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pensated for its loss in mobility, elasticity and thickness by a building up its weakened wall. But the exigencies of circulation demand a rapid buttressing of the structure, a lower grade of tissue more prone to degeneration forms the arterial patchwork. The artery which needs compensation is never thereafter as strong in its resistance of tension, its resilience is diminished and its nutrition is impaired by obliteration and obstruction of its vasa vasorum.

The compenastion is against hemorrhage as well as aneurism. It is true that compensation is neither full nor absolute, for in the majority of individuals suffering from the sequelae of cerebral hemorrhage, the arteries are markedly sclerosed, but were it not for the sclerotic patchwork the average age for cerebral hemorrhage would be advanced some one or two decades and aneurism would not then be a comparatively rare manifestation. Furthermore, compensation does not invariably occur. We may have cardiac compensation without intimal, and then the consequences are most disas trous. Again we may have neither cardiac nor intimal compensation, which would make for an immediately grave prognosis.

Symptoms. The sclerotic individual is usually emaciated, his skin falls in folds about his wasted muscles and prominent bony framework; his color is anemic; his head is bald, over the sunken temporal region we notice the temporal artery in its tortuous course, the cheeks are sunken also, and the pupils show the arcus seniles. The ocular bulb is comparatively prominent. In the upper extremity we notice the radial artery presenting from among the loose folds of redundant skin (the fatty areolar tissue having undergone almost complete absorption). The brachial artery is even more prominent because of its bolder course unflanked by osseous structure. Both brachial and radial exhibit considerable facility for lateral movement in their beds, a kind of subluxation, sometimes as much as half an inch of movement in each direction.

The back is stooped, the chest flattened anterio-posteriorly and the ribs, clavicle and scapula are startlingly prominent Frequently the emphysematous chest is noticed. The belly may be pendulous.

Aneurisms of the radial artery appeared in two cases of this series, as did varicose veins in two. Hypertrophy of the left heart is the rule.

The incidence of recent hernias is remarkable, this and the pendulous abdomen are merely other phases of the protean manifestation of arterio-sclerosis. The occurrence of hernia is due to the deficient nu

trition supplied to the belly wall by the narrow lumen. Some one of the abdominal weak points under a tension which previously had been well resisted and sustained now gives way, allowing an abnormal breach in its continuity.

The presence or absence of symptoms in the senile sclerosis depends, we believe, upon the degree of compensation, intimal and cardiac. If complete we may have an almost symptomless malady (until cardiac compensation begins to fail). If faulty we may have any or all of the accredited manifestations.

Vertiginous attacks are a frequent and baffling symptom and are most aggravated on arising from bed. Some amelioration is ob. tained as the day advances until at evening it may be of very slight degree. The vertigo is a subjective one, and though violent the falls therefrom are infrequent, as the individual learns to suppport himself with his stick and by abduction of the thighs to form a wide base in walking and standing. A sudden descent in barometric pressure and electric potential (the invariable precursors of an approaching storm) intensifies the vertigo as it does the joint pains and paraesthesias of the disease.

Sensations variously described as tingling, as if the skin were being pricked by many needles are somewhat common, or a persistent and intolerable burning of the skin may exist. A patient will complain of a scalp which seems persistently on fire, applications of cold water affording but little relief. Another will tell that his feet are so hot that in severely cold weather the bed coverings must be removed to render sleep possible, though persistently cold extremities are the rule.

Formication is a common manifestation. Pruritus is not infrequent and may involve the surface of the entire body. Cramps of both upper and lower extremity, more frequently the latter, are of common occurrence and seem to bear no relation to the activity of the individual, for at times the sufferer will be awakened from a deep sleep by these painful muscular spasms. Persistent headaches and hemicranias occur, the pains may be described as tearing or rending, though the majority are less severe. Tinnitus aurium is another aggravating symptom, this subjective disorder may become a terrific roaring or explosive sound, likened to that made be escaping steam from a nearby locomotive.

