EMPHYSEMA.

The next patient, a man 40 years of age, tinsmith by occupation, was in the hospital six weeks ago, but many of you did not see him at that time, since the regular winter session had not begun. His father is dead, from what cause he does not know. His mother is living and in good health. He has had ten brothers and six sisters, nearly all of whom died in infancy. Here again he is unable to give us information as to the cause of death. He was healthy until he had the small-pox, at the age of 15. After recovery he enjoyed good health for five or six years, when he acquired gonorrhoea. For one year and a half before admission (which was late in August of this year) he suffered from cough and slight expectoration. The expectoration has recently increased. For the past four months he has been subject to pain in the stomach and back, upon which symptom he lays stress. This is all of which he complains, except that upon slight exertion he has dyspnoea, especially in going up and down stairs.

When admitted the signs were about the same as at present, though the condition of the lungs has somewhat improved. After we have studied the state of the lungs we can better understand that of the heart.

Upon inspection we observed that the man was very poorly nourished. He has, therefore, improved considerably in flesh, weight, and strength during his stay in our hospital. The dorsal spine is slightly curved anteriorly, the right shoulder droops, and on raising the arm the right side is seen to be more or less retracted. This feature is much less noticeable than it was three months ago. As he breathes there is but little expansion of the chest. Only a slight up and down motion takes place. Vocal fremitus is about normal on both sides. (It was better on the left than on the right side when he was admitted.)

Upon percussion I find extra resonance-in fact, a semi-tympanitic note. The vesiculotympanitic sound is more marked upon the left side. This character of the respiration is less typical now than it formerly was. Rough râles are heard; there is relatively prolonged expiration and very weak vesicular murmur.

The last two signs point to the existence of moderate emphysema. In advanced cases the respiratory act is longer than the inspiratory. In this case expiration is only slightly prolonged.

Again, the diagnosis is not only established by the signs already pointed out, but is also strongly confirmed by the influence of overdistended lungs upon other viscera. The apexbeat is pushed downward and to the right, being most marked in the epigastrium. The area of hepatic dullness is increased, extending about one inch below the costal border. Upon inspection I perceive a feeble cardiac impulse. There has been actual improvement from retrocession of the lung. Upon palpation I also detect a faint thrill over the epigastrium, and to the left of the median line a pronounced impulse.

Percussion of the right side reveals cardiac dullness extending a little beyond midsternum. To the left there is pulmonary resonance within. the nipple line for at least one inch, showing that the lung has pushed the heart away or else everlaps it. When I practice auscultation I hear a murmur, which is most distinct in the fifth interspace to the left of the sternum. It is a systolic murmur, and becomes faint in going toward the left. There is an accentuation of the second sound just to the left of the sternum in the second interspace. Thus we have two characteristic signs of mitral regurgitation: the murmur most distinctly heard over the apex-beat, which is not here in the normal situation, and an accentuated second sound. We have also two signs of pulmonary emphy. sema. The overlapping of the lung prevents the recognition of the third sign.

Another interesting fact is the markedly irregular action of the pulse-arhythmia. I recognize two beats of the heart to one of the pulse. This has been called heart bigeminus. There is a strong impulse followed by a weak stroke, and after that an intermission. Occasionally, also, I perceive three rapid beats-the pulsus trigeminus. In short, the normal rhythm is utterly abolished. It is impossible to lay too much stress upon this marked irregularity. We often find a lack of rhythm in mitral disease, especially the pulsus bigeminus and, rather less frequently, the pulsus trigeminus. This condition, however, is not confined to affections of the mitral valve, but may accompany aortic lesions. It may even occur when no vulvular disease is present or, at least, discoverable. It is observed also in fatty or sclerotic degeneration of the heart, in consequence of changes in the coronary arteries. The cardiac ganglia may be the ultimate source of the irregularity.

or failing compensation.

