• :
Property of the
Lancaster City and County Medical Society
No
♦
THE
AMERICAN JOURNAL
MEDICAL SCIENCES.
EDITED BY
I. MINIS HAYS, A.M., M.D.
NEW series.
VOL. LXXIX.
PHILADELPHIA:
HENRY C. LEA.
1880.
69505
Entered according to the Act of Congress, in the year 1880, by
HENRY C. LEA, in the Office of the Librarian of Congress. All rights reserved.
PHILADELPHIA: COLLINS, PRINTER,
705 Jayne Street.
v. 19
TO READERS AND CORRESPONDENTS.
All communications intended for insertion in the Original Department of this Journal are only received for consideration with the distinct understanding that they are sent for publication to this Journal alone, and that abstracts of them shall only appear elsewhere subsequently, and with due credit. Gentlemen favouring us with their communications are considered to be bound in honour to a strict observance of this understanding.
Contributors who wish their articles to appear in the next number are requested to forward them before the 1st of February.
Compensation is allowed for original articles and reviews, except when illus- trations or extra copies are desired. A limited number of extra copies (not exceeding fifty) will be furnished to authors, -provided the request for them be made at the time the communication is sent to the Editor.
The following works have been received : —
Real-Encyclopadie der Gesammten Heilkunde. Herausgegeben von. Dr. Albekt Eulenberg. Lief. 1. Wien : Urban & Schwarzenberg, 1880.
Ein Beitrag zur Biologie der Bakterien. Von Dr. Med. Louis Waldstein, aus New York.
Ein Seltener Fall von Lipoma Fibrosum am Kopfe. Beobachtet und mitgetheilt von Dr. Carl Fibber. Leipzig, 1879.
Vorlesungen iiber neuere Behandlungsweisen der Syphilis. Von Dr. Carl Sigmune Ritter von Ilanor. Zweite vielfach vermehrte Auflage. Wien : Urban & Schwarzenberg, 1880.
Die Lungen syphilis und ihr Verh'altniss zur Lungenschwindsucht. Von Dr. John Schnitzler. Wien : Urban & Schwarzenberg, 1880.
Meine Erlebnisse irn Serbisch-Turkischen Kriege von 1876. Eine Krieg-schirurgische Skizze von Dr. F. Lange. Mit einen Vorwort von Dr. F. Esmarch. Hanover : Carl Euinpler, 1880.
Om Spetelska. Af. Med. Dr. Fr. Ekltjnd. Stockholm, 1879.
Contributo alto studio delle Pneumoniti da Infezione. Del Dott. Guido Banti.
Saint Thomas's Hospital Reports. New Series. Edited by Dr. Robert Cory and Mr. Francis Mason. Vol. IX. London : J. & A. Churchill, 1879.
St. George's Hospital Reports. Vol. IX. London : J. & A. Churchill, 1879.
Observations on Contraction of the Fingers ; also, on the Obliteration of Depressed Cicatrices. By William Adams, F.R.C.S. London : J. & A. Churchill, 1879.
A General and Historical Treatise on Cancer Life : its Causes, Progress, and. Treat- ment. By Robert Mitchell, F.R.C.S. London : J. & A. Churchill, 1879.
Glaucoma : its Causes, Symptoms, Pathology, and Treatment. By Priestley Smith. London : J. & A. Churchill, 1879.
The Riviera. Sketches of the Health Resorts of the North Mediterranean Coast of France and Italy from Hyeres to Spezia. By Edward I. Sparks, M.A., B.M. Oxon. Loudon : J. & A. Churchill, 1879.
Observations and Comments on Certain Convulsive Disorders. By Henry Day, M.D., F.R.C.P. London : J. & A. Churchill, 1879.
A Text Book of Physiology. By M. Foster, M.A., M.D., F.R.S. 3d ed. Revised. London : Macmillan & Co., 1879.
On Intermittent Broncho-Pneumonia. By H. Cripps Lawrence. London, 1879.
The Artificial Eye of Dr. E. Landolt, Director of the Ophthalmological Laboratory of the Sorbonne. Translated by Edgar A. Browne. London : Trubner & Co., 1879.
Bible Hygiene. By a Physician. London : Hodder & Stoughton, 1879.
The Pathology and Treatment of Venereal Diseases. By Freeman J. Bumstead, M.D., LL.D., late Prof, of Venereal Dis. at Coll. of Phys. and Surgeons, N. T. Fourth ed., revised, enlarged, and in great part rewritten by the Author and Robert W. Taylor, M.D. Philadelphia: Henry C. Lea, 1879.
A System of Midwifery ; including the Diseases of Pregnancy and the Puerperal State. By William Leishman, M.D., Regius Prof, of Midwifery in Univ. of Glas- gow. Third Am. ed., revised by the Author. With additions by John S. Parry, M.D. Philadelphia : Henry C. Lea, 1879.
8
TO READERS AND CORRESPONDENTS.
A Treatise on the Theory and Practice of Medicine. By John Ster Bristowe, M.D. Loud., Senior Phys. to, and Lect. on Medicine at St. Thomas's Hospital, etc. Second Am. ed., revised by the Author. With Notes and Additions hy James H. Hutchinson, M.D. Philadelphia : Henry C. Lea, 1879.
A System of Medicine. Edited hy J. Russell Reynolds, M.D., F.R.S. With Numerous Additions and Illustrations hy Henry Hartshorne, A.M., M.D. In three volumes. Vol. I. General Diseases and Diseases of the Nervous System. Philadel- phia : H. C. Lea, 1879.
Lectures on the Diseases of the Nervous System. By J. M. Charcot. Translated from the Second ed. by George Sigerson, M.D. Philadelphia : Henry C. Lea, 1879.
American Health Primers. Winter and its Dangers. By Hamilton Osgood, M.D. The Throat and the Voice. By J. Solts Cohen, M.D. The Mouth and the Teeth. By J. W. White, M.D., D.D.S. Philadelphia : Lindsay & Blakiston, 1879.
The Physician's Visiting List for 1880. Philadelphia : Lindsay & Blakiston.
Holden's Manual of the Dissection of the Human Body. Edited by Luther Holden, President of the Royal College of Surgeons, etc., and John Langton, F.R.C.P. Fourth ed. Philadelphia : Lindsay & Blakiston, 1879.
The Theory and Practice of Medicine. By Frederick T. Roberts, M.D., Prof, of Materia IVledica and Therap. at University Coll. Third Am., from the fourth London ed. Philadelphia : Lindsay & Blakiston, 1880.
Outlines of the Practice of Medicine ; with special reference to the Prognosis and Treatment of Disease; with Appropriate Formulae. By Samuel Fenwick, M.D., Lect. on Prin. and Prac. of Medicine at the London Hospital, etc. Philadelphia : Lindsay & Blakiston, 1880.
Atlas of Skin Diseases. By Louis A. Duhring, M.D., Prof, of Skin Diseases in Univ. of Penna. Philadelphia : J. B. Lippincott & Co., 1879.
Paracentesis of the Pericardium. A Consideration of the Surgical Treatment of Pericardial Effusions. By John B. Roberts, A.M., M.D. , Lect. on Anat. in Phila. School of Anatomy. Philadelphia : J. B. Lippincott & Co., 1880.
A Clinical Treati.se on the Diseases of the Nervous System. By M. Rosenthal. Translated from the Author's revised and enlarged edition, by L. Putzel, M.D. Vol. II. New York : William Wood & Co., 1879.
Diseases of Women. By Lawson Tait, F.R.C.S. New York: William Wood & Co., 1879.
Infant Feeding, and its Influence on Life or the Causes and Prevention of Infant Mortality. By C. H. F. Routh, M.D., M.R.C.P.L. Third ed. New York : William Wood & Co., 1879.
Yellow Fever, a Nautical Disease. Its Origin and Prevention. By John Gamgee. New York : D. Appleton & Co., 1879.
A Ministry of Health, and other Addresses. By Benjamin Ward Richardson, M.D., F.R.S., etc. New York : D. Appleton & Co., 1879.
First Lines of Therapeutics. By Alexander Harvey, M.A., M.D., Emeritus Prof, of Mat. Med. in Univ. of Aberdeen. New York : D. Appleton & Co., 1879.
Health Primers. The Skin and its Troubles. New York : D. Appleton & Co., 1879.
Consumption, and How to Prevent It. By Thomas J. Mays, M.D. New York : G. P. Putnam's Sons, 1879.
A Dictionary of the German Terms used in Medicine. By George R. Cutter, M.D. New York : G. P. Putnam's Sons, 1879.
Atlas of Human Anatomy. Arranged according to Drs. Oesterreicher and ErdL With Full Explanatory Texts by J. A. Jeancon, M.D. Part I. Cincinnati : A. E. Wilde & Co.
Hygienic, and Medical Reports by Medical Officers of the U. S. Navy. Prepared for Publication under the direction of the Surgeon General of the Navy. By Joseph B. Parker, M.D., Surgeon U. S. Navy. Washington, 1879.
The Climate, Botany, Geology, and Health of Santa Cruz and Vicinity. By C. L. A N DER80N, M.D. San Francisco : Wallace W. Elliott & Co., 1879.
Pocket Therapeutics and Dose Book. By Morse Stewart, Jr., M.D. Second ed. Detroit : Geo. D. Stewart, 1879.
The Multum in Parvo Reference and Dose Book. By C. Henri Leonard, M.D. Third ed. Detroit, 1879.
Practical Education. By George Woods, LL.D. Pittsburgh, 1879.
Popliteal Aneurism treated by a New Method of Compression. Reported by Dr. A. F. Sawyer.
Phlebitis of the Vena? Emissariae Mastoidese. By J. Orne Green, M.D. Boston. Infant Mortality. Vital Statistics. By Thomas B. Curtis, M.D. New York, 1879. Buildings for Insane Criminals. By Walter Channing, M.D. Boston, 1879. The Feigned Insanity of Troy Dye. By G. L. Simmons, M.D. The History of Massage. By Douglas Graham, M.D. New York, 1879.
TO HEADERS AND CORRESPONDENTS.
9
Notes on the Practical Course in Normal Histology given in the Laboratory of the Alumni Association of the College of Physicians and Surgeons, New York City. By T. Mitchell Prudden, M.D. New York, 1879.
A Glance at Insanity, and the Management of the Insane in the American States. By Pliny Earle, M.D. Boston, 1879.
Emotional Fever. By Andrew Fleming, M.D. Philadelphia, 1879.
A Contribution to the Study of the Aetiology of Skin Disease. By James C. White, M.D. Cambridge, 1879.
The Extirpation of the Ovaries for some of the Disorders of Menstrual Life. By William Goodell, M.D. Philadelphia, 1879.
A Conspectus of Three Different Forms of Acute Inflammatory Cardiac Disorder. By Roswell Park, M.D. Chicago, 1879.
A Plea for Cold Climates in the Treatment of Pulmonary Consumption. Minne- sota as a Health Resort. By Talbot Jones, M.D., of St. Paul. New York, 1879.
Lunacy Reform. By E. L. Seguin, M.D. New York, 1879.
Physiological Antagonism the Therapeutic Law of Cure. By Electus B. Ward, M.D.
Choreic and Choreiform Movements in Hysterical Children. By Landon Carter Gray, M.D. New York, 1879.
A New Theory in the Mechanism and Proper Treatment of Uterine Displacements. By George Cowan, M.D. Indianapolis, 1879.
Pyscho-Physiological Training of an Idiotic Hand. By Edward Seguin, M.D. New York, 1879.
The Terminology of so-called Rubeola, not Roseola. By Benj. H. Riggs, M.D., of Selma, Ala.
An Examination of the Usual Signs of Dislocation of the Hip. By Oscar H. Allis, M.D. Philadelphia, 1879.
Neurotomy : A Substitute for Enucleation. By Julian J. Chisolm, M.D. Rich- mond, 1879.
Medical Legislation. By Nicholas Senn, M.D. Milwaukee, 1879. A Systematic Method for the Education of the Color-sense in Children. By Swan M. Burnett, M.D.
Diphtheria. By John H. Gilman, M.D., of Lowell.
Report of Committee on Public Health Relative to Lunatic Asylums. Albany, 1879.
A Contribution to the Study of the Bullous Eruption induced by the Ingestion of the Iodide of Potassium. A Clinical Lecture on Tubercular Leprosy. By Jas. Nevins Hyde, M.D. Chicago.
CEsophagismus. By J. J. Henna, M.D. New York, 1879.
A Contribution to the Study of Laryngeal Syphilis. By Ethelbert C. Mor- gan, M.D.
Observations on One Hundred Cases of Carcinoma. By Dr. S. E. Satterthwaite, and Dr. W. H. Porter. New York, 1879.
Cerebral Topography. By S. V. Clevenger, M.D.
Memorial Oration in honor of Ephraim McDowell, The Father of Ovariotomy." By Samuel D. Gross, M.D., L.L.D., D.C.L. Oxon. Louisville, 1879.
Address before American Academy of Medicine. By Lewis H. Steiner, M.D.
Report of Adams County (Pa.) Medical Society. By J. W. C. O'Neal, M.D. 1879.
Transactions of the «New York Obstetrical Society, for the years 1876-8. Vol. I.
Transactions of the State Medical Society of Kansas, 1879.
Transactions of the Southern Illinois Medical Association, 1879.
Transactions of the American Dermatological Association, 1879.
Transactions of the Medical Society of New Jersey, 1879.
Transactions of the Indiana State Medical Society, 1879.
Transactions of the Massachusetts Medico-Legal Society, 1879.
Transactions of the Illinois State Medical Society, 1879.
Transactions of Mississippi State Medical Association. 1879.
Proceedings of the Alumni Association of Rush Medical College. Chicago, 1879.
Proceedings of the Association of Medical Officers of American Institutions for Idotic and Feeble-minded Persons. 1879. Philadelphia, 1879.
Proceedings of the Medical Society of the County of Kings, Oct., Nov., Dec. 1879.
Proceedings of the Pennsylvania Pharmaceutical Association, 1878-79.
Proceedings of the Academy of Natural Sciences, April-Oct. 1879.
Annual Report of the Surgeon General, U. S. A., 1879.
Biennial Report of the State Board of Health of California. 1879-79.
Report of the Board of Health of the City of Pittsburgh, 1878.
Report of the Board of Health of the City of Nashville, 1878. Nashville, 1879.
Report of the Health Officers of the City and County of San Francisco, 1879.
Report upon the Births, Marriages, and Deaths in the City of Providence for 1878. By Edwin M. Snow, M.D.
Regulations for Government of U. S. Marine-Hospital Service. Washington, 1879.
10
TO READERS AND CORRESPONDENTS.
The following Journals have been received in exchange : —
Deutsches Archiv fur Klinische Medicin. Bd. xxiv., Heft 1 to 6. Medizinische Jahrbiicher. 1S79. Heft 1 and 2.
Centralblatt fur die Medicinischen Wissenschaften. Nos. 23 to 49, 1879. Allgemeine Wiener Medizinsche Zeitung. Nos. 22 to 48, 1879. Deutsche Medicinische Wochenschrift. Nos. 23 to 29, 1879. Medicinisch-Chirurgisches Centralblatt. Nos. 22 to 46, 1879. Bibliothek for Ls?ger. Bd. ix. Heft 3, 4. Nordiskt Medicinskt Arkiv. Bd. ix., No. 8.
Upsala Lakareforenings Forhandlingar. Bd. xiv., No. 6. Bd. xv., Nos. 1, 2.
Anuali Universali di Medicina e Chirurgia. Luglio to Nov. 1879.
Commentario Clinico di Pisa. Luglio, 1879.
L'Imparziale. Nos. 11 to 22, 1879.
Lo Sperimentale. Guigno to Nov. 1879.
La Medicina Contemporanea. Guigno to Ottobre, 1879.
Giornale Italiano delle Malattie Veneree e della Pelle. Guigno to Ottobre, 1879.
Rivista Settiinanale di Medicina e Chirurgia. Nos. 5, 6, 7, 8, 9, 1879.
O Correio Medico de Lisboa. Nos. 13, 14, 17, 19, 20, 21, 1879.
Cronico Medico-Quirurgica de la Habana. Jan. to Oct. 1879.
La Gaceta Cientifica de Venzuela. Nos. 3, 4, 1879.
Gaceta Medica de Sevilla. Nos. 1 to 6, 1879.
Archives Generales de Medecine. Juillet to Dec. 1879.
Revue des Sciences Medicales en France et de l'Etranger. Juillet, Oct. 1879. Revue Mensuelle de Medecine et de Chirurgie. Juin to Nov. 1878. Annales de Dermatologie et de Syphiligraphie. T. x. No. 4. Annales des Maladies de l'Oreille et du Larynx. Juillet to Nov. 1879. Gazette Hebdomadaire de Medecine et de Chirurgie. Nos. 24 to 44, 1879. L'Union Medicale. Nos. 67 to 143, 1879. Le Progres Medical. Nos. 23 to 49, 1879. Le Moiivement Medical. Nos. 23 to 49, 1879. L'Annee Medicale. Juin to Oct. 1879.
Union Medicale et Scientifique du Nord-Est. Juin to Oct. 1879.
Revue Internationale des Sciences. Nos. 6 to 11, 1879.
Journal des Sciences Medicales de Lille. Juillet to Dec. 1879.
Le Concours Medical. Nos. 1 to 23, 1879.
The Retrospect of Medicine. Jan. to June, 1879.
The Lancet. July to Dec. 1879.
The Medical Times and Gazette. July to Dec. 1879.
The British Medical Journal. July to Dec. 1S79.
The London Medical Record. July to Dec. 1879.
The Practitioner. June to Dec. 1879.
Brain. July, Oct. 1879.
The Obstetrical Journal of Great Britain. July to Dec. 1879. The Royal London Ophthalmic Hospital Reports. Dec. 1879. The Journal of Anatomy and Physiology. July, Oct. 1879. The Journal of Physiology. July, Sept. 1879. Edinburgh Medical Journal. July to Dec. 1879. The Glasgow Medical Journal. July to Dec. 1879. The Dublin Journal of Medical Sciences. July to Nov. 1879. The Australian Medical Journal. May to Oct. 1879.
The usual American exchanges have been received ; their separate acknowledgment is omitted for want of space.
Communications intended for publication, and books for review, should be sent free of expense, directed to I. Minis Hats, M.D., Editor of the American Journal of the Medical Sciences, care of Mr. Henry C. Lea, Philadelphia. Parcels directed as above, and (carriage paid) under cover, to Mr. Charles J. Skeet, Bookseller, No. 10 King William Street, Charing Cross, London, will reach us safely and without delay.
All remittances of money and letters on the business of the Journal should be ad- dressed exclusively to the publisher, Mr. H. C. Lea, No. 706 Sansom Street.
The advertisement sheet belongs to the business department of the Journal, and all communications for it must bo made to the publisher.
CONTESTS
OF
THE AMERICAN JOURNAL
OF
THE MEDICAL SCIENCES.
NO. CLVII. NEW SERIES. JANUARY, 1879.
ORIGINAL COMMUNICATIONS. MEMOIRS AND CASES.
ART. PAGE
I. On Affections of the Ear arising from Diseases of the Teeth. By Samuel Sexton, M.D., Surgeon to the New York Ear Dispensary, Aural Surgeon
to the New York Eye and Ear Infirmary. . . . . . .17
II. Typho-Malarial Fever, the so-called "Mountain" Fever of the Rocky Mountain Region. By John Van Rensselaer Hoff, A.M., M.D., Assistant Surgeon U. S. Army. .......... 38
III. On a New Method of Treating Chronic Nasal Catarrh. By Harrison Allen, M.D., Professor of Physiology in the University of Pennsylvania. 60
IV. Abnormal Adhesion of Funis to Placenta, with Accidental Hemorrhage and Abortion. By Alex. Y. P. Garnett, M.D., Emeritus Professor of Clinical Medicine in the National Medical College of the District of Columbia. ............ 73
V. Subcarbonate of Iron as an Antidote in Arsenical Poisoning, with four Illustrative Cases of Recovery. By Charles A. Leale, M.D., of New York. 80
VI. An Experimental Inquiry into the Value of the Carbolic Spray as a Preventive of Putrefaction. By Lewis A. Stimson, M.D., Surgeon to the Presbyterian and Bellevue Hospitals, and Professor of Pathological Anat- omy in the Medical Faculty of the University of the City of New York. . 83
VII. Chloral Hydrate and Camphor in Toxic and Therapeutic Doses. By D. B. Simmons, M.D., Surgeon to, and Director of, Ken Hospital, Yo- kohama, Japan. ........... 89
VIII. On Fractures of the Cranial Bones. By John A. Lideil, A.M., M.D., of New York, late Surgeon to Bellevue Hospital, Inspector of the Medical and Hospital Department of the Army of the Potomac, etc. etc. 91
IX. Fatal Intestinal Obstruction by Gall-Stones. By Frank Woodbury, M.D., Physician to the German Hospital, Philadelphia. . . .124
X. On Litholapaxy. By Robert F. Weir, M.D., Surgeon to the New York and Roosevelt Hospitals, Lecturer on Genito-Urinary Diseases at the Col- lege of Physicians and Surgeons, New York. . . . . .130
XI. A Case of Inverted Womb, with supposed Malignant Disease of its Fundus; its Easy Reposition and Removal of Old Placental('?) Tissue; Perfect Recovery of the Patient. By Walter F. Atlee, M.D., of Phila- delphia. .139
12
CONTENTS.
ART. PAGE
XII. A Case of Reproduction of the Membrana Tympani. By S. O. Richer, M.D., of Washington, D. C 144
XIII. A Case of Croupous Bronchitis; Recovery under Treatment. By Thomas H. Streets, M.D., P. A. Surgeon, U. S. N. Hospital, Yokohama, Japan 148
XIV. Iritis Spongiosa (Fibrinosa). By Swan M. Burnett, M.D., Surgeon in charge of the Ophthalmic Division of the Central Dispensary, Wash- ington, D. C 153
XV. Cyanosis, Congenital Abnormality of the Heart. Two Cases. One Autopsy. By Samuel C. Busey, M.D., Professor of the Theory and Practice of Medicine, Medical Department of the University of George- town, and one of the Attending Physicians to the Children's Hospital, Washington, D. C 159
XVI. Neuroma involving the Ulnar Nerve; Excision with Entire Relief from Pain. By Wm. M. Findley, M.D., of Altoona, Pa. . . 161
REVIEWS.
XVII. The Medical and Surgical History of the War of the Rebellion. Part II. Volume I. Medical History. Being the second medical volume. Prepared under the direction of Joseph K. Barnes, Surgeon- General United States Army. By Joseph Janvier Woodward, Surgeon, United States Army. First issue. 4to. pp. 869. Washington: Government Printing Office, 1879. . . . 163
XVIII. A Treatise on Hygiene and Public Health. Edited by Albert H. Buck, M.D., American Editor of Ziemssen's Cyclopaedia of the Practice of Medicine, etc. 2 vols. 8vo., pp. viii. 792, vii. 657. New York: William Wood & Co., 1879 180
XIX. Chirurgie Oculaire. Par L. de Wecker. Lcqoiis recueillies et redi- g6es par le Dr. Masselon. pp. 419. Paris, 1879.
Surgery of the Eye. By L. de Wecker 186
XX. The Pathology and Treatment of Venereal Diseases. By Freeman J. Bumstead, M.D., LL.D., late Professor of Venereal Diseases at the Col- lege of Physicians and Surgeons, New York, etc. etc. Fourth edition, revised, enlarged, and in great part rewritten by the author and by Robert W. Taylor, A.M., M.D., Professor of Skin Diseases in the University of Vermont, Attending Surgeon to Charity Hospital, etc. etc. With one hundred and thirty- eight wood-cuts. 8vo. pp. 835. Philadelphia: Henry
C. Lea, 1879. 193
XXI. Clinical Medicine : A Systematic Treatise on the Diagnosis and Treat- ment of Diseases. Designed for the Use of Students and Practitioners of Medicine. By Austin Flint, M.D., Professor of the Principles and. Prac- tice of Medicine, and of Clinical Medicine in the Bellevue Medical College, etc. etc. 8vo. pp. 795. Philadelphia: Henry C. Lea, 1879. . . 199
XXII. Manual of the Principles and Practice of Operative Surgery. By Stephen Smith, A.M., M.D., Surgeon to Bellevue and St. Vincent Hos- pitals, New York. 12mo. pp. 690. Boston: Houghton, Osgood & Co., 1879 201
XXIII. A System of Medicine. Edited by J. Russell Reynolds, M.D., F.R.S., Professor of the Principles and Practice of Medicine in University College, London, etc. etc. With numerous additional illustrations. By Henry Hartshome, A.M., M.D., lately Professor of Hygiene in Uni- versity of Penna., etc. In three volumes. Vol. I. General Diseases and Diseases of the Nervous System. Royal 8vo. pp. 1127. Philadelphia: Henry C. Lea, 1879. 204
XXIV. Injuries and Diseases of the Lymphatic System. By S. Messenger Bradley, F.R.C.S., Surgeon to the Manchester Royal Infirmary, etc. 8VO. pp. viii., 144. London- J. & A. Churchill, 1879. . . . 205
CONTENTS. 13 ART. PA G K
XXY. Glaucoma: its Causes, Symptoms, Pathology, and Treatment. By Priestley Smith, Ophthalmic Surgeon to the Queen's Hospital, Birming- ham. With lithographic plates. 8vo. pp. xv., 281. London: J. & A. Churchill, 1879 206
XXYI. Hygienic and Medical Reports. By Medical Officers of the U. S. Navy. Prepared for publication under the direction of Surgeon- General of the Navy. ■ By Joseph B. Parker, A.M., M.D., Surgeon U. S. Navy; Assistant to the Bureau of Medicine and Surgery. 8vo. pp. viii., 1079.