Deafness was a complication in four cases. Persiatent lameness is a very frequent symptom. Many of our cases which we diagncse as chronic muscular rheumatism are in reality manifestations of arterial solerosis

the pain being due to the involvement of Paccinian corpuscles in the solerosis or arterial spasm.

The symptom complex variously named intermittent claudication, dysbasia anigosclerotiac or dyspragia, has been fully exploited of late, and in this connection I will mention in passing a case in this series, of claudication of the lumbar muscles. The patient was quite comfortable when sitting or lying on his bed, but suffered excruciatingly after walking briskly for a few minutes, yet gaining complete relief by a temporary return to bed.

The renal symptoms are those of the sclerotic or contracted kidney, there is an increase in the frequency and quantity of urination. The urine is clear, of low specific gravity and albumen is rare in cases uncompilcated by cystitis and prostatitis, but it is the exception to find a normal prostate and bladder in these individuals. Casts will reward a patient research.

Constipation is frequent, but is attributable only in part to arterial disease, faulty mastication from defective teeth, a sedentary life and ingestion of small amounts of water are other factors. Chronic bronchitis may be the exciting cause for the late hernias, some degree of bronchial irritation appearing in each cases. This and asthma are the two most frequent respiratory complica

tions.

Therapeutics.-The efficient therapy of arterio-sclerosis may be summed up in one word: Prophylaxis. When a man presents himself with arteries firm, tortuous and nodular, even the most hopeful and optimistic therapist will not promise to remove the nodosities. Though he may confront the gall-stone for its medicinal dissolution with amazing fortitude, the repair of the artery is more than he will assume.

Prophylaxis is accomplished by means of regular living, a sufficient dietary, no more; moderate indulgence in meats, the interdiction of alcohol and tobacco, mild and regular exercise, tepid bathing and abundant sleep.

In failing compensation the rational treatment must be rest in bed. The effect of vasodilators is nil in those cases exhibiting a lime infiltrated artery. The iodides, the

nitrites and trinitrin are useless. Rest in bed, massage, and possibly the cautious administration of digitalis, its congeners, or nux vomica are our most efficient agents.

In early cases the vertigo will respond to nitroglycerin or a course of calomel at times gives good results.

For the paraesthesias and insomnia gradually increasing doses of the tincture of hyos

cyamus, up to one-half dram daily serves well.

Large quantities of water should be ordered for these patients as they habitually take too little fluid.

We have noticed no benefit from the use of artificial blood sera, such as Trunecek's.

DIET IN ARTHRITIS DEFORMANS.-Thompson (Med. Rec.) recommends forced feeding with a full diet of animal food, the fats predominating. The ordinary meals should be supplemented by two or three luncheons Biliousness can be preduring the day.

vented largely by the use of simple bitters before meals, dilute hydrochloric acid with nux vomica after meals, drinking much water and the occasional use of a cathartic. -Denver Medical Times.

APPENDICITIS REMEDIES.-The treatment here, as in ordinary cases of acute appendicitis, was simple but effective. Opium in any form is worse than useless, dangerous in so far as it masks symptoms and arrests intestinal activity. Hyoscyamine, gr. 1-250, and strychnine arsenate, gr. 1-134, were given in a little hot water, and aloin, podophyllin and calomel, of each gr. 1-6, were given every thirty minutes till four doses were taken. The hyoscyamine and strychnine were repeated at hourly intervals till the pupil dilated and pain lessened, when the former was omitted, the latter being continued at twohour intervals. One hour after the last dose of aloin, etc., a hot saline draught was given and in two hours another, the last dose being followed in a short time by a copious foul stool. Olive oil carrying five grains of papayotin to the ounce was now given every three hours and three pints of an alkaline antiseptic solution thrown into the colon with the tube, patient in knee-chest posture. motions were passed into a bedpan, it not being deemed wise to allow the erect posture. Half-hourly, gr. 1-6 of calcium sulphide was exhibited from the first, and after the first stool, pupils being dilated, the hyoscyamine was dropped. A second stool bearing the concretons and plugs passed some hours later, and, as stated, the case was practically well from that time. Light hot applications were applied over the abdomen constantly. After the bowel had acted and palpation revealed the reduction of induration, small repeated doses of hydrastin and juglandin were given, every three hours, podophyllin gr. 1-67 being added to every other dose. Gentle massage with camphorated oil was made over the iliac region.-Am. Jour. Clinical Medicine.

