HOSPITALS FOR THE TREATMENT OF PHTHISIS. In a brief paper presented to the Medical Section of the Tenth International Medical Congress, recently held at Berlin, and published in the Münchener Medicinische Wochenschrift, August 26, 1890, Dr. Hermann Weber, of London, considers the treatment of phthisis, and makes an earnest plea for the establishment of institutions for the exclusive treatment of poor phthisical patients. As yet we know of no specific remedy for phthisis. If a disease can not be attacked directly it must be combated by strengthening the entire organism, including the diseased focus. It is a recognized fact that the greater the want of cleanliness and the larger the number of persons present in any cubic space, the larger will be the number of microbes. Suitable ventilation diminishes this number. Thus the indications in the treatment of such a disease as phthisis are: to support the general nutrition, to control cough, fever, hemoptysis, and sweats, and to disinfect the air of the rooms in which the patients live.

No class of cases requires more constant observation than consumptives do. On this account their treatment in institutions devoted exclusively to that object possesses, Dr. Weber rightly says, great advantages for most patients, and constitutes for many a condition necessary for convalescence.

In this connection climate becomes an important element. In the great altitudes of mountainous regions the air is clearer and more dilute, the barometric pressure is less, the amount of moisture is slight, the temperature is lower, there is much sunshine, and the wind is relatively still in winter. Here out-door exercise is almost always safely possible, and the appetite improves. The dryness and coolness of high regions causes increased pulmonary activity and secretion with increased cardiac action and pulmonary circulation, and the expansion of healthy lung structure exerts a curative influence upon adjacent diseased tissue.

In the selection of a residence for a phthisical patient. Dr. Weber says the following points should be considered: the air should be as free as possible from dust and organic impurities of all kinds; the soil should be dry; a southern or southwestern exposure should be selected; the dwelling should be high above the valley and the water-level, and, if possible, close to a wood, especially a pine wood. The place should be one on which there is abundant opportunity for physical exercise and for suitable employment, and provided with protected walks and seats. Rooms for patients should have a sun exposure, be well ventilated and amply large. For weak patients with fever there ought to be

verandas, with beds or lounges for use during the day.

The establishment and maintenance of institutions for the care of the poor phthisical would entail the expenditure of large sums of money, but the advantages derived from them would more than compensate for the additional expense. The condition of the patients would be alleviated and the condition of their families would be much improved. By timely treatment not a small proportion of patients would be cured entirely, or to such a degree as to become capable of work. The patients would learn a mode of living and acquire habits which would guard them against new attacks or relapses. They also learn how to dispose of their sputa so that it shall not be dangerous to others, and so the community is a gainer. Meanwhile general hospitals are by so much relieved of pressure and made free for the treatment of acute diseases. In all, it is clear that special hospitals for the treatment of consumptives are one of the great needs of the present day.Med. and Surg. Rep. ·

A NEW OPERATION FOR STRICTURE OF THE RECTUM. In no reports upon rectal surgery has the writer seen presented the principles and procedure of the following operation for strieture of the rectum, and therefore novelty is claimed in this report.

Mrs. B., aged thirty-two years, giving history of syphilis, a subsequent rectal stricture, and fistula in ano.

The symptoms of stricture growing worse each month, and not having more than one operation on bowels a week, brought patient under examination the 28th day of July, 1890. After inducing anesthesia, examination revealed a fistulous tract from superficial sphincter opening one and one half inches from anus, also flaps or folds of mucous tissue around the anus; within were infiltration and thickening of mucous and submucous structure, and about three inches above the anus an annular stricture almost occluding the rectum.

After dividing the fistula and superficial sphincter, a pair of uterine dressing forceps. were introduced through the stricture, by means of which sufficient dilatation was made to introduce a probe-pointed bistoury. Two incisions were then made, dividing the stricture bilaterally. Pratt's large dilating speculum was then introduced, dilating the rectum to its full capacity, being frequently turned in various directions for the purpose of thoroughly using a douche of warm carbolized water, and curette and silver nitrate to all suspicious pockets.

