strychnine is also of the greatest value. Massaging is also to be used in desperate cases. Electricity is also of great service. So are rarefied air and calisthenic. exercises obtained in the pneumatic cabinet treatment. To procure sleep at night morphine may be added to the hypodermic injections of strychnine.

Success in treating asthma depends as much on the proper management of the individual as it does on the administration of drugs in the proper doses and at the proper time. Principles can only be carried out by paying attention to details, hence each patient must be under the complete control of his physician in regard to his food, medicines, exercise, and everything else. This pertains particularly to old asthmatics who are constant sufferers. If the instruction which is given this evening is closely followed there are very few cases which will not yield to it; and as an illustration of what may be done in desperate cases I will conclude by relating the condensed histories of the two following examples, the second of which is still under occasional observation:

Case I.-A., aged forty-six years, a sufferer from asthma for thirty-five years -the attacks becoming more frequent and severe during the last three years. For four weeks before coming under observation he had been unable to lie down. on account of his disease. The injection of strychnine, one twenty-fifth of a grain, and morphine, one fifteenth of a grain, gave him almost immediate temporary relief. The morphine was discontinued after the second day, and one minim of a one per cent. solution of nitro-glycerin every four hours was substituted. The strychnine was gradually increased, and the nitro-glycerin omitted in the course of a week. Additionally he was kept quiet, received nourishing food, and strychnine by the mouth. In three days he was able to lie down, and in ten days more the asthma ceased.

Case II.-B., aged fifty years, an asthmatic for twenty-five years-daily attacks for one year, during which time he had been unable to lie down day or night. Came under observation six weeks ago, and received almost the same treatment as the previous case. The relief was prompt after each injection, but this had to be continued nightly for five weeks to keep the stubborn disease in abeyance. In two weeks he was able to lie down and is now practically well.

TRANSACTIONS.

DETROIT MEDICAL AND LIBRARY ASSOCIATION.

ANNUAL MEETING, OCTOBER 2, 1892.

THE PRESIDENT, GEORGE W. STONER, M. D., IN THE CHAIR.

SECRETARY'S ANNUAL REPORT.

MR. PRESIDENT AND GENTLEMEN: From the stand-point of your secretary the Detroit Medical and Library Association has concluded a most successful year. The attendance has been good, the papers plentiful, discussions spirited and instructive, pathological specimens numerous and varied, especially the varied forms of the greatly beset organ, the ovary. We have had little and big, black and white, smooth and wrinkled, cystic and non-cystic, innocent and dangerous,

and various other forms of ovaries. In fact when all others failed the ovaries never gave out, and I, as secretary, would thank the many and celebrated ovariotomists of this society for having, upon several occasions, helped me out of a good many deep holes.

Our papers and discussions have not been all by home talent. We have drawn for our supply from east, west, north, and south. DR. F. E. WAXHAM, of Chicago; DR. JAMES PRICE, of Philadelphia; DR. JOHN L. BRAY, of Chatham; DR. E. P. CHRISTIAN, of Wyandotte; DR. JAMES M. MARTIN and DR. J. A. WESSINGER, of Ann Arbor, together with DR. G. V. VOORHEES, of Coldwater, Michigan, are some of the names which have at intervals appeared upon the announcement cards of the association during the past year. Of these, as well as of our own active members' work for this year, we are justly proud. We have not only been cosmopolitan in regard to the source from which our entertainments have been drawn, but our papers and discussions have ranged over a wide field, embracing surgery, medicine, gynecology, obstetrics, pediatrics, dietetics, embryology, ophthalmology, bacteriology, otology, electro-therapeutics, neurology, etc.

We have had forty regular meetings of the association during the year with an average attendance of thirty-two, which might, by a little more diligence upon the part of the next secretary in getting up more interesting papers, etc., be increased considerably. Our largest attendance was eighty, our smallest, fourteen.

