The American Journal of the Medical Sciences

quent cases it might be wiser to resect this portion and include the edges in the abdominal wound. Suppuration between the muscles and peritoneum resulted from this cause in the case reported, but the pus was evacuated and the patient made a good recovery.

THE PATHOLOGICAL ANATOMY AND MODE OF DEVELOPMENT OF MITRAL STENOSIS IN CHILDREN.

SAMSON'S paper (Jahrb. f. Kinderh., xxxii., 1 and 2) is based upon the investigation of forty cases, of which nineteen were fatal and were followed by autopsy. Two classes of this disease are distinguished, the first of which includes those cases in which there is only slight contraction of the ventricular opening, signifying the initial stage of the disease. The second class includes those cases in which the disease is well developed. In the first group the author had observed ten cases. In these were more or less firm fibrinous vegetations, making a ring-like formation around the valve, and extending upon the leaves of the valve and upon the chorda tendina. In five cases the right ventricle was dilated, and in one the left auricle was hypertrophied. In two the weight of the heart was far more than was normal. In one case there was a coexisting congenital anomaly, the aorta springing from the right ventricle and communicating with both ventricles. In the last-mentioned case endocarditic vegetations were present upon the endocardium of the left auricle, and surrounded the mitral opening. Vegetations may disappear entirely in some cases and also the symptoms which arise from them. In other cases the results are dilatation of the ventricle and insufficiency. Simple stenosis was found in nine cases; in eight of which it was funnel-shaped, in one it was slit-shaped. The funnel-shaped stenosis is the more common form in childhood, but not in adult life. The following are the author's conclusions:

1. Stenosis of the mitral valve is not a congenital malformation. 2. It is related to endocarditis, but seldom to fœtal endocarditis.

In twenty-six of the author's forty cases rheumatism was a causative factor. In cases which are not of rheumatic origin the cause may consist in bad nutrition or disorder of the nervous system. Of the forty cases, nine suffered with chorea. Stenosis arising from disorder of the nervous system may consist in a valvular lesion which has been induced by violent heart action during a nervous attack. Thus a relation may be established between fright, violent heart action, chorea, and endocarditis.

THE TREATMENT OF CONGENITAL HARE-LIP.

KAPPELER, in the Arch. f. Kinderh., xii., 5 and 6, states that we are indebted to LANGENBECK for a safe operative method for closing hare-lip, and to WOLFF for a method which yields a good functional result—that is, the procurement of speech without nasal twang. The steps of Wolff's method include:

1. Operation under anaesthesia with the head hanging back, after Rose's method.

2. The use of methodical compression.

3. Antiseptic irrigation of the mouth while the head is dependent.

4. Performance of the operation in two stages, the flaps being loosened in the first operation, and five to eight days later the parts being refreshened and sutures passed.

5. The use of a protecting suture and a lateral incision suture.

The method will test the patience of a busy surgeon, but it is the only one which offers certainty of result, and the additional advantage that very young children can be operated upon without danger.

The author has used Wolff's method for adults, performing it at one sitting instead of two. Satisfactory results as to speech were attained by staphylorrhaphy, a soft elastic obturator being placed between the sutured velum wall and posterior pharyngeal wall, the speech being carefully regulated for a sufficient length of time subsequently. Obturators of various sorts have been devised to remedy the defect in the palate posteriorly, several of which are described.

TREATMENT OF THE CAUSES OF LIMPING.

SIMON states (Arch. f. Kinderh., xii., 5 and 6) that one of the commonest and most important causes of lameness in children is coxitis. It calls for attention at the beginning while it is still an arthritis and before there is tumor albus, abscess, or luxation of the head of the femur. Treatment should be general and local, the former having especial reference to general disease like scrofula, and consisting in the use of tonics and stimulants, codliver oil during the winter, and phosphate of lime. The local treatment consists primarily in immobilization, and whatever form of apparatus is used this must be a primary consideration. The author approves of the extension apparatus of Guersant, which is provided with weights for overcoming muscular contraction. It is sometimes necessary to use chloroform anæsthesia as an assistant to the apparatus in overcoming this contraction. The Guersant apparatus allows one to make the necessary inspection of the diseased joint and to use the necessary local means. If the leg has no defective position it is well to use that form of Guersant's apparatus which fixes the pelvis and the trochanter completely. Verneuil's and Bonnet's apparatuses are also recommended, though the expense of the latter may be considered an objection to it. If the disease has lasted a long time, and the leg is in a vicious position, with or without ankylosis, re-dressment under chloroform anæsthesia is indicated, and then immobilization if inflammatory conditions have disappeared. Abscesses should be opened and treated with iodoform-ether. If

