have recently had in my practice two cases of chloroform-poisoning. The quantity of the drug taken by each was about one ounce. A funnel and rubber stomach-tube were used, and the stomach thoroughly washed out in each case. Whisky and carbonate of ammonium were given by injection, and the usual mechanical measures recommended in such cases employed; but nevertheless both patients died.

The President suggested the use of apomorphia (gr. hypodermically) in such cases as the readiest means of bringing about prompt emesis; giving it as his opinion (in which he was supported by several of the Fellows) that the depressing physiological effects of the chloroform would not contra-indicate its use.

Dr. Thos. P. Satterwhite: By way of encouragement to physicians who may meet with cases of poisoning where the patients are found to be in extremis, I will present briefly the points of a recent case.

The patient (a young woman) was supposed to have taken an overdose of morphia. When I saw her she presented the symptoms of imminent dissolution. The pulse was scarcely perceptible, the surface of the body was cold, the countenance pale and pinched, and the respirations but six or seven per minute. The battery made no impression upon the muscles of respiration. The physicians, several of whom were in attendance, considered death to be certain, and had begun to discuss the question of an autopsy. Vigorous measures of relief were, however, persisted in, and the patient recovered.

Dr. W. Cheatham cited the history of several cases seen in practice and consultation, which were interesting in that they illustrated the extreme difficulty of diagnosis in some

forms of diphtheria. forms of diphtheria. In one case a paralysis of accommodation had followed as a sequela of a supposed follicular tonsillitis, thus almost to a certainty proving the pre-existence of diphtheria. In another a diagnosis of follicular tonsillitis had been made, and other children of the family had been allowed to stay in the room or even to occupy the same bed with the patient. Unmistakable signs of diphtheria were in a few days plainly visible. A third was a patient with hypertrophied tonsils, who came to him with a view to having them removed. There was no visible exudate upon the fauces or tonsils; but the character of the secretions from the naso-pharynx, flowing down over the posterior surface of the velum, led him to regard the case as one of diphtheria, and to decline to perform the operation. Subsequent developments proved the truth of the diagnosis.

Dr. F. C. Leber: I have seen a number of cases in which the constitutional symptoms were such as render the existence of diphtheria probable, but in none of these could any trace of a membrane be seen. Can diphtheria exist without the characteristic exudate?

Dr. Cheatham: I think so.

Dr. Samuel Brandeis: It is probable in these doubtful cases that the exudate may be present in some of the deeper hidden parts of the respiratory or alimentary tract. I doubt the existence of diphtheria without membrane.

The speaker cited the case of a child (seen in practice before the days of laryngoscopy) in whom the only symptom present for several days was earache. The child died suddenly of laryngeal stenosis, due to diphtheritic exudate; but at no time previous to this event was a pseudo-membrane demonstrable in the

case.

In another, laryngeal stenosis suddenly occurred after a few days' illness, during which no membrane had been visible. A tracheotomy was done; but the patient died upon the table. A few days after the death another child in the family was attacked with diphtheria of unmistakable character.

The President concurred in the position taken by Dr. Brandeis, and Drs. Satterwhite and Cottell each cited cases to the point.

Dr. I. N. Bloom reported the recent discovery of micro-organisms in tonsillitis lacunaris, which were the probable cause of the disease, and explained its contagiousness. He thought that some of the cases just discussed were probably simple follicular tonsillitis. The fact that others in the family had been similarly attacked, had probably led the observers (forgetful of the contagiousness of tonsillitis lacunaris) astray.

Dr. Turner Anderson: I will report briefly a case of placenta previa. November 21st, early A.M., I was called, but could not go, to see Mrs. multipara, in her second pregnancy, eight months advanced. She had gone to bed on the previous evening without premonition of impending trouble; but on awaking in the middle of the night she found that she had lost considerable blood. I saw the patient at 5 o'clock P. M. Her condition then was as follows: Pulse rapid and irregular. There was evidence that the patient had lost considerable blood, but reaction had been well established. There was great abdominal uneasiness, but no labor pains. The os was patulous, with a baggy condition of the posterior lip. The placental tissues and the vertex of the child could be felt through the anterior uterine wall. The examination caused a slight recurrence of the hemorrhage. I did not try to make out the exact attachments of the placenta, and so left in doubt the question as to whether the case was one of complete or partial placenta previa. A tampon was introduced, and uterine contractions encouraged by manipulation of the fundus. The tampon was left in situ for three quarters of an hour, and the manipulations resorted to with each recurrence of a pain. Evidence of hemorrhage being patent, I decided to remove the tampon, puncture the membranes, turn and deliver. The placenta was found attached posterolaterally over the lower half segment of the uterus in such a manner as to be involved in the dilating os. The delivery was accomplished without great difficulty or serious hemorrhage after the membranes were ruptured. The child was born alive, but died after one week, of congenital feebleness. The mother made a good recovery. The case brings to mind and supports the

axiom laid down by the late Prof. Henry Miller, viz., that "a contracting womb empty of its waters will not bleed, or, if it does, it will not be to a dangerous degree." I. N. BLOOM, M. D. Secretary.