The forty meetings were provided for in each case either by a paper or general discussion. The papers read were as follows: (1) "Chronic Nervous Dyspepsia," DR. B. P. BRODIE; (2) "Identity of Diphtheria and Membranous Croup," DR. W. L. WILSON; (3) "Bacteriology in Medicine," DR. HENRY J. HARTZ; (4) "Dietetics," DR. HENRY F. LYSTER; (5) "Electrical Therapeutics," DR. J. FLINTERMANN; (6) "Intubation," DR. J. P. O'DwYER; (7) "Malaria," DR. JOHN L. BRAY; (8) "The Treatment of Scarlet Fever," DR. CARL BONNING; (9) "Cataract," DR. EUGENE SMITH; (10) "Hæmoptysis," DR. GEO. Duffield; (11) "Retention of the Dead Ovaries in Utero," DR. HELEN F. WARINER; (12) "Intubation," DR. F. E. WAXHAM; (13) "Some Psychical Phases of Hypnotism," DR. W. R. CHITTICK; (14) "Albuminuria in Life Insurance Examinations," DR. S. G. MINER; (15) "Purulent Ophthalmia," DR. DON. M. CAMPBELL; (16) Varicocele," DR. T. A. MCGRAW; (17) "Is the Cure of Disease by Electrolytic Action well Founded or Not," DR. D. S. CAMPBELL; (18) "A Short Paper on Extra-Uterine Pregnancy," DR. A. BENNETT; (19) "Trachoma," DR. R. W. GILLMAN; (20) "A Short Paper on Influenza: Its Different Kinds and Best Treatment," DR. J. B. NEWMAN; (21) "Albuminuria in Pregnancy," DR. F. B. TIBBALLS; (22) "Stammering," DR. ALONZO BRYAN; (23) "Acetate of Lead in Hæmorrhage," DR. J. NEWELL; (24) "Interesting Translations," DR. J. V. BECELAERE; (25) "A Line of Action in Puerperal Convulsions," DR. DELOS PARKER; (26) "Three Surgeons," DR. G. V. VOORHEES; (27) "Intra-Uterine Amputation," DR. J. A. WESSINGER; (28) "A Foreign Body in the Ear," DR. WILLIAM LOCKHART; (29) "Scarlet Fever Concurrent with Typhoid Fever," DR. W. J. BRAND.

66

Four papers which had been promised are held over for future reading.

GENERAL DISCUSSIONS.-(1) "Treatment of Tuberculosis;" (2) "Are American Women Degenerating;" (3) "Pathological Evening;" (4) "Cholera;" (5) "Ethics of the American Medical Association."

There were in addition to these papers and general discussions, one hundred and five pathological specimens exhibited, forty-one cases reported, nine patients brought before the society, and two instruments shown.

The advisory council has had considerable work to do, but they have not done it, and I might say here that this committee is altogether too large and it is an impossibility to get it together. It has had one meeting during the year. A committee of three would be plenty large enough and would do the work well.

The following elections have taken place during the year: Active members, nineteen; corresponding, two; honorary, two. There are now awaiting for the action of the council: Corresponding members, three; active members, six. Making in all thirty-two additional new members.

The cold hand of death has been laid twice upon our members, removing two of the best known physicians of this city, namely, DR. C. B. GILBERT and DR. CHAS. J. LUNDY. One member has been expelled from the society, and one application refused admission. There are now one hundred and sixty-five active members.

All of which is respectfully submitted.

DON. M. CAMPBELL, M. D., Secretary.

STATED MEETING, OCTOBER 10, 1892.

THE PRESIDENT, FREDERICK W. MANN, M. D., IN THE CHAIR.

PATHOLOGICAL SPECIMENS.

DR. J. J. MULHERON presented a uterus. Epithelioma was diagnosed several months ago when the ulcerations of the cervix were cauterized with chloride of zinc. I saw the patient frequently thereafter and treated her with mild non-irritating applications. The cervix has been curretted twice, but in spite of this treatment there were signs of the encroachment of the disease on the vaginal and uterine walls. With the assistance of DRS. STONER, WRIGHT, and WAMSLEY, I performed vaginal hysterectomy. During the operation I was compelled to use several strong whip-cord guys in order to pull the uterus well down. The hæmorrhage was very profuse and many clamps were used to control it. The vagina was packed with iodoform gauze and the patient is doing well.

DR. H. O. WALKER: This specimen is a large osteo-sarcoma and was removed from a boy fourteen years old, presenting the following history: Four or five months ago he received a blow on the thigh which produced a large swelling. It was looked upon at first as being inflammatory but not subsiding under treatment the attending physician brought him to me for consultation. I diagnosed osteo-sarcoma and advised immediate amputation at the hip-joint. This I did by Wyeth's bloodless method. The boy has had no untoward symptoms, scarcely any rise of temperature, and not a drop of pus. I present herewith the pathological specimen, a photograph of the leg before amputation, another photograph of the stump, and one of the tumor on section.

DR. FLINTERMANN: I once saw a case similar to this during my student days which made a recovery.

DR. BECELAERE: Does the prognosis vary relative to the position at which the amputation is made, that is, in the continuity of the bone or at the hip-joint. DR. H. O. WALKER: It does. The majority of surgeons believe that the best results are obtained by removing the whole of the bone affected.

DISCUSSION OF PAPERS.

DR. WILLIAM M. DONALD read a paper entitled "The Relation of Chorea to Rheumatism." (See page 535).

