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less. Almost immediately the pulse responded to the injection, which was later fortified by a hypodermic injection of strychnine. The patient recovered satisfactorily.

The last case to which I will refer was one of ruptured tubal pregnancy complicated by an ovarian and tubal abscess of the opposite side. There was sepsis from the infected tube and ovary, together with profound depression due to the loss of blood incident to the rupture of the impregnated tube. I made an abdominal section and removed both appendages with the exception of a small portion of one ovary which afterward served to maintain the menstrual function. The patient was in collapse at the end of the operation, but was rapidly resuscitated by submammary infusions of salt solution. About one gallon was injected during the following twelve hours. Strychnine was also given. Her convalescence was remarkably free from complications. There was no undue thirst, the bowels moved freely twice a day, thought they had been habitually constipated; the urine was voided freely and in large amounts, and all signs of sepsis disappeared. I credit much of the result to the injections of normal salt solution.

I wish now to briefly outline the therapeusis of salt solution. Passing from the consideration of hemorrhage, suppression of urine from whatever cause deserves first mention. Charles McBurney used salt solution successfully in a case of suppression of urine following the removal of a renal calculus. In uremia of mild form enteroclysis will suffice, while in the graver forms, hypodermcclysis is most effective in diluting the toxines of the blood, and in favoring their elimination through the skin, bowel and kidneys. Not infrequently patients can be aroused from uremic coma by this means. If the condition of the patient is such as to warrant venesection, a quantity of the toxic blood may be withdrawn and replaced by an equal or greater amount of normal salt solution injected directly into the incised vein.

Uremia may be taken as a type of all forms of toxemia, and hypodermoclysis performed on the same principal-that of diluting the toxines of the blood, thereby rendering them less iritating, and favoring their elimination by stimulating the excretory organs. Under the generic term toxemia, I would include all the infectious diseases; namely, typhoid fever, scarlatina, diphtheria, the wound infections, including tetanus, erysipelas,, and puerperal sepsis; all localized infections

where there is a secondary general infection as in osteomyelitis, tuberculosis, pynephrosis, appendicitis, empyema and pelvic abscess. In all these conditions it may, in well selected cases, be advisable to perform a preliminary venesection.

In many of the so called "wasting diseases" such as chronic tubercular infection, chronic osteomyelitis and the like, where general debility results from a low grade of septic infection, enteroclysis and possibly hypodermoclysis would seem to promise good results.

Another class of cases to be mentioned is that in which large quantities of serous fluid have been lost which can be directly replaced by normal salt solution. This class includes cholera, cholera infantum, and serous effusions into the pleural and abdominal cavities.

Sturges injected twelve ounces of normal salt solution into the external jugular vein of a child in collapse from infantile diarrhoea, and the patient recovered. The French and German schools are loud in their praise of hypodermoclysis in the treatment of cholera.

Lewaschew, after many successful trials, recommended normal salt solution to be injected into the pleural cavity after the withdrawal of a large quantity of fluid.

I do dot wish it to be inferred that I offer normal salt solution as a panacea. I merely present it as a sheet anchor in hemorrhage, and as a most helpful and promising remedy in the other conditions above alluded to.

I have not referred to intra-arterial injections because I cannot see wherein they possess an advantage over the less formidable methods.

Intra-Peritoneal: It has been advised to inject normal salt solution into the peritoneal cavity through the intact abdominal wall-such a procedure needs only to be mentioned to be condemned. In abdominal sections accompanied by shock it may be of advantage to irrigate the peritoneal cavity with warm normal salt solution and to leave a quart or two of the injected fluid in the cavity.

Conclusions: For the purpose of favoring a discussion of the subject in hand I will recapitulate the following points:

1. Enteroclysis is the method of choice where normal salt solution is indicated providing there is time to await its effect.

2. The body temperature, vascular tension, renal, skin and bowel secretions are influenced in direct ratio to the temperature of the injected fluid.

3 Injected solutions of high temperature, however, may lower the body heat by promoting the excretions.

4. A solution at 60 to 70 degrees F. given within the colon, will first stimulate and later depress theblood tension and the secretions of the skin and kidneys. It is therefore to be used with caution, particularly in renal insufficiency.

