action, acid; albumen, one-eighth; sediment, heavy, white; not much coloring matter; sediment composed of leucocytes, urethral, pelvic, and bladder epithelium; a few red blood-corpuscles." Two months' treatment with tannic acid had failed to produce any beneficial effect; in fact, the analysis indicates a less favorable condition. The amount of sediment had increased. The acid treatment was continued, and an infusion in wineglassful doses every four hours of uva ursi 3j. and lupulin 3 ss. to the pint of water, was added. On the night of February 17th he had a very copious hemorrhage. The next day he was ordered to bed. Treatment suspended. I had determined to try the stigma of maize, and was awaiting its arrival. Analysis, February 21, 1881.-Color, light yellow; sp. grav., 1020; reaction, acid; albumen, large quantity; phosphates and chlorides, normal; heavy white sediment; leucocytes, in large quantity; some red blood-corpuscles; large amount of vesical, urethral, and pelvic epithelium." On February 22, the treatment with the fluid extract of the stigma of maize was commenced, at first in doses of one drachm every six hours, then four hours, and, finally, after several days' use without any observable effect, every two hours. The quantity of urine increased and ran up to sixty-four ounces a day. The amount of sediment diminished, and micturition became less frequent. The following analysis shows a marked improvement: 66 Analysis, March 8, 1881.-Sp. grav., 1020; reaction, acid; albumen, small quantity; chlorides, diminished; phosphates, normal; sediment, one-tenth; numerous leucocytes, very few red blood-corpuscles, epithelium from pelvis of kidneys and bladder diminished; crystals of uric acid, oxalate of lime, and triple-phosphates." With occasional variations in the frequency of the doses of the maize, the treatment was continued. The interval between the doses was increased when the amount of urine passed was excessive. "Analysis, April 4, 1881.-Sp. grav., 1015; reaction, acid; albumen, small quantity; urates, small quantity; phosphates, normal; few leucocytes, very few red blood-corpuscles, epithelium from pelvis of kidney and bladder greatly diminished. In an eightounce vial of pale yellow urine the white sediment barely covered the bottom of the bottle." The decided improvement since the 22d of February may have been due as much to the rest in bed as to the stigma of maize. He appeared so nearly well that I allowed him to leave his bed and sit up on the 8th of April, and for several days he continued to improve. On Thursday, 14th inst., he complained of intense pain immediately preceding defecation, deeply seated in the perineum, which he ascribed to "the piles." The pain was continuous when in the sitting posture. Micturition was very frequent and accompanied with a scalding sensation along the course of the urethra, which continued, gradually subsiding, for about ten minutes after each evacuation of the bladder. A rectal examination disclosed an acute prostatitis. He was again put to bed. Leeches were applied to the perineum, followed by hot fermentations and a hot sitz-bath morning and night. At this date, April 20th, he seems to be doing well. The urine remained unchanged, apparently, from the analysis of the 4th inst. During the entire course of the disease his bowels had been kept in a laxative condition, sometimes employing alkaline waters, at other times the formula known as Chelsea Pensioner. A few days after the hemorrhage on the night of February 17th, he was seized with orchitis attacking the right testicle, and there remains, even yet, sufficient evidence of its effect to mar the symmetry of those organs. The second case in which the drug was employed occurred in a lady suffering with cancer of the uterus. The vesical irritation and tenesmus were so constant that the poor patient could not sleep, notwithstanding the large doses of morphia which were taken at regular intervals to relieve pain. Her urine was densely loaded with mucus and pus. She was entirely relieved after several days' use of the fluid extract. Previous to its administration I had tried various remedies which I had been accustomed to use in such cases, without any lasting effect. The third case was a lady who, for a year previous, had suffered with vesical irritation and frequent micturition. The analysis of her urine exhibited the following condition : "Sp. grav., 1027; reaction, very acid; albumen, small quantity; color, yellow; sediment, red in color; urates, increased; numerous leucocytes; numerous uric acid crystals; bladder epithelium in large quantity." She was entirely relieved, and continued well for about a month, when there was slight return of the symptoms. The medicine was resumed. Case fourth occurred in a young lady who, for several years, had suffered from frequent and painful micturition. The pain was sometimes so intense as to cause her to scream. Analysis of urine.-Color, straw clear; sp. grav., 1037; reaction, very acid; albumen, none; sugar, none; urates, increased; sediment composed of urates, mucus and epithelium, urate and oxalate of lime crystals; vaginal and bladder epithelium in large quantities, mucus." She was greatly improved after a moderate use of the drug, and, probably, would have been entirely cured if the treatment had been continued. But, as so frequently happens with young girls, as soon as the intense suffering was relieved, the treatment was abandoned. She is again under treatment. The foregoing cases were all under treatment at the time of obtaining the drug, but with intermitting and partial success. Since, the two following cases have been treated with the same drug: One was a lady who had suffered for an indefinite time with subinvolution of uterus, metrorrhagia, and laceration of the cervix. She represented that the desire to "pass water" was so frequent during the sleeping hours that it was impossible to secure a quiet night's rest. Her statement was, that the night previous to my first visit she had been