It is only in recent years that the gravity of this disease has been fully recognized. The teaching that it is a trival affection, "no more than a bad cold," and gonorrheics have been permitted to marry, is responsible for its great prevalence and its far-reaching results.

The time was, and may be now (in some sections) were you to ask any intelligent layman or general practitioner who does not see much of the effects of gonorrhea and syphilis, which is the greater evil of the two, and he will invariably and unhesitatingly answer, syphilis.

Our men need education along these lines; as physicians we should impress them with the gravity of the disease and the importance of permanent cure before contracting the marriage state; too many men are permitted to marry with a latent gonorrhea, and in a short time infect a pure, innocent wife.

The physician should at no time consent for his patient to assume marital obligations until a permanent cure is effected.

Very much might be said along the line of prophylaxis, but I leave that to be brought out in the discussion of this paper, and I close with the interrogation, what is the duty of the physician when his patient heeds not his advice regarding marriage, before a radical cure is effected?

A NEW CAUSE FOR APPENDICITIS.-Pond, of Liverpool, claims to have proven that antimony in minute quantities is a cause for some cases of appendicitis, obtained from the rubber corks used in mineral waters, beer, etc., of which antimony is a constituent.

ACCORDING to the statistics of birth for a year, just published, the number of babies born in Manhattan was about 75,000. Of the 60,000 rceorded births, less than 12,000 were of American parentage. The Jews came first with 16,000, and the Italians came next with more than 11,000. The most striking and melancholy commentary upon the conditions among the poor, in what may be termed the foreign quarters of the city, is the fact that a fifth of all the chlidren born do not live a year, and more than 14,000 of them do not pass their fifth birthday.

A CASE OF MYXEDEMA.

L. J. HARVEY, M. D. GRIGGSVILLE, ILLINOIS.

8

this

DR. PATRICK recently said: "If we would put more time on cases of which we see great many, and less time on the cases which we see once in a lifetime, it would be a greater benefit to ourselves and to our patients. This undoubtedly is true, but should I follow the doctor's advice along this line I should be obliged at this time to give the history of some other case, for the simple reason, that my experience in this class of cases has been extremely limited; but nevertheless case has been very interesting to me because of its novelty, and will be so, I trust, to you for the same reason or otherwise. I do not propose to try to give you any facts regarding the history of this disease from personal knowledge, but ask your indulgence in making some quotations from the Twentieth Century Practice: "Myxedema is an affection characterized by widespread changes in nutrition as shown by the appearance of a solid edematous swelling of the subcutaneous tissues, dryness of the skin and arrest of development of its appendages, subnormal temperature, slowness of mental processes and execution of voluntary movements. This condition is due to loss of function of the thyroid gland and a consequent diminution of the supply of the secretion of the gland in the blood. Strictly speaking myxedema is a symptom or a collection of symptoms of destruction of thyroid gland tissue."

We have no means of knowing how long the disease may have existed, as there is no description of it in medical writings before 1873. Of the actual exciting cause of the changes in the thyroid gland which lead to the development of myxedema, in the great majority of cases we know as yet but little. In a few cases the destructive lesion of the thyroid gland has been traced to a definite exciting cause, e g., syphilis.

It occurs very much more frequently in women than in men, being nearly seven to one and between 35 and 45 years than at any other period. The larger number of cases occur in women who have borne children. It occurs most frequently in cold climates, and is probably more frequent in Europe than in any other continent. It occurs very rarely in any of the colored races.

The symptoms of myxedema develop slowly, and the onset is so gradual, in the majority of cases, that it is often difficult to ascertain how long the disease has lasted. It is more rapid in young adults than in those older.

The patient, Mrs. C., first came under observation in March, 1902, her age was 52 years. She had one child when 22 years old; no other pregnancies. During the ten years previous to 1902 she resided in California and Oklahoma, where she suffered many privations and hardships, and suffered great mental distress, which may have been a factor in producing the disease. In 1893 she had typhoid fever, being sick for three months. In 1894 she had a serious and long continued attack of pneumonia, and in 1901 had malarial fever, which was followed by rheumatism,

ment.

No. 1 shows the patient at the beginning of the treatNo. 2 after one year's treatment. and she was not able to walk for several months, and it was soon after this that I first saw her. At this time the face and limbs were badly swollen, bowels constipated, urine scant, high colored and heavily loaded with phosphates, but showed no albumen, this latter being absent, and no pitting on pressure eliminated what I first thought was a case of Bright's disease.

She complained of pain in every part of the body, but it was most severe in the left intercostal region. She was able to walk only a few steps and those with difficulty; was very nervous and restless and insomnia

No. 3.

No. 3 after two years treatment.

was

'marked. Her tongue was broad, thick and flabby, nose broad and thick; the lips thick, and mouth enlarged, with a peculiar action of the lips and tongue in speaking.

