was reduced to 20 grains, and a death was reported from this size dose. I reduced my minimum initial dose to 15 grains, and never heard of any bad results following the use of such doses. I will say that I have found chloral of great benefit in some exceptionally obstinate cases. I do sometimes encounter a case in which all the remedies will fail, then I resort to chloral; but it is very rarely that you are compelled to resort to it, and when I do so I use it in very small doses-15 grains, repeated with great care; but I never use it until DR. J. K. BAUDUY read a paper (see page 259 this I am compelled to, that is, in obstinate and intractable issue) on The Treatment of 1129 Cases of Acute Alcoholism. DISCUSSION. DR. DALTON.-This is too good a paper to be per. mitted to pass without commendation; it is certainly a most excellent essay. I especially agree with the Doctor as to the use of stimulants in this disease. I adopted that plan of treatment when in charge of the City Hospital, and especially did I observe the rule not to give opium. I had a formula which I used in almost all cases-bromide of potash, chloral, tincture of digitalis and tincture of capsicum. I remember but one case in the Hospital in which I gave whisky; I gave the man a glass of whisky because I believed that the other things were not going to succeed; he seemed to be no better and the remedies seemed to be failing; he was getting more nervous and was in an extremely tremulous condition; in fact, he was wild; after the dose he went to sleep, and rapidly recovered. I am not positive that the whisky helped him; he may have gotten along with out it. I would like to ask the Doctor what are his objections to digitalis? Dr. Bauduy.—I object to its use in large doses. DR. DALTON.-I take it that the reason for the Doc tor's objection to it is that he does not wish to spur the jaded horse, and I would like to have him state fully his ideas on that point, and also in regard to chloral. Chloral certainly does produce a depressing effect on the heart. I have found the infusion of quassia with tincture of capsicum and dilute hydrochloric acid act beneficially; I have always found this a most excellent remedy. DR. BAUDUY.—In answer to Dr. Dalton in regard to chloral I will say that I used a great deal of it in my earlier experience, and I also used morphine, then later on bromide and then chloral. But I became alarmed in using the chloral because I noticed in "Braithate's Retrospect," the results which followed its use in large doses. cases. I think the remedy has had its day. Referring to digitalis, to which Dr. Dalton adverted, I am not opposed to it, I think it is a most admirable remedy, and I combine it with various other drugs and use for a heart tonic. I referred in my paper to the very large doses of dig. italis which Drs. Campbell and Dalton will remember to have been administered some years ago, almost to toxic doses; I am almost afraid to mention the dose for fear I may make a mistake-dram doses, if not more. While I do not believe in the culmative effects of digitalis I believe in moderate doses it is almost invaluable. DR. FINLEY.—I have never given hydro-bromide of hyoscene in alcoholism, but I did give it in a case of morphine habit, as a substitute, and the result was that I had one of the finest cases of delirium I ever saw.— The patient talked for four hours, and I thought he would never stop. DR. BAUDUY.-I have given large quantities of digi talin in doses of about one sixtieth of a grain three times a day, and I have gotten good results from it; but I have never had any experiencs with a drug spelled digitalein, I know absolutely nothing about it. ST. LOUIS MICROSCOPICAL SOCIETY. STATED MEETING, THURSDAY EVENING, MARCH 23, '99. THE PRESIDENT, DR. CRANDALL, IN THE CHAIR. Tumor of the Aural Canal. DR. M. A. GOLDSTEIN presented a microscopic section of a tumor removed from the aural canal together with photographs of the specimen and a specially prepared photographic reproduction of the sections. The clinical history of the case was briefly given a follows: J. M., aged 64 years, a coal-oil dealer, presented him. self at the ear clinic of the Beaumont Hospital Medical College. Since early infancy the patient noticed a purulent discharge from the right ear which, in the last few years, had become profuse in quantity, and of of. fensive odor. Inspection of the affected ear revealed a tumor filling the entire external auditory canal, and projecting about one quarter of an inch beyond the meatus. This mass was easily circumscribed by a thin probe, and its attachment located in the fundus of the We know that when Sir James Y. Simpson first recommended the use of chloral he gave it in dram doses and quite a number of deaths occurred, not in his hands, but in the hands of other physicians in England. Then it was reduced to smaller doses and there were still several deaths resulting from the administration of 30 grains, reported in medical journals; then the dose canal. The tumor was easily removed in its entirety, by means of a cold snare; profuse hemorrhage followed. The canal was tamponed with iodoform gauze. On next inspection, a large, ragged perforation of the membrana tympani