compelled to get up every half-hour, passing at each time a very small quantity. She was entirely relieved. A week afterward there was a slight return, which yielded again to a few doses. The second case was a lady, who stated that she had suffered for two years with "congestion of the right ovary," and had been treated for that affection by various external lotions, and the internal administration of anodynes. I failed to recognize any enlargement or tenderness of the ovary, but did discover a retroflexion of the womb. She described a pain, which recurred every night after having retired, accompanied with a desire to evacuate her bladder. The pain was felt along the course of the right ureter. She was compelled to empty her bladder once every hour during the night, but not so often during the day. In this case the relief was not so prompt as in the preceding, but there was a gradual abatement of the vesical irritation and frequency of micturition. In addition to the use of the stigma of maize, the womb was adjusted, and retained in position by pledgets of absorbent cotton, saturated with carbolized glycerine. All these cases exhibit the beneficial effects of the drug, but I am not prepared to assert its curative influence with the confidence of Dufau and Vaulthier. It is a certain, but mild diuretic, when given in full doses at short intervals. IN the Cincinnati Clinic of April 19, 1879, I published a case as "A Contribution to the Sphygmographic History of Aortic Obstructive Lesions." The patient has since been under the care of Dr. H. T. Lowry, who kindly permitted me in January last to examine her case again, and assisted me in taking another series of tracings. April 8, 1881, the patient died, and a post-mortem examination of her heart was had. The case, for the purpose in view, is now complete, and is deemed of sufficient interest to warrant its full presentation. The following is reproduced from the publication instanced: "Mrs. T- -, aged sixty years, has suffered for several years from organic heart disease. She is thin and incapable of active exercise, but by going carefully usually attends to her ordinary household duties. Well-marked signs of hypertrophy of left ventricle. Action of heart strong, with jogging | impulse and regular rhythm. Systolic murmur, greatly emphasized at second right interspace, where also slight undulation and thrill are perceived. The murmur propagated upward along course of aorta, faint in other directions; at apex audible, but faint; audible in back. First sound well heard at apex but supplanted at base by murmur. Second sound distinct. No diastolic murmur. Radial pulse to fingers firm, slow, and prolonged. The clinical history admits of only one diagnosis: aortic obstruction without aortic reflux, and coëxisting hypertrophy of the left ventricle. The tracings shown were obtained at one sitting, July 16, 1878. The case, though evidently not one of extreme obstruction, from its wellmarked features is well suited for sphygmographic study. The cardiograms present an individuality of form which at once arrests attention. The systole is sustained as if the ventricle were laboring against an obstacle, and is slowly changed into diastole as if its work were not completely finished. The most striking feature is the great prominence of the auricular wave. One interpretation only can be given this phenomenon, viz., that it denotes hypertrophy of the left auricle. The tracings alone reveal this important feature of the case. "The tracings of the carotid pulse, No. 48, and of the radial, No. 49, are characterized by sloping ascents, rounded tops, and imperfect delineations of the secondary waves. They show also, high amplitude-notably of the carotid pulse-and high arterial tension. So while the first features indicate impediment to the exit of blood from the ventricle, the latter demonstrate that the arteries notwithstanding are well charged at each systole. "The time-difference, as shown, between the heart and beginning of the carotid pulsation, is .0833= one-twelfth of a second, and that between the heart and beginning of the radial is .1666-one-sixth of a second; which are correctly normal. But it will be observed that the interval between the heart and summit of the pulse is much greater than normal. "The type of pulse-trace instanced is constant in material aortic constriction, and the degree of deformation marks the amount of impediment to the passage of the blood. The type, however, may be simulated in the pulse below an aneurism or other source of arterial obstruction located beyond the aortic root. "The sphygmographic indications of ordinary aortic obstruction may be formulated thus: Heart's pulsation with sustained systole; arterial pulsation with sloping ascent and rounded or flattened top; interval between beginning of cardiac systole and beginning of arterial pulse normal. "A remarkable showing in this case remains to be considered. In No. 50, while the cardiogram conforms to the others, except in the greater modification induced by the respiration, the carotid trace presents a wholly different type from that of No. 48; and especially will it be observed that the carotid follows the cardiac pulsation at the very long average interval of .2275 second, which is about three times the time-difference of the other record. This is the only registry of the kind obtained among several observations, the others agreeing closely with No. 48. There was no fallacy. What is the explanation of this extraordinary change and contrast? It has been demonstrated that mitral regurgitation causes abnormal delay of the pulse. It is not difficult to conceive that under favoring conditions an intermittent reflux through the mitral valve may take place; and that in this instance, under the action of the hypertrophied ventricle and the mean-time sufficiency of the mitral valve, the ventriculo-arterial blood-pressure is at intervals increased to the point of preventing closure of the mitral segments, which then permit of reflow