the operation which remains to mark its performance, if it is done in a neat, careful and surgical manner, is a delicate cicatricial semi-circular line, which is in great degree concealed by the folding of the skin. the breast hangs downward, and a spot of cicatricial tissue where the drainage tube prevented union by first intention." Although this operation as proposed by Dr. Thomas has very manifest advantages in a limited number of carefully selected cases, it has apparently been forgotten by surgeons generally, and has been completely ignored by most of the text-books. Nor has it fared much better in periodic literature, for the writer has only been able to find the few following references to the procedure. Bryant, "Diseases of the Breast," page 107, alludes to Thomas' operation, but makes no comment. Alexander Jamieson, of Shanghai, China, British Medical Journal, June 9, 1888, page 1216, reports four cases of his own and one of his colleague, Dr. Boone, in all of which primary union and exceedingly satisfactory results were obtained. He was most gratified with the operation and its beautiful results. An illustration from a photograph accompanies the article. In view of the risk of adenomata of the female breast developing into recurrent fibro-cystomata he has always urged early extirpation of such tumors. But a seriously deformed breast, in the estimation of most young women, is a disproportionate price to pay for the avoidance of a danger which at worst is only probable. Hence he welcomed the advent of the new operation, as patients could be persuaded the more readily to permit operation at an early stage if assured that no serious deformity would result. In the same journal, December 2, 1893, page 1209, he reports an additional case and again warmly comends the operation to his fellow surgeons. John D. Hayward, British Medical Journal, February 23, 1889, page 410, reports the removal of an adenoma the size of an orange by this method. No vessels required ligation, the drain tube was removed on the second day, and the case was discharged cured in a week. It was impossible to see any difference between the injured breast and its fellow except upon raising the organ completely. The writer presents the following case as illustration that Thomas' operation can be readily and successfully applied to encapsulated or benign growths in the upper as well as the lower quadrants of the breast: Mrs. K. W., aged 36 years, white, housewife, entered the Polyclinic Hospital April 4, 1895. Her mother died at the age of 53 from an "abdominal tumor." Otherwise the family history was negative. Eleven years ago she bore a healthy child which she nursed. Perineum and cervix were then lacerated, but subsequently repaired. She has always enjoyed the best of health. Five months before admission she first noticed a lump in the upper and outer portion of the right breast. It was then as large as a marble. During the interval it had steadily increased, and during the preceding four weeks had given rise to shooting pains. Her weight had not diminished nor had her general strength or spirits suffered. A Upon examination, the breast was found to be the site of a hard, extremely movable tumor in its uppor and outer quadrant. It was not especially sensitive to pressure. In size it was as large as a duck's egg. It could be pressed downward from above so as to become subcutaneous at the nipple. finger tip passed down through the thin skin about the nipple could accurately define the inferior surfaces of the growth. It was dense, elastic and perfectly smooth. The extent of its movability was exceptional: it appeared to have hollowed out a large cavity in the cellular tissue by its constant excursions. The finger determined that there were no adhesions upon the under surface of the tumor. The axillary glands were not enlarged or painful to pressure. Diagnosis of adenoma was made and the Thomas method of removal decided upon. It was found easily feasible in this case to turn up the breast as a flap or trap door so as to extract the growth without leaving a disfiguring cicatrix. An incision five inches in length was made, semi-circular in form, in the line of the fold formed at the junction of the lower portion of the breast skin with that of the chest wall. This was carried down through a considerable amount of fat until the sheath of the pectoralis major was exposed. The loose cellular attachments of this to the capsule of the breast was then with great ease broken up by blunt dissection and an occasional snip of the scissors until the breast could be turned upwards upon the chest wall below the clavicle. The posterior wall of the capsule was now opened in a direction radial to the nipple over the tumor. This was found to be encapsulated and very loosly adherent to the pocket among the gland acini, which it had evidently formed by its movements. Blunt dissection by a forefinger freed it at a sweep at all points save the upper and outer, where a firm adhesion was discovered, which required division by the knife, but without opening the capsule of the growth. No ligatures were required. The gland was turned down into its normal position and the skin margins of the wound united by a subcuticular continuous suture of silk. No drainage was used. A snug and copious dressing was so applied as to obliterate the cavity from which the tumor had been enucleated. Acetanilid was dusted