Keeping up these antiseptic precautions for about twenty minutes, the speculum remaining.

in situ, paralyzing all muscular action, no difficulty was experienced in bringing down the stricture with a tenaculum and securing with an Emmett needle armed with catgut suture or loops, the mucous membrane, from the stricture to the anus, falling in folds and protruding from the anus like external pile tumors. An assistant then holding the stricture in position by means of the loop, the posterior folds of mucous tissue were removed with tenaculum and scissors; then making an incision half way around the anus posteriorly and removing corresponding cicatricial tissue in the stricture, the two surfaces thus denuded were securely brought together with catgut sutures. Nothing was at the time done with the protrusion of mucous folds on the anterior surface.

Usual dry dressing was applied, and patient, taking an opiate, was put to bed. No suffering or inconvenience followed. The bowels moved each day.and on the eighth day patient returned, when, with the aid of solution cocaine, the anterior folds left protruding on the day of the operation were snipped off with tenaculum and scissors. Entire recovery on fourteenth day from first operation. No trouble has arisen since.

The results of this operation were seen at various times by Drs. Jelks, Miner, Gaines, Collings, and Barry, jr., of this place, all of whom expressed their satisfaction.-M. G. Thompson, Journal Medical Association; from advanced sheets.

OPERATION FOR PROLAPSE OF THE RECTUM. In the Annals of Surgery, April, 1890, Dr. John B. Roberts proposes and describes how he conducted, in the case of a young woman, an operation for proctorrhaphy, which seems to meet all the indications. The anal aperture was so dilated that he could readily insert the ends of the five fingers of his hand into the rectum. When the bowel was prolapsed it protruded from the anus as a sausage-shaped mass about four inches in length. He then determined to cut out a V-shaped portion of the posterior wall of the rectum, the apex of the V being upward, and at the same time to diminish the anal aperture by excising a part of the sphincter muscle. This procedure would diminish the caliber of the lower part of the rectum and give it a narrow orifice, so that the inferior portion of the intestine would diminish in diameter as it approached the anus, instead of being a tube with a wide, almost funnel-shaped lower opening through which prolapse was constantly occurring.

The steps of the operation were as follows: Making a small incision in the middle line near the point of the coccyx, he introduced his fin

ger and broke up the cellular connections behind the rectum, as is done in preparing to excise its lower end for carcinoma. The sphincter muscle was then divided in two places by incisions, each about a half inch away from the posterior median line. By carrying these incisions obliquely backward through the skin until they met at the original incision near the tip of the coccyx, he included between them a triangular portion of tissue which had as its base about one inch of the anal sphincter. With scissors he then cut from the posterior wall of the rectum a long triangular piece consisting of the entire thickness of the wall. The apex of this V-shaped section was situated about three inches up the gut, while its space corresponded with the space between the incisions by which one inch of the sphincter muscle was removed.

After hemorrhage had been controlled with catgut ligatures, chromicized catgut sutures were used to bring the divided wall of the incised rectum together. The first suture was introduced at the apex of the wound, that is, three inches above the anus, and was tied with the knot within the bowel. Successive sutures were inserted, with intervals of about one third of an inch between them, until the lower margin of the rectal wound was reached. The last intra-rectal suture was placed just inside the margin of the anus. They were all tied upon the mucous surface of the bowel so that the knots were within the lumen of the intestine. In this manner the lower portion of the rectum was greatly reduced in diameter. The divided ends of the anal sphincter muscle were brought together by two catgut sutures and one wire shotted suture. The anal aperture was thus reduced, so that it was barely possible to introduce the tip of one finger; originally five fingers could readily be thrust into it. A rubber drainage-tube was then introduced into the cavity between the rectum and the sacrum, and the wound leading back ward from the anus to the coccyx was closed with numerous shotted wire sutures carried deeply by means of a strong and curved cervix uteri needle.

