was primary union. The sutures were removed. The patient left off the bandage. The iodoform gauze was changed daily, and balsam of peru instilled at the same time. The discharge from the ear became rapidly less, and in three weeks was scarcely perceptible. It never became purulent. The patient disappeared from observation. 16 the patient called to report. She had not been seen for eight months. During this time the balsam of peru was instilled daily into each ear. The discharge became purulent. Her hearing is much improved. She hears in each ear the watch MANN's five forks seemed better than air conduction. It was impossible to determine how much hearing. The operated ear resembles the right except he had with his diseased ear. The left ear was normal. Oct. 24, operation was performed under ether, Drs. OTTO and ANDERSON assisting. Half an hour later, the patient, while trying to vomit, and not having fully recovered from the effects of the ether, fell out of bed, striking the operated ear and bruising that side of his face. Since the operation there had been a watery discharge from beneath the collodion, as well as from the external canal. Five days later, the dressings were removed. All the sutures had pulled through. The wound looked healthy. Granulations had started. Iodoform gauze was loosely packed in the external auditory canal and in the wound over the mastoid. The dressings were changed about twice a week. The ear was not syringed. Two weeks after the operation the wound behind the ear had closed. Balsam of peru was instilled into the external auditory canal once a week. The discharge became offensive. The patient was seen the same day. The ear was wiped out with dry cotton, and the usual dressing of balsam of peru ar.d iodoform gauze was used. The ear was dressed three times a week, and the odor to the discharge ceased permanently. The discharge stopped entirely in less than three months after the operation. Oct. 20, 1895, 12 months after the operation, there was no discharge. The hearing was not restored. There was a collection of dry material in the canal which was not annoying or offensive. Case VIII.-Miss W., aged 10, has had a purulent discharge from both ears for more than eight years. At times the discharge was not noticeable. She has been treated during the last three years by the usual methods of treatment without much relief. The hearing has grown steadily worse. She has great difficulty in hearing loud conversation three feet away. Bone conduction is better than air conduction. The right ear has better bone conduction, as well as better air conduction, than has the left ear. March 26, 1894, operation on the left ear under ether was performed at the New York Eye Infirmary with the assistance of Drs. FRANCISCO and TREFONTAINE. Two days later iodoform gauze was inserted in the canal, and balsam of peru instilled. Four days later the dressing behind the auricle was removed. Along the line of the sutures there that the tympanum is enlarged posteriorly and above, and has more of the bone covered by a healthy cicatrix. The operation was not sufficiently thorough to remove all the diseased bone. Case IX. Mr. M., aged nine, has had a purulent discharge from his left ear for more than five years. He has been treated by a number of physicians. I saw him in August, 1895, and removed a polypus from the tympanum. The membrana and ossicles were absent. The hearing was doubtful. The right ear seemed normal. Sept. 30, under ether, the STACKE Operation was performed at the Northeastern Dispensary, Drs. OTTO and FINKLESTONE assisting. The light was poor. The mastoid was sclerosed and the antrum small. Seventeen days later the collodion dressing was removed. The wound had healed by primary union. The sutures were removed. The patient had partial paralysis of the facial, which was noticed first the day after the operation. Five weeks after the operation the canal was nearly filled with granulations, which gradually subsided after applications of chromic acid. The discharge from the ear has been very slight, never purulent, and finally ceased in two months. Balsam of peru was instilled into the meatus and canal several times daily. Case X.-Mrs. E., aged 27, was operated upon Dec. 4. 1895, Drs. OTTO and SHEPHERD assisting. The operation was done to relieve mastoid neuralgia and to cure the otorrhea. The membrane and ossicles were removed last spring. The antrum was opened before reaching the aditus. An unusual amount of the bone was removed, the cavity formed extending more than an inch behind the canal. Four days later the collodion dressing was removed and the wound found indrawn and united by primary intention. The canal was not packed. The blood-clot was allowed to form a dry crust in the canal; a portion of this crust was removed, and there has been a slight serous discharge since. The highest temperature was 99.9°, four days after the operation. A week after the operation the patient attended to her duties of teaching. Balsam of peru has been instilled into the canal three times daily. A small piece of cotton is worn in the meatus. Conclusions.