The

The Medical Society of City Hospital Alumni

Secretary, FRED. J. TAUSSIG, 2318 Lafayette Ave.

President, LOUIS H. BEHRENS, 374? Olive Street
Vice-Pres., WALTER C. G. KIRCHNER, City Hospital Treasurer, JULES M. BRADY, 1467 Union Avenue

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Dr. C. G. Wright presented a case lymphangioma of the hand in a negro child. Family history was not obtained; physical examination showed well-nourished child; palpation and auscultation negative. shows numerous small scars; inguinal lymph glands enlarged. There was multiple dactylitis of the right hand, the dorsal surface of the fingers being involved. The bones can be palpated in the mass, the enlargement being hard and nodular. The left hand is in good condition.

Diagnosis of lymphangioma was made. The condition has existed since birth.

DISCUSSION.

Dr. John Green, Jr., thought this was a very interesting condition. The condition of the eyes suggested struma. There is a phylctenular keratitis with some marginal trouble of the lids in this case. Yet he understood that the tuberculous nature of the condition was denied.

Dr. Horwitz asked whether specific treatment had been tried, the answer being that kalium iodid, had been given for the past two weeks, ever since patient entered the hospital.

Dr. Fruend asked if the condition was not syphilitic, what treatment should be insti

tuted?

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The case

trude through the labia majora. was fully demonstrated by Dr. Elbrecht to the society.

DISCUSSION.

therapy in these cases puzzling to the profesDr. F. J. Taussig said that the question of sion. The first thing to be considered is whether or not the patient will consent to an operation. If not, the cup and bell supporting pessary may be tried, but it is not usually successful. Another form of pessary that is not so well known is the Menge pessary which is a modification of the ordinary hard rubber ring with a stem which points outward. The main objection to the ordinary hard rubber ring is that it is easily expelled because it tilts. The idea of the bulb stem in the Menge pessary is to keep the round part transverse in the pelvis. The bulb end is short. He said that he has used this pessary with good results.

As regards the operative side of the case, Dr. Taussig said that he personally favored the operation of inverting the uterus in the vagina. If the tubes are resected, conception is prevented. By complete hysterectomy, the chance of cystocele forming must always be remembered. Furthermore, in such an operation the vagina is obliterated, which is objectionable in the married women. danger of hernia likewise must not be over

looked.

The

Dr. Elbrecht said that the prolapsus did not bother this patient, except when she was working. He did not think use of pessaries practicable in women who have to do manual labor: They produce excoriations of the vagina. He said that he has yet to see a pessary that will last. They irritate and produce inflammation. He does not like the operation of inversion. He believed the ideal operation (which he will do tomorrow on this patient) is to remove the uterus by the abdominal route and sew the broad ligaments together. This gives the intestines. something upon which to rest. This feature is accomplished in the Freund-Wertheim operation. Where the possibility of pregnancy cannot be excluded, it is not right to do this.

VENTRAL HERNIA WITH GANGRENOUS ULCERAATION OVER SAC.

Dr. Coppedge presented a case of ventral hernia with gangrenous ulceration over a sac. The patient was a very fat subject, female. She acquired a hernia in the median line. An operation was performed for this condi tion a few months previous to the presentation. But the protrusion recurred. There are now three protruding areas. Each protrusion is about the size of an orange. The abdominal walls are very lax. There is a gangrenous ulcer over one side. Notice the large scar of the laparotomy which runs across the abdomen.