The result of Dr. Roberts' operation was not very good, but this fact he attributes to a diarrhea and the entrance of fecal matter into the wound.

A CASE OF TRAUMATIC TETANUS: RECOVERY.-Albert T., aged fifteen years, while playing leap-frog with an elder brother on June 18th, was accidentally knocked over, and in doing so tore down a flap of skin from his forehead. The skin was laid in position and strapped over by his mother, and nothing unusual occurred until the 26th, when she noticed that

the boy could not open his mouth. He was brought for advice on the 30th, and when seen the jaws could not be opened more than half an inch, but there was nothing to account for it, There was a wound on the forehead which had begun to suppurate, though the flap of skin had in great part united. This was dressed and the boy ordered to bed. On July 1st he was seen at home; the jaws were more tightly closed, he had an anxious expression, some risus sardonicus, and the muscles of the neck were standing out prominently in a state of tonic spasm. To speak at all, he had to depress the lower lip with his finger. He was able to swallow; the pulse was quiet, and the temperature normal. He was ordered nourishing fluids, an icebag to the neck, a quiet and dark room, and a mixture containing five minims of tincture of belladonna to a dram of water every four hours. July 2d: Body stiff; begins to start at times. Abdominal muscles hard; limbs relaxed; jaws open somewhat when asleep. 3d Spasmodic attacks occur once or twice a day, during which he bites his tongue. Wound discharges some pus; to-day a thread of grass fiber was seen, and removed through the sinus. 5th: State of complete and continuous opisthotonos now present, with occasional spasmodic seizures, during which he becomes cyanotic. Is fed with difficulty, so that nutrient enemata were ordered to be given, as swallowing brought on an attack. The mixture was changed to one containing three minims of chloroform, three minims of tincture of digitalis, and ten minims of spirit of sulphuric ether, in a dram of water every four hours, as the heart and pulse seemed failing, with belladonna liniment to spine. From July 8th the spasmodic attacks began to be less severe; opisthotonos continued; but the arms became stiff; the swallowing was easier, but he had lost a good deal of flesh. July 28th: To-day another piece of grass fiber was removed from the wound, which then soon healed. For the first time he was just able to open the mouth and protrude the tip of the tongue. August 3d: Muscular spasm nearly gone; sleeps and swallows well. Medicine omitted. About the 10th he was up and well. Throughout the course of the disease the temperature was normal, and it may be concluded that the irritation from the grass fiber was a potent factor in lighting up the mischief.-H. H. Fisher, M. D., Lancet.

KELOID. The Edinburgh Medical Journal, August, 1890, says Leloir and Vidal have contributed some interesting facts to our previous knowledge of keloid. They describe the spontaneous and the cicatricial forms, and add what has been often confused with these, an account

of hypertrophic scars. In spontaneous keloid the number of the individual growths is sometimes very great. Thus, in a case observed by Amicis there were 318, the greater number spontaneous, but a certain portion secondary or cicatricial. They were arranged nearly symmetrically, and were most numerous on the arms. Examined microscopically, the epidermis and its interpapillary cones preserve their normal aspect. Keloid, unlike cicatricial tissue, arises in the corium, up to that time intact, and is, consequently, not a formation destined to repair loss of substance. The persistence of the interpapillary cones and of the papillæ is not met with in the secondary or cicatricial keloid, and is limited exclusively or nearly so to the true or spontaneous form. The authors, after careful examination, have not been able to find any alteration in the nerve filaments or to discover the smallest microbe. Cicatricial or secondary keloid is that which is developed in the thickness of a scar. It begins below the cicatricial neoplasm or at a point in its margin, but the ultimate growth has no connection with the extent of the scar in which it has arisen. Kaposi has stated that the hypertrophic scar closely resembles keloid, but the authors do not accept this view. An hypertrophic scar is usually redder, more vascular, and not so hard as kelcid. The latter, once removed, recurs almost constantly in the cicatrix left after the operation, or in the course of the stitches; excision of hypertrophied scars cures them completely, or they may spontaneously disappear. The authors have seen two instances of recent cicatricial keloid cured under the continued and regular application of mercurial plaster. The true keloid they find is best treated by repeated scarifications carried nearly as deep as the growth, and not more than two or three millimeters beyond its margin. These must be continued till there is a uniformly pliant and thin cicatrix. Should a nodule of induration not larger than a pin's head remain, this little by little enlarges, and the neoplasm recurs. The scarifications are to be two millimeters apart, and crossed at right angles. The pain can be much lessened by painting the part once or oftener with choloride of methylene.