-I. The STACKE operation is an improvement over the classical mastoid operation, and should always be done in acute and chronic mas toiditis when there has been suppuration of the tympanum. 2. To cure chronic otorrhea the Stacke operation is indicated in obstinate cases, and it is a better operation than any heretofore proposed. 3. If the operation is properly done, the discharge stops in a few months or less. If the otorrhea persists more than six months, a second operation may be necessary to remove the diseased tissue and bring about a cure. lation tissue. I overcame this obstruction and continued onward until I reached the sinus. Here there was so much cellulitis of the adjacent tissue that the probe could not advance farther. The symptoms clearly indicated that a foreign body had entered the frontal sinus, and that a pus focus existed. In order to relieve the external pressure which endangered the eye, a deep incision was made almost the entire length of the lid, and hot compresses were ordered to be applied 4. The dressing and after-treatment need further continuously. study. 5. Finally we should give STACKE the credit of suggesting an operation which is a distinct advance in the science of the surgery of the ear. New York: 64 East Fifty-eighth street. [For discussion see page 84.] ex By The left upper eyelid was red, tense, and greatly swollen. In fact, this extreme nonfluctuating swelling prevented him from posing the globe in the slightest degree. means of gentle digital manipulation a portion of the cornea became visible, and was seen to be normal, likewise the iris. There was considerable chemosis and some congestion of the palpebral conjunctiva, but practically an absence of secretion. A well-marked exophthalmus existed, and the eye was forced slightly downward and outward. On the upper edge of the narrow eyebrow, in its middle third, was observed a clean-cut opening about one-sixth of an inch in diameter. unable to explain the cause of this condition, but remembered that while boating on the Harlem River two days before, toward evening, he felt a stinging sensation on the brow. Upon touching the spot with a finger he noticed a drop of blood upon it. In answer to my query, he said he did not see any gunning party in the vicinity. Why I asked the question is self-evident. When he reached home. that night his eye began to hurt him, and the lid gradually swelled; flaxseed poultices were applied for two days, but not sufficiently assiduously, however, to destroy the eye. He was He had a chill, and his temperature, the time I first saw him, was 103 deg. F. per os. I ordered him to be placed in the wards, and continued the examination. A probe, which was inserted into the little opening, passed inwardly-i.e., nasally, and slightly backward-for three-eighths of an inch (9) mm.), and was there impeded by a dam of granu The next day pus made its appearance from the nasal portion of the incision, and also from the opening in the brow, and continued thus, accompanied by a fall of temperature, for a week. The swelling and chemosis were considerably reduced, but the pus still kept flowing. As the patient was now feeling stronger, I slit up the fistula with a bistoury, under anesthesia, to the frontal sinus. Here there was considerable granulation tissue, which I curetted. The traumatic opening into the frontal sinus being too small to permit an exploration to be made, I enlarged it with a mastoid gouge. The mucous membrane was greatly swollen, and the cavity contained pus in quantity. A careful examination, made by means of a probe, revealed the presence of a foreign body imbedded in the membranous lining, which, upon removal, proved to be a large-sized bird-shot.1 After having been thoroughly irrigated, the sinus was packed with, and drained by, bichloride gauze. The subsequent cure proved uneventful; the inflammatory symptoms subsided, the temperature became normal, and the wounds granulated; at the end of a fortnight, the patient left the hospital with the perfect use of both eyes. One point which I desire to emphasize in concluding is that the greatest care should be taken not to permit wounds, where pus has existed, to close too rapidly. They should be encouraged to granulate from below, but not to adhere above; unless they are well packed, this will usually occur, requiring then a reopening. It is hardly necessary for me to dilate upon the features of the case just described. The peculiar circumstance of a person being shot and remaining in ignorance thereof is a not uncommon experience in the heat of battle, but in the case of a civilian in time of peace it may naturally be regarded as an extremely rare event. New York: 46 West 35th street. Precocious Puberty.-M. H. CAMPBELL, of London (Sem. n.