5. In the subcutaneous method I believe we have all that is required where immediate effect is desired save where abdominal section may indicate intra-peritoneal injections; where the withdrawal of a quantity of blood has made it possible to give intravenous injections with the least possible loss of time; and where the serous cavities have been relieved of a quantity of fluid which may be replaced by normal salt solution.

6. As a rule no time is gained by the employment of the intravenous method, which should only be used when preceded by venesection for the withdrawal of a quantity of blood.

7. In intravenous injections it is possible to cause death from too great dilution of the blood, an accident quite impossible in hypodermoclysis or enteroclysis.

8. Normal salt solution is indispensable in the treatment of alarming hemorrhage, and is of great value in the treatment of the various toxemias, and in renal insufficiency. 9. After the removal of a large quantity of fluid from the pleural cavity the salt solution may be injected into the cavity as a substitute for the effusion, and will thereby lessen shock and relieve septic infection.

10. In cholera and cholera infantum, normal salt solution is invaluable as a substitute for the lost serum.

11. Venesection with the withdrawal of a quantity of toxic blood is indicated in toxemias where the patient is plethoric, and should be followed by intravenous injection of an equal or greater amount of normal salt solution.

12. In hemorrhage, normal salt solution maintains the circulation by adding to the volume of the circulating fluid which would otherwise stagnate in the veins because there is not sufficient volume for the heart to propel.

13. In toxemias normal salt solution dilutes the toxines of the blood and favors their elimination by stimulating the excretory organs.

100 State Street.

TWENTY-TWO CONSECUTIVE ARTHROTOMIES OF KNEE.

BY JOHN O'CONOR, M. A., M. D., T. C. D.
SENIOR MEDICAL OFFICER, BRITISH HOSPITAL, BUENOS AIRES.

All the cases here reported have been. treated during the past two years, and no selective process was adopted.

The rheumatic patients were operated on because their joint function seemed doomed, and in one case this treatment was undertaken as a forlorn hope to save the patient's life.

No apology is necessary for the drainage of gonorrheal knee joints, as all expectant plans have proved utterly futile; neither does the removal of blood and clots need any qualifying remark, further than that it is a surgical obligation.

As to traumatic "water on the knee," in my opinion no method of treatment has a brighter future before it than arthrotomy and drainage.

All the joints were irrigated during operation with mercuric lotion and in five cases the irrigation was repeated daily.

Drainage was continued in each instance until the serous discharge had ceased, and nothing but normal synovial fluid could be seen trickling from wound.

Splints were used only in six cases, and

were early discarded. Active motion was enforced as soon as the gauze drain was dispensed with, and in not a single case was there any cause for post-operative anxiety.

In this paper the term "discharged, cured" signifies that the joint was restored to its normal function and contour.

I. Traumatic Hemarthrosis.-F. M., aged 16, admitted on February 27, 1896, suffering from a large swelling of left knee joint. Three days previously, while exercising a polo pony, he was thrown off, and falling on to some stones, received a severe injury to left knee. On day of admission, as the joint was considerably distended, my assistant, Dr. Lind Cruickshank, very properly aspirated, and two ounces of blood were withdrawn, but as canula became plugged with clots, the joint could not be properly emptied.

February 28 arthrotomy was performed; five ounces of blood and many adhering clots were removed. The drain was removed four days later.

Discharged cured on April 1. During the past eighteen months he has frequently re

ported that left knee is as strong as right.

II. Traumatic Serous Effusion.-T. S., aged 38, admitted on January 29, 1896. While working in a ship's hold on January 14 a bag of maize fell on his right knee. On admission there was well marked redness and swelling, joint very much distended, hea! well marked and pain on the slightest movement.

March 9 arthrotomy was performed, three ounces of serum evacuated and drain left out on eighth day. Thirty-sixth day discharged cured. Two weeks later he resumed his work as stevedore and has since remained perfectly well.

III. Traumatic Hemarthrosis.-R. P., aged 31, admitted May 19, 1896. Five days previous he was thrown out of a dog cart and received a severe injury to left knee. On admission, knee was greatly distended, very painful to touch, heat well marked and a large extravasation of blood had taken place in popliteal and calf regions.