was observed, and the attachment of the pedi cle located within the tympanic cavity. The patient was seen but a few times after this and, apparently, made an uneventful recovery. The growth was re moved April 10, 1898. It is to regretted that the clinical data of this case were so incomplete, and that no light as to the charac ter of the removed growth was thrown on the subject from this source. originating from the wall of the tympanic cavity. Unfortunately, the author lost sight of the patient, and was, therefore, unable to report definitely as to the further developments in this case. He does not know whether there has been a recurrence of the growth. He granted that originally this may have been benign in character, but was inclined to the opinion that it has undergone malignant changes and, in its macroscopic and microscopic morphology, it appears to resemble sarcoma of the round celled type. In concluding, the author expressed his indebtedness to Dr. C. W. Schleiffarth for the excellent photographic reproductions of the microscopic section presented. This peculiar dull finish, on a black back ground, makes these photographs especially valuble for half-tone illus. trations. Dr. Ludwig BREMER presented microscopical sections of Macroscopically, the growth presented the following appearance: The tumor, by actual measurement, was determined to be 3 cm. in length in its longest diameter, 14 cm. in the transverse section of the edematous proximal end. The surface presented a very irregular appearance, intersected at various points by thin fibrous bands. The growth seemed twisted on its axis in several places. The large edematous end, constituting the Enarteriitis Proliferans Ataque Obliterans protruding portion of the tumor, was dense in character, covered by a fibrous envelope. The pedicle appeared very vascular and of much softer structure. At one point, located about one half cm. from the distal end, was a softened necrotic zone with the envelope of the growth still intact. in Nephritid. The kidney, sections of which were presented for mi croscopical inspection, was that of a patient who died from cerebral hemorrhage. There was sugar in the urine and the blood test for glycosuria was positive. The kidney did not present any pronounced changes The tumor was hardened in alcohol, embedded in macroscopically. The specimen, however, under the celloidin and sections made through the long axis of microscope, shows an interstitial inflammatory process. the growth. The sections were stained with safranin. The most striking feature is a proliferation of the enMicroscopically the surface presented frequent indenta-dothelial cells changing to spindle-shaped (connective tions, and was circumscribed by a thickened capsule. tissue) cells. The cells of the adventitia also partici This capsule, at one spot, about the center of the tupate in the proliferating process, though in a less demor, is invaginated, dipping down through two thirds of its thickness, forming a division between the two portions of the growth, thus dividing the tumor into a larger, denser, and a lesser soft and more vascular globule. At the places where the integument seems to be broken, ulcerated changes are observed. In structure the tumor is in part made up of fibrous connective tissue contained within which and distrib uted in greater areas throughout the entire growth are infiltrated masses of round-cells. Blood vessels are numerous. Of glandular elements the specimen shows nothing unless an oval area contained within the partitioned space previously described be considered of glandular character, which has undergone some form of degeneration. Two areas of softening and of possible necrosis are also contained within the growth, the specimen at this point, showing mucoid masses containing numerous round-cells. The complexity of the tissue which form this growth, the distinct infiltration of the round cells, distributed throughout the greatest part of the section, both of the fibrous portions and of the more vascular portions, the peculiar invagination or indentation in the body of the tumor, the many irregularties in its growths, lead to the conclusion that this is possibly a round-celled sarcoma, gree. A peculiarity brought out by differential staining with a mixture of acid Fuchsine and an alkaline dye is, that the outer ring of the proliferated and obturated vessel shows distinct acidofuchsinophilia. In some instances, the lumina of the arteries are clogged with spindle shaped cells. On superficial examination, one is tempted to look on these formations as being sclerosed glomeruli. This is especially the case with the completely obliterated arteries representing transverse sections. A series of transition pictures, however, demonstrates their true nature. In the brain of this patient miliary aneurisms leading to the fatal hemorrhage occurred in large numbers. * Probable Congenital Malformation of DR. ADOLF ALT showed specimens of the lens of the fellow-eye of the one shown at last meeting which pre sented the earliest symptoms of cataract formation but especially a peculiar duplication, triplication and split. ting up of the layer of capsular epithelium. The fel low-eye showed almost