Government Printing Office : Washington, 1879. . . - . .211
XXVII. Lectures on Diseases of the Nervous System. Delivered at Guy's Hospital. By Samuel Wilts, M.D., F.R.S.,*8vo. pp. viii., 472. Phila- delphia: Lindsay & Blakiston, 1879 214
XXVIII. Transactions of State Medical Societies.
1. Transactions of the Medical Society of the State of New York for the
year 1879. 8vo. pp. 703. Syracuse, 1879.
2. Transactions of the South Carolina Medical Association, April, 1879,
pp. xxxix. 85. Charleston, 1879.
3. Transactions of the State Medical Society of Kansas, May, 1879, pp.
117. Lawrence, 1879.
4. Transactions of the Medical Society of New Jersey, May, 1879, pp.
336. Newark, 1879.
5. Transactions of the Medical Association of Georgia, April, 1879, pp.
221. Atlanta, 1879.
6. Transactions of the Rhode Island Medical Society for the years 1878-9,
vol. ii. part second.
7. Transactions of the Connecticut Medical Society, 1879, pp. 214.
8. Transactions of the Arkansas State Medical Society, 1879, pp. 98. . 215
XXIX. Observations on Contraction of the Fingers (Dupuytren's Contrac- tion) and its successful treatment by Subcutaneous Divisions of the Palmar Fascia, and Immediate Extension. Also on the Obliteration of Depressed Cicatrices after Glandular Abscesses of Exfoliation of Bone by a Subcuta- neous Operation. By AVilliam Adams, F.R C.S., Surgeon to the Great Northern Hospital, etc. 8vo. pp. 80. London: J. & A. Churchill, 1879. 219
XXX. Photographic Illustrations of Skin Diseases. By George Henry Fox, A.M., M.D., Clinical Professor of Dermatology, Starling Medical College, Columbus, Ohio. Parts 1, 2, 3, 4. New York: E. B. Treat, 1879. . 220
XXXI. A Manual and Atlas of Medical Ophthalmoscopy. By W. R. Gowers, M.D., F.R. CP., Assistant Professor of Clinical Medicine in University Coll., etc. 8vo. pp. xii., 352. London: J. & A. Churchill, 1879. 221
XXXII. Statistics of Placenta Prasvia collected from the practice of the Physicians in the State of Indiana. By Enoch W. King, M.D., Galena, Ind. 8vo. pp. 50. 1879. . 224
XXXIII. Recent Works on Surgical Diagnosis.
1. A Practical Treatise on Surgical Diagnosis, designed as a Manual for
Practitioners and Students. By Ambrose L. Ranney, A.M., M.D., Assist. Prof, of Anatomy in Univ. of New York. 8vo. pp. xii., 386. New York: William Wood & Co., 1879.
2. A Guide to Surgical Diagnosis. By Christopher Heath, F.R.C.S.,
Professor of Clinical Surgery in University College, London, and Surgeon to University College Hospital. 12mo. pp. xii., 214. Philadelphia: Lindsay & Blakiston, 1879 225
XXXIV. The Heart and its Diseases, with their Treatment, including the Gouty Heart. By J. Milner Fothergill, M.D., M.R.C.P. Lond., Assistant Phys. to West London Hospital for Diseases of Chest (Victoria Park) ; Associate Fellow of College of Physicians of Philada. Second edition (entirely rewritten) . With illustrations. 8vo. pp. xvi., 476. Philadel- phia: Lindsay & Blakiston, 1879 . .227
14
CONTENTS.
ART. PAGE
XXXV. The National Dispensatory; containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicine. Including those recognized in the Pharmacopoeias of the United States, Great Britain, and Germany, with numerous references to the French Codex. By Alfred Stille, M.D., LL.D., Professor of Medicine in the University of Penn- sylvania, and John M. Maisch, Pharm. D., Professor of Materia Medica and Botany in Philadelphia College of Pharmacy. Second edition, thoroughly revised, with numerous additions. 8vo. pp. xi., 1680. Phila- delphia, Henry C. Lea, 1879 230
XXXVI. Vorlesungen iiber neuere Behandlungsweisen der Syphilis. Von Dr. Carl Sigmund, Bitter von Ilanor, etc. Zweite vielfach vermehrte Auflage. 8vo. pp. 160. Wien, 1880.
Lectures upon the Modern Treatment of Syphilis. By Dr. Carl Sigmund, Knight of Ilanor, etc. Second enlarged edition. . . . .231
XXXVII. Physiological Therapeutics : A New Theory. Bv Thomas W. Poole, M.D., M.C.P.S. Ont. 8vo. pp. viii., 220. Toronto The Toronto News Company, 1879 234
XXXVIII. Guide to the Examination of Urine, with special reference to the Diseases of the Urinary Apparatus. By K. B. Hofmann, Professor at the University of Gratz, and R. Ultzmann, Docent at the University of Vienna. From the second edition. Translated and edited by F. Forch- heimer, M.D., Professor of Medical Chemistry at the Medical College of Ohio, Cincinnati. With illustrations. 8vo. pp. 195. Cincinnati: Peter G. Thomson, 1879.
The same. Translated by T. Barton Brune, A.M., M.D., Resident Phy- sician Maryland University Hospital, and H. Holbrook Curtis, Ph.B. 8vo. pp. 269. New York: D. Appleton & Co., 1879. . . .236
XXXIX. A System of Midwifery, including the Diseases of Pregnancy and the Puerperal State. By William Leishman, M.D., Regius Professor of Midwifery in the University of Glasgow, etc. etc. Third American edi- tion, revised by the author. With additions by John S. Parry, M.D. With 200 illustrations. 8vo. pp. 732. Philadelphia: Henry C. Lea, 1879. 237
XL. Eyeball-Tension ; its Effects on the Sight and its Treatment. By W. Spencer Watson, F.R.C.S. Eng., Senior Surgeon to the Royal South London Ophthalmic Hospital, etc. 8vo. pp. 70. London : H. K. Lewis, 1879. 238
XLI. Spermatorrhoea: Its Causes, Symptoms, Results, and Treatment. By Roberts Bartholow, A.M., M.D., Professor of the Theory and Practice of Medicine in the Medical College of Ohio, etc. Fourth edition, revised. 8vo. pp. viii., 128. New York: William Wood & Co., 1879. . . 240
XLII. Drei Falle von Pneumopericardie. Von Dr. Herman Miiller, Privat- docent und Secundararzt der med. Klinik in Zurich. Deutsches Archiv fur Klinische Medicin. Bd. xxiv. Heft. 2. Ss. 158-174. Leipzig, 1879. Three Cases of Pneumopericardium. By Dr. Herman Muller. . . 241
XLIII. H olden' s Manual of the Dissection of the Human Body. Edited by Luther Holden, President of the Royal College of Surgeons, etc., and John Langton, F.R.C.S., Assistant- Surgeon and Lecturer on Anatomy at St. Bartholomew's Hospital. Illustrated with numerous wood engravings. Fourth edition. 8vo. pp. 692. Philadelphia: Lindsay & Blakiston, 1879. 246
XLIV. Health Primers. 16mo. New York: D. Appleton & Co., 1879.
1. Exercise and Training. By C. H. Ralfe, M.D. Pp. 96.
2. Alcohol; its Use and Abuse. By W. S. Greenfield, M.D. Pp. 95.
3. The House and its Surroundings. Pp. 96.
!. Premature Death ; 'is Promotion or Prevention. Pp.94. . . 247 XLV. Clinical Remarks on Gleet, its Causes and Treatment. By J. C. Ogilvie Will, M.D., Surgeon to the Aberdeen Royal Infirmary, etc. 8vo. pp. 31. London: J. & A. Churchill, 1879 248
CONTENTS.
15
ART. PAGE
XLVI. Diseases of Women. By Lawson Tait, F.R.C.S., Surgeon to Bir- mingham Hospital for Women ; Fellow of the Obstetrical Societies of London, Dublin, and Edinburgh, etc. etc. Second edition. 8vo. pp. 192. New York: Wm. Wood & Co., 1879. . 249
XLVII. A Text-Book of Physiology. By M Foster, M.A., M.D., F.R.S., Praelector in Physiology and Fellow of Trinity College, Cambridge. Third Edition, Revised. 8vo. pp. 720. London: Macmillan & Co., 1879. . 249
XLVIII. Memorial Oration in Honour of Ephraim McDowell "The Father of Ovariotomy." By Samuel D. Gross, M.D., LL.D., D.C.L. Oxon. Delivered at Danville, Ky., May 14, 1879. 8vo. pp. 77. Louisville: John P. Morton & Co., 1879 251
XL1X. A Treatise on the Theory and Practice of Medicine. By John Syer Bristowe, M.D. Lond., Physician to and Joint Lecturer on Medicine at St. Thomas's Hospital. Second American Edition revised by the Author. With Notes and Additions, by James H. Hutchinson, M.D. 8vo. pp. 1081. Philadelphia: Henry C. Lea, 1879.
The Theory and Practice of Medicine. By Frederick T. Roberts, M.D., B.Sc, F.R.C.P., Prof, of Materia Medica and Therapeutics at Univer- sity Coll., etc. Third American, from the Fourth London Edition. 8vo. pp. 1041. Philadelphia: Lindsay & Blakiston, 1879.. . . 252
QUARTERLY SUMMARY
OF THE
IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES.
Anatomy and Physiology.
page
Communication between the Aorta and Pulmonary Artery. By Dr. B. Baginsky 253
PAGE
On the Development of the Coloured Blood-Corpuscles. By Prof. Kayem 254
Materia Medica and Therapeutics.
On Benzoate of Soda. By Dr.
Ullmann. .... 254
The Physiological Action and The-
rapeutic Value of Sclerotic Acid.
By Nikitin 255
On Rectal Alimentation. By Prof. Brown- S6quard. . . .256
Medicine.
Exact Period of Commencing the | On the Etiology of Sensitive jSeu- General Treatment of Syphil is. rosis in the Region of the Median
By Prof. Sigmund. . . . 257 | Nerve. By Herr Fragstein. . 259
Asphyxia caused by the Ascaris On Hemiglossitis. By Dr. Noel
Lumbricoides. By Dr. C. Hirst. 258 Gueneau de Mussy. . . . 260
On the Etiology of Tabes Dorsalis. On the Effects of Benzoate of Soda
By Berger 259 in Diphtheria. By Gnlindinger. 260
16
CONTENTS.
PAGE
The Local Treatment of Putrid Ex- pectoration. . . . .261
Purulent Diaphragmatic Pleurisy. By Dr. Noel Gueneau de Mussy. 263
Case of Interrupted Respiration, due to the Movements of the Heart. By Lereboullet. . . 264
Heart Diseases Associated with
PAGE
Scarlatina and Measles. By Dr. Arthur Ernest Sansom. . .265
Phlegmonous Gastritis. By Drs. Glax and Lewandowsky. . .266
Renal Inadequacy. By Dr. An- drew Clark 267
On Salicylate of Soda for Urticaria. By Pietrzycki. . . .268
Surgery.
Traumatic Aneurism of the Scalp. By Dr. W. J. Tyson. . .269
Trephining for Traumatic Epilepsy. By Mr. "James F. West, Dr. Al- thaus, Mr. Bellamy, Mr. Adams, Mr. Hutchinson, Mr. Gay, Mr. Holmes, Mr. Durham, Mr. Bry- ant, and Dr. Douglas Powell. ' . 269
Cholecystotomy for Dropsy of the Gall-Bladcler due to the Impac- tion of Gall- Stone. By Mr. Lawson Tait, Dr. Coupland, Mr. Hulke. Mr. Morris, Mr. Spencer Wells, and Mr. Barker. . . 273
A Case of Uretro-Uterine Fistula cured bv Extirpation of a Kidnev. By Zweifel 275
Tubercle of the Urinary Organs. By Dr. Tapret. . * . .276
Litholapaxy, with the Report of a Fatal Case. By Dr. E. L. Keyes. 277
On the Treatment of Fractures. By Dr. Max Schuller. . . .277
Treatment of Fracture of the Patella by Opening the Joint and Wiring the Fragments. By Mr. Rose, Mr. Adams, Mr. Bryant, and Mr. Lister 278
Ophthalmology and Otology. On Sclerotomy in Different Forms of Glaucoma. By Dr. De Wecker. . 280
Midwifery and Gynecology.
On a Case of Quintuplets. By Dr. Volkmann 281
Difficult Labour from Distension of Foetal Bladder. By Prof. Co- melli 281
On Utero-ovarian Cesarean Ampu- tation. By Dr. Mangiagalli. . 282
Successful Case of Gastrotomy in Extra- Uterine Pregnancy. By Mr. Lawson Tait, Mr. Doran,
Mr. Knowsley Thornton, Mr. Spencer Wells, and Dr. Mat- thews Duncan. . . . .283
On Intra-uterine Therapeutics in the Puerperal State. By Prof. Griienwaldt. . . . .285
Spontaneous Expulsion of a Fibro- myoma. By Dr. Eggel. . . 286
On Castration of Women. By Dr. A. Schucking 286
Medical Jurisprudence and Toxicology.
Fungus Poisoning and its Treatment.
287
THE
AMERICAN JOURNAL OF THE MEDICAL SCIENCES
FOR JANUARY 1880.
Article I.
Ox Affections of the Ear arising from Diseases of the Teeth.1 By Samuel Sextox, ALD., Surgeon to the Xew York Ear Dispensary, Aural Surgeon to the New York Eye and Ear Infirmary.
Some time ago the writer was so much impressed with the frequent co- existence of aural and dental diseases in many of the patients who came to him with the former affection, that he resolved to assume the task of recording the results of any subsequent observations on the subject.
A carious tooth, that seemed to arrest the favourable progress of an acute otitis media purrdenta , was the means of first attracting my atten- tion specially to the teeth as bearing a more important relation to aural diseases than I had previously supposed ; and although the thought was not entirely new to me, nor yet original, the impression thus made by a single striking case was the occasion, subsequently, of more thorough examinations of the mouth in all cases being made.
On how reviewing the records that I have since kept of some fifteen hundred cases, I find that the teeth are more frequently the seat of disease than was at first suspected, for of these fifteen hundred aural cases, perhaps one-third owe their origin or continuance, in a greater or less degree, to diseases of the teeth. In searching the literature bearing on this subject, it is not surprising to find that the earlier writers who con- tributed to the otology of their day, failed to attach much, if any, import- ance to the sympathetic relations between the teeth and ears, although Ambrose Pare (1628), who devoted, comparatively, a great deal of space
1 A Prize Essay, for which the Medical Society of the County of New York awarded a gold medal, Oct. 27, 1879.
" The society does not consider itself as approving the doctrines contained in any of the essays to which the prize may be adjudged." No. CLVII Jan. 1880. 2
18 Sexton, Affections of the Ear from Diseased Teeth. [Jan.
in his work to the parts under consideration, especially to the teeth, found that in toothache the pain was soothed by applying a mixture of opium, castor, and the oil of roses, to the ear. This author, to obtain relief in these cases, frequently resorted to opening s vein behind the ears, or to the application of a small plaster composed of pitch and mastich to the " artery of the temple" on the side where the pain existed. The language indicates that the connection thought to exist was other than nervous. Du Verney (1683), author of the first treatise devoted to the ear, was not aware of the sympathetic nervous connection between the teeth and ears.
The otology of the fathers, indeed, did not include a knowledge of a nervous relationship ; and even at the beginning of the present century the writings of Saunders, Saissy, and others, allude to diseases of the teeth as affecting the ears in a manner most meagre, although anomalies of the throat were spoken of as causing deafness : principally, however, as offering a mechanical obstruction to the faucial openings of the Eustachian tubes. Even Toynbee, Wilde, Triquet, and their contemporaries, failed to contribute .to the knowledge of this subject in any material manner. The important work of clearing up this subject was left to the otologists of the present day, and in turning to our principal writers, we find the nervous relationship of the teeth and ears clearly recognized.
The more recent works, especially of Woakes and Cooper, give con- siderable space to this subject. Regarding the physiology of the nervous relationship, the treatise of Dr. Woakes more clearly establishes it than has hitherto been done.
Since physiological research has drawn attention to the fact that vaso- motor relations create instantaneous communication between parts widely separated — as between the teeth and the ears — we are enabled to make a more satisfactory diagnosis, especially as to etiology, in aural disease, and to establish a more rational system of therapeutics.
Treatment, based on the belief that the ear is nearly always invaded by disease extending from the throat per the Eustachian tubes, will, jt is be- lieved, give place to more successful methods, because founded on a more rational pathology.
The phenomena whereby affections of the teeth excite diseased action in the ears, cannot be better explained than by a reference to the formula of Dr. Woakes ; it reads : —
" The only obvious connecting link between the regions interested, is the con- tinuity of nerve-fibre. The simple continuity of sensori-motor nerves is insuffi- cient to produce the conditions under review, we must seek yet farther for the true medium by which they are brought about. This will be found in the rela- tions of the vaso-motor nerves, and the functions which it is their office to fulfil."
He believes that nearly all sensori-motor nerves comprise fibres belong- ing to the vaso-motor system, and that these fibres run in a contrary direction to the cerebro-spinal nerve with which they are associated.
1880.] Sexton, Affections of the Ear from Diseased Teeth. 19
" Thus, in speaking of a cerebrospinal nerve, say the vagus, we describe it as pursuing a course frOm the medulla to the respiratory organs, and the several viscera which it supplies. At the same time it must be remembered that it con- tains other febrill* in its sheath running from the viscera towards the nerve centres, some of which at intervals leave the sheath and enter a ganglion of the sympathetic, in their course to the general vaso-motor centre, situated in the medulla oblongata, at a point which has scarcely been determined for the human subject, though it has been accurately fixed in the rabbit. These fibres are then centripetal or afferent in their function, conveying impressions from the tissues to the sub-centres constituted by the ganglion, or to the general vaso-motor centre."
These fibres communicate with the caudate cells of the ganglion they enter, and they are thus brought into communication with remote parts through other nerves coming to the same ganglion. Nerves leading from the ganglion to the spinal cord follow its anterior columns, passing up- wards to the primary vaso-motor centre. The same course is pursued by the fibres of this system from the general centre downwards along the anterior columns of the cord, and leaving it when opposite an inter-vertebral foramen, they join a ganglion of the sympathetic, and 44 after similarly mingling with the caudate cells, quit it to seek their several destinations on the coats of the arteries whose calibres they regulate. Further, it is to be noted that by the automatic action of the general vaso-motor centre, the normal calibre or tone of the vessels is maintained." The author quoted, believes that the sympathetic ganglia play the part of sub-centres, acting independently of the general centre, and " that they are also correlat- ing organs by means of which afferent tissue impressions from one direc- tion are reflexly referred to a totally different tract."
The action of the vaso-motor nerves on the arteries, will be better understood by bearing in mind that the middle coat of all arteries contains circularly-disposed plain muscular fibres ; as the arteries become smaller, the muscular element becomes more and more prominent as compared with the elastic element, until, in the minute arteries, the middle coat con- sists entirely of a series of plain muscular fibres wrapped around the elastic internal coat. (M. Foster.)
Now whether the vaso-motor mechanisms depend entirely for their action on the sympathetic system or not, and whatever may finally be regarded as their modus operandi, it is known that —
' ' The tone of any given vascular area may be altered, positively in the direction of augmentation (constriction), or negatively in the way of inhibition (dilation), quite independently of what is going on in other areas. The changes may be brought about by (1) stimuli applied to the spot itself, and acting either directly on the local mechanism, or indirectly by reflex action through the general vaso- motor centre ; (2) by stimuli applied to some other sentient'surfaces, and acting by reflex action through the general vaso-motor centre ; (3) by stimuli (chemicaf blood stimuli), acting directly on the general vaso-motor centre." (M. Foster.)
The changes in the capillary districts are passive in their nature as they (the capillaries) do not possess muscular texture. Their calibre is en- larged when the supply of arterial blood sent to them is increased, and
20 Sexton, Affections of the Ear from Diseased Teeth. [Jan.
when the quantity is less they are sufficiently elastic to accommodate them- selves to the change. The tone of the arteries is maintained through vaso-motor influence, and an example of its withdrawal is seen in flushing, which is due to a loss of tone. During relaxation of the vessels more blood flows into them, and there is an increase of temperature. A dimi- nution in the size of the vessels occasions a flow of blood from the part, and temperature falls.
" Nerve fibres belonging to the sympathetic system are distributed largely to the bloodvessels, but their terminations have not as yet been clearly made out. By galvanic or mechanical stimulation, this muscular coat may in the living artery be made to contract. During this contraction which has the slow character belonging to contractions of all plain muscle, the calibre of the vessel is dimin- ished. During relaxation more blood flows into the artery. Division of the cervical sympathetic of the rabbit affects the circulation on that side, the whole ear being redder than normal, its arteries being obviously dilated, its veins un- usually full, innumerable minute vessels before invisible come into view, and the temperature may be more than one degree higher than on the other side. If the upper end of the cut nerve be now stimulated by the interrupted current, the ear again becomes pale, much paler than normal if the current be strong, the vessels diminish in size, so that the smaller ones disappear, and the temperature falls. When the current ceases, flushing again occurs." (M. Foster.)
Although the trigeminus and eighth pair of nerves, together with the sympathetic, bring into intricate relationship the buccal and pharyngo- nasal cavities and the ears, an anatomical description of their distribution would lead me too far. It is difficult to believe that any considerable lesion of these regions can long exist without affecting the ears (and indeed the eyes), and even more remote regions than those mentioned are fre- quently brought into sympathetic relationship with these organs of special sense as daily clinical experience proves.
Having presented this statement of the generally accepted theory of vaso-motor action, I shall now bring forward some of the diseases of the teeth that are commonly concerned in giving rise to sympathetic aural disease. The general surgery of the jaws, including the pathology of the subject, does not concern us as much as the minor diseases which are more likely to be neglected. It must here be confessed that, as a profession, our knowledge of the diseases of the teeth, gums, etc., is not what it should be. The teeth, which were once universally regarded as lifeless objects, are still treated by the profession in general without a due regard to the influence they exercise over the health of the individual.
It was not until the beginning of this century, when John Hunter, Fox, and others, laid the foundation of their true pathology, that the teeth were treated on a scientific basis. Within the present decade Wedl and others have brought the pathology of the teeth up to the standard of modern re- quirement. The apathy which has always existed on the part of the pro- fession regarding this subject has left the treatment of diseases of the teeth in the hands of men who have occupied themselves almostly exclusively with its mechanical department, and who, as a rule, have but little to do
1880.] Sexton, Affections of the Ear from Diseased Teeth. 21
with the teeth in a medical aspect. It is greatly to be regretted that a field of such interest has been abandoned by the profession. Many affec- tions of the teeth lead to most grave and intractable diseases of the regions ~ presided over by the sympathetic system, which are often suffered to be long unattended before they are brought under appropriate management. Thus an ear, eye, or throat difficulty may become firmly seated, or a neuralgia, which renders life intolerable, established. When I look back at the operation for the removal of Meckel's ganglion, which I twice wit- nessed, for the relief of facial neuralgia, it occurs to me that the most simple of remedies could have controlled that disease when it was first induced as was probable in these instances by a carious tooth.
The teeth are a prolific source of nervous diseases for sufficient reasons ; their development and decay, ill usage by improper foods and drinks, the unhealthiness of the saliva, the lack of cleanliness, etc., are all sources of greater or less irritation. The mouth, moreover, being richly supplied with nerves and bloodvessels which are distributed to its extensive* mucous membrane, is highly sensitive to all of these influences.
The ear begins to suffer from sympathetic dental irritation from the time of the appearance of the two central incisors of the lower jaw, which are cut at about the seventh month, until the completion of the first denti- tion, which is usually before the end of the second year. The gums may become alarmingly swollen during this eruption of the milk teeth, and in some rare instances periostitis of the jaw occurs. Wedl says, that accord- ing to Trousseau, the —
" Swelling of the gums is not an aching produced by the tooth beneath, but is rather due to the inflammation, and he adduces in support of his assertion the fact that this tmgescence occurs and disappears again, without the emergence of the tooth through the gum ; direct experiment also confirms this view, for if a needle be inserted into the swollen gum, it is found to be three or four millimetres in thickness, from the surface down to the tooth. . . . The painful swelling of the gum and the toothache give rise to various symptoms, particularly to flush- ing of the cheeks, salivation, fever, agitation, and likewise to a few nervous symptoms."