until the blood-pressure in front is reduced to the status at which the valve again becomes competent. Under the conditions, the behavior of the mitral valve would be analogous to the safety-valve action claimed for the tricuspid. "The alternative explanation applies a theory before advanced. It is that the changed aortic valves, although in this case usually yielding with sufficient promptness, at times become fixed, so to speak, and require additional time and force to open them. However, it is far easier to conceive of an intermittent patency of the mitral valve than of an intermittent fixing of the aortic valves. The mitral regurgitant theory also receives support from the existing auricular hypertrophy; for although this condition arises as a more remote effect of aortic obstruction, it is the natural and direct result of mitral reflex. Again, the peculiar and striking change of form of the carotid pulse can be accounted for better on the supposition of mitral insufficiency than on that of aortic fixing. On the other hand, in favor of the alternative theory, is the positive evidence, aside from the sphygmographic, of the existence of aortic lesion, and the negative evidence, save the sphygmographic, of the supervention of mitral reflux. It may be, however, that an apex systolic murmur, had it been listened for, would have been heard while the peculiar record was being and the aorta. The under surfaces of the valves were smooth, except opposite the attached borders, where calcareous tubercles presented. as well as the left, may produce a high auricular wave. And in view of the coexisting right ventricular hypertrophy, it may be considered probable that the cardiac traces were produced entirely by the right heart. This view is supported by the strict conformity to the same type of the heart traces, notwithstanding the marked changes in the pulse traces. It may be remarked, however, that the ventricles always begin to contract synchronously, so the beginning of the ascent, in any event, marked the beginning of left Hoventricular systole. This valvular disposition included a most remarkable feature. The third or functioning valve would move on its attachment, rising and falling en masse. Ordinarily, when down, it overlapped by a little the rigid border of the opening; but when pressed from above it would sink below the rim, and remain there as if locked, until pressed from below, when it would rise with a spring. to mult In the light of the sequel and post-mortem developments, the case can now be reviewed with pecu The traces indicated the intermittent operation of some factor which caused for the time a remarkable liar interest and profit. The second graphic examination gave results in consonance with those of the first, although separated by an interval of two and a half years; so I concluded that the diagnosis first arrived at was still sustained. The only real difference in the physical signs was the development of diastolic murmur over the aortic site, but this did not indicate to my mind the existence of aortic insufficiency to an extent worthy the name. The tracings showed the beginning of the arterial pulse in normal or delayed time, whereas had the valves been patulous, the pulse would have begun distinctly earlier than normal. The autopsy proved this item change in the time and form of the pulse. This change is strikingly shown in comparing No. 50 with No. 48, and has been fully described in the first account. The conditions of the aortic valves, found after death, afforded a full and complete explanation of this remarkable sphygmographic phenomenon; and it is interesting to note that the alternative explanations previously offered included the true one, and that the process there pictured was exactly that which in reality was taking place. The mechanism was this: Ordinarily the heavy valve which guarded the constricted orifice duly rose and fell, permitting the slowly rising pulse to begin of the diagnosis correct. Undoubtedly the murmur | within normal time after the beginning of ventricuwas due to the friction of the refluent blood against lar systole. But at intervals, under vigorous strokes the rough deposits, during the time the clumsy valve of the ventricle and large volumes of blood sent was falling into position. The form of the traces forth into the aorta, in connection, perhaps, with plainly indicated the presence of aortic stenosis, impediment in the capillaries, the arterial bloodbut not in an extreme degree, for the pulse was pressure would become so enhanced that the valve, shown to be, at times, ample and tense. And this in diastole, would be forced below the rim and so was the exact state of the orifice as proved post- locked or fixed in position. The next systole would mortem. The traces unmistakably indicated the require unusual time to raise the intra-ventricular presence of auricular hypertrophy, and this was con-blood-pressure to the point of dislodging the valve; firmed post-mortem, but as respects the right auricle, when dislodged, however, the latter would rise with instead of the left, as assumed. In this is the im- a spring and be carried wide open by the accumupressive lesson, that hypertrophy of the right auricle, 'lated pressure behind, and the column of blood would enter with unusual quickness, to be cut short, however, by the termination of systole. Thus the pulse-trace would change in time from accustomed normal to great abnormal delay, and in form from accustomed slow ascent and rounded top to quick ascent and pointed top. After a few beats the usual régimé would be restored, the change brought about by the reduction of arterial pressure following the comparatively small volumes of blood sent into the artery at each systole. In conclusion, the case well illustrates the rich and positive aids to cardiac diagnosis afforded by the graphic method. By this method alone could the amount of aortic stenosis have been so nearly approximated. By this method alone could the rare and peculiar form of aortic