éd., 1895, No. 50, p. 510), related the case of a boy 14 years of age whom he had known for 10 years. At five months the child had a growth of hair on the pubis. At two years of age the genital organs were fully developed, and have not At the same time the child had changed since then. erections and sexual excitement. Two or three years later he began to have emissions of semen. The fluid ejaculated had the appearance of normal semen, but it was not examined for spermatozoa. THREE CASES OF FISTULA IN ANO* By J. M. MATHEWS, M.D. Professor of Surgery and Clinical Lecturer on Diseases of the Rectum in the Kentucky School of Medicine; Rectal Surgeon to the Kentucky School of Medicine Hospital and the Louisville City Hospital, etc., Louisville, Ky. S EVERAL years ago Dr. LANGE, of New York, proposed to heal fistula in ano after operation, by first intention; in other words, doing an operation by which we can get apposition, and have these wounds heal by first intention. In the last ten days I have had such a run of cases that illustrate such a common type of fistula in ano, and which disprove his theory, that I will report three of the most typical ones. Case I.—A gentleman from an interior town of Ohio was sent to me after having had performed upon him four operations for fistula in ano, evidently by good men. One of the operations was done with the idea of getting union by first intention. The others were done by the open method. Examining this man I found that the channels which had been cut through were healed, and, to take a view of the buttocks and anus, one would suppose that the man had nearly recovered from his fistula in ano; but he knew by the great pain, especially the reflex pain manifested in the back and legs, that the disease had not been entirely eradicated. He had not been able to walk two blocks in three years. Upon introducing my finger about 1 in. above the external sphincter muscle, a small opening could be felt. No probe could be introduced into it. This was sufficient evidence to call for another operation, to which he reluctantly consented, remarking that he had already undergone, for the relief of his condition, four operations, resulting in only temporary benefit. Under chloroform, introducing my finger again into the rectum, with a little pressure it passed through the opening that had partially healed, and to my surprise I could then dilate the opening sufficiently to admit my three fingers; they went right back of the gut separating the latter from the sacrum. I also found that I could introduce my three fingers clear around toward the perineum. These channels were as slick as glass, without any indication whatsoever of healing by granulation. There were no granulations at all. This condition, of course, accounted for the reflex pain, from the fact that feces would pass into this opening and cause pain by irritation. It is not necessary to say that the operation I did was to completely lay open the sites of all these channels, and then dissect out the lining membrane, and curette the very bottom until I had got away the so-called pyogenic membrane that used to be spoken of by older writers. In less than two and one-half weeks the incisions have almost completely healed, pain has ceased to be a factor in the case, and a perfect result is assured. Case II.-This case was that of a man from Dallas, Tex., who had undergone 13 operations for 1 Exhibited at a meeting of the Faculty of the New York Red Cross. * Reported to the Louisville Clinical Society. fistula in ano, the first two having been based upon getting union by first intention. When he reported to me, I found that both sphincter muscles had been entirely destroyed by these numerous operations. It was then a question with me of restoration of the sphincter muscles, but more especially relief of the great pain from which he suffered. He was very reluctant to consent to another surgical procedure, inasmuch as 13 operations had already been performed and he had not been permanently relieved. As far as the fistulous channels were concerned, I found none that had not healed except one, which was at that time rather insignificant, but the mucous membrane protruded for nearly the entire circumference out of the anus to the extent of 11⁄2 in. Considering that pain was a factor in the case, I removed 2 ins. of the gut, and did an operation looking to cicatricial formation that would assist him in controlling his actions. Case III. This case was that of a woman, from the City of Mexico, who had been operated upon four times, each operation having been done by the stitching method. The result in her case was that the external wounds apparently had healed as far as the skin was concerned, but the anus was diverted from its natural direction, being to one side, a cicatricial formation from the perineum covering one-third or one-half of the anus. By the insertion of a probe, I discovered the original channel, which had not healed. The I claim that, in operating upon complicated cases of fistula in ano, if you do a thorough operation, either by curetting, which I do not much believe in, or by the open method, you cannot get apposition sufficient to insure healing by first intention. surgeon who practices that kind of a method is simply wasting his time and will not get good results. I do not believe that one case out of fifty of the ordinary run of fistula in ano can be so operated upon that you can possibly