Catarrhal affections of the buccal cavity and of the naso-pharynx are at this period of common occurrence and increase the dental irritation.
Caries of the milk teeth is frequently met with, and a very considerable number of children have toothache from this cause. The irritation in the infantile mouth from the causes above enumerated creates more or less sympathetic hyperagmia of the ears before attention is directed to that re- gion by earache. It is, therefore, generally found that a purulent otitis media has been established before the physician is called, and not unfre- quently great deafness already exists, the amount being difficult to estimate at this age, but in some cases it is sufficient to establish deaf-mutism : in- deed, the latter frequently occurs from non-purulent affections which pro- duce changes in the conductive apparatus that are unrecognizable by an examination per the external meatus. I think but few aural catarrhs of
22
Sextox, Affections of the Ear from Diseased Teeth. [Jan.
infancy have not been preceded by the hypersemia of first dentition. The instances of grave cerebral irritation from cutting the milk teeth are quite common, and tend to complicate the diagnosis of acute aural disease.
Second dentition commences about the sixth or seventh year, the first molars of this permanent set inaugurating the shedding of the milk teeth, which, with their alveoli, suffer reabsorption. Second dentition is con- cluded (with the exception of the wisdom teeth) by the cutting of the second permanent molars at the twelfth or thirteenth year.
The permanent teeth are liable to be attacked by caries as soon as they are cut. The first of this series, sometimes called the "six-year molar," is, according to Dr. Frank Abbott (manuscript communication), much exposed to decay when cut, as it is then imperfectly developed and very susceptible to the usual causes of decay, such as the lodgment of foods in the imperfect spots, etc., and furthermore it is generally thought to belong to the temporary set, and no notice is taken of it until pain results from exposure of the pulp cavity caused by excessive decay : children under eight years of age frequently experience the loss of the entire crown of this tooth from caries, and a neglect to preserve it often leads to inflamma- tion and abscess, which latter may open on the gum or face, or in severe cases necrosis of the jawbone may result. This particular grinder is, therefore, a source of much earache and toothache, every fresh cold caus- ing an exacerbation of the nervous irritation. The other permanent teeth are not exempt from attacks of caries at this period. Aural affections that have arisen from the sympathetic irritation of the first dentition are, in many instances, no sooner cured than they are again aroused into sudden activity by the cutting of the second teeth, the eruption of each tooth being the signal for an earache and otorrhoea.
The act of cutting the second teeth is attended by no greater difficulties than the first, unless there should be irregularities of structure or arrange- ment, anomalies that are, however, not unfrequent. Heath relates a case of malposition of the teeth that gave rise to a tumour ; in this instance some supernumerary teeth were found imbedded in the upper jaw of a patient aged twelve years.
During the period of the irruption of the second teeth the child begins his active out-door life ; and, indeed, the struggle for existence which now begins, calls for exposures before unknown. Catarrhal affections especially are now frequent.
A short time ago opportunity was afforded me to examine the aural cases in a large charitable institution containing children of both sexes who were almost exclusively within the period embraced by second den- tition. About six per cent, of the inmates were found to have otitis media purulenta, or were the subjects of earache. (I doubt not the actual number affected with aural disease was far greater, for only those reported who had eaiache or offensive discharges.) The examination of this group
1880.] Sexton, Affections of the Ear from Diseased Teeth.
23
of over thirty children, where second dentition was active, impressed me more than any previous observations on individual cases. In some of these cases there was earache and toothache at the same time, while in others the exact location of the pain could not be determined. The con- dition of the teeth of these children afforded an instructive study of this subject ; in all of them some anomaly was found to exist ; either the irruption of the teeth themselves had greatly irritated the gum, and this was especially the case where fragments of the coronary substance of the milk teeth still remained attached to the gum, or the second teeth were irregular, or carious. A general catarrhal condition of the mouth, aggra- vating all the above conditions, was commonly present.
During the first and second dentitions, it may be stated incidentally, the mouth has but little rest. The whole of the period of the first is fre- quently an uninterruptedly painful process, which is rapidly followed by the steady advance of the second teeth, whose early decay is imminent. To this can be added the irritation of adherent fragments of the milk teeth, and the not unfrequent anomalies of development, neglect of cleanliness of the mouth, and the presence of abnormal saliva. Affections of the throat, nose, and other parts, when present, increase all of these difficul- ties. The ear is particularly liable to attacks of catarrh when hyperemia exists from any cause, and there are but few persons who pass through the period of childhood without having at some time experienced from this source an earache.
The general health, moreover, can scarcely fail to suffer from this local irritation, as well as from the imperfect assimilation that arises from the difficulty experienced in the mastication of food.
The appearance of the third molar, or wisdom tooth, is very frequently the source of grave aural affections, and if the ear be found in a diseased condition when its irruption begins, there will be an aggravation of the malady. Prosopalgia, abscess, and even necrosis of the jaws, are very often developed by this irritation. The difficult irruption of this tooth, which comes through the gum between the 18th and 30th years, is owing mainly to the density of the alveolus and covering membrane, which at the late time of its appearance resist penetration.
Malposition of the wisdom tooth from anomalies of the germ is of occa- sional occurrence, and when from this cause it occupies a horizontal or oblique, position in the jaw, and is, in cutting, urged onward against the second molar, irritation results. In these cases the grinding surface of the wisdom tooth presses against the root of the second molar, causing greater or less neuralgic pain. Insufficient length of the jaws, especially of the lower one, occasions crowding, and obstructs the irruption of these teeth. In numerous instances the inflammatory action is not confined to the teeth, but the connective tissue as far as the pharynx is involved. Dr. Abbott (Ms. communication) relates two cases where phlegmonous inflam-
24 Sexton, Affections of the Ear from Diseased Teeth. [Jan.
mation proved fatal by asphyxia, and another, in which the abscess in the pharynx was ruptured by the patient, who violently grasped his throat to escape suffocation. Immediate relief was thus obtained, and ultimately he recovered. In this case the offending tooth, together with the first and second molars and the two bicuspids of the same side, with their alveolar attachments, were lost by necrosis.
At the present time a patient, aged 24 years, is under my care, who had a mild attack of aural inflammation from sea-bathing ; the membrane not clearing up, as I was accustomed to witness, a more close examination of the mouth was made, when it was discovered that a superficial abscess had formed over the left lower wisdom tooth of the same side. Closer inquiries elicited the fact that this tooth had been a source of more or less irritation for a year or two. Upon its removal the gum slowly healed, and the aural symptoms began to improve.
Another case has just been seen by me, that of a lady, aged 21 years, who has gradually lost her hearing during the past 18 months, and can now only hear shouting. For more than a year past earaches have been frequent, and the tinnitus aurium was so distressing that her rest at night was much broken. The membrane have become atrophied, and retraction has taken place. Examination shows the cause of this state of things to depend on the irritation of both the lower wisdom teeth that penetrated the gum with difficulty. Her upper wisdom teeth can be felt emerging from the maxillary tuberosities of the superior maxillary bone, and from her former experience trouble from their irruption is anticipated.
Sometimes these teeth are very late in cutting. Dr. Abbott relates (Ms. communication) the case of a man, aged 60 years, under his own observation, whose two upper wisdom teeth have just appeared.
Irregularities of this tooth are often observed. Heath, in his work on the jaws, reports the case of a woman where an upper wisdom tooth pro- jected through the cheek ; and he also mentions the fact that abnormally placed molar teeth have penetrated the inner plate of the alveolus, and lodged beneath the mucous membrane of the palate.
I myself have frequently observed anomalies of this tooth, especially where it has presented its grinding surface towards the buccal wail. The irritation in the jaw occasioned by this tooth is very apt to be soon felt in the ear, and the hyperemia thus occasioned in the external meatus or drum-head may easily mislead as to the real cause of the difficulty.
Should the throat be involved, as indeed it is likely to be, in these cases of difficult dentition, the sympathetic action in the ears will be found to depend also on influences other than the irritation of the dental filaments of the fifth nerve, for the pharyngeal and tonsillar branches of the eighth cranial nerve will bring the throat into direct relationship with the sym- pathetic system through which the ear is affected.
Severe aural irritation long continued may establish an inflammation,
1880.] Sexton, Affections of the Ear from Diseased Teeth.
25
the etiolog}r of which will be obscure, especially if the patient has been exposed to well recognized causes of aural disease, unless the part taken „ by the teeth be kept in mind.
However important the aural affections from the first and second den- titions may be regarded, they are equalled by those arising from diseases of the teeth subsequently. These affections of the ear in youth are nearly always of a painful nature, while, on the contrary, in those of later years that symptom is more likely to be absent.
The pain of the teeth, which we familiarly associate with their inflam- matory condition, is signally absent in many of their affections, and it is to the absence of this symptom that their chief danger is attributable. Clinical experience has furnished me with numerous examples illustrative of this fact, where most extensive and destructive disease of the teeth, gums, etc., were wholly unrecognized by the patient until his attention was drawn to them as the cause of tinnitus aurium and deafness.
The principal disease of the teeth met with at the period now under consideration, is- caries. On its frequency it is unnecessary to dwell, for but few individuals have failed to experience the nervous irritation by which it is sometimes accompanied.
Decay of the coronal structure of the teeth is not in itself painful, but, indirectly, it frequently causes irritation by the mechanical injury done to the tongue or gums by the sharp edges and points. Thus a jagged tooth may produce abrasions and ulcers on the tongue, or during the act of mas- tication the gums may be wounded. Hilton (" Rest and Pain," New York, 1879, page 45) gives a case where the tongue was wounded by a carious tooth, and the gentleman affected suffered greatly from a persist- ant earache, for which he had received local treatment without any relief being obtained. Mr. Hilton, on being consulted, discovered an ulcer on the tongue, which rapidly healed when the rough edges of an adjacent tooth were smoothed off, and there was no return of the disease.
A case has just passed out of my own hands which has an interest in this connection ; a child was suffering from an earache, the cause of which was not apparent until an examination of the mouth showed that the aural difficulty had its origin in the irritation produced by a fragment of enamel, left behind by a milk tooth, that was wedged in the gum along the side of a newly cut molar. The membrana tympani in this case was de- cidedly inflamed. The removal of the foreign substance from the gum, however, cured the disease.
The buccal mucous membrane, likewise, becomes diseased from the sharp points of teeth which cause its ulceration.
A consideration of the general pathology of the teeth would be beyond the scope of this paper, but regarding the progress of the caries which at- tacks the crown of the tooth it may be said, that it goes on, when not arrested, until finally it perforates the pulp cavity, when usually pain is
20
Sexton, Affections of the Ear from Diseased Teeth. [Jan.
.experienced. In many instances slight changes of temperature in the air inhaled, or in the fluids drank, will cause intense pain in an exposed dental pulp or unprotected neck. During pregnancy this sensitiveness seems to be much greater, and facial neuralgias, etc., are more common. There are, however, a great many persons who lose many or all of their teeth from caries without experiencing any pain, but who, nevertheless, seem to have reflex irritation affecting the ears all the same. These cases are fre- quently most grave as regards the incurable deafness resulting, because of the painlessness of the dental disease as well as of the long-continued aural hyperemia thus excited.
Inflammation, however, is seldom confined to the dental pulp, although it may in certain cases remain a long time in a chronic state. The peri- osteum of the root, and of the alveolus, is sooner or later the seat of acute or chronic inflammation, which may not remain confined to a single tooth. The gums as well as the periosteum are usually involved in the inflamma- tory process, which, in severe cases, extends to the jaws, the connective tissue, the glands, etc. Suppuration finally gives relief to these cases, although in some instances a train of grave and more chronic action sets in to last for months or years. Abscess of the gum is a common occurrence in connection with inflammation of the teeth. Affections of the antrum and nose can only be alluded to here, although, when present, they should not be overlooked in the treatment of aural disease.
A painless affection of the teeth is described by TTedl, which may be regarded as likely to excite reflex aural disease without the knowledge of the patient. He says : —
"In these cases, the gum becomes detached from the neck of the tooth, and pressure upon the alveolus forces out a puriform fluid. This condition, which has been described as pyorrhoea alveolar is, particularly by French writers (Toirac, and subsequently Desirabode), results, without notable pain, in the loss of the affected tooth. It also attacks whole sets of teeth in one or another jaw, and is met with, more frequently, in persons of middle age, and may last several months and even years. At last all the teeth in the jaAv become loose and are lost. While the latter effect is being produced, the inflammatory symptoms in the gums often disappear apparently ; but if pressure be made with the finger along the root, towards the neck of the tooth, a tenacious gelatinous fluid oozes out, indicating the existence of inflammatory affection. ... In these cases, then, we have to do, first of all, with a catarrhal inflammation of the gum, which afterwards extends to the root membrane."
Irritation from concealed fangs, left on extraction, or after decay of the rest of the tooth, is frequent, and from this source neuralgias arise in which the ear participates in numerous instances.
Hypertrophies of the teeth and alveolar processes are a common result of continued irritation of the dental nerves. Those of the periosteum of the root are, perhaps, the most common. These proliferations (exostoses) of the teeth may augment the size of the roots affected to several times their normal growth ; they are more frequently found on the bicuspids and molars than other teeth ; they are of slow development and give rise to
1880.] Sexton, Affections of the Ear from Diseased Teeth. 27
painful neuralgias. A case is reported in the Quarterly Journal of Den- tal Science, 1857 (cited by Wedl), by J. L. Levison, where death ensued from this cause, the irritation of the exostosis exciting inflammation of the membranes of the brain. Tomes (" System of Dental Surgery" cited by Wedl) reports two cases of epilepsy arising from exostoses of the teeth.
Abbott (Ms. communication) reports the case of a lady, aged 60 years, who suffered greatly from neuralgia for ten years, during which time she had two operations performed (division of dental nerves) without benefit. The removal of a tooth having on its root an exostosis gave entire relief.
In another case all the molar teeth were removed from the upper jaw of a lady for neuralgia, and were all found to have hypertrophied fangs. It is noted as of interest in this case that the teeth were all sound and had an- tagonizing teeth.
Wedl remarks that : " Exostosis is a disease of old age. The painful- ness is due to increased tension of the nerves of the periosteum of the root, and to secondary affection of the branches of the nerves of the pulp.'* Where aural disease has been established from this cause, the neuralgias also present are frequently thought to have their origin in the ear.
Catarrhal inflammation of the gums occurs at all ages, and' usually in connection with affections of the teeth. Its duration when chronic in character is indefinite. Chronic catarrh of the gums may give rise to periostitis of the roots of the teeth, when reabsorption of the margin of the alveolar processes sometimes takes place, and the tooth becomes loos- ened. Catarrh, however, is usually confined to the incisors, and seldom attacks all the teeth at the same time.
In acute exanthemata the gums are subject to irritation, and may after- wards remain in a hyperaemic state, especially during the period of denti- tion.
Hypertrophy of the gums and Epulis must be regarded as probable causes of aural disease.
Anomalies of secretion of the mouth are of frequent occurrence, and an excess of either alkalinity or acidity may exist.
Odontolithus depends on an excess of the normal alkaline condition. Under the head of tartar, Wedl describes several varieties of this affection, The most common are the white-porous, the gray-brownish, dark -brownish, dark brown with black superficial layers, now and then like ebony, and dirty green. The deposit of tartar on the teeth begins at the border of the gum, and insidiously progresses until, in some instances, one or more of the teeth are entirely covered.
Ambrose Pare (English translation by Tho. Johnson, London, 1634, p. 666 et seq.) described this condition as "Earthly filth of yellowish colour which eats into them [the teeth] little by little as rust eats into iron. . . . This rusty filthiness, or as it were mouldiness of the teeth doth also oft- times grow by the omittings of their proper duty, that is chawing.'*
28 Sexton, Affections of the Ear from Diseased Teeth. [Jan.
Wedl says, " Castle asserts that the tartar sometimes is deposited even in the foramen which serves for the transmission of the dental nerves, and occasions severe neuralgias in the branches of the fifth pair ; that it is de- posited, also, upon artificial teeth, upon the gold and silver or gutta percha on which the artificial teeth are set, but never within or upon the alveolar processes."
The coronal surfaces of the teeth are unaffected by the contact of tartar, but it soon sets up irritation of the gums which become swollen, bleeding easily, and finally suppurating in the severer cases. There is a retention of purulent mucus and particles of food, which undergo decomposition ; and catarrhal inflammation with its secretions is frequently present and in- creases the formation. The teeth, as the disease advances, become loos- ened, and sometimes toothache is present. The tartarous masses, when rough, irritate the gums. This disease is said to be the most frequent cause of dental caries.
Tartar seldom attacks the teeth before the sixth year, but children are sometimes subject to its rapid formation.
The foul breath of this affection is a prominent symptom ; in fact a deposit of small extent is often quite sufficient to taint the breath, and when other cause for foul breath is unknown the mouth should be examined.
This most superficial presentation of some of the affections of the teeth scarcely serves as an introduction to the interesting pathological field to wdiich so many aural diseases owe their origin, but it is hoped that from what has been brought forward a better knowledge of the etiology of aural diseases may finally be obtained.
From a careful study of some of these affections I have thus been led to the conclusion that they may arise from causes not indicated by the ac- cepted etiology: such are diseases of the meatus auditorious externus, known as seborrhoea, obstructing accumulations, diffuse and circumscribed inflammations, and inflammations of the middle ear.
Any treatment of these affections, based on local symptoms alone, will frequently be unavailing, and success can hardly be assured without atten- tion being given to their true causes. A familiar illustration of the modus operandi of the above-mentioned affections of the meatus is witnessed where the nervi-vasorum supplying the vessels that go to this region con- nect by their filaments through some of the sympathetic ganglia with the nerve coming from a diseased tooth. The result of the irritation of the dental filament of the fifth pair is a transmission of the irritation along the nervous route thus established to the ear, where vessel dilatation takes place. The vessels going to supply the meatus are thus distended beyond their normal state, and congestion, acute or chronic, takes place. Pain in the tissues is then experienced as a result of an acute attack, or on the other hand, where chronicity is the condition, pain is less marked. We Lave here to do, probably, with a reflex irritation conveyed to the anterior
1880.] Sexton, Affections of the Ear from Diseased Teeth. 29
auricular branch of the temporal artery in its ramifications on the walls of the meatus auditorius externus with resulting hyperemia of the part. One sequence of active hyperemia may be diffuse inflammation of the meatus ; another may be circumscribed inflammation, or chronic hyperemia may exist, resulting in an unusual secretion of cerumen. The latter condition remaining active for a longer period of time, the meatus may be completely occluded by the hypersecretion, and intermittent periods of excitation will most likely be attended by exfoliations of epithelium, which give rise to ceruminous plugs of alternate layers of epithelium and cerumen, a trans- verse section of which will possess the characteristic annular appearance of an exogenous growth. When a furuncular inflammation is the conse- quence of this vaso-motor action the stage of hyperemia has, of course, been passed, and we have to deal with a true inflammatory process, the persistency of which is well known.
The treatment of these boils in the ear is less likely to be unsuccessful when their remote cause is ascertained. Plyperemia thus induced in the external auditory meatus by reflex action frequently manifests itself by a slight increase of the normal ceruminous secretion, or by an itching with a desire to scratch the parts ; or there may be a distressing feeling of formication deep in the ears.
The fact that the conductive apparatus in many of these diseases of the meatus is but little affected seems to strengthen this hypothesis of their origin, for the tympanum receives its principal blood supply from the tympanic branch of the internal maxillary and the stylo-mastoid branch of the posterior auricular, sources independent of the vascular supply of the meatus. It is quite unlikely, however, that any serious aural trouble can long exist in any given region without neighbouring tissues being more or less involved.
It is a significant fact, worthy of mention in this connection that the sympathetic aural affections of infancy and youth are principally confined to the middle ear, and it should be borne in mind that the entire nervous distribution for the milk teeth, together with their alveoli, etc., give way to another development belonging to the teeth that are destined to be permanent.
Affections of the root membrane may arise from the use of mercury, which acts through the gums, and may affect a whole set of teeth, espe- cially those of the under jaw, which are most in contact with the saliva. The teeth are, without much if any pain, forced out of the alveolar pro- cesses by the swelling of the periosteum. Albrecht (cited by Wedl) states that several other substances may produce similar effects, but that it is not such a common occurrence with them as it is with mercury. Such are the preparations of gold, copper, arsenic, antimony, iodine, and the em- ployment of digitalis and opium, castor and croton oils, and cantharides may have a like effect. A dark-brown deposit from tobacco smoke is
30 Sexton, Affections of the Ear from Diseased Teeth. [Jan.
often found on the lingual surface of the upper molars, and to a less extent on the teeth. This deposit, which may attract tartar, occurs frequently in connection with denudation of the tangs, especially among seamen, who are known to be great smokers. In this affection a gradual encroachment on the gum takes place, causing its absorption, a process favored, perhaps, by senile changes, as youthful smokers seem to be exempt.
In the foregoing pages I have endeavoured to show some of the injurious influences that diseased teeth have on the ear, and it now re- mains to consider the no less important ones that arise from the attempts made to preserve them, or replace them, when lost, by artificial devices.
Cavities in the teeth are filled with a variety of substances when the ravages of caries become manifest. I shall only allude here to those known to be injurious, premising, however, that future investigations may, in throwing more light on the subject, determine that other fillings are inimical to health.
The most universally used filling, excepting perhaps gold, is an amal- gam consisting of about two parts of tin, one of silver, and as much mercury as will cause the mass to adhere together. Actual experiments show that 0.12 grammes of the tin and silver mixed as above will require 0.09 grammes of mercury to form the cohesive mass used by dentists for filling teeth. Where ordinary care is not exercised in the preparation of this material, a larger quantity of mercury would remain. The quantity of this amalgam inserted in a single tooth varies from 0.60 to 4.00 grammes, and in the mouths of many individuals as much as 20.00 grammes have been found inserted in the teeth. This amalgam, composed so largely of mercury, is usually much exposed to the attrition of mastica- tion and the movements of the tongue and cheeks. The free mercury which it was found to contain by Dr. William Stratford (Ms. communica- tion), is worn off in small particles by the friction in the mouth. These particles, when submitted to dilute hydrochloric acid, yield a chloride of mercury. That toxic effects may result from wearing these fillings in the teeth is, therefore, established.
Of fillings, in general, it may be said that not unfrequently necrosed matter or a diseased dental pulp are covered up by fillings inducing great irritation from the confined products of inflammation or decomposition. Although this condition is usually characterized by great pain, yet when the irritation assumes a chronic form, it may long exist without there being sufficient pain to attract attention. Under these circumstances caries and periostitis may supervene, and even exostosis of the fangs may occur.
Amalgam fillings are frequently built out, as it were, on a carious tooth, and after gradual disintegration from wear, their roughened surfaces may cause ulcers on the gums or tongue.
It lias been observed that when teeth have amalgam fillings, the effect is to weaken the enamel.
1880.] Sexton, Affections of the Ear from Diseased Teeth. 31
A variety of metals are sometimes found in the teeth, such as gold, „ platinum, silver, tin, and amalgam, and even different metals are often in- serted in the same tooth, sometimes in the same cavity. When a metallic or vulcanite plate is also worn in the mouth, the conditions for harm are yet more favourable.
Artificial teeth are worn by an exceedingly numerous class, and it is believed that the health of a large number of these people is imperiled by the material used in the construction of plates, as well as the methods of fitting them to the mouth. This subject, therefore, has an interest which concerns the profession at large, as well as the specialist. The healthful- ness of plates worn in the mouth, especially the vulcanite, has been much discussed, but no definite conclusions in regard to the matter seems to have been reached ; at all events, the dentists in this country, to a limited number only, reject materials the use of which is thought to be injurious. The extent of the injury sustained by the race, traceable directly to the harmfulness of dental work, cannot be easily estimated, for those who have defective teeth prefer that fact to be unknown to others, and dentists have not always found it to their interests to discard present methods before less harmful ones are discovered. It is probable that the demand for cheap dental work has led to the more frequent employment of these injurious substances. These plates are frequently put into the mouth over carious fangs, inflamed gums, and collections of tartar, completely encasing them, and retaining the foul secretions and decomposed particles of food usually present. The ingress of air or cooling liquids is prevented under these circumstances, and the decomposition of the retained fluids, etc., is thereby favoured. The upper plates are especially obnoxious under these circumstances. Entire plates are often found under these conditions, sup- porting one or two artificial teeth only.