THE PROTEIDS IN THE URINE IN VARIOUS FORMS OF ALBUMINURIA.-The conclusions reached by Paton are as follows:

1. Senator was right in his conclusion that, in all cases of albuminuria, both of the chief proteids of the blood plasma are present.

2. The proportions of serum-albumin and serum globulin may vary within wide limits, the quotient of the amount of serum-albumin divided by the amount of serum-globulin being

sometimes as low as 0.6, sometimes as high even as 39.

3. In acute nephritis, when blood is absent. the quotient is high; when hemaglolin is present the globulin is, of course, in excess.

4. As the disease becomes more chronic, the quotient sinks, and in the terminal stages of the disease may sink as low as 0.6. This alteration depends upon the condition of the patient rather than upon the state of the kidney, and is probably related to a similar change in the blood plasma.

5. Amyloid disease can not be distinguished from the ordinary forms of chronic nephritis by the high proportion of serum-globulin, as was formerly maintained by Senator.

6. Maguire's suggestion that functional albuminuria is characterized by the high proportion of serum-globulin is not correct.

7. In every case the proportion of the proteids to one another varies much in the course of the day, and, in comparing the proportion of these proteids in different cases, it is necessary to examine specimens of the mixed urine of the twenty-four hours, and to take into account the nature of the diet.

8. The proportion of serum-globulin is always highest during the night. It falls greatly after breakfast, when it reaches its lowest point in the twenty-four hours. In most cases it again rises in the evening. The precise connection of the alteration in this proportion with the taking of food can not be considered as definitely settled.

9. Milk diet, as observed by Lecorché and Telamon, has a peculiar effect in increasing the proportion of serum-albumin.

10. The amount of proteids passed appears to bear a tolerably direct proportion to the amount of proteids taken, and, excluding milk diet, the increase of the proteids in the urine on a rich diet in these substances appears to be chiefly due to an increase in the serum-albumin.

11. The variation in the proportion of the albumin to the globulin in the urine is frequently so great that we can hardly believe that it is connected with a similar change in the plasma. The few experiments we have performed would suggest that a high pressure favors the transudation of serum-albumin, while a low pressure increases the proportion of globulin transuded.-British Medical Journal.

HEPATIC ABSCESS.-At a recent meeting of the Academy of Medicine of Paris, M. Hache related the history of four cases of abscess of the liver, of which two were cured and two died, and made the following observations: Pain in the hepatic region, fixed, limited, and exasperated by pressure, whether irradiating to

scess.

the shoulder or not, may be considered as one of the best symptoms of the existence of an abThe pain may be very violent without being accompanied by any complication in the peritoneum or the pleura. However, too much importance can not be given to it as an indication of the exact locality of the purulent seat, as the abscess may be at a certain distance.

Widening of the intercostal spaces is a consequence met with in all enlargements of the liver, but where one or two are abnormally enlarged the surgeon would be right in supposing that under that spot the liver was more particularly enlarged. Fluctuation can not be ob tained unless the abscess is superficial. Exploration of the organ, even with a large trocar, is inoffensive; but M. Hache preferred the needle, as it allowed to seek for the abscess if not found at the point supposed. As to the subsequent operation, the advantages of incising simultaneously the liver and the abdominal wall, as recommended by Little, were in his mind very doubtful. The after-treatment is simple. All washings or injections should be proscribed if the abscess flows freely and without odor. Iodoform powder poured into the drainage-tubes is sufficient. The prognosis must be based on the general condition of the patient, and especially of the digestive tract, for anorexia and diarrhea are the two great enemies to be dreaded.—Medical Press and Circular.