along the suture line. On the fifth day the suture was removed and primary union found. No deformity of the breast was observable. One week later it was difficult to see any difference between the breasts. The cicatrix could only be seen by raising the breast, except at each side where for about an inch a hair line cicatrix-the extremities of the incision-could be observed, and this only upon close inspection. Dr. Joseph McFarland reported the tumor to be adeno-sarcoma. The woman was kept under observation for a period of more than two years and during that time her general health continued exceptionally good. No difference could be detected between the two breasts except upon close inspection, when the extremities of the incision could be observed. The hollow made in the gland by the former presence of the tumor had been obliterated. REPORT OF FIVE CASES OF DIPHTHERIA, FOUR OF WHICH WERE BY WILLIAM H. WELLS, M.D. Adjunct Professor of Obstetrics and Diseases of Infancy in the Philadelphia Polyclinic. ALTHOUGH reports of cases of diphtheria treated successfully by the use of antitoxin are now quite numerous, yet a series of six cases all occurring in one family and all but one treated by this means seems to the writer to be of enough interest to warrant publication. As before stated, all of these patients were treated with antitoxin except the grandmother, who refused positively to have the injections made. Her attack was, however, very light, the membrane being confined to one tonsil. Her case was of rather special interest from the fact that she has presented for some months symptoms of malignant dis ease probably of the pylorus but whether or not this had anything to do with lessening the severity of the attack of diphtheria I am unable to say. The presence of the characteristic bacillus of diphtheria was demon strated by cultures made from the throats of every case, an average of three cultures from each individual. CASE I. I was called on June 4th of the present year to see J. W., a female child 41⁄2 years of age, who had been taken sick two days before my visit. The patient had a temperature of 102 degrees. I had been sent for because the mother became anxious about the peculiar appearance of the child's throat. On examination a large patch of membrane could be seen on each tonsil; there was some cough with some slight difficulty in respiraedema of the uvula and a marked laryngeal tion. A culture from the child's throat was immediately made and sent to the City Laboratory and in due time a report returned proved the presence of the bacillus of diphtheria. As this was the first case of diphtheria which had presented itself to me for some time and not having had the opportunity of using antitoxin, I asked the advice of my friend and neighbor, Dr. Edwin Rosenthal, and on the evening of the day of my first visit (the third day of the disease) he and I injected 2000 units of Mulford's standard antitoxin, all of the usual technic being used. The site selected for the injection in this, as in all the other patients, was the mass of muscles on either side of the spinal column at about the inferior angle of the scapula. On the morning following the first injection there was little if any improvement in the child's condition, the temperature remained high and the cough persistent; there was also some bleeding from the nose. 2,000 units more of the same strength of antitoxin were injected and the spray of hydrogen dioxid solution which we had been using was continued every two hours. About thirty-six hours after the second injection a well marked red line could be seen surrounding the membrane on both tonsils and some forty-eight hours later the membrane was rapidly disappearing. The child suffered no reaction whatever from the injection, nor was there any cutaneous eruption. The cough and fever rapidly disappeared. The treatment in addition to the antitoxin consisted of the spray of hydrogen dioxid solution before mentioned, and a tonic consisting of a small quantity of digitalis, aromatic spirit of ammonia and whisky. Later the tincture of ferric chlorid was administered. I have given the treatment of this case rather fully because the same method was used in all the others. CASE II.-On June 14th, ten days after the first child was attacked, May, a sister 10 years of age, showed unmistakable symptoms of diphtheria; the location of the membrane. being the right tonsil and the right side of the uvula, later spreading to the left tonsil. She was seen on the second day of the disease. The constitutional symptoms were more severe then were those of the first child. In this case for the next 24 hours after my first visit I contented myself with thoroughly spraying the parts affected and administering rather large doses of the tincture of ferric chlorid and general tonics, all of which had no effect whatever. At midnight of the day of my second visit I was sent for because the larynx was evidently becoming invaded. The same dose of Mulford's standard strength antitoxin as was used in the first case was injected with almost the same results, the membrane having the same red line surrounding it and shortly after disappearing. This patient suffered slightly from shock, but whether this was from the antitoxin or from the poison of the disease it is impossible to say. She soon passed into an uninterrupted convalescence. CASE III. On the 18th of June, Anna, another child of the same family, aged 2% years, was taken with diphtheria of tonsillar type. As she was seen in a very few hours after the membrane appeared, but 2,000 units of antitoxin were used, with the same results as in the previous cases, except that no period of weakness followed as in the second case. CASE IV.