May 20 arthrotomy was performed, five ounces of blood and a quantity of clots removed. Drain left out on fourth day. He was discharged on the fiftieth day. He could now bear his weight on limb, and move joint through a right angle. A month later he was able to ride about the camp without any inconvenience. I saw him on December 4, 1897, and found knee normal in appearance and movement quite restored.

IV. Old Traumatic Hemarthrosis with United Fracture.-P. S., aged 30, sailor, admitted on June 2, 1896. While working on deck on February 3, 1895, he was knocked down by a sea, and immediately afterwards found left knee very much swollen and painful. A month later he was taken to a hospital, where he said: "They treated me for congealed blood in the joint, and with a hot probe they made an opening and squeezed the blood out." The knee remained stiff and swollen until March 5, when crossing a plank from wharf to ship he fell into the water, his left knee striking the curbstone as he fell. His "mates at once recognized that knee cap was split in two."

On admission on June 2, 1896, the left knee joint was considerably thickened, apparently distended, active movement absent, patellar bursa considerably enlarged, any attempt at passive motion caused intense pain. On palpation a united vertical fracture of the patella was readily felt. June 4 arthrotomy was performed. No serum or blood found, but on introducing finger behind patella six strong bands were encountered, firmly con

necting the posterior surface of patella to femur. After futile attempts to rupture these with the finger, a strong curved scissors was introduced and the adhesion divided. Considerable hemorrhage followed, so much so that it was thought advisable to irrigate with turpentine lotion and pack joint with iodoform gauze. The patellar bursa was then opened and two ounces of dark blood were removed. Drain removed from joint the sixth day. Discharged on fortieth day. He walked out of hospital without a trace of a limp. Function completely restored. A month later he undertook stevedore's work.

V. Traumatic Hemarthrosis.-P. W. W., aged 29, admitted on July 8, 1896. While playing polo three days before he received a severe blow on right knee. July 9 arthrotomy was performed, three ounces of blood removed; drained until seventh day. Discharged cured on twenty-fourth day. Constantly reports that his "knee is as strong as ever."

VI. Chronic Rheumatic Arthritis with Effusion.-G. P., aged 36, admitted August 14, 1896, suffering from swelling, with slight pain and stiffness of right knee; this, he said, "was an old complaint;" has "been treated by many doctors, and as it is interfering with my work, I want to have done with it." By a process of exclusion, rheumatism was diagnosed, and potassium lodide blisters, Scott's dressing and a splint were used for one month. Massage was then used for fourteen days, but as the effusion did not show the slightest tendency to abate, arthrotomy was performed on October 1. Six ounces of turbid serum, and many old lymph masses, detached by finger from recesses of joint, were evacuated. Drain dispensed with on fifth day. Discharged cured on October 28. When he came for inspection two months later the joint was found normal.

VII. Chronic Synovitis.-A. C., aged 28, admitted November 10, 1896. Six months previous he had an injury to knee which caused swelling, pain and stiffness. In spite of rest and bandaging some thickening remained. As he found that he could not carry on his occupation as circus rider, owing to pain when he attempted acrobatic performances, he entered hospital on above date.

November 12 arthrotomy was performed. A piece of thickened synovial membrane was excised and about an ounce of sero-synovial fluid removed. Discharged cured on November 30. Some months later Mr. Treves kindly wrote to me that he had seen patient and thought that he was fit to resume his work.

VIII. Acute Serous Effusion.-M. H. B., aged 22, admitted August 25, with pain, swelling, heat and stiffness of right knee, due to an injury received by falling from a horse. Scott's dressing and splint were applied until October 7. As no improvement took place, arthrotomy was performed, and three ounces of flaky serum removed. Discharged cured on November 23. Seen frequently since operation and remains quite well.

IX. Gonorrheal Arthritis.-S. A., aged 34, admitted on March 20, suffering from gonorrhea and pain, stiffness and effusion in left knee. March 24 arthrotomy was performed, four ounces of green turbid serum with numerous large lymph flakes removed. Gauze drainage continued for three days. April 10 wound had healed. Joint normal in contour and function. Frequently seen during past six months. No relapse took place.