XEROSIS: ESSENTIAL OR PRIMARY SHRINKING OF THE CONJUNCTIVA: PEMPHIGUS OF THE CONJUNCTIVA. This interesting but fortunately rare disease has, up to the present, I believe, proved incurable in spite of many methods of treatment which have been tried; sooner or later the end is the same-the whole conjunctival sac shrinks, and the cornea becomes opaque. Many applications have been used; perhaps most success has been obtained by partial or complete union of the edges of the lids. I wonder if, in the early stages, the disease could be arrested by transplantation of conjunctiva, such as from the rabbit; it need not be done all at once, but little by little, and could readily be performed under cocaine. Dr. Wolfe's method might be used.

I do not know whether this has ever been suggested or carried out; very likely it has; it is difficult to hit upon something new nowadays. I have not seen a case of late, but should be disposed to give this method a trial. Where the outlook is so dark I think one might try any thing; it could but fail. My plan would be to remove a flap of the diseased conjunctiva, beginning with the inferior sac, and to put in a considerably larger piece of healthy conjunctiva-say from the rabbit.-S. J. Taylor, M. D., Lancet.

able papers in the sessions, while Dr. John A.

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THE MISSISSIPPI VALLEY MEDICAL

ASSOCIATION.

The pro

The meeting of this society, just held in Louisville, was in every way a success. The books of registration showed that a large number of delegates, were in attendance, I while the visitors were many. gramme was too full for any thing like successful utterance in the time allotted to the meeting, and as a consequence many papers were read by title. The scientific sessions were all well attended, and under the able administration of President Mathews a large amount of work was disposed of. Few of the papers read were under the average of medical society deliverances, while some showed their authors to be men of fine intellect and capacity for work. What is true of the papers is true of the discussions. They were spirited and of unwonted interest. The proceedings were strictly scientific, all topics relative to ethics, politics, and the irrepressible question of medical education being promptly ruled out of order.

Several distinguished visitors from the East contributed no little to the interest of the occasion. Dr. Frank Woodbury, of Philadelphia, and Dr. Stansbury Sutton, of Pittsburgh, read

dress of the society to a large and admiring audience. This genial gentleman and eminent surgeon began his professional career in our city, having entered upon his first course of lectures at the Medical Department of the University of Louisville, from which he graduated in 1869. The city was honored by his presence, and extended to him a most hearty welcome, which was gracefully reciprocated in many ways with Southern warmth by the ardent, modest, simple-hearted man. His able handling of the vexed question of medical education and his beautiful tribute to his teachers in medicine in the address, with his masterly demonstration of his bloodless amputation at the hip-joint in the lecture hall of the University, have passed into the medical traditions of the

town.

The social features of the meeting were not suffered to fall below the high level of Louisville's former doings in this direction. The dinners and receptions were sumptuous, and, being graced by the ladies, lacked nothing in beauty, brilliancy, and zest. The banquet was one-sided, but the viands, wines, and oratorical effervescences were competent to keep the gustatory and auditory reflexes of the guests in delightful ebb and flow until the time

"When merry milkmaids click the latch,

And rarely smells the new mown hay,
And the cock hath sung beneath the thatch
Twice or thrice his roundelay."

The exhibit hall was filled with wares pertaining to the doctor's work, and made a strikingly beautiful display. The best manufacturers of chemicals, pharmaceuticals, and instruments were represented. Among the exhibitors the editor found numerous old friends and added, he trusts, many new ones to the list that he hopes will never be filled. When one notes the vast sums of money, the wealth of invention, and high artistic skill expended upon the physicians' armamentarium, one can not suppress the thought that if hygienic and therapeutic successes were able to keep pace with progress here, disease would soon be banished from the earth, and the physician's occupation, like Othello's, be