valvular obstruction have been in any sense made known. By this method alone could have been settled the question, raised by the presence of aortic diastolic murmur, as to competency or patency of the aortic valves. And by this method alone could have been determined the auricular hypertrophy, albeit it failed to distinguish the affected auricle. Besides the method joined the other signs in the determination of left ventricular hypertrophy, and gave a permanent record of the variations of the pulse in amplitude, celerity, tension, and rhythm. THE INTERRUPTED GALVANIC CUR- PITAL, ETC. to me October 2, 1880, with the following history: In December, 1879, a year previously, she awoke one morning with a sensation of pain and stiffness in the right hip, and on rising, found that she could walk only with difficulty. The pain increased so that at intervals it was very severe, but at no time during the course of the disease, had she been entirely unable to move about. Nothing seeming to afford positive relief, she spent the following summer at Richfield Springs, where she slightly improved, but on returning to the city in September, she soon found herself even worse than before. My examination revealed the fact that while she was quietly seated the pain was not great, but on attempting to rise it was excruciating and the stiffness very great. After moving about a few moments, this stiffness in a measure wore away. The hip in the region of the gluteal muscles had atrophied in a most extraordinary manner. The left hip, although sympathizing with the pain, was plump and full, but in the right the nutrition had been so impaired that in the hollow thus formed, the convex surface of a small dinner plate would fit admirably. The pain was about equally diffused over the hip, in the groin, and half way down the thigh. Firm pressure over the affected parts caused no pain, on the contrary, decided relief accompanied the act, and in bed it was impossible to sleep in any other position than on the right or diseased side. SCI-cases the faradic current was the most serviceable, I Acting on the experience of the past, that in such attempted its use for some weeks. Benefit followed, but it was only temporary. In an hour or so the pain and stiffness would be as great as ever. The constant current was tried, the galvano-cautery, etc., but at the end of two months, the patient had not improved in the slightest. It then occurred to me that if the operation of stretching the nerve could prove so efficacious in certain cases, as had been reported, why might not powerful galvanic shocks be utilized for the same purpose. I immediately made the trial, beginning with eighteen cells. While no special benefit immediately followed, the pain and stiffness were at least not aggravated, as I feared they might possibly be. BY A. D. ROCKWELL, M.D., ELECTRO-THERAPEUTIST TO THE NEW YORK STATE WOMAN'S HOSAr the last meeting of the American Medical Association, Dr. Gibney reported thirty-two cases of sciatica treated by the strong galvanic current, in which very excellent results were obtained. In my remarks upon the paper, however, I held that cases of sciatica were in their nature and manifestations so diverse, that it was impossible to hope for uniform results from any one method of electrical treatment. In some instances strong currents, especially where there is so much sensitiveness that slight pressure causes pain, may very decidedly aggravate the distress and do more harm than good. In regard to the whole subject of neuralgic pains in various parts of the body, I have often observed that in those cases where pressure proves painful, mild continuous galvanic currents are most effective; while in those conditions in which firm pressure over the affected part causes no pain, and often relieves, the faradic current is indicated. During the past severe winter, sciatica has been very prevalent, or so it would seem from the unusual number of cases that I have been called upon to treat. Some have yielded to one method, some to another, and several have proved most intractable. In the details of their management, however, nothing has been found especially worthy of comment, that has not been before recorded, except in one case. In this, powerful interrupted galvanic currents effected a prompt cure, after the failure, not only of all other methods of electrical application, but also after the ineffectual use of the actual cautery, external applications, and internal medication. Taking into account the length of time the disease had existed, the ravages that resulted, and the harsh method through which relief followed, the case was to me of unusual interest. CASE.-Miss J, aged twenty-eight years, came The strength of the current was increased every day, until finally forty cells were used. The museular contractions that followed were quite violent, but the results that followed in the course of a week surpassed expectation. The pain and stiffness rapidly decreased, and rest in bed was possible in any position. At the end of a month, all pain and stiffness had vanished, and, with the exception of a certain weakness in the leg, the patient considered herself quite well. I apprehend that but few cases of sciatica call for such really heroic treatment as this; injury rather than benefit would in most instances follow; but in passing in review quite a number of cases of this disease in which treatment availed but little, I quite firmly believe that a certain proportion of the number might have been speedily benefited by the method of procedure detailed in the preceding case. In the future I should not hesitate to make use of it freely in suitable cases. Such cases I should describe as associated with pains, more of a dull and aching than of a sharp and darting character, where firm pressure and vigorous rubbing is not disagree able, and frequently affords relief, and in which neither the continuous galvanic current, nor the faradic current, from which most would be expected, avail anything. |