Plates are constantly found in the mouth as described above, without pain or apparent inconvenience to the wearer, owing to the tolerance acquired by long use. That septsemic poisoning may occur under such favouring circumstances is possible, for the diseased tissues are frequently bathed in pus.
That we should find this state of things common among the uninformed is not a matter for surprise, but the neglect which the subject has received at the hands of the profession is to be regretted. It would be imprac- ticable to bring forward here the numerous cases where, from a want of proper knowledge of the subject by both physician and dentist, permanent injury to the patient has resulted from wearing unsuitable plates in the mouth.
One instructive case, however, may be related with advantage where the victim was a physician under my own observation. He had worn in his mouth for six years a gold plate supporting two upper incisor teeth. The plate seemed to be satisfactory in every way, when the wearer, find-
32 Sexton, Affections of the Ear from Diseased Teeth. [Jan.
ing his breath becoming very foul, applied to a dentist to have removed any tartar that might have accumulated on his teeth. Tartar was only suspected to exist on the lower incisors, but the dentist, who in this instance was also a physician, thought it well to explore the whole mouth, when, to his patient's surprise, he found the gum to be partially detached from the lingual surface of all the upper teeth, the denudation extending down the teeth a distance of from five to seven millimetres below the gum. The origin of the foul breath was now discovered to be the ulcerous con- dition of the separated gum, the retained pus soon becoming decomposed. The denuded fangs were slightly coated with tartar. The patient now re- called to memory the fact that for more than a year he had experienced tinnitus aurium and slight deafness. This state of the mouth was attributable to a bad fitting gold plate, which pressed the teeth of the upper jaw where the gum was attached, and its constant movements kept the gum in a hyperasmic condition. In this instance the patient was un- conscious of any disease in his mouth. He was in the prime of life, and his health in general was unexceptionable, yet he himself was experiencing the modus operandi of the denudation of the teeth from disease resulting from the pressure and movements of an ill-fitting plate in his own mouth.
Experiences like the above are by no means infrequent, and it is to be feared that the teeth are, in too many instances, treated by those whose mechanical skill is greater than their pathological acquirements.
Gold, platinum, and vulcanite are the principal substances used in the construction of plates ; of the latter, more will be said further on. Silver and celluloid are sometimes also used. Gold is never employed in its purity, but is alloyed with silver and copper down to 18 or 20 karats of fineness ; gold plates decompose slowly in the mouth, but some old plates readily yield, when washed by saliva, traces of copper. Silver is liable to be attacked by the acids of the saliva or foods, and, is, therefore, not a de- sirable metal for plates. Platinum, on the contrary, is least liable of all metals used for this purpose to be affected by chemical agents ; where its use requires great inflexibility, it is hardened by the addition of iridium. In all kinds of plates the mineral teeth are fastened by means of platinum pins.
It should be noted that in all of the plates (excepting, perhaps, those of platinum) more than one kind of metal is used in their construction, which arrangement may admit of chemical action taking place, and where a gold plate touches amalgam fillings the latter seems to wear away more rapidly. The same result has been observed where amalgam and gold fillings touch. Metallic plates are thus often found in contact with fillings. What the effect of these metals, constantly worn in the mouth by some individuals, may be on their health, cannot at present be stated with certainty, but the well-known fact that when two different metals are brought into contact in the presence of a dilate acid or solution of a salt, a current of elec-
1880.] Sexton, Affections of the Ear from Diseased Teeth. 33
tricity is generated, should lead us to infer that their harmlessness to either w the sick or well is problematical.
The questions of the action of metals on the body in health and disease — metalloscopy and metallotherapy — were prominently brought forward by Dr. Burq thirty years ago, and Charcot and others have recently com- pleted an investigation of the subject, a report of which is just issued. From the existing knowledge on this subject, however, we cannot derive any assistance, and a further consideration of the subject would lead me too far.
Vulcanite plates, however, produce diseases that are more frequently the source of reflex aural disease than any of the others worn. They have been in use for over twenty years, and there adoption is very general. The constituents of this material are caoutchouc, the sulphur required in the vulcanizing process, and vermilion, or the sulphide of mercury, used for the color it imparts. The quantity of the latter ingredient is believed to be equal in weight to both the other substances mentioned, accurate knowledge, however, is withheld by the manufacturers. These combined substances form a plastic mass which is found in commerce as thin sheets suitable for moulding into plates for the vulcanizing process. This plastic substance when chewed for several hours is so much broken up that it parts with the vermilion, and Dr. Stratford (Ms. communication) found that when the saliva of persons thus chewing it was treated with a suitable re- agent, it yielded a salt of mercury.
Two instances have come to my knowledge where the employes in a dentist's laboratory acquired the habit of chewing this soft preparation. They were about 18 years of age. One of these young men who had been addicted to this habit for nearly a year, had an eruption on the inside of his arms, which remained while he continued this practice ; the eruption was red and scaly, and the itching was excessive. The other youth only continued the practice for three weeks, but during this period of time he was rarely without a large wad in his mouth. In a week's time after commencing, he experienced itching on the inner aspect of the arms, and during the second week there was an eruption similar to that of the person above described ; the eruption extended to the face and legs, and the itch- ing was most intolerable, especially at night.
During this time he felt badly, and his lips were sore. At the end of the third week he abandoned the habit and the "eruption of the skin gradu- ally disappeared. Neither of these persons voluntarily swallowed the saliva, which was very copious during the chewing, as it had a " sickish taste." The sputa became coloured by the vermilion after several hours active chewing. The history of theses cases is not complete, as I myself only saw the eruption on the arms of the youth to whom reference was last made above. I presume, however, it was the affection described by authors under the name of eczema mercuriale. No. CLVII Jan. 1880. 3
Si Sexton, Affections of the Ear from Diseased Teeth. [Jan.
To bake this soft material into plates of sufficient hardness to support artificial teeth, a temperature of about 160° C. is required. This degree of heat is not sufficient to completely volatilize the contained vermilion and sulphur. Vulcanite plates are porous, and when the process of baking is imperfect, as is frequently the case, their colour is brighter, they are less dense, and, therefore, when used, more readily part with the vermilion and sulphur which they contain. In the process of finishing these plates, the fine filings become packed into these pores, ready to be gradually given up as the plate is worn. The acids, which sometimes are found in the mouth, do not materially affect vulcanite plates, but when subjected to the action of the saliva, which is ordinarily alkaline, it is believed that they are liable to become softened, and, therefore, more easily broken down. The gradual disintegration of these plates, as they are worn in the mouth, liberates a salt of mercury whose poisonous effects are well known.
Until physiological science has more accurately determined the effects of small quantities of mercury and sulphur when taken into the system by absorption, and until we are able to estimate how much of these drugs are given off when the plates are constantly retained in the mouth, no reliable estimate can be formed of the effects of wearing them. In judging of the action of powerful agents like the salts of mercury, the action of minute quantities of other drugs may serve us as a guide : thus, Dr. E. G. Loring (Piffard's edition of Philips's Materia Medica and Therapeutics, page 28, et seq.) states that he has dilated his own pupil for twelve hours with the 4 6 0V00 0I> a grain 0T" atropia. I myself have tasted the bitter in 20^0 0 of a grain of picric acid. Arguments, however, are scarcely required as to the undesirability of taking mercury into the system when not inten- tionally administered under competent advice.
Vulcanite plates, besides yielding a poison, are otherwise injurious to health. Inquiries from dentists elicit the fact that at least one-third of all those who attempt to wear them experience great irritation of the mouth, an irritation that is frequently accompanied by hyper-secretion of the buccal fluid. The sufferer usually lays aside the plate until informed of the necessity of becoming accustomed to its presence by uninterrupted use. Vulcanite is a non-conductor of heat, and the effect of its contact with the highly sensitive tissues of the mouth is to produce hyperemia and inflam- mation. Another source of injury is the very close contact of these plates, which is maintained by atmospheric pressure and may favour the absorption of their substance. In such cases the hard palate, on account of the larger surface it exposes to the plate's action, suffers the most, but the gums and the lingual and buccal surfaces seldom escape.
The hyperemia which a continuance of the thermic and irritant action produces on the hard palate is frequently very marked; the parts are often found bathed with pus, especially the granular development that under these circumstances is found in the "air chamber" of the plate.
1880.] Sexton, Affections of the Ear from Diseased Teeth.
35
In some instances these granulations are polypous in their nature. The - lower plates are in some respects less irritating, because they are not so large or so closely fitted, but, on the other hand, from being more com- pletely exposed to the saliva in the bed of the mouth, they are liable to earlier softening and disintegration. When these plates are worn unin- terruptedly day and night, of course their injurious effects are much greater.
The practical results of wearing vulcanite in the mouth are frequently seen ; I have the notes of one where a gentleman, aged sixty-five years, wore a full upper set day and night for a period of ten years. He suffered during this time from constant irritation, and the heat of his mouth re- quired that the plate should be frequently removed and the mouth cooled with water. Constantly increasing irritation finally seemed to be the cause of a carcinomatous growth, and after an operation for its removal, he died.
A medical friend of the writer has communicated a case that further elucidates the effects of these plates. He was consulted by a lady aged thirty-one years, whose principal complaint was of burning sensations in her mouth and throat. She had for six years worn a small vulcanite upper plate sustaining two teeth, but for about three months previous to her visit she had worn a larger plate, which seemed to greatly- increase her difficulty. Her lower molars and bicuspids, which were previously sound, wrere becoming loose from denudation of the fangs and caries of the necks. The secretion of saliva was so excessive that the pillar upon which she lay at night was by morning saturated. She had been advised by her dentist to wear the plate day and night, and thus get used to it. Examination of the mouth of this patient showed the gums, tongue, hard palate, and whole buccal mucous membrane, as well as the throat, to be swollen and hypersemic. The eyes suffered sympathetically, and she was generally nervous and depressed. This condition was unimproved by any treatment until a small gold plate was substituted for the vulcanite : she then made a complete recovery.
Another case coming under my own observation has a particular in- terest in this connection. The case was that of a gentleman of fifty-five years of age, whom I was called to see in consultation with Dr. C. J. Dumond. He had long worn a full set of artificial teeth mounted on vulcanite plates. His health had been for many years much shattered from some cause. For about a week before I saw this patient he had worn a new set of upper and lower vulcanite plates. They were of a bright brick-dust colour, and, therefore, it is probable that they were imperfectly baked. The lower plate rested in part on a portion of gum made sensitive by the recent removal of two teeth from the left side of the jaw. After wearing these new plates for about a week, he was suddenly taken ill. The symptoms were nausea, which was soon followed by
36 Sexton, Affections of the Ear from Diseased Teeth. [Jan.
vomiting and purging, and the stomach was painful to the touch. These symptoms increased in severity from day to day, until he called in his family physician ; he had not done so earlier on account of his absence from town.
The doctor, on making an examination of the case, suspected that some toxic agent was at work, and when inspecting his mouth discovered the vulcanite plates to which allusion has been made. When I saw the patient, with Dr. Dumond, the more acute symptoms had passed away, and he only complained of prostration. The mouth, which had been sensitive and feverish, was better; the tongue, however, was still some- what swollen and heavily furred on the left side. The patient made a rather slow recovery from this attack, and for some weeks he suffered from a cutaneous eruption over most of his body. He has not since worn the vulcanite plates.
The interesting feature of one-sided coating of the tongue, in connection with irritation of gums or tongue on the same side, has been reported by Hilton ("Rest and Pain"), and by him attributed to sympathetic irritation through the nerves, the Gasserian ganglion being thought to be concerned.
Celluloid has been brought forward as a substitute for vulcanite in the construction of plates, but it has not been adopted to any extent. An objection to this substance would be its non-conductivity.
Regarding plates in general, it may be said that, if badly fitted, they are liable to do harm if any teeth remain in the mouth, by pressing the gums against the natural teeth ; this pressure creates hyperemia of the gum, and it is, therefore, probable that a constantly shifting plate always does some injury.
That all of the morbid conditions of the mouth which have been herein described may exist without serious or recognizable aural affection being developed, cannot be denied, but progressive disease of the ears, often without the occurrence of pain, is, in my experience, more common when these oral affections are present than when the mouth and throat are in a healthy state.
In many of the aural diseases that depend for their origin on reflex nervous action, there is one pretty uniform symptom which comes on after irreparable injury has been done to the conductive apparatus: that symp- tom is tinnitus aurium.
In accumulations of cerumen, etc., in the external meatus, even when enormous, the patient is usually unaware of their presence until, from some accident, such as bathing, they become impacted against the drum- head ; then the unbearable tinnitus and pain require attention.
In conclusion, the writer would earnestly draw attention to the import- ance of a more general knowledge of orology being acqured by the pro- fession. Frequent attacks of toothache should not be unheeded in any case, as the nervous irritation from this source not only sets up local in-
1880.] Sexton, Affections of the Ear from Diseased Teeth. 37
flammation that often leads to periostitis or abscess, but even more im- portant lesions in distant parts may follow.
An oroscopic examination should be made whenever occasion seems to require it, in order that, if necessary, the patient may be sent to a com- petent dentist to have such mechanical assistance as the case may demand. No practitioner, moreover, can be too well informed on the known or probable effects of the introduction of metals, etc., into the mouth to be constantly worn, as he may thereby prevent the mouth being made the depot for the receptacle of substances that sooner or later exert a dele- terious influence ; for the number of individuals who, at the present time, are thus wearing substances either known to be poisonous or whose action yet remains, in doubt, is very large.
The early decay of the permanent teeth, especially of the first or "six- year" molar, which parents, or others interested, are likely to neglect from inadvertently regarding it as belonging to the temporary set, and, therefore, destined to be lost, is important to be kept in mind, for from this source springs much of the earache of childhood. The delay in the cutting of the third molars, or wisdom teeth, is another cause of reflex phenomena induced by the teeth most important to be not overlooked.
Allusion has been made to the exceedingly small particles of poisonous drugs gradually worn away from plates and fillings, and to the almost in- appreciable reflex irritation from slowly acting pathological processes set in motion by the teeth ; these, it may be said, are the more dangerous when their existence is not suspected. Such plates as are mentioned above, the writer has seen abraded by use until worn through.
It is believed that after a candid review of this subject it will be un- denied that affections of the ear are not unfrequently induced by pre- existing pathological changes in or about the mouth. It naturally follows that judicious treatment necessitates a careful appreciation of these etiolo- gical factors. It is not, however, in the province of this essay to discuss the treatment of oral diseases, and as to the management of the ear itself, when affected by reflex influences, the subject is too important for the limits to which the unexpected length of this paper warns the author that it must be confined. He will, therefore, defer the subject of treatment until another occasion.
In the foregoing paper it has been the writer's aim to touch on the more common of the oral affections that exert an influence on diseases of the ear, knowing that any account of the pathology of the buccal cavity and its contents approaching completeness, would carry him beyond the scope of this essay.
Regarding the influence known as reflex action, by means of which we are enabled to account for pathological changes in the ear which were hitherto veiled in mystery, it must be said that our knowledge of its phe- nomena is as yet lacking in completeness, but enough is known, through
38
Hoff, Typho-Malarial Fever.
' [Jan.
the confirmation of clinical experience, to vastly increase our knowledge of the etiology of disease.
The writer feels that this important subject has been treated by him somewhat imperfectly, but as fully as his experience thus far warrants. The important practical bearings of the matter herein discussed must be his excuse for bringing it at this time to the notice of the profession.
Bibliography. — Du Verney, Tractatus de Organo Auditus, Norirnbergas, 1684. Amhroise Pare, GEuvres d', Paris, 1628. Austin Flint, Jr., Physiology of Man — Nervous System, New York, 1878. M. Foster, A Text-book of Phy- siology, 2d edition, London, 1878. E. H. Triquet, Traite Pratique des Maladies de 1' Oreille, Paris, 1857. Burnett, A Treatise on the Ear, Philadelphia, 1877. Curtis, Treatise on the Physiology and Diseases of the Ear, London, 1819. D. B. St. John Roosa, A Practical Treatise on the Diseases of the Ear, New York, 1873. Hilton, Rest and Pain, 2d edition, New York, 1879. Saunders, The Anatomy of the Human Ear, etc., Philadelphia, 1821. Joseph Williams, Treatise on the Ear (Prize Essay), London, 1840. William Dufton, The Nature and Treatment of Deafness and Diseases of the Ear, etc., London, 1844. Years- ley, Deafness Practically Illustrated, etc., 6th edition, London, 1863. Wilde, Practical Observations on Aural Surgery, etc., Philadelphia, 1853. Cooper, Clinical Lectures upon Inflammation and Other Diseases of the Ear, London,
1878. Gray, Anatomy, Philadelphia, 1870. Kempton, Sympathetic Nervous Affections connected with the Teeth (From the Transactions of the College of Dentists of England for 1861), London. Abbott, Caries of the Human Teeth, read before the New York Odontographical Society. Burq, Etude Experimen- tale sur la Metalloscopie et la Metallotherapie. MM. Charcot, Buys, et de Dumontpallier, Rapports faits a la Societe de Biologie (1877-1878), Paris,
1879. Woakes, On Deafness, Giddiness and Noises in the Head, London, 1879. Phillips, Materia Medica and Therapeutics ; Vegetable Kingdom, New York, 1879. Heath, Injuries and Diseases of the Jaws, London, 1868. Wedl, The Pathology of the Teeth, Philadelphia, 1872.
Article II.
Typho-Malarial Fever, the so-called "Mountain" Fever of the Rocky Mountain Region. By John Van Rensselaer Hoff, A.M., M.D., Assistant Surgeon U. S. Army.
If there be a disease peculiar to the Rocky Mountain system, its inves- tigation and accurate determination become each day of greater public importance, for even now the waves of civilization are lapping to the base of the Rockies, and soon its swelling tide will overflow the whole region. From time to time there have appeared in American medical periodicals articles under the caption " Mountain Fever," giving description of a febrile disease of somewhat peculiar character, which apparently is indigenous to the country vaguely denominated the Rocky Mountain region. Owing doubt- less to the sparseness of population, the rarity of the disease, and, not least, the fact that the pioneers of our profession in this extreme western country are, as a rule, workers, not recorders, the literature of the subject is extremely meagre. The weight of authority, so far as evidence is ob-
1880.]
H o f f , Typho-Malarial Fever.
39 *
tainable, seems to be in favor of a malarial causation. Assistant-Surgeon Charles Smart, U. S. Army, in his very instructive paper on "Mountain Fever and Malarious Waters," says:1 . . . " Mountain fever is not de- pendent upon any peculiar mountain miasma, but is a malarial remittent with adynamic tendencies." He further says:2 "If. . . disease be per- mitted to run unchecked for a few days the patient falls into a condition ^indistinguishable from typhoid, and which often proves fatal," etc. Sur- geon E. P. Vollum, U. S. Army, writes:3 "It is a malarial fever com- mencing as an intermittent, passing on to a remittent, then into a typhoid condition."
Surgeon J. L. Town, and Assistant-Surgeon J. D. Hall, U. S. Army, state that at Fort Shaw, Montana,4 " remittent and typho-malarial, and probably enteric fevers, are not infrequent in the spring and fall; . . . these, in the parlance of the country, are termed mountain fevers indis- criminately." Other medical officers with whom we have had opportunity to consult, express the opinion that the disease is of remittent character, of malarial origin ; an opinion which seems to be very generally acquiesced in, judging from the comparatively large number of cases of remittents reported from posts within the Rocky Mountain belt. So far, then, as has been determined, we recognize under the term " mountain" fever a dis- ease beginning as an intermittent, continuing (?) as a remittent, and ending in typhoid, or, as Dr. Smart5 formulates it, 1st, "a primary stage of one, two, or more weeks during which the individual is more or less oppressed by the influence of the materies morbi ; 2d, the development of fever, more or less marked, and more or less rapid in its course, with irre- gular remissions, and much more mental depression and muscular pros- tration than the patient's pulse and temperature would prepare the observer to find;" 3d, "a typhoid stage, marked by prostration, emaciation, low delirium, and coma vigil."
"With a view to assisting in the accurate determination of a question which is certainly now sub jit dice, and regarding which positive conclusion can be reached only through carefully recorded clinical histories and anatomico-pathological examinations, we present the notes of five cases of so-called " mountain" fever which fell under observation at Fort Fetter- man, Wyoming, in the autumn of 1878. Late in the spring of 1878, eight companies of cavalry, four from stations on Union Pacific Railroad, and four from post on extreme frontier, rendezvoused at Fort McKinney, Wyoming, thence marched to Clear Creek, Wyoming, and went into per- manent camp. We are indebted to Dr. A. J. Gray, U. S. A., chief medical officer of the column, for the following : —
1 American Journal of the Medical Sciences, January, 1878.
2 Circular No. 8, War Dep't, Surgeon-General's Office, 1875.
3 Idem. 4 Idem. 5 American Journal of the Medical Sciences, January, 1878.
40
Hoff, Typho-Malarial Fever.
[Jan.
" Our command, consisting of two battalions 5th Cavalry, numbering in all about five hundred men, took the field May 24, 1878, < as a party of observation' in the Powder River country. Not a man was sick in starting. The command was splendidly equipped; ample and suitable clothing and tentage, and abundant rations. The morale, moreover, could not have been better. The first permanent camp was reached June 14. It was located on the Clear Fork of Powder River, three miles from the eastern base of the Big Horn Mountains, at the point where they reach their highest elevation, viz., 12,000 feet, and are covered by perpetual snow. The camp was on a grassy plateau, twenty-five feet above the level of the stream, with sufficient incline to secure free surface drainage, the soil being a gravelly drift without alluvium. Clear Fork, from which the water-supply was furnished, takes its rise in the 'Ice Lakes' (glaciers), at the base of the granite ,crest of the mountains, and flows rapidly by many small streams for ten miles through a dense pine forest, all the streams then uniting to pass through a gorge or narrow caikon, from which it rushes over rocks and boulders, making one continuous line of foam five miles to our camp, where the stream has an average width of twenty feet, and depth of eighteen inches. The water is soft, clear, and pleasant to the taste, except that late in the season there was a suspicion of vegetable infusion. The temperature of the water was at no time above 50° Fahr. The command remained in this camp until July 15 — one month — during which a few cases of intermittents appeared, in all of which there was a history of previous malarial toxemia. There were many cases of disease of the digestive organs, responsibility for which, in my opinion, largely rests with the sutler. There were also a few cases of acute rheumatism.
" The second camp was on Rock Creek, four miles north of the previous site, and differing therefrom in no important characteristic, nor was there any noticeable change in the sick report. The duties of the men were light. Scouting parties were sent out during the summer in various direc- tions, composed of from one to four companies. There were occasional drills, and the usual guard duty. The atmospheric temperature was equa- ble, and never oppressive. Showers were of almost daily occurrence through the entire season.
" On the 5th of September orders were received to cross the mountains to the southwestward, to intercept hostile Indians coming down from the Yellowstone National Park. This movement necessitated a reduction of all extra clothing and rations, and the use by the men of the so-called ' shelter' tent, which falls far short of affording protection against severe weather, such as was experienced in this movement. On the seventh the eastern crest was crossed, and camp made in a well-watered natural clear- ing at an altitude of about 9000 feet. Toward evening a cold rain began to fall, which at 2 o'clock A. M. turned to snow, and continued all through the next day's march, falling to the depth of twelve inches or more on a level. The storm continued during;' the night of the 8th, but we left it early in the evening by coming down out of it into clear weather, on the west side of the range, into the valley of Painted Rock River. During the 9th our march lay down the valley of the stream, or rather across its numerous tributaries, all turbid and swollen from the melting snow, which had just fallen on the mountains, and which, let me say, was the first snow since the previous spring. On the 10th and 11th the command crossed the Owl Creek Mountains, also covered with snow recently fallen, and on
1880.]
H o f f , Typho- Malarial Fever.
the 12th reached the Wind River. Since the 7th the command had marched over high mountain ranges, by an unfrequented trail, where there was no possibility of "encountering the results of animal decomposition, and where there were no marshes, and little vegetation of any kind aside from the pine forests. The water-supply had all the time been from the melting snow. The health of the men continued good until the night of the 12th, when the first case of intermittent developed in a strong young soldier of good habits (Case IV.). The trouble yielded readily to large doses of quinia-sulphate, and he was able to resume duty on the 16th.
" Camp Brown, which the column reached September 14, is situated at the eastern base of the Wind River Mountains, and is surrounded by no unfavorable sanitary condition ; on the contrary, the physical characteris- tics are eminently favorable to healthfullness, which is abundantly attested by the condition of the garrison stationed there. The command, to which the writer was attached, remained at this place five days, during which occurred three peculiar cases of sickness, one being that before mentioned, and the two others men who were left at the hospital at Camp Brown, when we started on our homeward march, September 19. On the morn- ing of the 20th, a fourth case of this disease presented, and the subject sent back to hospital. These cases I have not since heard from. Our return march was by the well-known Sweetwater trail, and was made under conditions in every way favorable to healthfulness; yet several cases of the disease developed during the march to Fort Fetterman.