DISCUSSION.

Dr. Deutsch said that no operation would be justifiable on such a case. He had never seen such a large protrusion before. He thought the ulcer could be excised so as to prevent the death of the patient from gangrene.

Dr. Elbrecht stated that the patient's condition had improved since entering the hospital. The ulcer was healing. The operation that had previously been performed was the overlapping operation of Mayo, made in this case by Dr. Brown of the City Hospital. The speaker did not believe that any surgical procedure would avail at this time. thought it would only be surgical exercise to attempt to repair the condition. He did not think that the ulcer should be healed by grafts, but rather preferred the method of healing by scar tissue, thus strengthening the abdominal walls.

SPINA BIFIDA.

He

Dr. Given Campbell presented a case of spina bifida. The patient is a girl of 12 years. Ever since birth she has been unable to use the lower extremities, bladder and rectum. This condition he stated was undoubtedly a meningo-myelocele, with projection of the lower part of the spinal cord into the tumor. Part of the nervous tissue was defective and produced the paralysis and the paralytic club-foot. This condition is always found where the spinal cord is in the tumor. The condition is more to be classed as a surgical disease than a neurological. The other limb in this case, being useless, was amputated. Sensation was not entirely absent.

INSULAR SCLEROSIS.

Dr. Campbell then presented a case of insular sclerosis. The patient was a woman of 28 years. The trouble began two years ago. The practical point to be deduced from the

case is that where there is a nervous trouble of an organic nature in a person of this age, it is apt to be multiple sclerosis. Starr in his recent text-book says that out of 10,000 cases he only found this condition 27 times.

Dr. Campbell then presented another case which he was inclined to believe was also

multiple sclerosis. The history of the first patient (age 28 years) was that she noticed a numbness four months ago. She cannot use the right hand in eating. The knee jerks are increased; Babinski reflex increased. The pupils react to light. Nystagmus is present. There were no signs of mental disturbance. The feet sometimes swell. She has a distinct nervous disturbance of the bladder. The ankle clonus present stamps the organic nature of the trouble. The essayist said that the most common diffuse organic condition that occurs in young women is multiple sclerosis. Among the symptoms are intention tremor, being a trembling in the hands when an individual attempts to perform some voluntary act that require precision. In this case there is a distinct jerk of the eye-ball. Among the important symptoms which this case show are spastic condition of the lower limb and the ankle clonus. If the condition were due to a specific trouble, there would be sluggishness to light reaction. Another important point found by Dr. Green who examined the case, in the two temporal halves of the optic discs, there was a tendency to atrophy which is symptomatic of multiple sclerosis. The speaker said that the condition is sometimes confounded with hysteria. When in doubt, he said that you are more apt to be right in calling it multiple sclerosis rather than hysteria. The cther patient presented shows the phenomenon of ""scanning speech," that is to say, an accentuation of words in talking much like one accentuates in scanning poetry. The intention tremor was very pronounced in the second case. The speaker believed the rest cure the best treatment. The salicylates. iron and quinine help some cases. The tendency of the disease, however, is to progress. Some patients bold their own for twenty years with this condition.

DISCUSSION.

Dr. John Green, Jr., stated that he had examined the eyes of the first patient presented last November. There were some suggestive symptoms of insular sclerosis. Her vision was good. The left pupil was larger than the right. The reaction to light was sharp. The visual fields were apparently quite normal.. He was only able to apply through finger tests at the time of