X. Chronic Rheumatic Arthritis with Effusion.-A. L., aged 48, drunkard, admitted on May 27, complaining of pain, swelling and stiffness of right knee, with transitory pains in other joints. Arthrotomy was performed on May 31 and two ounces of flaky serum removed. Drained for two days. Discharged on June 7, with good movement, and no trace of swelling. Two months afterwards he reported that he had normal movement in the joint.

XI. Gonorrheal Arthritis.-C. N., aged 30, admitted on March 19, suffering from "an old clap," and a recent swollen and stiff right knee joint. Arthrotomy was performed on June 13, and he was discharged cured on July 12. In this case the pharmacopeia, blisters, aspirations, Scott's dressing, splints and massage had each a trial, but after eightyfour days the expectant plan was dropped, and one ounce of flaky serum, with a piece of thickened synovial membrane, were removed by incision. No relapse within five months.

XII-XIII. Acute Rheumatic Arthritis.C. H. B., aged 41, admitted on June 21, suffering from acute rheumatism. Symptoms on admission were, temperature 102 degrees, tongue thickly coated, pulse 80, continuous sweating, anorexia, urine scanty, high-colored and a trace of albumen, slight pain in left elbow without swelling. Both knee joints were swollen and painful. Patella floating, with some peri-articular inflammation and slight edema.

Notwithstanding a liberal and prolonged use of the salicylates, alkalies, turpentine quinial, flannel blankets, and fluid diet, the case gradually assumed a fatal type. July

17 arthrotomy of right knee was performed, and four ounces of turbid serum, with many large masses of lymph, were removed. July 24 arthrotomy of left knee was performed, and six ounces of similar stuff evacuated. All constitutional symptoms disappeared after the second operation. Stiffness gradually became less and he was discharged, with fair movement, on September 17.

Two months later, when he presented himself for inspection, he could walk without a limp; joints found normal in appearance and general health excellent.

W.,

XIV. Traumatic Hemarthrosis.-J. aged 35, admitted on June 1, suffering from pain and swelling of left knee joint, caused by his having fallen down a ship's hold on previous day. June 2 arthrotomy was performed, and five ounces of blood and clots evacuated. Drained for four days. Discharged cured on July 7.

XV. Traumatic Hemarthrosis.-R. K., aged 20, admitted on June 10. On the previous night he fell from his bicycle and sustained an injury to right knee. On admission, joint was considerably distended and painful. June 11 arthrotomy was performed, and twelve ounces of blood and clots removed. Drained for three days. Discharge cured on June 29.

XVI. Acute Serous Effusion.-J. B., aged 30, admitted July 24, with tumor, dolor, calor, and rubor of right knee, caused by his having "twisted his leg" two days before "in a ship's hawser." July 26 arthrotomy was performed, and three and a half ounces of serum removed. Drained for two days. Discharged cured on August 6. Resumed his work as sailor two days later.

XVII. Gonorrheal Arthritis.-A. R., aged 27, entered hospital on July 21, suffering from gonorrhea and swelling, pain and stiffness of right knee. July 26 arthrotomy was performed, and five ounces of turbid, flaky serum removed. Discharged cured on August 14. No relapse within five months.

XVIII. Gonorrheal Arthritis.-W. W., aged 28, admitted on September 13, with gonorrhea and effusion, pain and stiffness in right knee. September 25 arthrotomy was performed, and four ounces of turbid, flaky serum evacuated. Drain removed three days later. Discharged with movement through a right angle on October 4. A month afterwards function was completely restored.

XIX.-XX. Double Gonorrheal Arthritis.S. C., aged 46, admitted on November 4, with gonorrhea and pain, effusion and stiffness in both knee joints. November 6 double arthrotomy was performed, and turbid serum

and lymph masses removed from both joints. Drains left out on November 8. Discharged cured on December 3.

XXI.-XXII. Double Rheumatic Arthritis.P. G., aged 59, admitted on November 12, with acute rheumatism. As medicinal treatment showed no tendency to reduce the swelling of knee joints, double arthrotomy was performed on November 18. Three and a

PATHOLOGICAL RELATION BETWEEN

THE NOSE AND EYES.