" These cases all presented the same general phenomena in the begin- ning. Invariably the first complaint was that of feeling cold, and ' aching all over.' Then there was loss of appetite, thickly coated tongue, and'consti- pated bowels. The disease was in no instance ushered in with a well-marked chill, and during the first twenty-four hours the fever was always light; but there was mental obscuration, sometimes delirium, and more or less inertia, the subjects seeming not to care whether they lived or died, or what was done with or for them. The patients always admitted a feeling of distress, but never could localize it, except in one case (the man who subsequently died at Fort Fetterman, who complained greatly of pain in his head and the 'back of his neck'). The fever once developed, never after wholly left the patient, but exhibited a decided daily exacerbation, beginning with chilliness for a period of half an hour or so, accompanied by cold, clammy sweat, and followed by an intensely hot skin, Avith small and rapid pulse. These exacerbations generally continued about eight hours, sometimes longer, and then would follow a period of eight or ten hours of lower tem- perature and comparative freedom from discomfort, during which sleep was possible. There was an increasing, but not a great degree of prostra- tion, as every man was able to ride his horse during the day's march of eighteen to twenty-five miles, and continued to do so daily without assist- ance until Fort Fetterman Avas reached. There were wanting the dis- tinctive symptoms characteristic of typhoid, and yet quinia seemed to have no effect to prevent or control the daily returns of the high fever, though administered in large doses."
The command reached Fort Fetterman Sept. 28th, and Dr. Gray trans- ferred to this Hospital the following cases, the most serious of those under treatment.
Cases I. and III — Tertian Intermittent Fever. Case II Remittent Fever.
42
Hoff, Typho-Malarial Fever.
[Jan.
| Cases IV. and V. — Quotidian Intermittent Fever.
Case I. — Aged 22 ; family history good; strong physique; never had any serious illness ; temperate habits ; first taken sick September 6th, 1878 (while en route to Camp Brown, Wyoming) with severe headache, fever and pain in abdomen : no chill or epistaxis ; had fever for short time daily for five or six days ; upon reaching Camp Brown, felt much better, but febrile condition continued, and, with resumption of march, headache again became severe. Treatment, quinia. Admitted to hospital September 29th; complained of no pain, but felt debilitated; was anaemic, though in good flesh and spirits; conjunctiva and skin clear; hearing normal ; tongue heavily covered with whitish glazed coat, which, disap- pearing at tip and edges, left a clearly- defined pinkish border ; thoracic and abdominal viscera normal ; no tenderness over liver, spleen, or caput coli, and no eruption on body ; pulse full and soft ; urinary secretions normal ; appetite good. We regarded this case as a mild though typical form of " mountain" fever, and, that its symptoms might not be modified by medication, the treatment was purely placeboic — Aquas lavandul., ^ss, three times a day.
The history of the case presents nothing of interest other than that of simple continued or sub-continued fever. The temperature chart is shown in the accompanying plate. There was a daily sweat, but no chill, and the sweat was1* not very copious ; no pain in head (save for a day or so after entering hospital) or abdomen, and at no time after admission any tenderness of spleen or liver, and no cutaneous eruption. The bowels were slightly constipated, but so slightly that cathartics were found necessary only twice during the time the case was under observation.
Case II Aged 30 ; strong constitution ; no history of previous ill- ness ; of temperate habits ; was taken sick September 20th, upon leaving Camp Brown ; complained of headache, anorexia, general debility, with constipation ; had daily chill, fever, and sweat until 28th, when fever be- came continued; had not been ill before during campaign, and never had intermittent fever. Admitted to hospital September 29th. Patient fairly well nourished; of spare habit; conjunctiva injected; countenance flushed, skin dry; lips swollen and cracked; tongue thick, swollen, fissured, and heavily coated at centre, clear and red at tip and edges ; mouth filled with thick viscid saliva ; taste bad ; breath offensive ; thorax clear on per- cussion ; complains of pain at lower portion of both lungs on taking full breath; respiration rough, with mucous and subcrepitant rales; expecto- ration stringy and slightly streaked with blood; liver and spleen somewhat enlarged and painful on palpation ; abdomen generally tender ; micturition painful ; urine scanty and high colored ; bowels constipated; mind clear ; cephalalgia excruciating ; pain referred principally to occiput, seemed to extend downward, causing patient to assume characteristic posture of cerebro-spinal meningitis ; hearing obtunded.
2dth. Potassii bromid. et chloral hydrat., aa gr. xv at once, to be fol- lowed by Magnes. sulph., ^ ss, and simple enema : milk diet.
30///. Passed restless night; headache continued; no appetite; bowels moved freely. Ipecac, gr. xv every 3 hours. This remedy was used purely tentatively.
The temperature record is given in the accompanying plate.
Having several cases under treatment at the same time, we determined to study the action of different remedies to ascertain as certainly as pos-
1880.]
H o f f , Typho-Malarial Fever.
43 ,
44
Hoff, Typho-Malarial Fever.
[Jan.
sible which offered the nearest approach to a specific in this disease. We had reached the conclusion that quinia was the remedy par excellence, simply because we had used it exclusively, but, for want of experience with other remedies, were in doubt whether or no this one belonged to that large class of post hoc, ergo propter hoc remedies, so frequently ap- pealed to.
Oct. 1. No perceptible improvement; unable to sleep; complains of pain, referred principally to occiput ; slight nausea from medicine ; noemesis ; bowels constipated; no appetite. Ipecac, gr. xv three times a day, magn. sulph., § ss at once.
2d. Slept a little during night; headache continues; bowels open ; urine sp. gr. 1024, acid, slight trace of chlorides; no albumen.
3d. Comfortable night ; tongue still heavily coated and swollen ; teeth covered with sordes ; mouth foul ; breath very offensive ; complains of pain all over body.
Uh. Bowels moved spontaneously during night; urinated freely; pain in head, lungs, and abdomen less severe ; profuse sweat from 6 to 8 P.M. ; no chill; oil-silk jacket to chest; quinias sulph. gr. xv, acid, hydrobromic. 5ss, at 11 A.M. and 8 P.M.; slop diet; urine, sp. gr. 1022, acid, no albumen, chlorides present; patient flighty. This was the seventh day since last chill. We had continued the use of ipecac, with very slight or no perceptible effect upon the fever, and fearing further experiment, admin- istered quinia, with decided advantage. Up to this time, the evening tem- perature ranged above 104° F. On the 4th inst., 7 A. M., it stood at 104|°; at 7 P. M. 100|° F., with decided improvement in all symptoms. The oil-silk jacket was ordered to protect thorax from chill, patient fre- quently throwing covering from him during night.
5th. No pain ; has been very comfortable for twenty -four hours ; mind collected; bowels open; urinary secretion free; no eruption on body; tongue very thickly coated and slightly yellow ; expectoration stringy, but not rusty ; breath very foul ; appetite poor.
Qth. No change, except profuse sweating from 1 P. M. till midnight ; quinias sulph. gr. xvi, acid, hydrobromic. 3j at 11 A. M. and 8 P. M.
7th. Sensation of heat all over body ; otherwise very comfortable ; no indication of rash; tongue thick and flabby, with heavy whitish coat, but always clear at tip and edges ; expectoration whitish and stringy, essen- tially that of bronchitis, now without capillary complications ; no pain upon inspiration.
Sth. Appetite improving ; otherwise no change ; has been entirely rational since 4th inst., and seems in good spirits.
9th and 10th. General symptoms unchanged ; bowels and kidneys acting regularly ; temperature erratic, with upward tendency. 9th. Quinias sulph. gr. xv, acid, hydrobromic. tt^xv at 9 P. M. 10th. Quinise sulph. gr. xv, acid, hydrobromic. rr^xxx at 11 A. M. and 9 P. M.
11th. Comfortable night; felt chilly during morning; no eruption on skin; cold sponge-bath for 20 minutes, when temperature exceeds 103° F. (one bath given at 12 M.); perspired freely from 6 to 9 P.M., and con- tinued to perspire less freely through night ; urine, sp. gr. 1028, acid, no albumen, chlorides present.
12th. Very weak, but feels generally better ; emunctories working freely ; tongue clearing off; expectoration decreasing ; no pain ; no eruption ; quinias sulph. gr. xv, acid, hydrobrom. ir^xy at 9 P. M.
1880.] Ho f f, Typho-Malarial Fever. 45
loth to loth. No marked change; some perspiration during night of 13th, but no chill; tongue still heavily coated; vini albi %iv during day (continued from 13th to 22d). (14^ inst.) Quin. sulph. gr. xv, acid, hvdrobrom. ttiwxv at 9 P.M. (15th inst.) Quin. sulph. gr. x, acid, hydro- brom. n^xv at 9 P. M.
16^. After a quiet night, at 9 P.M. had severe chill, which lasted fifteen minutes, followed by fever reaching 106 -J-° F., and gradually de- clining ; there were no symptoms other than those observed in simple intermittent. Urine, sp. gr. 1020, alkaline, chlorides present in full quan- titv ; quin. sulph. gr. xv, acid, hydrobrom. n^xv at 10.30 A. M., and 9 P.M.
17th. Slept well and feels better; appetite improving; tongue still somewhat coated; expectoration slight; no fetor of breath ; no bad taste in mouth; bowels constipated; magn. sulph. ^ss at 6.30 P.M.
18th to Nov. 2. During this time, convalescence proceeded to complete recovery. Quinia was administered sufficiently often to keep system under its influence until 22d inst., at which time all medication was stopped. Specific gravity of urine descended to 1013, but albumen was at no time present. Convalescence, once established, rapidly proceeded to recovery, and patient seemed to have regained full strength several days before oppor- tunity offered to* join his proper command. Lung complications (for we take it that the pulmonary difficulty was simply a complication, not a necessary concomitant) rapidly disappeared with increasing strength, and at date of return to duty, patient to all appearance was entirely well.
Case III. — Aged 17 years; medium constitution; general health good. First taken sick crossing Big Horn Mountains (about September 8th) while exposed to snow-storms ; complained of soreness all over body and stiffness in joints ; some headache ; had two or three chills before reaching Camp Brown, Wyoming, but continued to perform full duty until two days after leaving, at which time he became worse; had a severe chill, followed by fever and sweat; taking tertian form until 27th inst., when fever became continuous; never before had chills and fever ; during summer was not ill ; had no diarrhoea, on the contrary, was constipated ; while marching across mountains drank a great deal of water, without effect on bowels ; appetite continued good; mind rational; had cold in head, but no trouble with lungs ; noticed red pimples on chest and abdomen two days before reaching Camp Brown, which disappeared in two or three days ; felt badly for several days before first chill; did not have nose-bleed. Admitted to hospital September 29th, P.M. ; face slightly flushed; conjunctiva clear; tongue heavily covered in middle, clear and pink at tip and edges ; coating slightly yellowish (tobacco stain ?); thorax clear on percussion; respiration normal vesicular ; no pain upon full inspiration ; bowels constipated ; slight tender- ness of abdomen, less marked over region of liver ; heart normal ; pulse full ; skin dry ; no eruption on body ; complains of headache and thirst ; otherwise comfortable ; appetite good.
29^. Magn. sulph. ^ss and simple enema at once, followed by potassii bromid. et chloral hydrat. aa gr. xv ; slop diet. P. M., T. 104.2° F., P. 87, R. 28.
30th and Oct. 1. General condition unchanged ; bowels moved freely ; headache disappeared; complained of hunger. Sept. 30^. A.M., 103.2° F., P. 88, R. 26 ; P. M., 104.4° F.,P. 88, R. 27 ; Oct. 1. A. M., 103.2 ° F., P. 82, R. 24 ; P. M., 104.4° F., P. 88, R. 26. Urine, quantity about normal; sp. gr. 1021, alkaline, no albumen, chlorides present ; liq. ammon. acetat. %ss every 3 hours (an experiment).
46
PI o f f . Typho-3Ialarial Fever.
[Jan.
2d. Sleepless night ; tongue clearing ; face flushed ; fever high ; com- plains of no pain, and seems bright and perfectly rational. A. M., 101.4° F., P. 78. R. 25 ; P. M., 104.6° F., P. 64, R. 26.
3^. Growing weaker, but makes no complaint ; appetite still good ; bowels constipated ; fever very high ; continue liq ammon. acetat., quinire sulph. 5??. acid, hvdrobrom. n^xxx, in two doses af 7 P. M. ; magn. sulph. §ss in morniog. A. M., 102.8° F.. P. 86, R. 25 ; P. If., 104.4° F., P. 90, R. 24.
4th. It will be observed that at 7 P. 31.. odinst.. the thermometer indi- cated a temperature of 104.4° F.. at which time a large dose of quinice sulph. was given. Passed a comfortable night ; quite drowsy in morning ; tongue clearing; breath offensive; tenderness of abdomen diminishing; appetite still aood ; urine, sd. gr. 1012, acid, no albumen, chlorides in in- creased quantitv. ' A. M., 99.2° F.. P. 72. R. 22 ; P. M., 102.2° F., P. 78, R. 28.
bih to 7th. No marked change, oth. Bowels being constipated, a simple enema was ordered 11 A. 31.. followed by small evacuations; in evening had quiniae sulph. 5ss, acid, hvdrobrom. 5j« in two doses at 7 P. M. 6th. Magnesia sulph. ^ss. 7th. Quinia? sulph. gr. xv, acid, hvdrobrom. 5ss at 10 A.M. and 9 P.M. 5th. A. M., 101.2° F., P. 80, R. 26; P.M., 103.4° F.. P. 88, R. 26. 6th. A. M., 100.4° F.. P. 78. R. 22 ; P. M., 103.2- F.. P. 84. R. 28. 7th. A. M., 102.6° F., P. 82, R. 23 ; P. M., 104.4- F., P. *90, R. 28.
8th to 10th. In spite of high temperature, appetite continues reasonably good : complains of the insufficiency of gruel and broth diet ; says he is always hungry. Sth. Perspired considerably during morning; bowels were open : kidnevs acting freely : chlorides present in urine in full quan- tity. A. M.. 101.4° F.. P. 80, R. 22 : P. M., 104.2° F.. P. 88, R. 28. 9th. Quinire sulph. crr. xv, acid, hydrobrom. ttt,xv, at 11 A. 31. and 9 P. 31. A. 31.. 102.6° F., P. 88, R.'28: P. 31.. 104.2° F., P. 90, R. 28. 10M. A. 31.. 101.2° F.. P. 96, R. 24; P. 31., 104.2° F., P. 88, R. 24.
11th to 12th. Tenderness of abdomen disappeared; has grown very weak, but mind remains clear, and spirits good; tongue less coated. 11th. Quiniie sulph. gr. xv. acid, hydrobrom. tt^xv, at 11 A. 31. and 9 P. 31. ; cold sponge-bath twenty minutes, when temperature exceeds 103° F., to be repeated every half hour, pro re nata (bathed three times). Vini albi giv during day. (12f* to 19th.) 11th. A. 31.. 103° F., P. 94, R. 24; P. 31., 103.8° F., P. 84, R. 26. 12th. A. 31., 100.4° F.. P. 86, R. 24; P. 31.. 103.2° F., P. 82. R. 28.
loth. Comfortable night. Tongue characteristically coated; breath offensive; bowels constipated: a papular eruption on chest and abdomen of bright-red colour, painless, and disappearing on pressure (this remained for many days, and the papules multiplied in quantity) ; sweating profuse 6.30 to 7.15 P. 31. ; bathed 1 P. 31. ; magn. sulph. £ss 7 A. 31. ; quiu. sulph, gr. xv. acid, hvdrobrom. ttt,xv at 10 A. 31. and 9 P. 31. Continue wine. A. 31.. 100.6° F., P. 88. R. 25 ; P. 31.. 103.6° F., P. 90, R. 24.
l\th. Slept well through the night; seems bright; sweated copiously ; bathed 1. 4. and 7 P. 31. Quinia sulph. gr. xv. acid, hvdrobrom. ni^xv at 9 P. 31. Continue wine. A. 31. 98.4° F., P. 82, R. 24 ; P. 31., 104.4° F., P. 98, R. 24.
loth. Sweated for one and one-half hours during night very freely; no tenderness of abdomen : gurgling in right iliac fossa perceptible for first time; somewhat flighty. Bathed 1 P. 31. ; urine sp. gr, 1016, acid, no
1880.] Hopp, Typho-Malarial Fever. 47
albumen, chlorides present in full quantity; bowels constipated; tongue clearing: up. To continue wine, and have magn. sulph. 3ss A. M. A. M., 100.8° F., F. 86, R. 24; P. M., 104.4° F., P. 96, R. 24.
16^7«;tol8^. No change in general features. 16th. Bowels moved freely during the night ; sweating commenced 5.30 P. M. ; continued for several hours. Quiniaa sulph. gr. xv, acid, hydrobrom. n^xv 10.30 A.M. and 9 P. M. A. M., 99.6° F., P. 80, R. 22; P.M., 105.2° F., P. 102, R. 26. 17th. Profuse sweat from 2 till 5 A. M. ; sponged at 1 and 4 P. M. A. M., 99.8C F., P. 94, R. 22; P.M., 104.2° F., P. 94, R. 24. 18th. Quinite sulph. gr. xv, acid, hydrobrom. ir^xv at 10.30 A.M. and 9 P.M. Wine as usual. Sponged 7 A.M, 1, 4, 7, and 8.30 P.M. A.M., 102.6° F., P. 96, R. 32 ; P. M., 105.2° F., P. 102, R. 28.
ldth. Slept well until 4.30 A. M., then had a severe chill which lasted for an hour. Tongue clearing ; no sordes on teeth ; very weak, with ex- cessive fever; heart action feeble. Frozen cloths to chest and abdomen; ice eap to head. Sp. vini pallid ^iv in milk-punch during day. Tinct. digitalis r^x at 11 A.M. Omit wine. A.M., 105.6° F., P. 132, R. 28; P. M., 101.8° F., P. 114, R. 28.
20th. Had chill from 1 to 2 A.M., followed by high fever; began to sweat at 8.30 A.M., and continued all day; bowels moved freely; stools small and light coloured ; frozen cloths applied from 7 to 8 A. M. Quiniaa s n 1 1 > 1 1 . gr. xxx, acid, hydrobrom. tt^xxx in two doses at 11 A.M. Omit digitalis; continue brandy. Urine sp. gr. 1015, alkaline, no albumen, chlorides a trace, high coloured. A.M., 104.6° F., P. 128, R. 30 ; P.M. 97.6° F., P. 102, R. 20.
21st to 24^. During this time the fever remained comparatively low ; patient each day perspired profusely ; chlorides in urine increased from a trace to nearly normal quantity. On 21st, quinice sulph. acid, hydro- brom. 5ss in two doses 8.30 P.M. A.M., 98.2° F., P. 100, R. 24; P. M., 101.8° F., P. 106, R, 26. 22d. Quinice sulph. gr. xv, acid, hydro- brom. ttt^xv at 9 P. M. A. M., 98.6° F., P. 90. R. 22 ; P. M., 101.2° F., P. 100, R. 24. A. M., 99.4° F., P. 85, R. 22 ; P. M., 101.0° F., P. 92, R. 24. 24^. Quinire sulph. gr. xxx, acid, hydrobrom. rr^xxx in two doses 7.45 A. M. ; atropia? sulphat. gr. ^ at 8 P. M. Brandy continued. A. M., 100.4° F., P. 86, R. 26 ; P. M., 101.4° F., P. 100, R. 24.
2bth. Had a chill from 5 to 8 A.M. ; complained of great thirst; ice cap to head ; frozen cloths to chest and abdomen 1 to 4 P. M. Continue brandy; bowels open. A.M., 103.4° F., P. 118, R. 26; P.M., 102.8° F., P. 114, R. 26.
26M. Comfortable night ; has good appetite ; no pain ; no tenderness of abdomen ; perspired freely from 8 A. M. to 6 P. M. Had a severe chill at 6.40 P.M., lasting twenty-five minutes, followed by fever. To continue brandy. Atropine sulph. gr. morning and night. Quinise sulph. gr. xxx, acid hydrobrom. tti^xxx in two doses at 7 P.M. A.M., 98° F., P. 86, R. 20; P.M., 103.2° F., P. 124, R. 27.
27^ to November 2. A period of almost complete defervescence, during which patient gained strength and improved in every particular ; his ap- petite, as always, continued good, and mind clear, though body weak and spirits occasionally depressed. 27th, was wakeful and thirsty during early night, but slept soundly latter part and during morning. 2%th. Sweated copiously from 6 to 7.30 P. M. ; quinise sulph. gr. xv, acid, hydrobrom. n^xv at 10.20 A.M. and 5 P.M. ; continue brandy and atropia. 29^ and 30th. Improvement continued; had C30th) quinise sulph. gr. x, acid, hy-
48
H o f f , Typho-Malarial Fever.
[Jan.
drobrom. n^x at 7 A.M. On the 31st there was some sweating during day; patient had quiniae sulph. gr. x, acid, hydrobrom. n^x at 11 A.M. and 9 P. M. On Nov. 1st and 2d there was also sweating. 2c?. Quinia sulph. gr. x, acid, hydrobrom. r^x at 8 A. M. 27th, A. M., 99.2° F., P. 98, R. 24; P.M., 99° F., P. 86, R. 20. 28^, A. M , 98.2° F., P. 61, R. 22; P.M., 100.4° F., P. 82, R. 16. 29th, A.M., 98.4° F., P. 76, R. 18 ; P. M., 99.4° F., P. 92, R. 22. 30th, A. M., 98.8° F., P. 84, R. 18 ; P.M., 99.2° F., P. 78, R. 22. 31st, A.M., 99.2° F., P. 84, R. 16; P. M., 98.4° F., P. 90, R. 24. Nov. 1st, A. M., 98.4° F., P. 82, R. 20 ; P. M., 99.6° F., P. 84, R. 24. 2d, A. M., 99.2° F., P. 84, R. 22 ; P. M., 99.6° F., P. 96, R. 20.
3d to 8th. Marks a gradual exacerbation of fever, the morning tempera- ture being normal, or a little above, fluctuated through day, but showing always a quite markedly higher evening register. The specific gravity of urine gave very little indication of severity of fever, and chlorides remained about normal, as had been the case except during the first days of the dis- ease. There was no complaint of pain, no mental hebetude during this time, and appetite continued remarkably good. 3d. Quiniae sulph. gr. v, acid, hydrobrom. n^x at 9.30 A. M. and 9 P. M. Ath. Some sweating during day. Quiniae sulph. gr. v, acid, hydrobrom. n^v at 9.30 A. M. and 5 P. M. 5th. Sweated at 7 P. M. Quiniae sulph. gr. x, acid, hydrobrom. ni^x 7.30 A. M. Qth. No change, except an appreciable increase in tem- perature. Quiniae sulph. gr. xx, acid, hydrobrom. n^xx at 9 P.M. 1th. Passed good night ; complained of no pain ; appetite good ; no thirst. Quiniae sulph. gr. x, acid, hydrobrom. n^xx at 11 A.M. and 9 P.M. 8^. Fever increasing ; has slight headache. Quinia sulph. gr. xv, acid, hydrobrom. rr^xv at 9 P.M. Frozen cloths to chest and abdomen, and ice cap to head from 1.30 till 9 P. M. (intermitting every 20 minutes). 3d, A.M., 99.2° F., P. 84, R. 18; P.M., 100.2° F., P. 94, R. 20. Uh, A.M., 99.6° F., P. 92, R. 22; P.M., 101.4° F., P. 106, R. 26. 5th, A.M., 101.4° F., P. 122, R. 22; P.M., 102.6° F., P. 112, R. 24. 6th, A.M., 98.8° F., P. 102, R. 24; P.M., 102.6° F., P. 112, R. 26. 7th, A. M., 100.2° F., P. 112, R. 26 ; P. M., 103.2° F., P. 118, R. 26. 8th, A.M., 102° F., P. 108, R. 22; P.M., 104.8° F., P. 126, R. 26.
$th. Very restless through night ; mind clear, and appetite, as usual, good ; bowels open ; urinary secretions normal ; fever running high ; no chill ; no sweat ; ice to head, and frozen cloths to chest and abdomen almost continuously from 10 A. M. till 7 P. M. At 3 P. M. complained of pain in abdomen, not further localized, which was relieved by sinapism and sol. morph. sulph. (gr. xvj to ^j) ni^v hypodermically, and disappeared in an hour. Urine sp. gr. 1018, acid, no albumen, chlorides normal. A.M., 102.6° F., P. 112, R. 24; P.M., 105.6° F., P. 124, R. 23.
10th. Slept well ; continues to enjoy food ; no delirium ; ice cap and frozen cloths applied at usual intervals from 1 to 7.30 P. M., during which time patient complained of headache. Quiniae sulph. gr. xxx, acid, hvdro- brom. 3ss at 8 A. M.. A. M., 104° F., P. 112, R. 23 ; P. M., 102.8° F., P. 110, R. 24.