The skin of the face, breast, arms and hands was thick, hard, dry, wrinkled and scaly; the eyebrows and lashes were absent and

she was rapidly becoming bald. Speech was slow, and all voluntary movements were slug. gish and the mental faculties were dull. There was marked hallucination, she insisting she could not walk, as one limb was shorter than the other. The appetite was very poor and digestion imperfect; pulse 70, tem. perature 97. The thyroid gland was completely atrophied so far as we were able to dis

cover.

Regarding the treatment will simply say that the many and varied symptoms were met and overcome as far as possible, but the special treatment for the myxedema which gave relief was a tablet containing 5 grs. of thyroid extract given three times a day. In a few weeks she began to show improvement, and this has so far replaced the absent principle in the blood that she now has a soft, natural skin; hair is abundant soft and silky and of a dark natural color; the pains have disappeared, and return only when the treatment is suspended. The functions of the body are all naturally performed, and she is doing the housework for a family of six people.

The fact that this was a typical case of myxedema is what makes it of the greatest interest.

PLAGUE IN HAWAII.-Because of some cases of plague in Honolulu, an outgoing quarantine has been instituted.

AT the fourteenth annual meeting of the Association of Millitary Surgeons of the United States, which opened in Detroit on September 27, Major Jefferson Randolph Kean, U.S. A., of Washington, D.C., was announced to be the winner of the Seaman prize for 1905. This is a prize of $500, offered for the best essay on "The Prevention of Disease in the Army and the Best Method of Accomplishing that Result."

OF

LIME WATER IN THE TREATMENT WARTS.-An English physician some time ago accidentally learned that lime water taken internally is almost a specific for warts. When taking lime water for some digestive disturbance he found that a wart that had been troublesome disappeared from his finger. He tried this remedy on other cases of warts, and found that the warts disappeared. He recommends the taking of a wineglassful of lime water after the midday meal, with a little milk. By this method warts will disappear after from four days to three weeks. The simplicity of the procedure will recommend it for universal adoption. Med. Age.

be to arrest its progress, and destroy its virility, the tube in some cases becoming pervious and capable of again performing its function. (These cases with their damaged ciliary membrane interfering with the proper descent of the ovum, are said to be sometimes responsible for tubal pregnancy). When the infection is more virulent, nature failing in her effort to destroy the germs, proceeds to circumscribe, or wall off the offending material, by throwing out inflammatory lymph, causing coaptation of the walls of the tube, both at the fimbriated and uterine ends; the tubes becoming edematous and heavy fall back toward the pelvic floor, where from contiguity of tissue, they become adherent to the adjacent organs. Thus fixed in their new position the germs in some cases seem to lose their virility before the pus sack attains any considerable size, the contents become inspissated, and the damage wrought, and disability caused is comparatively small, being limited to the malposition of the organs, and the adhesions holding them in their unnatural position. The more usual course, however, is a continued enlargement, by reason of the pyogenic lining membrane, until a tumor of considerable size is formed, which if spoutaneous evacuation does not take place, may attain enormous proportions. I recall seeing a case some years ago, from which nearly two gallons was removed from the two tubes enucleated.

Symptoms.-The surgeon seldom sees these cases in the acute stage of the disease, when seen, however, they are, if of gonorrheal origin, preceded by more or less acute inflammation of the urethra, vulva and vagina, followed by pains in the pelvic, accompanied by painful micturition and a varying degree of temperature.

In streptococcus infection the symptoms are more acute and grave, usually ushered in with a chill. The fever soon becoming alarmingly high, with corresponding pulse; after a period of from six to fifteen days, if from gonorrheal, and from three to twelve weeks; if from streptococcus, the acute symptoms subside, but the patient is far from well, she has pelvic pains, painful and frequent menstruation, more or less sero-sanguineous vaginal discharge, painful micturition and defecation, from adhesions and pressure, bearing down pains and backache and usually though not always an evening temperature.

Diagnosis.-The diagnosis is not usually difficult. The history of an attack of gonorrhea, septic labor or miscarriage can usually but not always be elicited; when such infor

mation is forthcoming it is of diagnostic im. portance, frequently the history of an initial attack is wanting, the patient says she began to have painful menstruation tenderness of lower abdomen, lack of animation, etc. The general appearance of the patient is sallow complexion, stooping and careful gait, etc. will indicate suffering more or less constant and acute. Digital examination reveals an immovable pelvic floor, indurated masses can sometimes be detected on one or both sides of the vaginal vault, or perhaps in Douglas' cul-de-sac, tender and perhaps slightly fluctuating, if of large size, a tumor may be felt above the pelvic brim.

Treatment.-Preventative treatment is of paramount importance; the best means of protecting the innocent from the latent gonococcus, is commanding the attention of our societies today, which presages a better understanding of the subject by the profession.

The general practitioner who usually sees these cases, first, must be impressed with the seriousness of this disease, which he too often treats with levity. The laity must also be educated; must be instructed as to the fearful danger lurking in the slight and apparently harmless gleety discharge, and the direful results following woman's inoculation. This knowledge can probably best be disseminated through the agency of our state board of health, to whom is entrusted the general supervision of the interests of the health and life of the people.