-About the same time, the children's grandmother, a woman of some 65 years, was attacked, but very lightly. The constitutional symptoms caused but little discomfort. Cultures, however, showed the presence of characteristic bacteria of diphtheria. This patient positively refused the antitoxin treatment. She has decided evidences of pyloric cancer. Her treatment consisted of stimulants and the use of hydrogen dioxid spray. None of these patients showed any form of skin eruption. Eber, a boy of the same family, aged 6 years, was, while the other children were sick, taken with a chill and general malaise. His throat became inflamed, but not ulcerated, nor was there at any time any membrane; a light, erythematous eruption covered his whole body for a few days, and then rapidly disappearrd. Early in August the two boys Frank and Eber went to visit relatives in a small town in New Jersey, near the city, Eber taking with him a small doll with which one of his sisters had played. It is stated that there were cases of diphtheria in the town visited at the time. One of the children in the family visited took the disease, as did Frank also; both children were skilfully treated by injections of antitoxin by a physician living in the town and both recovered. CASE V.-On August 10th, Eber, who had just returned home, was taken with diphtheria, the symptoms being well marked. Culture proved the nature of the disease. He was seen by me about 36 hours after the membrane first appeared and was immediately given 2,000 units of antitoxin and subsequently put on the same treatment as the others. Prompt recovery followed. In reviewing the history of this interesting series of cases it seems to the writer that the favorable termination of all of them must have been due to the effect of the antitoxin; the first two children presented decidedly severe cases, and it is at least fair to suppose that the others, all of whose initial symptoms were far from light, would have had severe attacks, had it not been for the timely use of this remedy. FURTHER COMMUNICATION UPON A CASE OF MENINGITIS.1 BY AUGUSTUS A. ESHNER, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic; Physician to the Philadelphia Hospital; etc. ON March 22, 1897, I presented2 to this Society a man, 49 years old, exhibiting many symptoms of posterior spinal sclerosis: awkwardness of gait; uncertainty of station; reflex iridoplegia; degeneration of the optic nerves; thickness of speech; diminution of sexual desire; hyperesthesia and paresthesia; enfeeblement, followed by abolition, of the knee-jerk, first upon one side and then upon the other. There were present, besides, some symptoms of general paresis: tremulousness of face, head, lips, and tongue; derangement of memory and epileptiform convulsions. In addition, there were vertigo, with some deviation to one side in walking; impairment of hearing; unilateral sweating of the left side of the face and head, with an absence of perspiration on the entire right side of the body, and a general preponderance of the symptoms upon the left side. The patient had, some twenty one years before, been overcome by the heat. He had had an attack of gonorrhea, but denied other venereal infection, and there were no obvious secondary manifestations of syphilis. The patient had been previously exhibited to the Society by Dr. Charles K. Mills, who considered the case as probably one of posterior sclerosis of slow development, but at that time no change was found in the fundus oculi. The obscurity of the diagnosis was dwelt upon on the occasion of my presentation, and the opinion was expressed that a condition of chronic or old basilar meningitis, involving especially pons, medulla, and cerebellum, seemed best to account for the varied symptoms present. The treatment consisted in the administration of strychnin sulfate, gr. thrice daily, and the patient was rendered fairly comfortable. Nothing noteworthy occurred in the further history of the case until the night of November 30th, when the patient was seized with a series of convulsions, at the close of one of which death took place. The post-mortem examination was made by the Coroner's physician, Dr. H. W. Cattell, to whom I am indebted for the following notes: On removing the calvarium, the dura mater was found not adherent to the bone in this situation. The vessels generally were greatly injected, and the capillaries were somewhat more prominent than normal. All of the sulci in the Rolandic area on both sides exhibited a grayish white, delicate, fibrous reticulum, which was slightly elevated from the presence of subjacent fluid. There was no indication of any process suggestive of recent bacteriologic involvement. The appearances were rather those of chronic fiibrous thickening of the pia-arachnoid with moderate adhesion to the brain surface. The blood vessels forming the circle of Willis were thickened, and gaped when cut. Many of them contained small fibrous nodes. The fibrous thickening of the meninges, previously referred to, was especially pronounced in the neighborhood of the basilar artery and upon the pons