11th, Rested comfortably ; bowels open ; urinated at regular intervals; ice cap and frozen cloths applied, with stated intermissions, from 10 A. M. till 12.30 P. M., 4 to 6.30 P. M. Epistaxis frequently throughout day (a new feature in case). Quiniae sulph. gr. xxx, acid, hydrobrom. n^xxx at 10 A. M. Urine, sp. gr. 1021, alkaline, no albumen, chlorides normal. A.M., 103.4° F., P. 110, R. 26; P.M., 99.8° F., P. 112, R. 18.
1880.] Ho f f, Typho-Malarial Fever. 49
1 2th. Slept most of night ; feels very comfortable, and has not lost zest for food. At 3 P. M. complained of stomach ache , relieved by sinapism. Diet restricted entirely to gruel, soups, etc., with eggs (cooked rare). Continued to take sp. vini gal. ^iv daily in form of milk-punch. Though body had become emaciated, considerable strength remained — sufficient to enable patient to move with slight assistance from one bed to another. Quinise sulph. gr. xxx, acid, hydrobrom. ni^xxx at 8.30 P. M. A. M., 100.4° F., P. 110, R. 20; P.M., 103.8° F., P. 126, R. 23.
13^. Patient for first time complains of fever ; says he feels " hot," though he reports a comfortable night. Fever is telling upon strength ; heart action rapid and somewhat irregular; pulsation weak. Ice cap and frozen cloths applied at usual intervals from 10 A. M., to 9 P. M.. Tr. digitalis et tr. ferri chlor. aa n^x four times daily. Brandy increased to ^viij in twenty -four hours. Urine, sp. gr. 1025, alkaline, chlorides present. A. M., 102° F., P. 118, R. 22 ; P. M., 105.2° F., P. 128, R. 30.
lith. Pulse very rapid and weak ; heart's impulse hardly perceptible ; mind perfectly clear ; tongue but slightly coated ; teeth without sordes ; sweated profusely through morning. Diet restricted to milk with lime- water, together with brandy. Digitalis and iron continued. Quinise sulph. gr. 1, acid, hydrobrom. r^l at 7.30 A.M. A.M., 104.8° F., P. 126, R. 22 ; P.M., 101° F., P. 108, R. 24.
loth. Very restless night ; no delirium ; tongue, which had nearly cleaned off, again thickly coated characteristically, tip and edges being clear and pink ; fever very high ; ice cap and frozen cloths applied at regular inter- vals from 1.30 to 7.30 P.M. 2.45 P. M. complained of pain in bowels, relieved by sinapism. Digitalis and iron continued. Quiniae sulph. gr. xxx, acid, hydrobromic. tti^xxx at 8.30 P.M. Urine, sp. gr. 1024, acid; chlorides present. A.M., 101.2° F., P. 108, R. 26; P.M., 104.4° F., P. 112, R, 26.
16th. Slept well all night; feels drowsy and weak; perspired freely during night, completely saturating bed clothing. Heart's action more regular and stronger ; bowels open ; urinates regularly. Ice applied three times during afternoon. Digitalis and iron continued. A. M., 100.4° F., P. 102, R. 28 ; P. M., 104.4° F., P. 130, R. 28.
17th. Rested easily, and would feel very comfortable were it not for sweat, which keeps him in perpetual bath ; tongue thickly coated and breath offensive ; teeth clean ; sweat continued all day. Quinise sulph. gr. xl., acid, hydrobrom. n^xl. 7.30 A. M., atropise gr. J-q morning and night. Omit digitalis and iron. A. M., 104.2° F., P. 118, R. 26 ; P. M., 101° F., P. 112, R. 28.
18th. Sweating still continues, not very profuse, and chiefly observable in morning ; pulse stronger and less frequent ; tongue still heavily coated ; appetite has disappeared entirely; urine, sp.gr. 1019, acid; chlorides. A. M., 101.6° F., P. 96, R. 28. P. M., 101.8° F., P. 98, R. 26.
19th. No marked change ; feels very weak and has no desire for food ; tongue and throat dry ; pupils dilated. Quinise sulph. gr. xxx, acid, hy- drobrom. xxx at 10 A.M. Omit atropise sulph. A.M., 101° F., P. 98, R. 26. P. M., 99.6° F., P. 106, R. 28.
20th. Slight improvement ; slept well and feels comfortable ; eruption on chest and abdomen still present ; no pain on pressure over any part of abdomen ; tongue slightly clearing ; heart's action stronger and more regular. A.M., 100.2° F., P. 98, R. 22. P.M., 101.4° F., P. 110, R. 24.
No. CLYII Jan. 1880. 4
50
Hoff, Typho-Malarial Fever.
[Jan.
21st to December 16. During this time convalescence may be said to have been established, and the case completed with hardlv a symptom worthy of remark. 21st A.M., 99.2° F., P. 95, R. 22. "P.M., 99.8° F., P. 106, R. 28. 22d A. M., 97° F., P. 98, R. 22. The tenor of the record is simply improvement. Quinia was given in five-grain doses from time to time sufficient to keep the system under its influence. The bowels, somewhat inclined to constipation, were kept open by occasional doses of Rochelle salt. Slop diet was resumed on November 25th. On 28th brandy was discontinued, vini albi 3yj, substituted, and this on Dec. 10th was reduced to Jiv. Dec. 12, full diet ordered. Dec. 16th, patient pro- ceeded to join his company at Fort D. A. Russell, and we have since heard that he entirely recovered.
Case IV. — Aged 23 years ; powerful physique ; family history good ; temperate habits. Following is an extract from early history of case by patient, written at our request : " Came into this country during latter part of February, 1878 ; stationed at Omaha Barracks. May 24th station changed to Fort Laramie. May 26th joined 5th cavalry, and proceeded to the site of the new post, Fort McKinney, on Clear Fork, Wyo. Re- mained in camp at this point and immediate vicinity three months. Dur- ing this time I went on various scouts, to Custer battle-field, Lodge Pole, and Crazy Woman's Creek. Health was excellent ; I never felt better in my life. Early in September marched for Camp Brown, third day crossed Big Horn Mountains, camped on Bates Creek ; four inches of snow dur- ing night ; marched all next day through heavy snow storm, wet and chilled through ; next night went to Indian camp, which was in damp place, stayed two hours, came away feeling chilly, and noticed my neck was slightly stiff ; next day felt quite chilly, neck worse, that evening saw doctor, he called complaint intermittent fever, gave quinia and compound cathartic pills. Reached Brown in ten days ; riding in hot sun and fatigue had made me much worse ; remained at Brown four days, then set out for Fort Fetterman, reached that post after a ten days' march." Never had typhoid or any other fever — except intermittent eight years ago, which illness lasted six weeks — subsequently had occasionally chilly feeling, but no regular attack of disease. Since May 26th been continuously in the field far from all settlements. Before attack bowels were regular, had no catarrh in head or lungs and no epistaxis. Disease was not ushered in by regular chill, but rather a chilly sensation (occurring only twice) ; had daily for two weeks more or less high fever, lasting a short time, and fol- lowed by sweat ; appetite poor ; bowels constipated ; no tenderness of abdomen, and no rash on body ; principal cause of complaint a severe pain in back of neck, but no headache ; has indistinct recollection of what happened after leaving Brown.
Transferred for treatment Sept. 28th, 4 P. M., at which time symptoms were severe nasal catarrh, and acute bronchitis, with free secretion ; no pain; no abdominal tenderness except over region of liver, which organ is slightly enlarged ; no eruption on body ; heart action strong and regular; pulse full ; fever high ; mind wandering ; tongue thick, flabby, coated at centre, clear on tip and edges ; breath fetid ; bowels constipated, urine scanty and high coloured ; excoriation over sacrum.
2Stk. Pil. Hydrarg. gr. x, 7 P. M., to be followed by Rochelle salt £ss in early morning. P.M., 105.4° F., P. 100, R. 18.
29fh. No sleep ; copious movements of bowels in night and day. 6 P. M., had involuntary passage of feces and urine, fouling bed. 9 P. M.,
1880.]
Ho f f , Typho-Malarial Fever.
51
sweating profusely ; mind wandering but controllable ; no pain. Liq. amnion, acetat. 5'j every two hours. Milk diet. A. M., 103.6° F., P. 100, R. 28. P.M., 104° F., P. 100, R. 22.
30th. Slept nearly all night; mind flighty; tongue dry and glazed; saliva thick and viscid ; no sordes ; throat sore ; pain in right iliac fossa on pressure ; bed sore forming on buttocks ; bowels open A. M., passage small, flaky, light yellow color ; urinary secretions free. To continue treatment and have sponsre bath whenever temperature exceeds 103° F. A. M., 101.8° F., P. 94JR. 26. P. M., 103.4° F., P. 100, R. 24.
Oct. 1. Restless and flighty through night, cough frequent ; nasal catarrh improving ; tongue clearing slightly ; conjunctiva injected ; appetite good. 10 P.M. in profuse sweat preceded by slight chill. Cold sponge bath 9 A. M. Quiniae sulph. gr. xv, acid, hydrobrom. ni^xxx, at 11 A.M. and
8 P. M., continue liq. amnion, acetat. A. M., 102.8° F., P. 100, R. 28. P.M., 103° F., P. 102, R. 22.
2d. Wakeful and wandering till 6 A. M., then slept most of day ; urin- ates in bed; is irritable when awake; mind controlled by effort of will. Simple enema 7 P. M., followed by copious light-coloured evacuations; bed-sore spreading ; slight perspiration in evening. Omit liq. amnion, acetat. A. M., 98° F., P. 96, R. 24. P. M., 102.4° F., P. 98, R. 28.
3d. Delirium well marked, requires constant watching to prevent escape from bed ; only complains of hunger ; urinary secretions regular, and, as usual, voided in bed. Quiniae sulph. gr. xv, acid, hydrobrom. n^xxx at 11 A.M. and 7 P.M. A.M., 100.4° F., P. 88, R. 24. P.M., 101.8° F., P. 92, R. 28.
4th. Comfortable night ; catarrhal symptoms disappearing ; tongue less thick and coated; simple enema 11 A.M., followed by two dejections; mind very much more collected ; recognizes friends and converses with them rationally. Cold sponge bath 4 P. M. A. M., 100.4° F., P. 84, R. 28. P. M., 102° F., P. 88, R. 24.
5th. Delirious through night, flighty and nervous through day ; urinated in bed ; bed sores not improving though all care is taken to prevent foul- ing and pressure ; appetite very good. Cold sponge 8 A. M. and 4 P. M. Quiniae sulph. gr. xv, acid, hydrobrom. rr^xxx 7 P.M., chloral, hydrat. gr. xv at 10.30 P.M., to be repeated at 12 P.M. if necessary. A.M., 101.6° F., P. 76, R. 28. P. M., 102.8° F., P. 90, R. 22.
6th. Slept well till 2 A. M., became restless. Chloral repeated, then slept until 9 A. M. ; enjoyed breakfast, and feels well ; is still flighty ; coughs occasionally with little expectoration ; tongue coated, protruded tremblingly and with difficulty ; no bad taste in mouth. Cold sponge
9 A.M. and 4 P.M. Simple enema 11 A.M., producing small dejec- tions. Pil. cath. comp. iij 8 P. M., quiniae sulph. gr. xv, acid, hydrobrom. ntxxx. 8 P. M. A. M., 100.6° F., P. 84, R. 20. P. M., 100.6° F., P. 88, R. 30.
7th. Quiet sleep till 1 A. M., then becoming restless had chloral, hydrat. gr. x, and rested well till morning ; bowels moved twice during night ; no pain ; mind clear in morning, somewhat flighty during afternoon ; tongue still coated, has brassy taste in mouth ; nasal catarrh still trouble- some. Potassii bromid. gr. xv 7 P.M. A.M., 98.8° F., P. 84, R. 26. P.M., 98.6° F., P. 78, R. 30.
8^. Comfortable night ; bed sores still angry ; excoriations are appear- ing on both great trochanters ; small boils forming at various points on lower extremities ; sat up short time during day. Potass, chlorat. sol.
52
Ho f f , Typho-Malarial Fever.
[Jan.
(gr. xv. to gj) for mouth wash. A. M., 98° F., P. 88, R. 28. P. M., 99° F., P. 88, R. 24.
9th. Little sleep till 5 A. M. ; fouled bed twice with urine ; asleep dur- ing morning ; simple enema was given to relieve constipation (non-effec- tive) ; appetite voracious ; no eruption on chest or abdomen ; lungs clear ; liver and spleen very little if any enlargement. Quinise sulph. gr. xv, acid, hydrobrom. ni^xxx 4 P.M., pil. cath. comp. ij 9 P.M. A.M., 100.2° F., P. 100, R. 32. P. M., 100.2° F., P. 100, R. 28.
10th. Rested well after chloral hydrate, gr. x, 11 P. M. Sat up most of day ; mind perfectly clear ; had passage from bowels after simple enema ; feces hard, lumpy, and light coloured. A. M., 98° F., P. 92, R. 24. P.M., 100.2 F., P. 100, R. 28.
11th. Slept twelve hours, seems greatly improved ; tongue clearing off; general condition promising ; mind clear ; bed sores healing ; boils, of which fresh crops appear almost daily, very troublesome ; appetite good ; bowels constipated. Quiniae sulph. gr. xv, acid, hydrobrom. n^xxx 7 P. M., pil. cath. comp. iij 9 P. M. A. M., 98.4° F., P. 84, R. 28. P. M., 100.2° F., P. 100, R. 24.
12th. Bowels moved during night, otherwise slept undisturbed ; another movement at 2 P.M., dejections soft and light coloured; nasal catarrh almost disappeared ; strength rapidly returning ; sits up most of day and enjoys reading. . A. M., 98.4° F., P. 88, R. 20. P. M., 98.8° F., P. 100, R. 22.
13th. No change. Pil. cath. comp. iij 8 P. M. A. M., 98° F., P. 84, R. 20. P.M., 98° F., P. 100, R. 20.
lAth. Wakeful and restless through night; fouled bed with urine ; sat up most of day and had excellent appetite ; mind rational. Quinise sulph. gr. xv, acid, hydrobrom. n^xv 9.30 P.M. A.M., 99° F., P. 96, R. 20. P.M., 100.2° F., P. 96, R. 20.
15th. Fouled the bed. This non-control of bladder arises from no func- tional difficulty, but is due simply to weakness, and in part to want of mental balance. Says he feels perfectly comfortable, sits up most of the day, reads and talks understandingly ; tongue clear; bed sores improving ; boils still appearing in fresh crops ; perspired during night and had bad dreams. A. M., 98° F., P. 96, R. 20. P. M., 101.6° F., P. 100, R. 20.
16th. No change. Abscess of parotid gland, right side, opened (with lancet), discharging pus freely. Quinise sulph. gr. xv, acid, hydrobromic. n^xv 7 P. M., pil. cath. comp. iij 9 P. M. A. M., 101.2° F., P. 120, R. 16. 9 P.M., 100.6° F., P. 120, R. 16.
18th. Had Rochelle salts ]§j A. M. '; quinise sulph. gr. xv, acid, hydro- brom. t^xv at 7 P.M. A.M., 98° F., P. 96, R. 16. P.M., 101.4° F., P. 100, R. 20.
19th. Comfortable night; had two motions from bowels; urinated freely ; apparently convalescent ; is growing stronger ; has, as always, ex- cellent appetite, and feels well in every particular. Boils, still numerous, give occasional discomfort. Has been entirely rational for several days ; perspires daily but not excessively. A. M., 98.4° F., P. 100, R. 20. P.M., 101° F., P. 100, R. 16.
20^ to 25th. Case progressed very favourably ; bowels moved regularly ; appetite continued remark ibly good ; strength increased daily. On 22c? dressed without assistance, walked about room, and during day wrote several letters. 21st. Quinise sulph.gr. x, acid, hydrobrom. n^x 7 P.M. 22d. Quinise sulph. gr. v, acid, hydrobromic. rr^xv 7 P. M., repeated 7
1880.]
H o f f , Typho-Malarial Fever.
53
P.M. 23d. 20th. A.M., 99° F., P. 96, R. 16. P.M., 99° F., P. 96, R. 16. 21st. A. M., 98.4° F., P. 96, R. 16. P. M , 99.2° F., P. 88, R. 16. 22d. A.M., 100.4° F., P. 100, R. 16. P.M., 99.2° F., P. 96, R. 16. 23d. A.M., 99.8° F., P. 100, R. 16. P. M., 99.2° F., P. 100, R. 16. 2UL A.M., 99.2° F., P. 112, R, 16. P.M., 100.2° F., P. 92, R. 16. 2bth. A.M., 100° F., P. 100, R. 16. P.M., 101.6° F., P. 98, R. 16.
26^. Restless night ; pain in left side over region of spleen, which organ is considerably enlarged ; tenderness in hepatic region ; feels weak and inclined to keep his bed, though more comfortable when sitting up ; has pain upon taking full inspiration ; cannot lie on right side ; no pul- monary lesion. Quinire sulph. gr. xv, acid, hydrobrom. t^xxx 7 P. M. A.M., 101° F., P. 100, R. 16. P.M., 102.6° F., P. 104, R. 20.
27th. Slept well ; still complains of sharp stitch-like pain in left side ; emunctories' working freely. 12 M. Quinias sulph. gr. x, acid, hydro- brom. n^x. 2 P. M., had a severe chill, lasting half an hour, followed by fever and sweat. A.M., 101° F., P. 100, R. 16. P.M., 106° F., P. 124, R. 20.
28^. A.M., 99.4° F., P. 88, R. 16.
From this time case went on to rapid and satisfactory recovery ; for several days the evening temperature ran up above 100° F., then gradually receded to the normal. The pain in left side did not entirely disappear for ten days. Nov. 4th patient took a short walk in open air, and con- tinued to do so each pleasant day until he left this station (loth). So soon as exercise began the bowels became regular, strength returned very rapidly. Quinia was continued in decreasing doses at stated intervals until 3d inst.
Case V — Aged 32 years; taken sick about September 10, 1878, while crossing Big Horn Mountains with command. Previous history very meagre; patient upon admission and afterwards being in no condition to give information. It will be observed that the case was transferred as quotidian intermittent. AVe learned from surgeon in charge that patient's principal complaint was severe pain in back of head and neck. In a lucid interval patient told me attack was ushered in by headache and pain in bones ; he had no diarrhoea, bowels being generally regular, but micturi- tion difficult.
Admitted to hospital September 29th, P.M. Medium-sized man; large head ; light hair ; spare habit ; body considerably emaciated ; strength greatly reduced ; mind wandering ; tongue almost normal size, slightly coated in centre, clear and pink at tip and edges; teeth clean ; conjunctiva clear; pupils reacting equally. On back of neck scar, evidently of recent blis- ter; thorax somewhat dull all over on percussion; respiration superficial; slight roughness upon inspiration; heart action weak, otherwise normal; abdomen, without eruption, generally tender on pressure; liver enlarged and tender; spleen enlarged, but not painful upon palpation; no appetite; thirst great; throat slightly sore; expectoration viscid and whitish; no pain in chest or abdomen, but severe pain in back of head and neck.,
29th. Solution morphice sulph. (gr. xvj to ^j) tt^v, hypodermically, to relieve pain, p. r. n. Milk diet; sponge bath. A. M., 104.8° F., P. 82, R. 30.
30th. Restless and delirious through night ; complains of headache. Con- tinue morphia p. r. n., and have quiniae sulph. gr. iij every three hours. A. M., 102.8° F., P. 78, R. 28. P. M., 102.2° F., P. 78, R. 28.
54
Hoff, Typho-Malarial Fever.
[Jan.
Oct. 1st. No change; mind wandering, but controllable; pain in head still very severe. Continue treatment. A. M., 101.8° F., P. 78, R. 26. P. M., 102.8° F., P. 80, R. 24.
2d. Tongue clearing; headache somewhat relieved; restless during night ; not as weak as symptoms would lead to expect ; heart action good ; micturates regularly and without much difficulty; urine, sp.gr. 1024, acid, albumen a trace, chlorides a trace. Continued treatment, and add atropire sulph. gr. ^ to morphia for hypodermic injection. A. M., 102.4° F., P. 70, R. 20. P. M., 104.6° F., P. 14, R. 24.
3d. Seems to feel a little better this A. M., probably due to naps caught during night; head still aching, and abdomen very tender; bowels con- stipated. Quinise sulph. gr. xv, acid, hydrobrom. n^xxx morning and night; magn. sulph. %ss, A. M. Milk and gruel diet. A. M. 103.2° F., P. 74, R. 22. P. M., 102.8° F., P. 80, R. 20.
Ath. No change except less pain in head; bowels open during night; sleepless and wandering ; some appetite, and considerable strength. Omit treatment. A. M., 100.2° F., P. 78, R. 20. P. M., 102.6° F., P. 72, R. 26.
5th. Still flighty and restless; complains of no pain, but mind in such condition of hebetude that little can be learned regarding sensations ; uri- nates freely ; bowels open ; expectoration thick and slightly rusty ; sub- crepitant rales in right lung; abdomen still tender; profuse sweat 6.30 to 8 P. M. Quiniae sulph. gr. xv, acid, hydrobrom. n^xxx at 11 A. M. and
8 P. M. Urine, sp. gr. 1022, acid, albuminous, chlorides present. A. M., 101.6° F., P. 72, R. 20. P. M., 102.8° F., P. 72, R. 20.
6th. Comfortable night; tongue clearing; teeth without sordes; still complains of pain on pressure over liver; expectoration viscid with slight rustiness. A. M., 100.6° F., P. 72, R. 20. P. M., 102.8° F., P. 84, R. 20.
7th. Feels well; mind collected; still has pain in right side; expectora- tion viscid, but not rusty; no albumen in urine; heart's action regular and strong; strength fair. Quinise sulph. gr. xv, acid, hydrobrom. xxx, 10 A. M. and 9 P. M. A. M., 101.4° F., P. 78, R. 19. P. M. 103.8° F., P. 86, R. 24.
8th. Generally improved ; slept well and feels quite bright; entirely ra- tional. Omit medicine. A. M., 99.6° F., P. 76, R. 18. P. JVL, 102.6° F., P. 78, R. 22.
9th. Symptoms at morning visit favorable; slept most of night; is with- out pain, and has quite an appetite, though still confined to soups and gruels; mind perfectly clear. 9.15 P.M., complained of severe pain in bowels, of colicky character; ordered sinapism, enema, terebinth., Magen- die's solution morph. n^v (hypodermically), and repeat in one hour if necessary; quinias sulph. gr. xv, acid, hydrobrom. ni^xv, at 10 A. M. and
9 P. M. Urine, sp. gr. 1024, acid, no albumen. A. M., 99.8° F., P. 74, P. 20. P. M., 102.4° F., P. 82, R. 18.
10th. Slept very little; had colicky pain more or less through day; ab- domen hard and tender to touch ; somewhat relieved by sinapisms and hypodermics of morphia. At 9.30 P. M. pain became excessive ; morphia and mustard continued, the latter substituted by turpentine stupes. 10.30 P. M., brandy £j; cold cloth to head. A. M., 101.2° F., P. 84, R. 22. P. M., 104.4° F., P. 116, R. 28.
11th. Great prostration; heart's action weak; breathing costal ; abdomen tender in all directions, hard and tympanitic ; perspiration cold and pro-
1880.]
H o f f , Typho -Malarial Fever.
55
fuse; delirious; both pupils contracted (from opium); turpentine stupes and morphia continued, with brandy. A. M., 105.2° F., P. 138, R. 14. Died at 11.35 P.M.
Xecropsy.1 — Omentum contains considerable fat, is very much injected, and has numerous adhesions to intestines; liver increased by about one-half its size, of dark-brown colour, smooth surface, no abdominal adhesions, somewhat softened and tilled with blood ; gall-bladder very much dis- tended, contains no calculi ; spleen about twice normal size, capsule tense, and so friable that it ruptured on removal under most delicate manipula- tion ; parenchyma pulpy, of blackish-red colour, and almost liquid con- sistency, being gorged with black blood; peritoneal cavity contains a thin yellow fluid of fecal odour; peritoneum above umbilicus is reddened and somewhat rough with slightly velvety appearance, below umbilicus there is a thin transparent layer of coagulated fibrine with occasional opaque patches; intestines covered with a rough-whitish layer, and matted to- gether, contents fluid, no hardened masses ; eighteen inches from caput coli was found a perforation of ileum, through which the same yellowish fluid, seen in peritoneal cavity, was pouring out; internally the whole in- testinal canal was covered with mucus and epithelial masses, which exuda- tion was most marked in ileum and colon; about the ileo-erecal valve (within twenty-four inches) in small intestine, were several well-defined elevations of circular form, the periphery being raised ridge-like, a line above the general surface, the size of these plaques was about that of a half-dime piece. At a point corresponding to the rupture already men- tioned, was found what was evidently an ulcerated Peyer's patch, with its centre as though punched out by a cutting instrument. There was also enlargement of the solitary glands; kidneys large, smooth, and white, right weighing 8-| ounces, left 9 ounces (not examined internally) ; both lungs were universally adherent to pleura (adhesions very firm) ; heart small, flabby, and of yellowish colour ; pericardium contains but little , fluid; blood very dark coloured; thoracic viscera not examined internally; dura mater strongly adherent to cranium, pia mater injected, arachnoid covered with patches of pearly exudation ; brain substance soft.