After infection has gained ingress into the fallopian tube of woman, if seen in the initiatory stage, the treatment should be palliative; for surgical interference at this time is very dangerous, you have no well defined neal coverings have not as yet become imabscess cavity to attack, the adjacent peritoagglutinated surfaces would cause a rapid munized, and any disturbing of the lightly spreading of the infection, and probably and early fatal termination; instead give frequent and copious vaginal douches of hot water, use ice applications to abdomen, and opium when necessity seems to require. After the subsidence of the acute symptoms, is the time of election for surgical interference; an operation slight in character, but with much promise of a permanent cure, without mutilation, is now indicated, namely, vaginal incision and drainage, which, if performed early, will cases; if deferred, however, until the lining I believe, cure a large majority of these wall of the abscess cavity becomes pyogenic the probability of a cure by this method, are small indeed for, anything short of a total destruction of all the pyogenic lining membrane, by curette, caustics, or otherwise, will

result in a permanent fistulous tract, or recurrence of the abscess.

Vaginal drainage is usually performed in the following manner, after thoroughly cleansing the parts the vaginal wall is pressed up against the point selected for puncture, with the index finger, which also serves as a guide for a pair of scissors, or sharp pointed clamps, upon their withdrawal, the scissors or clamps should be opened, thus making an opening large enough to permit of the introduction of a gauze pack, after the cavity has been thoroughly explored, curetted and irrigated.

Very little hemorrhage will be encountered in this procedure if care is taken to avoid the uterine artery. Other dangers of this operation are the possible wounding of the ureters, bladder or rectum, and the more common accident of transfixing a loop of the ilium. That these dangers may be lessened I have conceived and carried into execution with gratifying results in a number of cases, the idea of an extraperitoneal drainage, which I will describe:

An incision posterior to and slightly to one side of the cervix, is made cutting down to the peritoneum, which is then followed by dissection, with the finger upward, close to the uterus, separating the anterior and posterior folds of the broad ligament, until the tube is reached, after which it is punctured and treated as in ordinary vaginal drainage. If the case be a double pyosalpinx, the incision should extend in a semi-circle across the entire vaginal vault; the dissection, after reaching the uterine body, being carried to either side of that organ, until the fluctuating mass is encountered. This method, in addition to lessening the danger of the accidents mentioned, entirely obviates the possibilities of the purulent abscess contents, flowing to leaking into the pelvic cavity, and setting up a general or localized peritonitis. After vaginal drainage the pack should be left in two or three days, after which the cavity should be thoroughly irrigated daily with boric acid solution, and re-packed until by granulations and contraction it is entirely obliterated, which in adaptable cases, will occur in from two to four weeks. Unfortunately cases of pyosalpinx are usually referred to the surgeon at a later period than the one just described; the improvement after the initiatory symptoms have subsided, encourage the patient, as well as her phyiscian, to think that she is going to make a spontaneous recovery, and it is only after months, aye perhaps years, of a varying degree of ill health, that the surgeon's services are solicited; then a very different operation is required, that of enucleation. Some very eminent surgeons, among them Pryor, of New York, enucleate

through the vagina, with excellent results, but for the less frequent and less skilled operator, the abdominal route should be chosen, whereby his tactile sense may be aided in the difficult dissections and manipulations by the sense of sight.

The opening having been made, the omental adhesions properly dealt with by ligation, if any interfere with the examination, the pat ient should be placed in the Trendelenburg position, and the free abdominal cavity walled off by the use of hot moist pads, the fundus located the finger can usually be worked down to Douglas' cul-de-sac, and from this point the adhesions around the tubes carefully broken up; sometimes, however, the better point of ingress will be found out on the dorsal wall of the pelvis, where after getting the fingers down behind the tube, by a rolling motion, the entire mass is dissected up retaining its normal attachments to the uterine body.

At this point the question of a pan hysterectomy must be considered, for many excellent surgeons, among them Mann, of Buffalo, advocate a complete hysterectomy, whenever it is necessary to enucleate a fallopian tube by reason of its infectious contents.

To remove the pyosalpinx and leave an infected uterus, will only partly alleviate the patient's symptoms, if at all, and the results will be unsatisfactory in the extreme; the patient continue to drag out a miserable existence for a time, and finally return, or more likely, seek the services of another surgeon, who will be called upon to operate for the condition you have failed to relieve; this question requires serious thought and close discrimination, if the patient be young, the pyosalpinx single, the other tube and uterus healthy, the purulent mass should be removed, after ligation at the cornu, and an effort made to save the apparently healthy viscus; if an endometritis exists, the uterus should be carefully curetted and packed with iodoform gauze, a small drain of the same material being drawn through an opening in the cul-de-sac, if any question exists as to the sterility of the field.

On the other hand, if the patient is approaching the menopause, the other tube under suspicion, or the uterine tissue boggy and friable, a complete removal of the organs, including the cervix, should be made, provided of course the physical condition of the patient does not contraindicate this major operation, by reason of the additional shock entailed. After pan hysterectomy, performed in the usual way, an iodoform gauze plug should be drawn down through the opened vault of the vagina, leaving the upper end a little above the cut edges of the vaginal walls.