exactly the same disturbances concerning the capsular epithelium layer and besides an anterior polar cataract which in this case showed no structure, but deposits of lime in granular form. He further showed a lens from another subject with safety going further through by denuding the bone the same changes in the epithelium and in which the from the anterior surface and shaving off the redundant new lens fibers instead of growing forward and inward portion, suturing the periosteum and letting it heal from the equator, grew backward along the posterior primarily. The growth in length could not be stopped capsule, similar to the manner in which the epithelium except by attacking the epiphysis which would be hazis seen to grow on the posterior lens capsule in a great ardous, many cataracts. The particular changes found in these three lenses he thinks must be looked upon as congenital malformations. Further details of these cases will be published in the American Journal of Ophthalmology. J. S. MYER, M.D., Secretary. NEW YORK ACADEMY OF MEDICINE. Section of Orthopedic Surgery. MEETING OF FEBRUARY 17, 1899. Hypertrophy of the Tibia. DR. S. KETCH presented a girl 4 years of age whose right tibia was greatly lengthened and thickened with decided anterior bowing. He had first seen the patient in December, 1898. The ephyses were thickened but the enlargement was not confined to them. It was most marked at the middle of the shaft but included the whole bone; as was seen by the x rays. Length: right leg, 19; left leg, 18§; right tibia, 94; left tibia, 84. Circumference: right thigh, 94; left thigh; 10; right calf, 8§; left calf, 77. The disease had begun eighteen months ago with a small lump on the leg and pain at night and when she walked. This was Dr. Ketch's second patient of the kind. The first one was a girl 11 years of age who had been presented to the Section in November, 1897, had been operated on for the purpose of shortening and straightening the bone, and had again been before the Section in March, 1898, with reralting improvement and ability to walk about (see MEDICAL REVIEW, December 25, 1897, p. 459, and July 23, 1898, p. 68). The bone had been found to be solid, the cavity being obliterated. Neither of the patients had received any benefit from antisyphilitic treatment. There was doubt as to the cause of this growth of the bone. It was not improbable that the trouble began in the periosteum. It was a question whether something ought not to be done early in the way of an operation to arrest the process, such as an incision through the periosteum which might at least relieve the tension. DR. T. H. MYERS said that this affection was extremely rare. He did not think that any drug could produce a meterial improvement, though it might prevent further progress of the disease. Such cases were sometimes assumed to be syphilitic for lack of better information, though no history or symptoms of that in fection could be elicited. DR. H. GIBNEY said that in addition to the treatment which had been suggested he would go further and complete the operation straightening the leg by the re moval of a wedge shaped piece of the bone and maintaining the correct position by plaster of Paris dressings. DR. MYERS thought that incisian would only relieve the pain. He would not operate until the child had at tained its growth or the disease had stopped. DR. G. R. ELLIOTT said that it was of pathological in. terest that the tibia alone was affected while the fibula remained normal. There was but little deformity com. pared with the decided bowing which had been an indication for operation in Dr. Ketch's former patient, in whom the pathological findings were diffusely distrib. uted throughout the entire thickness of the bone. He asked what effect tying the nutrient artery of the bone would have on the progressive atrophy. DR. KETCH said it would probably stop the growth of the bone. DR. ELLIOTT suggested the possibility of resulting necrosis. DR. A. B. JUDSON said that if the whole limb was af. fected symmetry might possibly be promoted during the growing period by checking the vascular supply of the larger limb, by bandaging or lacing the whole limb, and increasing the vascular supply of the smaller limb by venous compression. At the same time the functional activity of the one could be lessened and that of the other increased by the use of an ischiatic crutch or other apparatus having the same affect, with a high sole under the shorter limb. But as the diagnosis was absent and the pathology unsettled he could not suggest a reasonable treatment. DR. KETCH said that at an earlier stage some of the operative procedures suggested might have arrested or prevented the abnormal growth of the bone but, on the other hand, they might have promoted it. He was op posed to the removal of a portion of the bone during the growing period. As the parents of the child desired active treatment an incision might be recommended as likely to stop the pain which he thought was due to tension. Enlargement of Epiphyses. DR. MYERS presented a girl 16 months of age whom he had seen for the first time on January 10, 1899. The epiphyses of the radii, femora, tibæ and the entire phalanges of several