get union by first intention. These remarks are called forth more especially from reading in journals; within the last week I have read reports of such cases in three or four of them. One operator goes so far as to say that fistula in ano he no longer fears, in that he gets union by first intention by the LANGE method. Certainly surgeons who have had much to do with operating for great cavities around the rectum (they are more than sinuses) recognize that these cases cannot be cured. until the lining membrane of these cavities is dissected out and followed in different directions until all are divided, and that it is impossible to get a proper apposition. Therefore, I take it that the older methods-those practiced by the old masters, if you please, fifty years ago-have never been improved upon. They state that fistula in ano must heal from the bottom by granulation. They knew the pathology or the etiology of this condition about as well as we now know it, and it cannot be said that, because of the aseptic or antiseptic methods which have been introduced, we can change the manner of operating upon fistula in ano. In conclusion, I believe that in the vast majority of cases of fistula in ano the procedure should be the open method, and our operation must be done looking to healing by second, and not by first, intention. REPORTS AND VIEWS A MEDICO-LEGAL QUESTION To the Editor of the A. M. S. BULLETIN: J. M., aged 55 years, a baker by trade, at 3 a.m. on the morning of July 19, while slightly under the influence of liquor, was attacked by two men, and struck a severe blow over the upper and inner border of the left supra-orbital ridge, inflicting a lacerated wound in the tissues, 3/4 in. in length, and exposing the pericranium The force of the blow was such that he was felled to the ground, and there remained until one hour later, when he was found by the police, bleeding profusely from the wound, and with his mental faculties so dazed and confused that it was not possible to get from him a succinct statement: he was not, however, nor did he subsequently become, unconscious, or lapse into a condition of stupor. It was at the time impossible to de termine whether the dazed condition of his mind was due to the blow, to the concussion which might have resulted from striking his head when he fell, or to the partial alcoholic intoxication under which he was laboring, or whether it was due to the combined influences of these several causes. The man was taken to the hospital, his wounds dressed, and he was put to bed. No untoward symptoms followed, and 24 hours later he had recovered entirely from the mental confusion which existed immediately subsequent to the receipt of the injury, and was able to appear in the police court and identify his assailants. The dressings from the wound were removed after the lapse of 72 hours, when the wound was found to have healed by first intention, and at that time, with the exception of a slight conjunctival ecchymosis of the left eye, the man was considered well. On the eighth day after the receipt of the injury he was discharged from the hospital, apparently as well as before the receipt of the injury. He remained under observation, seemingly well, for 10 days—i.e., until 18 days after the receipt of the injury when he was taken with symptoms of encephalitis, followed by those of compression, and, after lying in a stuporose condition for a week, he died. Post-mortem examination revealed the existence of two large abscesses in the right hemisphere of the brain, which had already found their way into the right lateral ventricle. There were also smaller abscesses elsewhere in the brain, and an examination of the lungs disclosed a like condition existing there; i.e., the presence of several circumscribed abscesses. A careful examination of the inner and outer tables of the skull and of the meninges, beneath the site of the wound, failed to reveal the slightest injury, or to give any evidence of extension, by continuity, of EL PASO, Texas, August 22, 1895. Treatment of Dry Rhinitis.-F. SIEBENMANN (Med. Week, 1895, III, p. 562). Anterior dry rhinitis is a variety of nasal disease which is not generally recognized in spite of its being very common, as is evident from the fact that it is met with in 10 per cent. of all cases of nasal diseases. This affection is said to be the cause of recurrent epistaxis and non-syphilitic perforations of the nasal septum. Anterior dry rhinitis is ushered in by a painful sensation of tension, and the formation of crusts in the nares and around the vibrissæ. The mucous membrane assumes a dark-red color, and is sometimes dry, at other times covered with viscid secretion. The crusts situated on the septum becoming detached spontaneously or by scratching, give rise to hemorrhage and ulcers, which may lead to perforation of the septum of the nose. The treatment of anterior dry rhinitis consists mainly in the application of ointments calculated to exert a favorable influence on the mucosa by stimulation of its secretory function and softening of the The vibrissæ should be cut short, and the