I must call your attention to another manifestation in this case. When the man was admitted there was abdominal pulsation, together with pain, for which latter symptom he had been blistered. This might raise a thought of aneurism of the descending aorta, which is often evidenced by a pulsating tumor. But the mere presence of pain and pulsation is not enough to warrant the diagnosis of aneurism. We must have a dilating impulse communicated by a tumor which can be grasped by the hand (so that we may feel the dilating impulse). If, in addition, a bruit is heard, the signs point to the diagnosis of aneurism.

In this case the epigastric pulsation is proba bly due to the impulse of the heart against the diaphragm and transmitted to the left lobe of the liver. When the tricuspid valve is involved a re flux may help to cause the pulsation. When this man was admitted, by placing one hand below the liver and the other in the right axilla a thrill was perceived by both hands.

More might be said about this case, but, as the hour has expired, I shall have to postpone further remarks to a future occasion.

Upon examination the uterus was found to be enlarged and retrodisplaced, but not fixed. The cervix was hypertrophied and deeply torn. A careful examination of the abdomen revealed nothing abnormal. As the subjective symptoms were evidently due to the diseased condition of the uterus, the patient was etherized on the 20th of October, when the cervix was amputated and the interior of the womb curetted.

The

The patient made a rapid recovery from these operations, with the relief of all of her former symptoms. former symptoms. On the 3d of November, however, she began to complain of pain and slight soreness over the entire abdomen. The temperature and pulse were normal. pain increased in severity, but showed no tendency to become localized. An examination of the pelvis and abdomen revealed nothing except a slight soreness over the entire surface of the belly, but not accentuated at any one point.

A chemical or microscopical examination of the urine excluded disease of the kidneys or bladder. At no time was the temperature and pulse abnormal.

As will be seen from the foregoing history, pain was the prominent symptom. There was, however, nothing in its character or location pointing to any organ or region of the abdomen as the seat of the disease. Again, the action of the bowels and bladder was normal; there was no interference with the process of digestion, and the physical examination gave a negative result. Under these circumstances, therefore, a diagnosis was impossible. As the patient, however, continued to suffer and demanded that something be done for her relief, I made an exploratory abdominal incision before my class at the Medico Chirurgical Hospital, on November

Operation. The median incision was selected as being the best from which to make a general exploration. Upon opening the abdomen the appendix was found adherent to the brim of the pelvis. After freeing the adhesions the organ was brought into view, ligated, and cut off. The stump was curetted and wiped thoroughly with an acid solution of corrosive sublimate. The abdomen was then closed without irrigation or drainage.

Result. The patient made a prompt recovery.

Examination of the Appendix.-The following is a report from the Kyle-Da Costa Laboratory:

The Macroscopic Examination.-The appendix had been opened by a longitudinal incision which extended above and below the inflamed area and exposed the fin of a fish. The tissues surrounding the base of the fin are highly inflamed. The irritation caused by the foreign body in its passage down the appendix is marked by a well-defined line of inflammation. (Fig. 1.)

The Microscopic Examination.-The examination of sections made from the inflamed area shows that the pressure and irritation of the foreign body had caused capillary thrombosis, or a blocking up of the circulation, which was almost complete. The obstruction to the circulation is furtherincreased by a tran

Fig. 1. The appendix, showing the fin of a fish.

sudate and possibly by a proliferation of exuded corpuscles. The hæmorrhagic area lacking nutrition through pressure shows marked swelling and beginning granular change, and is almost at the point of breaking down. This part being necessarily infected and forming a

Fig. 2.-Microscopic section, showing hæmorrhagic area.

could have had but one termination unless relieved by surgery, namely, death.

The lesson, therefore, taught by this case is, to my mind, a simple one. It is this: Operate upon all cases of appendicitis as soon as the diagnosis is clear. There can be no medical treatment for a disease such as appendicitis unless we have at our command the means or methods for determining the exact pathologic condition present in a given case. The advocates of the medical or expectant plan of treatment can bring forward no rational argument against the urgent necessity for surgical interference until they first point out those signs or symptoms which will enable the physician at the bedside of his patients to say with absolute certainty this case is catarrhal and will recover, or that patient is about to have a perforation in the appendix, therefore an operation is at once indicated.