fingers were enlarged. The joints of the ankles, knees, fingers, wrists and the right elbow DR. V. P. GIBNEY suggested a linear incision through were swollen and somewhat restricted in their motions. the periosteum and if that could be done with perfect | The enlargement at the ankle joint was peculiar, sev eral of the tarsal bones sharing in it. She walked with DR. V. P. GIBNEY said that the focus of diseased bone might suffer a traumatism and thus cause an extension of the process and give rise to this outward manifestation. He recalled a case seen twenty years ago. The child's knee was full of fluid. It was thought surely to be synovitis and a glowing prognosis of re. covery in a few weeks was made, but after six or seven years' treatment recovery took place with a stiff knee. Primary osteitis with secondary synovial distension oc⚫ curred before the gross signs of the osteitis which called the attention of the practitioner to some trouble in the DR. KETCH said that the obvious feature of the case was a very exaggerated change in nutrition-an overgrowth of some kind, the effect of some not so obvious diathetic cause. He had seen localized changes in scorbutus which were very similar. DR. V. P. GIBNEY said that the changes were similar to those seen in chronic rheumatoid arthritis which he had repeatedly seen in typical forms in children 7 and 8 years of age and he did not see why it should not attack a child 16 months old. This, however, would not explain the growth of the long bones and phalanges. His first thought was of scorbutus but the condition would have disappeared with the ohild on the diet stated. Syphilis could be excluded. If pushed for an opinion he would say it was a case of multiple bone tu berculosis, a condition which could be less easily excluded than any of the others mentioned. The boggy feeling of the joints, the fact that there was effusion in the joints and the statement that flexion of the knees and an unwillingness to walk had followed an attack of cholera infantum all supported the view that it was an instance of bone tuberculosis. He would raise the question whether synovitis was not one of the earliest signs of tuberculosis in a child. He advised putting the child in a wire cuirass and keeping the limbs extended. It was not good to allow the child to walk. DR. KETCH said that primary synovial tuberculosis was rare in children. DR. JUDSON had noticed the contraction of the knees and hips but thought it was not the result of the reflex muscular action of joint disease and that the fact that the contractions were nearly symmetrical pointed to a more general cause than tuberculosis of the joints affected. He did not think that synovitis was an early incident of osteitis and that primary synovitis could be differentiated by the absence of the usual signs of oste itis, which were muscular atrophy and reflex action and a prolonged history of inconstant lameness and pain. Synovitis should not be considered as liable to run into osteitis, although practically it was well to relieve a synovitic joint from weight bearing. DR. KETCH said that he had rarely seen synovitis as an early sign of tuberculosis. DR. ELLIOTT said that fluid in a joint immediately after a traumatism pointed clearly to a synovitis directly due to traumatism. If tuberculosis followed it resulted from a further injury to the bone itself which made a proper nidus for the tubercular growth. In other words a dual injury and the fluid in the joint was entirely distinct from the true tubercular lesion and in no way connected with it. The later tubercular development might delay the absorption of the primary synovial excess and the latter might come to complicate the tubercular joint. DR MYERS had seen effusion early in tubercular joint disease but did not consider it of diagnostic value. In spite of the fact that the patient had had apparently an antiscorbutic and antirachitic diet he could not help thinking that the trouble was due to one of these diseases rather than to tuberculosis. The child was not very sick. The principal changes were in the epiphyses and phalanges and seemed to him to be due to some form of of nutritional disease. The congested epiphyses could fully account for the pain and tenderness, but he would adopt the suggestion made and protect the joints by keeing the child quiet. Cases of Coxa Vara. DR. MYERS also presented a boy 8 years of age who had waddled, and was walking worse every year, since he began to walk. His muscles were strong. A certain rigidity of all the muscles of the lower extremities made examination somewhat difficult. The motions of the hip joints, especially flexion and abduction were somewhat limited. There was no dislocation but the neck of the femur was seen in the skiagram to be bent down as in coxa vara. The diet had been very good. The boy was a little bow-legged and flat-footed. DR. H. GIBNEY found no shortening and trochanters but slightly above the line. He thought the waddling might be due to flat-foot. DR. V. P. GIBNEY said that the radiograph showed forward rotation and little bending backward of the femoral neck at its junction with the shaft. The opinion was expressed by several speakers that the boy had coxa