and medulla, the nerves coming off from which passed through the thickened membrane. The under surface of the cerebrum, the olfactory and the temporal regions were remarkably free from thickened membrane, which was, however, prominent in the fissure of Sylvius along the course of the middle cerebral artery. About three-quarters of an inch from the point of origin of the left middle cerebral artery was a small, well-formed 1 Read before the Philadelphia Neurological Society, December 20, 1897. sacculated aneurism about the size of a small pea. The island of Reil and the retro-insular convulsions displayed no abnormality other than atheroma of the blood vessels, and a small clot of blood on the right side, apparently contained within a miliary aneurism. There was considerable edema in the neighborhood of the optic chiasm, and the optic nerve appeared flattened from above downward and diminished in size, from thickening of the overlying membrane. The left lobe of the cerebellum was the seat of an enormous hemorrhage, which had ploughed its way into the fourth ventricle, and thence through the iter into the third and also into the left lateral ventricle. So enormous was this extravasation, that a considerable clot of blood was found in the posterior horn of the left ventricle. The foramen of Monro and the adjacent nervous tissues were torn apart and replaced by bloodclot. Sections through all parts of the brain failed to disclose any other seat of hemorrhage, recent or remote. The injection of some portions of the arbor vitæ of the cerebellum was especially pronounced. Concerning the other organs, it seems only worth saying that the kidneys exhibited an extremely slight degree of parenchymatous inflammation, while the heart was somewhat enlarged, with healthy valves and orifices, and the lungs were edematous and emphysematous. Owing to the conditions under which the autopsy was held, it was not possible to obtain even the smallest portion of tissue for careful study. It could not be decided from the macroscopic appearances, whether or not the upper portion of the spinal cord exhibited any changes, particularly in the posterior columns. Selection OBSTINATE SYPHILIS AND GLEET. SOME cases of syphilis, as you know, are most intractable, and resist everything we employ. A very good remedy in the latter stages of syphilis is Donovan's solution; this is especially beneficial in longstanding palmar psoriasis, as well as in manifestations about the mouth and tongue. Still there are, as I have remarked, certain cases, such as ulceration and necrosis about the palate and nose, etc., which seem to yield to nothing. For these we have a remedy to fall back upon which is extremely serviceable; in fact, so much so that I may say I have never seen it fail. I refer to Zittmann's treatment. It is not much known, and still less is it employed; I have, however, had at least a dozen patients who have undergone this particular form of treatment. The course lasts a fortnight, and consists in keeping the patient in bed in a hot room up to a temperature of at least 80° F. For the details of this treatment I cannot do better than quote from the able book on syphilis by my friend Mr. Alfred Cooper. The decoctions and pills are made from the following formulæ : Zittmann's decoction, No. 1, the strong decoction. And in a linen bag, white sugar and aluminum sulfate of each 2 drams, mercurous chlorid (calomel) I dram I scruple, red mercuric sulfid I scruple. Add to this 3 gallons of water, boil gently down to I gallon; strain, and put into four 40-ounce bottles. Zittmann's decoction, No. 2, the weak decoction To the dregs of No. 1 decoction add sarsaparilla root, 2 ounces, lemon peel, cardamoms and licorice root, of each I dram, to 3 gallons of water boiled down to I gallon; strain, and put into four 40-ounce bottles. The pills Mercurous chlorid (calomel).. 2 grains. 5 grains. 2 grains. Mix. Diet consists of-Breakfast-boiled egg or bacon, tea (no sugar); butcher's meat for lunch, with vegetables, but no fruit; dinner-soup, fish, and poultry. On the evening before beginning treatment, 2 pills are taken, and for the next four days, at 9, 10, 11, and 12 o'clock in the morning, half a pint of strong decoction is taken very hot; at 3, 4, 5, and 6 P.M., half a pint of the weak decoction is drunk cold. The patient should keep in bed except for one hour every evening. On the fifth day he may get up and may have a hot bath, and, if he likes, a little brandy, or whisky and soda. In the evening 2 pills are administered, the patient starting the decoctions the next day as before. After 15 days the treatment is discontinued. There are thus three series of four days each, with one day interval between each. It is a most admirable method of treatment. I was at my wits' ends how to cure a young fellow who had been ordered to join his regiment abroad. He had an attack of secondary syphilis, viz. : ulceration of the pharynx and of the soft palate; and although after a time all mercury was stopped, and his throat was carefully painted with nitrate of silver, 20 grains to the ounce, and subsequently sulfate of copper, 4 grains to the ounce, he did not improve beyond a certain point. After a course of Zittmann he went out apparently quite well after a fortnight. He is now continuing his mercurial treatment in the form of pills while abroad.-MR. SWINFORD EDWARDS in Clinical Journal, December 15, 1897. |