It is not within the power of any physician or surgeon to know what will be the termination of the disease during the course of an attack of appendicitis. And yet those who decry the work being done by abdominal surgeons in inflammations of the appendix content themselves by dividing appendicitis, clinically, into several forms. This is simply impossible unless the exact condition of the inflamed organ is known in all cases.

tained with alumnol. A most brilliant success is to be expected. Hoarseness is due to severe catharrhal swelling of the mucous membrane, or to modifications in the tension and vibrations of the vocal cords, or to copious secretions of mucus. The mucus becomes granular and easily expectorated.

In acute affections 2- to 1-per-cent. inhalations were prescribed, without being followed by any decided symptoms of irritation.

Also in chronic forms in which silver nitrate proved useless, alumnol in the form of powders with 2 to 10 parts of alumnol to 10 parts of starch were most effective. Alumnol likewise exercised a good influence upon the catarrhal symptoms of luetic and tubercular processes, but no specific action upon the malady itself. The styptic action of alumnol is also worthy of note: 1-per-cent. nasal douches have frequently brought hæmorrhage to an end in the course of a few seconds, even when simple tampons produced only a temporary effect. Alumnol must, therefore, be admitted to the front rank among astringents.

AURAL CHOLESTEATOMATA.

A

By E B. GLEASON, M.D., Surgeon in Charge of the Nose, Throat, and Ear Department of the Northern Dispensary, Philadelphia. URAL CHOLESTEATOMA is a name applied to various pathological conditions of the auditory canal, middle ear, and surrounding structures. In some instances the name is used to designate a true new growth within the temporal bone, similar to cholestea tomata of other bones of the skuil. The name is, however, more frequently applied to a collection of inflammatory products within the tympanum, mastoid antrum, or auditory canal, the mass consisting of desquamated epithelial scales, cholesterine crystals, fatty and caseous pus, in various proportions. Generally the greater proportion of the accumulation consists of laminated epithelial scales closely packed

one about the other.

Burnett* describes a similar condition under the name of "laminated epithelial plug in the auditory canal," stating that the disease was first described by Wreden, of St. Petersburg,† and named by him keratosis obturans, in contra-distinction to cerumenosis obturans, i.e., impacted cerumen.

*Treatise on the Ear, p. 178.

† Archives of Opth. and Otol., 1874.

In the latter condition the ceruminous character of the mass filling the auditory canal is recognized by the ease with which it may be removed by syringing. Impacted cerumen is readily soluble in warm water; probably more soluble in water than in oil, glycerin, and other fluids sometimes prescribed to be dropped into the ear "to soften the ear wax." Closely-packed epithelial laminæ within the auditory canal are not soluble in water, and the mass cannot be removed by simply syringing. Usually the accumulation has to be removed piecemeal, layer by layer, slowly and carefully with forceps, curette, and probe.

The

Burnett's account of his first case of laminated epithelial plug is interesting. outer end of the mass was covered by cerumen, which was readily removed. "Owing, however, to the fact that the auditory canal was rendered abnormally tortuous by two exostoses of the canal, one above, the other below, it required careful picking and syringing for half an hour for eight days before all the foreign body was removed."

I have in my cabinet a two-drachm vial completely filled with a mass of epithelial scales that I removed from the auditory canal of a patient at the Northern Dispensary three years ago, since which time it has been immersed in a mixture of glycerin and water without the slightest change having occurred in the appearance of the epithelial scales. They still look like thin pieces of buckskin sliced from the surface of a piece of chamoisleather with a sharp knife.

In this case the laminated epithelial plug was removed piecemeal, mostly by means of Gross's ear instrument, the hooked extremity of which was inserted "flatwise" between the wall of the auditory canal and the epithelial plug for a short distance, when the hook was turned toward the centre of the canal and made to penetrate the mass. Upon withdrawing the instrument, a certain amount of the impacted epithelial scales were loosened so that they could be readily grasped with the forceps and removed. Proceeding carefully in this manner the entire mass was removed in the course of an hour without the slightest discomfort to the patient, whose hearing was then so nearly normal that she did not again apply at the dispensary for nearly a year. On this latter occasion she complained of a sense