DR. J. FLINTERMANN: This is a very interesting and important subject. Authorities have always claimed that there is a relationship existing between chorea and rheumatism, but no one has been able to explain the exact nature either of rheumatism or chorea. In chorea there must be a certain center influenced in order to produce the symptoms, but we also know that these symptoms may affect either the upper or lower extremity or the facial muscles. We further know that the affection is confined to one side and it is hard to explain these variations upon the rheumatic theory, that is to say, it is difficult to see why the rheumatic poison circulating in the blood should affect one set of cells at one time and another set of cells at another time, but these cells may be differently affected by different kinds of poison circulating in the blood. The one-sided chorea might easily be explained upon the embolic theory. The disease is found mostly in young people because in them the nervous system is in an undeveloped state, a slight cause producing the result. While we must admit that many cases of chorea are preceded by rheumatism, still there are many more cases of the latter which are not followed by chorea. We further see many cases of chorea following diseases which are distinctly not rheumatic in their nature, such as torticolis or arthritis following scarlet fever. In the case which DR. DONALD reports of the lady suffering for many years I would not look upon her case as one of chorea but rather one of hysteria. Chorea may have many causes. The cases vary as to the locality of the choreic manifestations, therefore the central irritation must vary as to its locality. When paralysis of sensation occurs the sensory centers must be involved. Many cases of chorea come from fright and they certainly are not of rheumatic origin. After the presence of heart murmurs in choreic patients we know that these patients are almost always extremely anæmic. May not many of these murmurs be due rather to the anæmia than to any valvular lesion? How is it that chorea attacks the female much more frequently than the male? Surely if rheumatism were the cause one sex would be equally affected with the other. To my mind, therefore, it is doubtful if rheumatism is the sole cause of chorea.

DR. DAVID INGLIS: In discussing the paper of DR. DONALD we need to clear the ground of certain matters which frequently lead. to confusion. First, chorea is not a disease but a group of symptoms. It happens that several groups of symptoms which all present the common characteristic of coördination of intentional movements, but which in other respects differ widely, are commonly given the title of chorea. There is an essential difference between habit chorea and rheumatic chorea. So, too, we can clearly separate hereditary chorea. Again, there are choreas of a hysterical type.

The chorea of commonest occurrence, and that in which the relationship with rheumatism has been long recognized, is of acute onset, is essentially self-limited, is rarely fatal, and to the motor incoördination are usually added evidences of impaired action of the higher cerebral centers, in the shape of general motor weakness, intellectual defect more or less profound, and emotional instability. It is clearly wrong to claim to explain cases showing such widespread yet transitory nervous defect by the pathological lesions observed in entirely different forms. Similarly we cannot accept the pathological lesions found in the chorea, so-called, of the lower animals, as explanations of the chorea which we discuss to-night. There is reason to believe that the choreas of the quadrupeds are more truly allied to spinal ataxia than to rheumatic chorea. In short, it is not to be believed that the occurrence of such gross lesions as dilatation of the central spinal canal, softening of distinct areas of the cord, or patches of sclerosis, are types of the pathological processes which occur in rheumatic chorea. It is not reasonable to believe that a series of symptoms which experience shows to be almost always transitory and of comparatively short duration, is the result of lesions so destructive and permanent.

The chorea of pregnancy, while of much greater fatality, and showing a much greater intensity of symptoms than the common cases of rheumatic chorea, still resembles it in the acuteness of onset, the simultaneous onset of symptoms of mental and emotional and general motor weakness. It is fair to judge, then, that the post-mortem appearances in the somewhat frequent fatal cases of chorea of pregnancy, and the rare cases of fatal rheumatic chorea, afford a picture of the pathologieal processes which is reliable. If so, it seems evident that the process is one of widespread hyperemia which passes, according to the severity and continuance of the condition, into serous infiltration, minute hemorrhages, venous thrombosis, diffuse softening of the nervous substance adjoining the blood-vessels involved.

The whole process involves a more or less complete impairment of the nutrition of the nervous elements which shows itself functionally as irritable weakness in the motor, the sensory, and the mental processes.

The relation of chorea to rhematism involves, then, the method by which such a hyperemia is induced. Before considering this, however, it ought to be stated that these post-mortem appearances characterize the gravest types of chorea, and we should bear in mind that it is entirely possible, indeed, altogether probable, that the rheumatic poison may affect the nutrition of the nervous cells directly without causing any hyperemia at all, a state of things which probably exists in by far the larger number of cases of chorea.

Returning, then, to the gross pathological changes, Are we to accept Kirke's theory? Kirke, and after him Hughings Jackson, believed that a rheumatic endocarditis caused fibrinous exudate upon the valves of the heart, that small particles were dislodged and plugging the arterioles in the spinal and cerebral centers caused foci of inflammation and softening. To accept this seems to me impossible for several reasons. First, it compels us to assume that fibrinous exudates are in the habit of becoming, so to speak, pulverized. The area of nervous matter implicated in the diseased process in chorea is so large that we would need to imagine, not an occasional, but a multitude of such emboli. The onset of the whole group of symptoms is often simultaneous so that we would H*