the examination at the hospital He said in the differential diagnosis between hysteria and multiple sclerosis, it is of great importance to get a careful estimation of the color fields There did not appear to be any true nystagmus, but towards the end of the lateral excursions to the right and to the left, there was a slight twitching It is characteristic of the nystagmus of multiple sclerosis-this condition being more marked than the physiological nystagmus. There was no ocular paralysis. Mobility was free in all directions. The patient never "saw double." The ophthalmoscope revealed pallor of the discs. The atrophy of multiple sclerosis is a post-neuritic atrophy. The speaker said that he was loath to ascribe the temporal pallor in this case of sclerosis because of the absence of other signs of persistent sclerosis. Green called attention to the fact that ocular examination is often of the greatest assistance in estimating easily the differential diagnosis between multiple sclerosis and hysteria. Last year Dr. Schwab and the speaker reported such a case. There was slight ocular atrophy. The fields were contracted in the usual way, not inverted. There was no evidence of tubeshaped fields. It is said that certain of these cases present eye symptoms years before the other symptoms of multiple sclerosis appear, and therefore it behooves the neurologist in any doubtful case to have the eyes examined.

Dr.

Dr. Elbrecht in discussing the case of spina bifida presented by Dr. Given Campbell said that most of these cases die within the first week of life. Operation for their cure are not successful. In view of the high mortality of the operation, the doctor did not approve of operation. Dennis has reported 57 cases, 25 operated, 15 deaths, 7 recoveries, 3 recoveries with nc improvement. The doctor said that these cases often occur in bunches, he having seen four at the Female Hospital in six weeks. The contraindications for operation are involvement of the bladder, hydrocephalus, club-foot and marasmus. Deaths after operation occur from meningitis through infection.

method used in the treatment of these cases is the injection of Norton's fluid, such as was formerly used in the treatment of hernia. This method has a mortality of 40%. not, therefore, proper to advise operation in cases of spina bifida.

It is

DR. B. O. KERN, former city physician at the City Hospital, St. Louis, has been appointed chief physician at the poorhouse to succeed Dr. John M. McKeage who has been appointed assistant chief physician at the same institution.

A CASE OF ANEURISM OF THE THORACIC AORTA WITH ULCER OF THE ESOPHAGUS AND PERIGASTRITIS.*

WM. H. RUSH, M. D.

ST. LOUIS.

THE subject of this report, an American, a licensed night-watchman, 56 years old, presented himself at the medical clinic of the Washington University Hospital on September 6th, 1905, when I made the following

notes:

The patient's mother died of typhoid fever; cause of father's death unknown. No disease of hereditary significance in the family. Chews tobacco; has not drunk alcoholics to

excess.

The patient has had measles, pertussis, malaria, pneumonia twelve years ago (probably on the right side), influenza, gonorrhea and a chancroid. No chancre so far as known, and no secondary manifestations of syphilis remembered. Had suppurating glands in the neck nine years ago, excised by Dr. Dixon.

The present trouble began five days ago, with pain in the left side in the region of the pectoralis muscles. The pain is constant, is increased by a deep inspiration, by a cough or a sneeze, or by sudden elevation of the left arm. There is no pain in any other part of the body. There is dyspnea on exertion. The patient has had no chill, and, so far as he knows, no fever. Had a severe "cold" two weeks ago, with cough. The appetite is fair, no increase of pain after eating; bowels constipated. The patient has continued at work.

Physical Examination. -Tall, slenderly built, somewhat stooped, rather poorly nourished man. Teeth badly decayed, mouth foul with tobacco. Scar below the left ear and one at the angle of the jaw on the same side. Respiration sounds and percussion note normal over the entire lung surface. Pulse intermittent, apex beat felt in the fifth interspace one-half inch to the left of the mammary line. Cardiac dullness from the left border of the sternum to the line of the

apex impulse. An occasional soft, blowing murmur, systolic, loudest at the apex, transmitted to the left. Liver dullness at the sixth rib. A walnut-sized gland in the left axilla, painful on pressure, not fluctuating, which the patient says appeared after infection of a wound in the left hand twelve months ago. No general glandular enlargement. Tenderness and extreme muscular rigidity in the epigastrium. Tenderness in the pectoralis major and over the intercostal mus

Meeting May 17, 1906.

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