healing has advanced so far that a relapse into a bad position is not to be feared, the immovable apparatus may be replaced by a movable one. After one to three years healing will usually be so far advanced that the patient can go about on crutches. Since relapses are to be feared, one must not begin to lay aside supporting apparatus until ankylosis of the joint in a good position has occurred. Coxitis is one of the most deceptive of diseases, and almost always ends with shortening of the leg to a greater or less extent. Another cause of lameness consists in congenital luxation of the hip-joint. This is usually incomplete and increases by degrees. By using suitable apparatus the destructive process in the head of the femur may be retarded. Arthritis of the knee- and ankle-joints may be treated at first with revulsives, vesicants, and immobilization. Internally one may give salicylate of soda in the acute stage, and in chronic cases tincture of colchicum in five- to ten-drop doses, suspending its use for a time after eight or ten days. Tonics must also be employed, also massage and weak currents of electricity. Passive movements of the joint should also be practised to prevent stiffness. If there is periostitis or a small abscess, one may inject iodoform ether; if there are large abscesses, curetting under the most careful antisepsis is advisable. If there is inflammation of the trochanter, immobilization is of first importance, and then one may use revulsives or actual cautery, burning even to the bone. To relieve the pain one may give belladonna and hyoscyamus, the limb being enveloped in cotton.

Another cause of lameness is infantile paralysis. Should it begin with fever, the treatment should first consist in derivatives, such as flying blisters and the actual cautery, then hot-air baths to cause profuse sweating. At night one may give chloral, and during the day aconite and nux vomica in doses of ten drops or less. When the febrile period is over the galvanic current may be used every three days for ten minutes at a time. Carefully regulated gymnastic exercises will also be of service, also sulphur-baths, salt baths, and tonics-especially nux vomica.

In paralysis from brain lesion electricity is not indicated. One must lessen rather than increase the excitement of the nervous system. If the brain lesion is of syphilitic origin, iodide of potash should be used. If there is sclerosis of the brain, bromide of potash and iodine may be given in combination. All excitement must be avoided, and the treatment be directed to that lesion which is the fundamental cause of the lameness.

A NEW METHOD FOR THE TREATMENT OF TUBERCULOUS PROCESSES. LANDERER, in the Arch. f. Kinderh., xii., 5 and 6, states that the favorable result which we are sometimes able to obtain in connection with the treatment of local tuberculous processes is due to the formation of scar-tissue, and hence the transformation of tuberculous processes into solid scars, is the aim of therapy. The tendency to the formation of such tissue in tuberculous processes is very slight, on account of their low vascularity and their slight tendency to energetic inflammatory action. Hence the problem is to cause an inflammation which may result in the formation of this desirable scar-tissue, and this the author has endeavored to do with chemical means, safely and aseptically. Sublimate and carbolic acid may become deposited and be a source of toxic

influence, hence they might not be able to accomplish a permanent beneficial effect. An excellent anti-tuberculous agent is to be found in balsam of Peru, which has been recommended by Sayre in the tamponade of tuberculous cavities. A plaster containing 1 part of balsam of Peru, 3 of adhesive plaster mass, and 1 of wax, was found very useful in bone swellings. In fistulous processes the granulations were scraped away, balsam of Peru was introduced, and a firm scar was quickly the result.

An emulsion containing 1 part each of balsam of Peru and gum-arabic, 94 parts of almond oil, 10.7 of chlorate of potash, and 100 of distilled water, was found useful for percutaneous injections in tuberculous joints. Since the blood-stream carries tubercle bacilli from the primary focus of infection to distant parts, why may it not also be used to carry means for the destruction of the bacilli? This would furnish a warrant for the intra-venous injection of emulsion of balsam of Peru. Experiments have abundantly shown that foreign matters can be thus carried to various parts of the body. A series of positive results was obtained in puppies by the intra-venous injection of the emulsion referred to. Of course, it is not asserted that balsam of Peru is a specific for tuberculosis. Easily soluble materials of similar action might be found, and then there would be an inducement to give up the expectant method of treatment which has been in vogue so long in the treatment of tuberculosis.

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EDWARD P. DAVIS,

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CONTENTS.

ORIGINAL COMMUNICATIONS.

PAGE

Treatment of Chronic Ringworm in an Institution. By LOUIS A. DUHRING, M.D. 109

Ten Cases of Excision of the Knee-joint. By JOSEPH D. BRYANT, M.D.

Some Curable Forms of Rheumatic Gout. By EDWARD BLAKE, M.D.

Aphasia due to Sub-dural Hemorrhage without External Signs of Injury; Opera-

tion: Recovery. By L. BREMER, M.D., and N. B. CARSON, M.D.