vara in a mild and not strictly typical form. DR. ELLIOTT thought that the condition dated from early rachitis in all probability. The picture was a logical one and the femoral neck had changed simultaneously with the bowing of the legs, both having been more or less plastic. DR. KETCH said that the traces of rachitis were obvi ous. Coxa vara was sometimes made to include cases that were not dependent on bending the bone. Some cases were due to deviations caused by abnormal epiphyseal growth resulting in a change in the angle of the neck of the femur. On the other hand the peculiar gait of coxa vara was not infrequently attributed to knock knees or bow-legs. DR. JUDSON said that coxa vara might be considered to mean an abnormal, or varous relation of the neck of the shaft caused by lesions of different kinds all of which were not yet recognized. DR. V. P. GIBNEY said that in coxa vara we had found one new disease or condition to rule out in our study of his disease. Many cases of "hip disease" in adolescents which recover and have relapses, but never get very bad, having from one-half to three-quarter inches shortening, were really cases of coxa vara. DR. KETCH presented a boy 11 years of age who had had a limp (left leg) in winter but not in summer, for three years. Pain and inability to walk on rising disappeared entirely in the afternoon. There had been no history of rickets or rheumatism. Abduction was limited, especially in flexion. Outward rotation abnormally free, trochanter one half inch above line, no atrophy. Right leg, 28 inches; left leg, 27 inches. The skiagraph showed a change in the angle of the neck. * ** Treatment of Coxa Vara. DR. JUDSON suggested mechanical means for permitting locomotion while the affected part is relieved from the weight of the body as long as the bone was in a growing or plastic state. wrists and the right hip. For the first year improve. ment had followed massage and medical treatment. For the past four and one half years the right hip had gradually become stiff and painful in walking. When first seen by Dr. Myers in February 1898 there was some spasm but no shortening. Motion of hip: flexion, 16 degrees; abduction, 10 degrees; external rotation, 10 degrees. A short traction hip splint was at once applied and is still worn. There had been no pain since June 1898 and the man considered himself greatly improved. DR. KETCH recalled the case of a man in whom the terrific pain of a sarcoma of the femur had not been relieved by powerful narcotics but had been relieved for a time by traction made with a long hip splint and afterward, as more convenient, with a short splint. Fracture of Neck of Femur in an Infant. DR. MYERS showed a specimen of fracture of the neck of the femur in a child eight months old. A large amount of callus was present within and without the lower fragment inward one third the diameter of the periosteum. There was a lateral displacement of the bone. There was no change in the length of the bone. No history could be obtained except that the injury must have occurred before the fifth month. * A New Pelvic Rest. DR. MYERS also showed a pelvic rest, especially well suited for the application of spica bandages which included the trunk and thighs, as it could remain in place until the spica was fully applied and could then be easily withdrawn. It was made of a piece of sheet steel, x1x14 inches, bent upon itself so as to form three sides of a square. The ends were hammered out so as to form oblong planes about three inches broad and five DR. V. P. GIBNEY said that when the affection was single good results could be obtained from the use of the hip splint. He saw no objection to the wearing of inches long. When in use one of the planes rested a jointed splint for some months, affording, not absolute but modified, protection, enough to shut out traumatism. DR. H. GIBNEY said that the ischiatic crutch for this purpose was easily adjusted and comfortably worn and allowed the limb to hang free. DR. MYERS said that when both femora were affected mechanical protection was attended with difficulties and it was not easy to keep the abolescent patient, like the one he had present, quiet. DR. JUDSON suggested the use of a bicycle. DR. KETCH in such a case would improve the general nutrition and prepare the parents for a long wait. upon the table and the other supported the sacrum while the upright connecting them was directed toward the feet. Treatment of Vomiting of Pregnancy.Hermanni (Therap. Monatshefte, January, 1899), desiring to prove the results published by Frommel and Rech, treated by basic orexin, pregnant women suffering from repeated and even uncontrollable vomiting, both in the beginning and in the last weeks of their pregnancy. All these patients, Hermanni declares, without exception, have immediately improved and soon entirely recovered, in a most marked manner. The DR. MYERS related the history of a patient 26 years daily dose employed in the nine cases has been from 60 of age, who had suffered five and one half years from to 90 centigrammes, taking two or three a day in caprheumatism in the ankles neck, shoulders, elbows and sules or powders of 30 centigrammes. * * * Pain Relieved by Traction. |