In reviewing the foregoing clinical histories it is reasonable to assume that the external causes of disease were identical, since the outward con- ditions of the patients were entirely similar. True this is only an assump- tion, incapable of absolute proof, but certainly plausible, and the truth of which is demonstrable up to a point rarely reached in such investigations.
It will be observed that the command had been absent from permanent settlements four months, sufficiently long to preclude the probability of the materies morbi having remained latent from the time the column first took field until the disease appeared. Between June and September the troops did not approach any settlement save that of Camp Brown, where they remained but a few days, and intercourse with which during their sojourn was necessarily restricted by discipline of the camp.
Assistant Surgeon C. H. Winne, IT. S. Army, Post Surgeon, Fort
1 The cranial, thoracic, and abdominal viscera were sent to the Army Medical Mu- seum in as perfect condition as possible, for examination there, which will prevent a very detailed description here.
56
Hoff, Typho-Malarial Fever.
[Jan.
Washakie, TTyo. (formerly Camp Brown), writes, in reply to request for information as to prevalence of typhoid or typho-malarial fever in 1877 and 1878 : " Intermittents and remittents are noted (on hospital record), but neither typhoid nor typho-malarial are noted." Dr. R. B. Grimes, U. S. Army, who was Post Surgeon at Brown, in 1878, and some years previous, states : "I was stationed in the Wind River country over four years, and I am positive that I never met with a case of typhoid fever in that region. ... I have no reason whatever to believe that there were causes or influences at Camp Brown to generate typhoid."
The first permanent camp of the cavalry was established in a region heretofore almost undefiled by human foot, leaving entirely out of con- sideration human settlement, and communication with which was, by reason of its very isolation, restricted. The second camp, but a few miles distant, was equally isolated. The road to Camp Brown through the Big Horn Mountains, an almost disused Indian trail (during the march over which in most of the cases the disease manifested itself), was virgin of settlement or civilization. From all of which conditions it would be diffi- cult to imagine any immediate or remote human origin for the disease germs.
A due consideration of the circumstauces surrounding the command, leads us to seek for the predisposing causes of disease in or about its camps on Clear and Rock creeks. These rapid streams take source in the Big Horn Mountains, and draw their supply from the snows which perpetually cap the summit of this elevated range. The summer of 1878 was excep- tiouably hot, so warm indeed that the snow disappeared entirely from many of the peaks, which, according to tradition obtaining among the few trappers who have hunted that region, were never before uncovered. It is to be regretted that a systematic analysis of these waters was not made, but judging from the rough test of taste, their snow origin was unmistak- able, and there was "a suspicion of vegetable infusion." More accurate tests would, doubtless, have confirmed this suspicion of organic matter, since at this time the water supply was from snow probabl) many seasons old, which each year became more and more impregnated with organic germs filtered through superimposed strata. " That these cases," Dr. Gray writes, " were malarial, there is in my opinion no room for doubt, but whence came the toxic germs ? Reasoning by exclusion I am compelled to attribute their source to the water formed by the melting snow."
Such conditions would certainly be deemed sufficient to account for any malarial manifestations — and such we may assume were predisposing causes to disease in the foregoing cases ; the exciting causes being the hardship and exposure consequent upon the march through the mountains. If there were other causes, immediate or remote, they do not appear.
Conceding the causes of diseases as identical, it logically follows the diseases are similar, and this supposition is borne out by coincidence in
1880.]
Hoff, Typho-Malarial Fever.
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mode of onset, symptoms, and course in all cases whose clinical histories have been herein set forth. Case V. presented no special features not attributable to individual idiosyncrasies. On admission, patient seemed more under influence of materies morbi ; but, so soon as system became amenable to remedies, temperature fell, pain disappeared, appetite im- proved, and there was fair promise of recovery. But this man undoubt- edly had typhoid fever, and died from its effects. Surgeon J. J. Wood- ward, U. S. A., writes : " In your case the lesions found in the specimens sent to the Museum are those of ordinary typhoid fever ;" hence, by the terms of our hypothesis, all these cases must be typhoid.
This conclusion may not be accepted without protest ; running water from virgin snow is not generally believed to be deleterious, and certainly not to contain the germ from whence alone typhoid is held to grow. Possibly, Case V. suffered from another disease than the rest ; but, if so, there was nothing to indicate the difference.
" Mountain"1 fever is far from being a typical enteric, even though the latter, save as to its pathology, is a never constant entity. " The diseases which are produced by the specific poison of typhoid fever," writes Lieber- meister,2 " differ a good deal among themselves ; some of the diseases are so serious that life is almost inevitably destroyed by them ; others are so trifling that patient and physician are left in doubt whether there were really any disease at all ; and between these extremes we find every gradation."
In enteric, the fever has a curve marked briefly by a gradual rise, con- tinuance, remission, and finally intermission. The histories of the fore- going cases would indicate that they came under observation here during second and third periods, i. e., continuance and remission.3 The thermo- metry records in a general way attest this ; there are, however, some sudden and marked deviations which seem to indicate the probability of other than typhoid influences being at work.
It will be observed that, in every case under consideration, there were at intervals, occurring with greater or less regularity, chill, fever, and sweat — frequently all three — inevitably two of these pathognomonic stages of intermittent fever. The recurrence of these symptoms was so frequently observed that they could hardly be regarded as the " after fever" of the
1 Writers previously quoted, while not conceding the identity of " mountain" and typhoid fevers in their description of the former disease, certainly give a recognizable picture of the latter. This question of identity finds its counterpart in the discussions of the nature of fevers once supposed to be indigenous to the Appalachian Range, and now generally recognized as enteric.
2 Ziemssen's Cyclopaedia, vol. i. p. 76.
8 Drs. Smart and Gray give the period of incubation of " mountain" fever as about two weeks. Dr. Williamson (Smart, American Journal of the Medical Sciences, 1878) says : "When morbid process is fairly established, you will have a case of disease that will run from three to five weeks before you can see the commencement of con- valescence."
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Hoff, Typho-Malarial Fever.
[Jan.
Germans, and certainly not as relapses, of which more than two are rarely encountered ; moreover, we have to take into consideration the mode of onset of the disease, which at least so closely resembled that of intermit- tent that the patients were transferred as suffering from this disease in its typical forms.
Although the fever was high and long continued in several cases, in but one (V.) was there an approximation to the status typhosus — while in the only other case (IV.), in which head symptoms were at all promi- nent, the fever was by no means excessive — though both had involuntary dejections. Diarrhoea did not appear ; on the contrary, the patients were all more or less constipated ; there was no tympanites or meteorismus. In but one (III.) was there anything that approached in appearance the typical roseola. No epistaxis early in any case, and no intestinal hemor- rhage. Convalescence was rapid, and the hair did not fall. In two (II. and IV.) there was acute nasal catarrh. Herpes labialis appeared in three (II., III., and IV.).
Imbued with the idea that typhoid fever could not originate de novo, or remain latent in the system for a longer period than four weeks, we have been slow to conclude that " mountain" fever was in any wise related to enteric ; in fact, we have heretofore advanced the theory that the fever of this region was a subcontinued fever of purely malarial origin ; that the temperature curve showed daily exacerbations and remissions of such character as to lead to the belief that we had a mixture of types, but not of diseases. In the light of further experience and pathological anatomy, we are obliged to abandon the position then taken, and acknowledge " mountain" fever as essentially typhoid.
W e, however, contend that the morbific causes are not solely those of enteric, but that they are modified by the mater ies morbi of intermittent fever — a fact which we believe to be substantiated : 1st. By deviation from the normal temperature curve of typhoid ; 2d. By the difference in many symptoms, which, taken singly, would be of little importance, but, in the aggregate, are entitled to grave consideration ; 3d. By the action of quinia, which seems to have a specific effect other than the simple anti- pyretic influence exerted in typhoid.
From which the following is deduced: —
1st. The fever of the Rocky Mountain region is a hybrid disease, the prominent features of which are typhoid — the modifying, intermittent; is, in fact, the typho- malarial fever of Woodward.1
2d. It appears during or after exposure incident to field-service, gene- rally, though not necessarily, in late summer and early autumn, and seems
1 The question of hybndity of disease has no place in this essay ; that such mon- grels are recognized, at least in our country, "goes without saying;" that they should be recognized in Europe seems conclusively proved by Dr. Woodward (Trans. International Medical Congress, Phila. 1876. Paper on Typho-malarial Fever).
1880.]
Woodward, Typho- Malarial Fever.
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to bear no relation to typhoid infection as now usually accepted by the profession.
3d. At its inception, this disease manifests itself as an intermittent of quotidian, tertian, or other form ; this stage is followed (in about two weeks) by the typhoid stage, lasting in neighborhood of four weeks, in which typical typhoid symptoms may be observed, modified to a greater or less degree by intermittent indications.
4th. The pathological anatomy of the disease is that of typhoid fever.
5th. The treatment should be antiperiodic and antipyretic.
Fort Fetteeman, Wyoming Territory, 1879.
Memorandum. By J. J. Woodward, M.D., Surgeon U. S. Army — Without at present committing myself either for or against the views ex- pressed by Assistant- Surgeon HofF in the foregoing interesting paper, I wish to state that, besides the specimens from the fatal case he describes (Nos. 1418, 1419 and 1420, Medical Section), the Museum possesses another specimen from a case of the so-called mountain fever, contributed by Assistant-Surgeon A. C. Girard, U. S. A. The patient was a quarter- master's teamster, who died at Fort Keogh, Montana Territory, March 18, 1879. On the autopsy, characteristic typhoid ulcers were found in the small intestine, one of which had perforated and was the immediate cause of death. (The specimen is No. 1482, Medical Section.) Now, it is easy enough for those who have made no autopsies in this disease to be led by speculative considerations to insist, as my friend, Assistant- Surgeon Charles Smart, U. S. Army, has done (this Journal, January, 1878, p. 34), that mountain fever is merely "a. malarial remittent with adynamic tendencies ;" but such positive observations as those of Drs. HofF and Girard will serve to show how unsafe it would be to repose confidencein immature generalizations of this kind.
A like criticism applies to the views Assistant-Surgeon Smart has ad- vanced in the same paper (p. 38 et seq.) with regard to the camp fevers of the late civil war. Clinical observation in the Army of the Potomac, which even " an occasional autopsy" did not serve to enlighten, have led him to adhere strongly to the opinion that our camp fevers were merely remittents which assumed an adynamic type towards their close, and that they were not often complicated with the typhoid process, which, indeed, he imagines to have been comparatively rare. In a subsequent publica- tion,1 after insisting that " the camp fevers of this country are malarial, the germ being either air-borne (rnalarial) or water-carried {aqua- malarial)" the same gentleman writes of typhoid fever: "In more populated districts, the specific germ of typhoid may add its train of
1 Hygiene of Camps, in a work on Hygiene and Public Health, issued, in lieu of a translation from the German volume on the same subject, as Vol. XIX. of the Ameri- can edit, of Ziemssen's Cyclopaedia, New York, 1879, p. 148-9.
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Allen, Chronic Nasal Catarrh.
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symptoms to the list of camp fevers. It is a disease which has, without doubt, invaded our camps in many instances ; but that it figured during the late war — simple or masked by malarial concomitants — as largely as we are called upon to believe by Dr. Woodward, has been shown by the writer to be exceedingly doubtful." In support of the opinion contained in the last clause of this passage, the author refers to his article in this Journal just cited.
Now, certainly the testimony of Assistant-Surgeon Smart, recorded in that article, is quite valuable as an addition to a great deal of other evi- dence of the same kind which tends to show the similitude that existed between the early stages of the majority of the camp fevers of the late war and ordinary malarial fevers ; but he himself informs us (this Journal, Jan. 1878, p. 40) that he " saw many such cases in their inception, few com- paratively at their termination." Had he been able to follow his fever patients to the hospitals of Alexandria and Washington, he would have learned that, in the great majority of the autopsies made in fatal cases, unmistakable typhoid lesions were recognized in the small intestine; and, had he extended his inquiries to the other general hospitals, he would have found that this was equally true of them all. In point of fact, the records of the post-mortem examinations of fever cases made during the civil war fully support the views I have heretofore expressed of the extreme fre- quency of the typhoid complication ; and their publication (in the third medical volume of the Medical and Surgical History of the War) will convince the reader that the views expressed by my friend in the two papers to which I have just referred are inaccurate historically, and that their general acceptance would be pregnant with mischief in future wars.
Article III.
On a New Method of Treating Chronic Nasal Catarrh. By Harrison Allen, M.D., Professor of Physiology in the University of Pennsylvania.
In the course of my clinical studies in chronic nasal catarrh, I have become interested in a method of local treatment which presents, in my opinion, decided advantages over those ordinarily employed. Method is, perhaps, too complimentary a term to use in speaking of the resources of the physician usually relied upon in treating this obstinate affection. Let me rather say that, in a treatment which has hitherto possessed but little or no method, I have endeavoured to institute one, that I have used with success — a few simple means of reaching and medicating the labyrin- thine surfaces of the nasal chambers and the obscure region of the pharyn- geal vault.
1880.]
Allen, Chronic Nasal Catarrh.
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It is impossible to enter fully into the subject of the treatment of nasal catarrh without some consideration of the etiology of the affection. I will, therefore, briefly state my views of the causation of at least an important group of cases.
The nasal chamber being a modified portion of the respiratory tract, it follows that its functional integrity is dependent upon the freedom with which a current of air can pass through it.1 Obstruction is fatal to its effi- ciency ; for not only is the sense of smelling lost, but the unconscious effort to breathe through the nose ordinarily causes congestion and distress, and at all times the normal outflow and distribution of mucus is interfered with. Nasal mucus has a tendency to flow backward. The gentle inclination of the floor of the nose from before backward, and the dip of the turbinated bones, determine this. Nasal obstruction interrupts this flow, and occasions accu- mulation and subsequent inspissation of mucus, or a reversal of the current, which results in escape of the secretion at the nostrils. If it is conceded that these statements are correct, all that becomes necessary to make their application to chronic nasal catarrh is to demonstrate the existence of obstruction in that affection. This is not difficult to do. The patient should be seated in front of the physician as though the laryngoscope was about to be employed ; namely, by the side of a powerful lamp, the light of which is reflected, from a mirror on the brow of the physician, directly into the nostril. In order to illuminate properly the nasal chamber, a speculum is necessary. One may use Folsom's speculum as modified by myself,2 or the ordinary vulcanite ear speculum modified by converting the round or oval opening into an elliptical one, as shown in figure 1. Such
Fiff. 1.
OOoo
Calibres of the aural specula. Calibres of the nasal specula.
an instrument permits a deeper entrance to be effected than with a wider form — keeps the hairs of the nostril well out of the way, and protects the alae from accidental contact of irritating drugs. In the normal nasal chamber the turbinated bones do not touch the nasal septum, neither do the middle or inferior turbinated bones impinge on each other, or the floor of the nose. Should, however, chronic nasal catarrh be present, the middle turbinated bone is often seen lying close against the septum, or the
1 For limitation of this statement, with discussion as to the olfactory and respiratory values of the nasal chamhers, see Dr. Wm. Ogle, Med.-Chir. Trans, vol. liii. 1870, p. 263.
2 This simply comprises in soldering the vertical wire to the upper border of the lower flange. It thus permits a wider space for introduction of instruments. The instru- ment thus modified is for sale by Mr. Gemrig of this city.
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Allen, Chronic Nasal Catarrh.
[Jan.
inferior turbinated bone is found occluding the inferior meatus.1 It must never be forgotten that the range of variation in the details of the normal nasal chamber is very great, and care must be exercised not to confound the foreshortening of a deflected yet healthy nasal septum, lying with its most prominent part in front of the inferior or middle turbinated bone, with the contact I have associated with the symptoms of one form at least of chronic nasal catarrh. Neither should the mere contact of the ante- rior portion of the middle turbinated bone against the septum be looked upon as of necessity an exciting cause of nasal catarrh. Not infrequently perfectly healthy persons will exhibit such contact over a small surface. But in such instances the contact is always found to be slight — the apposed surfaces barely touching — and a probe can be passed without pain or sense of obstruction. In the contact which has clinical significance I should expect firm pressure of the scroll and septum against one another, and some pain to follow manipulation.
When the point of contact is recognized, the indication for treatment is to destroy it. This is accomplished by means of local remedies applied to the mucous membrane at and about the places of contact, or, in examples of abnormal deflection of the nasal septum, by removal of the offending portions of bone. In the case of the inferior turbinated bone, the swollen and engorged tissues occupying the inferior meatus may be removed by the knife.
In carrying into effect the above rules of treatment, I have adapted several instruments to the special needs required. These I will now describe. To make topical applications to the interior of the nasal chamber, I em- ploy a simple cotton carrier closely resembling the instrument in com- mon use by the aurist. It consists of a single tapering rod of soft iron, slightly roughened at the smaller end for convenience of holding a pledget of absorbent cotton, and fixed in a small wooden handle at the other. A wooden handle is preferable to a metallic one, since the latter is liable to fall out of the nasal chamber from its own weight if the hand supporting it be removed for but a moment. It may be bent at an angle; the
1 It is well to remember that obstruction may occur either from a sentient surface being squeezed, or by the same surface on the opposite side, i. e., in the other nasal chamber, extending its parts beyond the limit assigned by nature. Thus a deviation of the perpendicular plate of the ethmoid bone to the left may compress the left mid- dle turbinated bone, or, if the turbinate of this side be small, it may escape compres- sion, while the right turbinated bone may extend its natural limits, and, by following the receding septum, may actually press against it. It by no means follows, there- fore, that obstruction is always met with upon the narrowed side, although this is very often the case. It is an observation every one has often repeated that the inferior turbinated bones grow downward, in cases of cleft palate, and in a measure occupy the space in the roof of the mouth. In the same way asymmetry of the lateral masses of the ethmoid bone is often associated with deviation of the perpendicular plate. When this deviation occurs slowly, or is congenital, the parts are adapted and the result is harmonious ; when, however, it is acquired, it is liable to excite disturbance.
1880.]
Allen, Chronic Nasal Catarrh.
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shape seen in figure 2 is the one ordinarily sufficing. The absorhent cotton can be steeped in any desired substance, and carried to the spot selected through the nasal speculum. The pledget of cotton should be moistened in water and warmed for an instant over the flame of the lamp.
Fie:. 2.
Thus prepared it does not irritate the mucous surfaces more than any other intruding solid substance. After employment of various agents, I have found the best results from a combination of tannic acid with carbolic acid or iodoform, held in suspense in gelatine.1 The object of employing gelatine rather than water or spirit is to enable the medicine to remain for a long time in contact with the affected parts, and, in dis- solving, to form a thick fluid which measurably imitates the consistency of the normal secretions of the parts. Thus syringing the nose with a simple fluid can have but a transient effect, while the medicine reaches perfectly healthy surfaces as well as the diseased ones. The method here recommended restricts the application to the spot where it is needed, and allows the medicine to slowly dissolve. I have often succeeded, in cases
Fig. 3.
of pronounced contact between the septum and the anterior portion of the middle turbinated bone, in introducing a plate of gelatine, medicated with tannin and carbolic acid or other drug, into the space behind the point of contact. Here it would remain, if aptly lodged, for a period varying from an hour to half a day.
In some instances where much resistance is to be overcome, I have
1 I append the formulae of the preparations I ordinarily employ, which are made for me by Borell, of this city.
Stiff iodoform preparation, with geranium and carbolic acid : fy. Pure carbolic acid, grs. v ; fluid ext. geranium maculatum, gtt. xv ; distilled glycerin, gtt. x ; powdered iodoform, 5iijss ; French gelatine, 3j ; water, a sufficient quantity. Dissolve the gelatine in a little water, then add the other ingredients, and rub to a smooth paste.
Stiff iodoform preparation without geranium : if,. Pure carbolic acid, grs. v ; dis- tilled glycerin, gtt. x; powdered iodoform, 5iijss; French gelatine, 3j ; water, a suffi- cient quantity. Dissolve the gelatine in a little water, then add the other ingredients, and rub to a smooth pa6te.
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Allen, Chronic Nasal Catarrh.
[Jan.
found it advantageous to introduce the gelatine plates with a pair of for- ceps, of the design shown in figure 3. In using this instrument, the blades should be so held as to spread from above downward. This enables the operator to manipulate the instrument freely, since the space between the septum and turbinates, while at all points narrow, is sufficiently high to enable the largest desired plate to be introduced and lodged with rela- > tive ease.
When it is desired to employ a powerful astringent, such as sulphate of copper or nitrate of silver — in a word, any fluid agent, the effect of which it is required to limit to a small space — the instrument shown in figure 4
Fig. 4.
may be employed. The instrument is a glass syringe fashioned after the plan of the hypodermic syringe, but much smaller. Attached to it is an adjustable nozzle bearing a long delicate pipe of gold or platinum. The medicine is drawn up in the syringe ; the nozzle is fixed securely, and a pledget of absorbent cotton is wrapped round the free extremity of the latter. The pledget of cotton should be somewhat larger than that rep- resented in the woodcut. Thus prepared the instrument is carried to the affected spot through the speculum, and the piston of the syringe pushed a sufficient distance to saturate the cotton. From one to two drops of the liquid is all that is necessary to accomplish this. The syringe is then allowed to remain in position long enough to insure a thorough application. By the time this has been accomplished, more or less mucus has collected about the spot; so that, when the instrument is withdrawn, the cotton, being enveloped in mucus, is so protected that no action upon the general mucous membrane of the nose is appreciable. The strongest applications can be employed in this way with perfect safety. I often employ nitrate of silver in saturated solution. Inspection subsequent to the application (in the event of silver being used) reveals, by the white patch of albu- minate of silver at the spot touched, the accuracy of the method.
The above plans of treatment are as efficient in reaching the roof and sides of the naso- pharynx as the nose. The shafts of the instruments are of sufficient length to reach the most remote points. I have found that a perfectly straight cotton carrier or syringe pushed steadily through the inferior meatus, or the interval between the inferior turbinated bone and the septum, will reach the centre of the pharyngeal vault. If after this vantage the instrument be slowly drawn forward at the same time that it is kept in contact with the roof, it is felt after a little, in favourable tests, to slip upward. This upward motion is due to the probe passing from the pharynx into the nasal chamber directly in front of the sphenoidal
1880.]
Allen, Chronic Nasal Catarrh.
65
sinus. In those forms of catarrh which are accompanied with marked occlusion of the nasal chamber between the septum and the anterior por- tion of the middle turbinated bone, the secretion is liable to accumulate in the upper portion of the nose. At the same time, owing to the morbid condition of the membranes which supervene upon such long-standing interference with the normal condition of the parts, the secretion becomes more or less inspissated. Such a locality cannot be reached by the un- aided efforts of the patient, nor by the nasal douche, without the employ- ment of a degree of force which would be dangerous to the integrity of the middle ear. The cotton carrier, employed as above indicated, will remove with ease such accumulations. I have repeatedly succeeded in bringing away large masses of tenacious semi-inspissated offensive mucus from an apparently perfectly clean nasal chamber immediately, after the most careful syringing and the fruitless use of the douche. It must be remembered that this region cannot be inspected either from in front through the speculum, or from behind by reflected light. After removal of the retained mucus, the surfaces can be medicated by the long-nozzled syringe — the same manipulation being employed, namely, to push the instrument through the nose into the pharynx, and then slowly withdraw- ing it, at the same time exerting a slight upward motion, until the end of the instrument slips to a higher plane, when it is known to be resting in front of the sphenoidal sinus.
I have already mentioned the fact that, among the causes of nasal irritation leading to chronic catarrh, abnormal deflection of the nasal septum is con- ' spicuous. In some instances this is so pronounced as to prevent relief following any medication of the surfaces. This condition I have success- fully met by cutting away the offending osseous projections. A knife (Fig. 5) has been devised which, being composed of a single piece of
Fig. 5.
The detached figure at the end of the instrument represents a transverse section of the file-knife.
metal, as in a dental instrument (such as a plugger or chisel), is bent at a moderate angle and presents a double file-cutting edge anteriorly. The instrument can be introduced into the nose, and by a to-and-fro motion readily cuts or files down the yielding spicule-like projection.1
1 The instruments described were made by S. S. White, the well-known manufacturer of dental instruments, Philadelphia.
No. CLVII Jan. 1880. 5
Allen, Chronic Nasal Catarrh.
[Jan.