M. A. Castex states (Rev. Internal. de Rhinol.; Med. Bulletin) that, if the nasal fossae may be the cause of numerous ocular affections, the contrary is rarely observed. He describes the case of a patient attacked by atrophic rhinitis and at the same time by amaurosis due to atrophy of the papillae. All would be explained if rhinoscopy showed, for example, an affection of the sphenoidal sinus compressing the chiasm of the optic nerves or the base of the skull. No lesion of the kind, however, was discovered, and the connection between the two maladies is unknown.

Affections of the nasal fossae may be complicated by various ocular lesions. Acute rhinitis occasions dacryocystitis, conjunctivitis, and orbital abscess. Simple hay fever exhibits an oculo-nasal variety. Generally, however, acute rhinitis causes nothing more than pain in the eyes. Chronic hypertrophic rhinitis, so rich in various reflexes, is sometimes accompanied by dacryoconjunctivitis, phlyctenular conjunctivitis, spasmodic astigmatism, myopia, asthenopia, cataract, and even exophthalmic goitre.

Atrophic rhinitis produces a special dacryocystitis and sometimes a partial optic neuritis. It aggravates wounds of the cornea, which must be protected in every way against infection of nasal origin. Various diseases of the nose, and in particular mucous polyps, determine different ocular reflexes. The same is true of intra-nasal operations and even of galvano-cauterization.

Affections of the sinuses play a predominant part, which is explained by the fact that the orbit is surrounded in all its parts by those cavities. Empyema of the maxillary sinus pushes the eye upward, produces tumefaction of the lower lid, chemosis, iritis, and exophthalmos. It is more difficult to interpret orbito-facial neuralgia, paralysis of the third pair, and atrophies of the optic nerve. Diseases of the frontal sinus are well known to oculists, as is also sphenoid and ethmoid sinusitis (photophobia, blepharo spasm, periorbital neuralgia, optic neuritis, scotoma).

half ounces of flocculent serum were removed from right knee and four ounces from left. Irrigation, with drainage for four days. Constitutional symptoms promptly disappeared. Patient was allowed out of bed on November 28, and discharged cured on December 6.

I think these cases tend to prove that surgery deserves a trial in some common affections of the knee joint.

By

The mode of causation of these accidents is sometimes very simple,-as, for instance, in case of infection of the eye through the lachrymo-nasal canal. The vascular theory of Ziem is based upon the connections between the circulation of the eye and nose. A stasis in the nasal fossae gradually arrests the circulation in the orbit and eyeball. relieving the nose, the circulation of the eye is re-established. The nervous theory of Berger is founded upon irritation of the terminal branches of the trigeminus. these hypotheses have an individual value. In cases of ocular troubles, also, it is often necessary to examine the nose, and make use of cocaine in order to learn whether it abolishes the reflexes.

All

BACTERIOLOGY OF ACUTE ARTICULAR RHEUMATISM.

MM. Triboulet and Cayon have made an additional report to the Societe Medicale des Hopitaux of their bacteriological observations with reference to acute articular rheumatism. (Gaz. Hebdom.; Va. Med. SemiMthly.) In December, 1897, they described a diplococcus which they had found in six cases of the disease. So that the following report represents their researches from that time to the January meeting of the society: 1. They found the same diplococcus as that previously described in eleven consecutive subsequent cases of the disease.

2. It was found by direct microscopical examination of the blood of patients-sometimes abundantly.

3. Hence acute articular rheumatism is a septicemia.

4. This septicemia may be either simple or complex, as two micro-organisms (diplococcus and a minute bacillus)-sometimes three, as one case also exhibited the "bacillus of Achalme"-occur in the same patient. But the diplococci occur invariably in every case and always predominate.

5. As the valvular (cardiac) lesions are caused by the diplococcus, it must be held clinically responsible for the disease.

6. Intravenous injection of a pure culture of the diplococcus in a rabbit, indeed, caused large enough vegetations on the mitral valve in twenty days to produce death by acute mitral stenosis.

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