patient must not under any circumstances pick off crusts. the crusts with his nails. Lastly, to improve the general condition, recourse is had to saline baths and the administration of iron, arsenic, cod liver oil, creosote, etc. The ulcers of the nasal septum, which are the source of the epistaxis, Dr. S. treats by applications of potassium permanganate in solid form. This method of treatment is said to give much better results than the galvano-cautery, which has the dis advantage of damaging the nasal septum. The manner of application is as follows: A probe, with a piece of cotton-wool twisted round the end, is slightly moistened and dipped in finely powdered potassium permanganate. This having been applied to the affected region, the surplus is wiped away. Dr. S. also states that the application of potassium permanganate in this way is an excellent means of treating dilatation of the veins of the nasal sep tum. Fecundity of some French Women. Three sisters, of Lille, were pregnant in the aggregate 70 times. Of 53 children, however, only 21 lived. The large infant mortality was attributed to the unsanitary condition of their dwellings. American Civil Procedure relating to the question of privileged communication. The objection was sustained by Medico-Surgical Bulletin the Court and the consultant's testimony excluded. Manuscripts received only on condition that they are contributed exclusively to this Journal. When a paper has been read before some society, the date and place of reading should be specified Authors will please write on one side of each sheet only. It is urged that the writer will so arrange the text, where the subject-matter permits, that the article can be subdivided under special headings Contributions in foreign languages will be received for publication in English Reprints in pamphlet form will be furnished to Contributors free of expense. Authors wil please state if such are desired; or whether a Cash Equivalent is preferred Return of manuscript in case of rejection can be assured only by request sent with the manuscript itself PRIVILEGED COMMUNICATIONS.-The Court of Appeals has recently handed down a decision interesting to the profession, bearing, as it does, directly upon the question of privileged communications. A woman sued a railroad company for injuries she had received in a railroad accident. During her illness the attending physician called in a consultant; both of them examined her to find out if her spine had been injured. When the suit was tried the plaintiff had the attending physician called as a witness, but did not call the consultant. The railroad company, in its defense, however, called upon the latter to give his opinion of the injuries. The plaintiff's counsel objected to the consultant's testifying, on the ground that it was a violation of a section of the Code of The plaintiff won the case. On appeal by the railroad company to the Court of Appeals, it was decided that inasmuch as one of the physicians had been called to testify by the plaintiff she had waived. her right in the matter of privileged communications. "The considerations and reasons upon which the statute was founded no longer exist when full disclosure is made by either with full consent of the patient, and every party to the transaction thus disclosed is relieved from the injunction of secrecy." The section of the code referred to reads: "A person duly authorized to practice physic or surgery shall not be allowed to disclose any information which he acquired in attending a patient in a professional capacity, and which was necessary to enable him to act in that capacity.' WE await with much interest a further report on the discovery said to have been made by Prof. ROUTGEN, of Würzburg, of a property that the light emitted from a Crooke's tube has in penetrating opaque substances such as wood, flesh, most other organic substances, and at least one metal, namely, aluminum. According to the cable dispatches in the Sun the discoverer has photographed metal weights which were inclosed in a wooden box, and a man's hand, showing only the bones, the flesh not being visible. It has also been used, so it is reported, to photograph broken limbs and bullets embedded in the flesh. Later news says that Prof. KLUPATHY, of the Pesth University, has obtained even greater success in photographing concealed objects. If this reported discovery proves to be true, it would be of immense value to at least two branches of medicine-surgery and obstetrics; the size of the fetal head as compared with the maternal pelvis. could be readily determined by such photographs. Its value in surgery, particularly bone surgery, can be easily understood. Until we have learned more of the detail, however, we are disposed to be skeptical regarding this new triumph of science. Frowns and Prophylaxis.—Some Brooklyn women recently discussed ways and means for stopping expectoration in public places. It was suggested to gain the offender's attention, and to make the victim so uncomfortable by frowns and remarks that he will have to desist to escape this novel persecution. |