In illustration of the employment of the instruments and manipulations already given, I will now give abstracts of cases from my note-book.
Case I T. M., aged 28, came under treatment Dec. 27, 1878; has
suffered from chronic nasal catarrh for ten years. During this time had been under treatment, but with no result further than temporary improve- ment. Complains of sense of heat and fulness in the nose. Discharge abundant. Upon inspection with speculum, the inferior turbinated bone was seen in contact with the septum. The inferior turbinate touched the septum at the angle in the latter answering to the anterior end of the perpendicular plate of the ethmoid. By careful employment of the double angulated cotton carrier, contact between the middle turbinated bone and the septum is detected, although these parts were invisible, owing to the relation of the parts near the floor of the nose. The right side of the nose is larger than the left, and nowhere exhibits any contact of the turbinates with the septum. The patient cannot locate the trouble in either side of the nose, although it was evident that the mischief had its seat in the left side only. He cannot sleep on the right side, owing to the functional loss for respiratory purposes of this half of the nose, while the face is half- buried in the pillow.
Chronic follicular pharyngitis with engorgement of the adenoid tissue at the roof vof the pharynx, coexisted with the above condition.
After the removal of the nasal discharge by the cotton-carrier, the post- nasal pharyngeal syringe, holding a weak solution of carbolic acid and fluid extract of geranium, was employed as a general cooling and slightly astringent wash to the irritated surfaces. After which, applications of nitrate of silver in saturated solution were made to the inferior turbinated bone, and plates of gelatine charged with iodoform were lodged in the nasal chamber behind the point of contact of the middle turbinated bone and the septum.
This treatment was continued twice a week ; once a week an application of London paste was made to the roof of the pharynx.1 The patient at once acknowledged improvement. The contact between the inferior tur- binated bone and the septum was broken up, and inspection was permitted of the deeper parts of the nose. Improvement began at the time of the
1 The employment in my hands of London paste in the treatment of adenoid dis- ease of the roof of the pharynx has been followed uniformly by good results. When the pharynx is tractable the paste can be readily applied to any part of the naso- pharynx. The instrument is a simple rod of soft thick wire, which will enable the operator to press the free end into any curve desired. Finding by a little practice the curve that is best suited to the individual case, a small quantity of the paste is col- lected upon the cotton on the end of the wire, and, the patient holding the tongue down, the operator, placing the rhinal mirror in the oro- pharynx with one hand, with the unengaged hand inserts the wire in the oro-pharnyx, and being thus aided by reflected light he carries the paste (with entire freedom from the danger of touch- ing healthy or sentient surfaces) to the place or places desired. The pain of such application to diseased glandular structures is not as severe as would be & priori sup- posed. In the majority of instances the patient makes no complaint, in others a slight sense of soreness and sense of heat alone ensues. When the pharanyx is so irritable as not to permit of this manipulation, I succeed in introducing the London paste through the nose to the roof of the pharynx, either through a Zaufal speculum, by means of a straight, small cotton carrier, or without protection of any kind if the nasal chamber be moderately capacious.
1880.]
All ex, Chronic Nasal Catarrh.
67
separation of these two surfaces. The contact between tlie middle tur- binated bones and the septum was more obstinate, but in time also suc- cumbed. Patient discharged February 17th, cured.
Case II S. W.", aged 24. Has complained of nasal catarrh for a
year. Came under treatment Dec. 4, 1878. On the right, which is the smaller, side contact at middle turbinated bone was detected. Nothing- abnormal could be detected in the nasal chambers other than this point of contact. Existing with the catarrh, was a slight chronic pharyngeal and laryngeal inflammation requiring treatment. Local applications to the region of contact so far improved the parts that, by Dec. 30th, no contact existed, and the improvement was decided. Patient ceased reporting Feb. 27, 1879, relieved of his nasal difficulty.
Case III J. C. B., aged 40 years, who had suffered from nasal
catarrh for many years, came under treatment Nov. 26, 1878. The dis- charge is not excessive, but is liable to follow abrupt changes of tempera- ture, particularly those determined by passing from a warm to a cold room. She has been compelled to retire from the table owing to a sudden flow of secretion dependent upon the difference in the temperature of the dining-room and the room left a short time before. She has been much annoyed in the same manner upon entering a church or other uniformly warmed building in cold weather. The general health is good ; no pharyn- gitis or laryngitis. Patient complains of a local dull ache at the root of the nose.
Upon examination, there was found on the right side of the nose close contact between the middle turbinated bone and the septum. The former was swollen and of a dull purplish colour. The left side of the nose was normal. The treatment consisted in making applications of saturated solutions of sulphate of copper to the surfaces of contact, and wedging in plates of gelatine and iodoform above and behind the point of contact. Improvement was almost immediately announced, and the patient was discharged cured March 6, 1879. She has since returned at long inter- vals with some slight return of the symptoms, but a single application was alone needed to relieve them.
Case IV C. S., aged 13, suffered from chronic nasal catarrh for
three years. The discharge, which was chiefly pharyngeal, was copious. The patient referred his symptoms to the pharynx, complaining that his throat was sore, at the same time acknowledging a persistent slight pain at the root of the nose. The patient also suffers from functional heart dis- ease. On the date of the first, examination, Dec. 26, 1878y discovered contact between both the middle turbinated bones and the septum. Both inferior turbinated bones swollen and red. Applied saturated solution of nitrate of silver, by the syringe, to the region above points of contact and the under free surfaces of both middle turbinated bones. After two such applications, after an interval of three days, the pharynx and nose received a general application of the fluid extract of geranium and carbolic acid. Subsequently, a paste composed of iodoform and gelatine was applied to the upper surface of the nasal chambers, near the point of former contact. Patient ceased reporting Jan. 31st, very much improved. Returned March 24th, with the report that he had remained perfectly well for one month, at the end of which time symp- toms slowly returned. The main features of former treatment were repeated, ending in improvement, which was probably permanent. The patient ceased reporting, and has been heard of indirectly through his parents as being well of his nasal difficulty.
68
Allen, Chronic Nasal Catarrh.
[Jan.
Case V A. M. H., 70 years of age, has had nasal catarrh for fifteen
months. It appears to have followed, or, at least, to have been coincident with, a fall from a horse. Complains of congestion of the head, dizziness, and neuralgic pain in the left side of the head and face ; the pain being accurately limited to the terminal branches of the fifth nerve. The dis- charge is entirely from the left side of the nose.
Upon examining the nose, found the middle turbinated bone of left side pressing firmly against the septum. Extending upward and outward from the septum on a lower plane to the former, was a bony outgrowth almost entirely occupying the middle meatus. The inferior turbinated bone was normal. Inspissated discharge was found lodged between this exostosis and the middle turbinated bone. The pharynx irritable, with moderately enlarged swelling to the median side of the palato-pharyngeal folds. The roof of the pharynx occupied with tenacious discharge. The treatment was instituted Feb. 1, 1879, and consisted essentially of the application of agents already mentioned. The next visit upon the 3d of February, she reported improvement. An ointment of aconitia, one grain to the drachm, was ordered to be used upon the skin over the painful spots, in addition to the local remedies applied to the interior of the nose. Improvement continued steadily both in the discharge and the neuralgia until Feb. 25th, the pain now being restricted to only the left half of the lower lip. The discharge almost disappeared, the pharynx being entirely free, and a small quantity alone, of a whitish, semi-fluid character, lying upon the exostosis. The patient then passed from treatment for two weeks, at the end of which time she reported with the statement that the pain had gradually abated, notwithstanding there had been no treatment for a fortnight, the discharge remaining about the same. Another fortnight elapsed before she again reported, with the account that her symptoms were worse, the discharge had returned, the pain had been renewed, this time with a spe- cial tendency to location in the roof of the mouth. She accounted for these unfavorable conditions by having caught a fresh cold. It was now sug- gested to her that the treatment wonld probably remain palliative so long as the exostosis was permitted to remain in position in the nose, and she was advised to permit its removal ; this, however, she declined. At a subsequent date, however, she permitted Dr. R. M. Smith, who was attending my patients during my absence from the city, to attempt to re- move it, in which he was entirely successful, the file-knife already de- scribed, being the single instrument he required. The discharge after this operation almost immediately disappeared, without, however, permanently affecting the neuralgic pains, which persisted when the patient last reported.1
Enough has already been said, I trust, to show the efficacy of the above line of treatment, in cases of nasal catarrh which are associated with oc- clusion of one or more points of the nasal chamber. It is seen that im-
1 Since the notes of this case were put in type, I have received a letter from the patient giving a discouraging account of her health. Both the discharge and the pain had returned. I will allow the case to stand, however, for the following reasons : In the first place, it is the only case I have met with in which the symptoms appeared to follow an injury ; second, the complication of the disease with obstinate facial neu- ralgia, which is most probably due to secondary inflammatory changes about the deep nerve trunk ; third, because of the relief which followed treatment, the patient en- thusiastically acknowledging the same.
1880.]
Allen, Chronic Nasal Catarrh.
69
provement is apt to occur at the times when such occlusions disappear. In a word, the restoration of the nasal chamber to its proper use, i. e., as a respiratory chamber, is often alone sufficient to cure the disease.
A more difficult phase of the study of nasal catarrh presents itself when the occlusion is between the inferior turbinated bone, and the floor of the nose. In this class of cases improvement is more gradual, and recurrence more frequent, owing probably to the erectile character of the mucous membrane covering this bone. The same class of remedies, however, is valuable here as in contact between the middle turbinated bone, and the septum.
As I said in the beginning of this paper, pressure or occlusion within the nasal chamber accounts for a portion only of the cases of nasal catarrh as met with in practice. A variously defined group of cases is encountered in which the nasal chambers are everywhere capacious, and yield nowhere any abnormal contact. These are probably instances, when not local expressions of constitutional conditions, due to rhinitis, fluxes, the result of structural changes in the membrane itself, or the sequence of imper- fectly guarded chambers, which permit the two free ingress of irritating currents of air, and thus the membranes are continually exposed to the contact of extraneous substances, art d to abrupt changes in temperature. If the last reflection prove true, it will be seen that those nasal chambers that are either too narrow or too wide, are both liable to the same general affection.
The following case will serve as an illustration of catarrh associated with a capacious nasal chamber.
Case VI R., age 72, reported for treatment March 11, 1879. Suf- fered from nasai catarrh for two years. Is subject to attacks of parox- ysmal sneezing. Comparative comfort ensues for a day or two thereafter. Upon examination of the nasal chambers, found the left side capacious, no contact anywhere ; the right side contracted anteriorly but no obstruc- tion noted. The trouble is referred to the left side entirely, in which a sense of obstruction, located high up is complained of. Contrary to the rule in such cases, no point of contact or occlusion can be detected upon the most careful examination. Under applications of extract of geranium and carbolic acid with post-nasal syringe continued improvement was acknowledged. By April 2d, all the symptoms were in abeyance, although the discharge had not entirely ceased. After this date, viz., April 2d, the trouble measurably left the nose, the symptoms being chiefly referable to the pharynx.
Toward the latter part of May, geranium and carbolic acid was discon- tinued, and fluid extract of ergot substituted. The obstruction at the root of the nose had, by this time, permanently disappeared, the discharge lessened, though the tendency to sneezing persists, together with a marked degree of pharyngeal irritation, which latter is gradually subsiding.
The instruments above described have been expressly designed to meet the necessities of cases in which there is undue narrowing of the interior of the nasal chamber. Thus, for example, it would be difficult if not im-
70
Allen, Chronic Nasal Catarrh.
[Jan.
possible for a mass of the consistence of an ointment, or a base of the con- sistence of gelatine, to be retained in position any length of time when the dimensions of the chamber are normal or too wide.
In ozoena, the nasal chambers are, as a rule, not only capacious, but the turbinated bones are stunted, and the elements of the mucous mem- brane everywhere atrophied. I mention this specially, since no structural feature has hitherto been recognized in nasal catarrh, not present in the normal chamber ; and my efforts have been directed to overcome, by ap- propriate manipulation, the structural peculiarities which I assume to exist. They have but an indirect value in any other class of nasal affections ; nor do I intend that the treatment in any case should depend upon such ma- nipulation. The history of every individual case should be carefully con- sidered, and the true value of local and constitutional conditions borne in mind.
I propose adding to the foregoing clinical observations a few statements concerning the variations and occasional obstruction in the nasal chambers of the skeleton. The statements are deduced from the examination of 151 adult crania. While it is acknowledged that this number is inadequate to secure a satisfactory average, it may serve as a basis for an approximate estimate, and quite enough to establish the clinical fact, viz., that varia- tions and resultant obstructions of the chambers are often met with.
Thus, out of 58 skulls preserved in the Wistar and Horner Museum, 18 only exhibited normal nasal chambers; in the remaining 37, 19 were narrowed on the left side and 21 on the right. It is a common observa- tion that the nasal septum is rarely perfectly straight, but exhibits a slight inclination either to one side or the other. As an equally common obser- vation, we may repeat the fact (the truth of which many recognize in their own persons), that breathing is much freer through one side of the nose than the other.
Owing to the composite nature of the nasal septum, its errors of posi- tion are not of one kind- Thus, deviations occur in the perpendicular plate of the ethmoid bone, at the ethmo-vomerine suture, and in the superior maxilla. In the living subject deviations are also seen in the triangular cartilage ; but of the soft parts I do not now speak. Devia- tions of the perpendicular plate occur in the form of a slight bulging, and occurs commonly in such wise that the convexity of the curve is directed to the left side. Deviation of the superior maxilla occurs in the anterior part of the palatal process near the anterior nasal aperture, and, of course, upon that portion of the bone appearing at the triangular notch of the septum. This deflection lies directly within the nostril of the subject, and is very readily seen in clinical examinations. It is always acute, and exists in many skulls where the remaining portions of the sep- tum are straight. Deviation at the ethmo-vomerine suture takes place
1880.]
Allen, Chronic Nasal Catarrh.
71
behind the apex of the notch for the triangular cartilage. It rarely affects the suture far back, and never, does so unless in continuity with the ante- rior deformation. The condition is strictly one of hyperostosis at the sutural line. It is commonly directed to the left, and has been often spoken of by writers as constituting the single form of septal deviation ; hence the statement that the septum is generally inclined to the left. The growth may exist, however, from the side of a perfectly straight septum, a concavity not existing of necessity upon the opposite side.
The above-mentioned forms of deviation exist together or separately. When they exist together the perpendicular plate may be deflected to the right, the ethmo-vomerine excrescence to the left, and the maxillary spur to the right, or the first two may be directed to the left, and the vomerine to the right. Thus there may be within a single nasal chamber, three surfaces of abnormal character, each of which is capable of fretting swollen mucous surfaces.
To these general statements I will affix brief descriptions of a few crania, selected from the Wistar and Horner Museum, which yield points in confirmation of the above-named clinical statements. The numbers used are the cabinet numbers : —
3918. Process at ethmo-vomerine suture marked; maxillary spur present on both sides.
268. Remarkably strong process at the ethmo-vomerine suture, which almost touches the middle turbinated bone of the right side. There' is a corresponding moderate concavity on the left side. Maxillary spur present, and directed to the rigfht.
261. Perpendicular plate nearly straight, the slight inclination present being to the left; nevertheless, a close contact exists between it and the superior turbinated bone. The middle turbinated bone is mu- tilated.
104. The perpendicular plate is deflected to the left, and contact exists between it and the middle turbinated bone. 90. The ethmo-vomerine growth is directed to th'e right, and almost touches the corresponding middle turbinated bone.
266. The deflection is confined to the perpendicular plate, and is seen on the right side. The skull is remarkable for exhibiting a small exos- tosis on the corresponding middle turbinated bone, which lies in con- tact with the perpendicular plate. 3916. The ethmo-vomerine growth is large, and touches the left middle turbinated bone.
Skull without number in Dr. Neill's collection. The ethmo-vomerine growth touches the normal middle turbinated bone of the left side.
A second skull in the same collection. The ethmo-vomerine excrescence is very large ; its free surface lies within the middle meatus.
It is thus found that among fifty-eight skulls collected for teaching purposes, and not supposed to possess any unusual, much less rare features, six exhibited contact between the superior and middle turbinated bones and the septum. In two, the contact, while not demonstrable, probably
72
Allen, Chronic Nasal Catarrh.
[Jan.
existed in the living subject, and in one the process of deflection escaped contact only by being lodged in the middle meatus.1
In the following crania, contact existed with very, slight septal devia- tion, or none.
247. The left superior turbinated bone touched the septum. 98. The left middle turbinated bone deflected outward, and impinged
upon the descending process (processus Blumenbachii). In the skull marked 96 the perpendicular plate was straight, but both
middle turbinated bones almost touched the septum, and in life it is
very likely they did so touch.
There can be no doubt, therefore, that contact exists in a fair proportion of individuals. Is it of necessity a cause of irritation ? The correct an- swer to this question probably lies within the following sentences : Persons who have irritable throats, and who therefore resist examination of the oral and vocal passages, would be likely to suffer from quickly induced obstruction in the nasal chambers ; contrariwise, obstruction, if of slow origin, and happening in persons who have passive oral and vocal pas- sages, may exist without creating sneezing, pain, or even discharge. As a rule, it may be said obstruction is followed by loss of function and distress ; and when such obstruction exist, it should be removed when practicable.
1 Only those facts bearing upon the immediate object of the paper, secured by this examination, have been placed together in the text.
An interesting group of observations is here epitomized ; some of which may pos- sibly have relations to clinical conditions which have not been appreciated : —
(1) The posterior portion of the perpendicular plate of the ethmoid bone i6 always exceedingly thin and often more or less absorbed, since large irregular openings are met with. In one skull this portion of the plate was almost entirely destroyed ; a mere ring of bone defining the position of the parts.
(2) In two examples the two middle turbinated bones had advanced toward one another and touched in the median line through a large septal perforation. The sep- tum being intact at the posterior nares, it would be impossible to detect such a lesion with the rhinal mirror.
(3) While the foregoing conditions are seen, the vomer at the posterior nares is never deflected, and with exceeding rarity absorbed. I have seen but two examples of such absorption, or possibly imperfect development ; one of these was seen in a patient by the rhinal mirror, the other in a cranium in the Wistar and Horner Museum.
(4) While the posterior portion of the perpendicular plate tends to be absorbed, the anterior tends to become thickened. This thickening is often accompanied with a peculiar chalky whiteness, a result probably of calcification of the triangular cartilage as it joins the perpendicular plate. This feature is more marked in the skull of the white race than in negroes, in whom indeed the plate may be thin throughout.
(5) Negroes, and probably all races other than the civilized whites, exhibit few examples of depletions of the septum. Thus out of 93 negro crania examined only 20 were deflected, and but three of these to any marked extent.
(6) In one cranium the palatal bones sent up nearly half way on either side of the vomer at the posterior nares a delicate process, which materially assisted in strength- ening the septum at that place.
1880.] Gaenett, Abnormal Adhesion of Funis to Placenta. 73
Article IV.
Abnormal Adhesion of Funis to Placenta, with Accidental Hemor- rhage and Abortion. By Alex. Y. P. Garnett, M.D., Emeritus Pro- fessor of Clinical Medicine in the National Medical College of the District of Columbia.
The following case addresses itself to our consideration as a subject illustrating the disastrous and unavoidable results which may follow those morphological caprices of nature sometimes manifested in the progress of fcetogenesis : —
The subject of this case is a lady about 24 years of age, of delicate physique, dark complexion, above medium height, rather inclined to be thin in flesh, having suffered for several years with imperfect digestion. I had officiated about twenty-two months before at her first accouchement, which was not characterized by any circumstance of special note.
I was called to her on February 14th, and found her suffering with a slight uterine hemorrhage, which had made its appearance during the previous night, and continued at short intervals up to that hour — about 11 A. M. I ascertained that she had not menstruated since the twelfth of the previous October, and although there had been none of the usual accompaniments of pregnancy appreciable to her, she suspected that such a condition existed, as she had observed an evident increase of size, which, coupled with a suspension of the catamenia for four months, she con- sidered sufficient grounds upon which such a conclusion might be based. > A careful examination resulted in my making the diagnosis of pregnancy with accidental hemorrhage. Some simple sedative was administered, and the patient directed to rest quietly in the recumbent position until further development, or an entire cessation of the bleeding occurred. On the 22d of the same month, eight days having elapsed, I was again summoned to see my patient, who had experienced a slight return of the hemorrhage after a suspension of seven days, during the greater part of which time she had confined herself to the bed. There was no pain whatever, or any manifestation of uterine contraction, and none had been experienced at the time of my first seeing her. She was again subjected to a careful examination, which, in view of suspected pregnancy, was con- fined to external manipulation, auscultation of region of uterus, and digital exploration to determine condition of cervix, the result being a confirma- tion of my previous diagnosis, although I had failed to discover by auscul- tation any action of the foetal heart. It is scarcely necessary to mention, that up to this period no motion of the child had been experienced by the mother to settle definitely the question of pregnancy. Perfect rest in bed, application of cold cloths to pubes, and digitalis and opium in small quantities were prescribed, together with light diet, absence from stimu- lants, avoidance of all excitements, including social intercourse.
From this date to the 14th of March she continued, at intervals varying from two to four days, to experience slight hemorrhagic dis- charges (although observing faithfully the directions which had been given her), but at no time of sufficient severity to require the use of the tampon. On the 14th the bleeding returned with some violence, but as yet unaccompanied by pain or any indications of uterine action. An
74 Gaenett, Abnormal Adhesion of Funis to Placenta. [Jan.
examination, per raginam, revealed a soft undilated os, well-defined cervix, with a considerable augmentation in size of the uterus, but no in- dications— if we except the hemorrhages — of approaching abortion. Vaginal injections of cold water and vinegar, equal parts, were used, in addition to the remedies previously prescribed. Fearing to take the chances of leaving her for the night without additional security against the bleeding, a soft sponge tampon was introduced. On the morning of the following day the tampon was removed, and the cold acidulated injec- tions renewed. She continued during the day to have a slight oozing of blood, and as there was still an entire absence of pain I did not replace the tampon again. On the 16th she remained in about the same condition as the day previous, in good spirits, free from pain, and but little hemorrhage.
Early on the morning of the 17th, I was called somewhat hastily to visit her, finding, when I arrived, that there had been a return of the bleeding during the latter part of the night, attended with slight inter- mittent pain. I became satisfied that the desired denouement was at hand, and a miscarriage inevitable. Placing one hand upon the external surface of the abdomen over the womb, with the index finger of the other hand applied to the os, I could plainly distinguish feeble uterine contrac- tions during the existence of pain. It was not until night, however, that I found it s practicable to introduce my finger sufficiently, without unwar- rantable force, to ascertain the presentation of a round body, which was readily recognized as a foetal head.
From this period the pains continued with regularity, at long intervals and insignificant effect, until the following morning, wThen, after one hour of increased uterine effort, she wras delivered of a five months' foetus, float- ing within the unruptured sac of membranes, with placenta firmly attached on its foetal aspect to the umbilical region of the child ; which latter, contrary to my expectations, gave unmistakable evidence of feeble vitality. The womb contracted well after the accouchement had been completed, and the mother passed through the period of convalescence without any disturbing incident whatever.
Naturally curious to ascertain, if possible, the special cause that had produced such persistently recurrent hemorrhage, and which had finally culminated in the partial death and expulsion of the foetus, I proceeded to examine in detail the contents of the sac, together with its adherent pla- centa. I regret to say that this was necessarily limited to a mere inspec- tion and manipulation of the foetus and its environments, as I was not permitted to remove the specimen from the house, thereby depriving me of an auxiliary examination by the microscope.
On opening the sac, and allowing the liquor amnii to flow off, I found a male foetus of five months, much etiolated in appearance by, I presume, the limited amount of maternal blood with which it had been supplied, but in all respects normally developed. The funis, apparently healthy, wras of the usual length, but had twice encircled the body of the child just above the pelvis, and apparently drawn the umbilical region of the foetus close in contact with the surface of the placenta, between which and the cord, ex- tending one and a-half inches from its umbilical attachment, there had been established a firm adhesion (see a, fig 1), so that it was impossible to move the child in an opposite direction without making direct traction upon
1880.] Garnett, Abnormal Adhesion of Funis to Placenta. 75
the placenta itself. Divided at the point of adhesion most remote from the umbilicus, the remaining portion of the cord encircling the body of the foetus was readily uncoiled, being free from other entanglements or attach- ments of any kind. Having detached the infant by peeling off the section of the cord which was found attached to the placenta, my attention was next directed to an examination of this latter organ. I found it about the size usually met with at this period of utero-gestation ; its upper third, or that portion which had been attached nearest the fundus of the uterus, presented on its uterine aspect a dark-red glazed appearance interrupted by the usual anfractuosities here seen, having additionally numerous dark- red granular projections, or what I supposed were fibrinous clots ; the re- maining two-thirds had the appearance of having been recently separated from its uterine attachment,