CHICAGO MEDICAL SOCIETY.

Stated Meeting, November 1, 1886, E. J. Doering, M. D., President, in the chair.

Dr. Albert E. Hoadley read a report of five cases illustrating a treatment of the more severe forms of stricture of the rectum :

CASE 1. J. H. G., an engineer, aged forty, with history of piles of eight years' standing, and stricture two years. Examination revealed a hard carcinoma of the rectum within one and a half inches of the anus, immovable on account of adhesions to the sacrum. The adjacent parts were involved and the bowel completely occluded. The general condition of the patient was bad. Abdomen swollen and very tender. Had not had a passage from the bowels for two weeks. Could not take food without immediately vomiting. Pulse feeble, 120, temperature 102°. At the first examination Dr. Hoadley succeeded in separating the adhesions sufficiently to pass a syringe pipe beyond the immediate stricture. A half pint of soap-water was injected a number of times during the afternoon and evening, with the effect of bringing away considerable matter and gas and giving great relief to the patient. Three operations were performed at intervals by which a fair canal through the cancerous mass was made, but without relief to pain. At the fourth operation the lower end of the growth and sphincter ani were divided with one stroke of the knife. There was little hemorrhage. The relief obtained by the division of the sphincter was tenfold greater than that from all the other operations.

CASE 2. A laborer, forty-two years old, with history of hemorrhoids, and stricture of five years' standing. Examination revealed a firm unusual stricture within two inches of the anus. Syphilis could not be excluded, so he was put on large and increasing doses of iodide potassium, and a systematic dilatation with an elastic bougie commenced. After four weeks

a bougie one inch in diameter could be passed. without difficulty. There was no particular irritation at the seat of the stricture, but the bowels were very irritable and there was an increasing diarrhea. The stricture and sphincters were thoroughly divided and the wound packed with gauze on which dry persulphate of iron had been sprinkled. Relief was immediate and complete. Examination two months after the operation showed the wound to be nearly healed, and the patient feels better than he has felt for a year previous.

CASE 3. An American woman, aged thirtynine, the mother of three children; she had a stricture of nine years' standing. When the stricture was divided it was found that the rectum contained a carcinomatous mass, almost occluding the canal, higher than could be reached with the fingers. The sphincters were divided back to the coccyx and an incision was made through the mass nearly to the sacrum, and a piece of gauze pressed on the wound to prevent bleeding. A large-sized drainage-tube was placed in the bowel above the disease. The rectum was packed, and all secured with a T bandage and the patient put to bed. After the fifth day she rapidly improved, and left the hospital within a week after the operation. Three months afterward she was comfortable and had gained six pounds.

CASE 4. A German woman of fifty-six years, the mother of several children. She had enjoyed good health until the development of the stricture of the rectum about three years before. The stricture and sphincters were divided, and on introducing the finger the bowel was found blocked up with other strictures of a malignant character. These were dilated with the fingers. A violent inflammation supervened and the patient's life was threatened. She made a slow recovery, and was convinced that she was made worse by the operation. Dr. Hoadley thought that if the strictures had been incised instead of divulsed, the patient would have derived benefit.

CASE 5. An American of sixty-seven years, the mother of four children. Labor had always been normal and easy. She had a stricture of five years' standing. Examination revealed two or three open sinuses and fluctuating ab

scesses in the ischio-rectal region. The abscesses and sinuses were opened and packed with iodoform gauze and the stricture divided, the sphincter being dilated. Great relief followed the operation, which was made to relieve pain and not with the hope of prolonging life. From a study of these cases Dr. Hoadley deduced the following principles:

First, it is dangerous to practice divulsion of malignant stricture of the rectum; second, division of a severe stricture of the rectum without dividing the sphincters is of little practical value and has no tendency to cure; third, division of malignant strictures with the sphincter gives great relief and tends to prolong life; fourth, division of severe non-malignant stricture with the sphincters gives great relief and tends to perfect cure; fifth, division of both stricture and sphincter, whether malignant or non-malignant, is not attended with danger. Therefore we may conclude, that in all severe strictures of the rectum, whether malignant or non-malignant, complete division of the stricture and all the tissues below it back to the tip of the coccyx affords the greatest relief, and of the non-malignant strictures, the best means of permanent cure at our command.

Dr. J. Frank thought that if the author had divided his paper into relief for malignant strictures and treatment for non-malignant strictures, it would have been a better classification. He had not had much experience with malignant strictures, but had divided one in the manner described by the author, by cutting down through the cellular tissue. He thought there was little danger in performing the operation, and was surprised at the small amount of hemorrhage. But the benefit from the operation lasted only for a short time; there was relief at first, but in six or eight weeks the same symptoms returned. Even in extirpated cancerous growths, as far as his information went, they generally return within a year. He had had one case in which the whole cancerous growth was extirpated, but in six or eight months it commenced to return, and in a year's time the patient died with cancer. He thought that in dividing the strictures care must be taken not to go too far up the bowel, or too deep, as the peritoneum might be cut into.