feces. On the 26th the patient camplained of pain in the legs. I ordered five grains of Dover's powder to be given as occasion required. On the 30th the neck and back were again blistered. On April 2 the boy was somewhat more sensible. Improvement was steady for several days, consciousness returned and he retained his passages. On the 12th the strabismus was better; I gave five grains of potassium iodid and four drops of tincture of opium three times a day with Dover's powder as required. On the 20th he was able to sit up in a chair. On the 30th the eyes were straight and he was better, but weak and unable to walk. He has not good control of his extremities. On April 30 I saw a child on Oregon street at 9 p. m., who had had several spasms and was comatose. He was unable to swallow and remained so until he died. At the same time I saw another child with Dr. M. The result was similar. May 1 I saw a child on Hamilton street in a spasm. The head retracted and the spasms continued until death. April 27 Mr. B.'s girl complained of pain in the neck and sore spine. Her head was slightly retracted. April 30 she was delirious and comatose. May 1 she had a diarrhea. I gave an oleaginous mixture, opium, and turpentine. On the 3rd the child died, apparently from want of power to resist the depression. In looking over the accounts of different epidemics which have occurred in this country, it seems to me that the lesson to be learned is that opium is the principal and most important remedy in the treatment of this disease. The next most important indication is to control the congestion at the base of the brain and around the spinal cord. Any means which will control this condition will be indicated. I believe the report justifies blistering. Cold has been applied but unless it is well applied, not making the patient and bed wet, it is impracticable. My experience has not been favorable in making applications when the patient is delirious. Dr. Flint's treatment seems to me indefinite and not in accordance with the principles of the pathology of the disease. Dr. Clark, I understand, advises larger doses of potassium iodid, frequently repeated. In the South where depletives were used the cases were almost universally lost, and I may say the same of Philadelphia. When I have seen veratrum viride given the results have been the same. Almost all the sedatives have been employed with like results, generally unfavorable, and in the end the profession has found that opium controlled the conditions more directly than anything else. Such facts are worth more than any theory, unsupported by clinical experience. CASES OF PROCTICA ILLUSTRATING THE VALUE OF THE ROUTINE PRACTICE OF PROCTOSCOPY BY THOS. CHAS. MARTIN, M. D., CLEVELAND Teacher of Proctology in the Cleveland College of Physicians and Surgeons, Proctologist to the Cleveland General Hospital, Etc. C ASE I. Six weeks ago an unmarried woman, about thirty years the statement that she was suffering from fistula in ano and a copious purulent discharge from the rectum. On bimanual eversion of the buttocks and ocular inspection of the ischiorectal space I discovered the external orifice of the fistula situated in the posterior anal quadrant. Probing determined that its depth did not exceed a half centimeter. By means of the short anoscope it was possible to determine that the fistula had no internal orifice. A half ounce of pus escaped from the rectum on the withdrawal of the obturator from the anoscope. I at once inverted my chair which placed the patient in a posture equivalent to the knee-chest posture, introduced my proctoscope, withdrew the obturator, and saw that the anterior concave areas of the inflated rectal chambers were submerged in pus, and that the mucous surfaces of the chamber-walls and rectal valves were eroded in many places. I bailed out about six ounces of pus, and then observed that the rectum was abruptly obstructed opposite the sacral promontory. At this point there was a multifolding of the mucous membrane on the anterior wall, from which emerged a stream of pus on each inspiration. Placing my hand upon the abdomen I pressed backward and was able to increase the flow of pus, and by several repetitions of this maneuver to see that at this situation there was an abscess discharging into the rectum. The patient was referred to me during an interval in my hospital service and was accordingly transferred by Dr. White to Dr. Humiston, who operated and evacuated about a quart of pus from a tubovarian abscess. Without proctoscopy this patient might have been considered a subject to be cut for fistula. Case II. In the spring of '97 a patient was referred to me by Dr. R. H. Pepper, of West Virginia, which illustrated the value of proctoscopy to the abdominal surgeon. The man was about thirty-two years of age, an emaciated subject, and was sent to me to be relieved of some internal hemorrhoids. Anoscopy revealed the hemorrhoids, but the proctoscopy, which wonderfully ballooned the rectum, exposed to view a tumor about the size of a hen's egg situated at the junction of the sigmoid flexure and rectum. The patient was put to bed for a few days when he was again examined by me in company witht Drs. Rosenwasser and Crile. To these gentlemen I reported my finding and asked them to make a bimanual examination of the patient, by means of which, I may add, we each failed to discover any confirmation of the proctoscopic finding though the patient was profoundly narcotized— and was a much emaciated subject. On proctoscopy we discovered the tumor which rested upon a sessile base about five centimeters broad; it projected from the posterior wall to the height of three centimeters. At my request Dr. Crile removed from it a piece of tissue which proved to be that of a malignant adenoma. The patient was counseled to return to his home and on the appearance of any signs of obstruction to report again and submit himself to an operation for its relief. I am told that subsequently he visited Dr. Mathews at Louisville and Dr. Murphy at Chicago, and, finally, Dr. Coley at New York, to whom he was sent for the toxin treatment. The growth had progressed to such a size and was so prolapsed by this time that bimanual examination was able to discover its presence. It chanced that Dr. Crile of Cleveland, was present at Dr. Coley's examination and was able to extemporize a proctoscopic examination, and at Dr. Coley's request he again removed a piece of tissue. The microscopic inspection confirmed the diagnosis which was made at a time when the patient himself did not suspect the existence of the tumor, and when expert abdominal surgeons were unable to detect its presence though assured of its existence. Had a proctoscopy been performed when the patient first sought treatment for piles, which was perhaps a year or two before he visited Dr. Pepper, the benign adenoma could probably have been removed by means of the snare. Case III. A woman aged thirty-two years, married and childless, was referred to my clinic in January of this year by Dr. C. B. Parker. She had been under the treatment of several physicians for stricture of the rectum which, the patient claimed, had been many times subjected to divulsion. On bimanual eversion of the buttocks ocular inspection of the field discovered an anovaginal fistula with complete division of the transversus perinei, and of the external sphincter ani at its anterior quadrant. Voluntary contraction of the external sphincter pulled the divided sphincter-ends backwards so that the sphincter occupied only the posterior half of the anal circumference. Contraction of the sphincter, instead of closing, opened up the anus. Digital inspection discovered a stricture at the levator ani zone whose lumen was one centimetre in diameter. It was sufficiently elastic to permit the painless introduction, under infiltration anesthesia, of a proctoscope two centimeters in diameter. Proctoscopy disclosed a general hypertrophic proctitis with much erosion of the mucous membrane and such a degree of hypertrophy of the lowermost rectal valve as is equivalent to the so-called annular stricture of the upper rectum. Application of atomized solutions of nitrate of silver cured the proctitis within a few weeks and divulsion and instrumental massage restored the rectal valve to its normal form and elasticity, bilateral division of the fibers of the levator ani and their fascias removed the strictures at that zone and the following procedure restored the continuity of the sphincter and reestablished fecal continence: Under infiltration anesthesia the sphincter-ends and contiguous tissues were freshened and sutured, the mucocutaneous surfaces united, subcutaneous oblique division of both transversus perinei was performed, the last bone of the coccyx was disarticulated from its fellow and thus the muscular structures set adrift about the sphincter, which being relieved of the possibility of muscular tugging united promptly, and restored the mechanism of defecation. Case IV. A young man, a student eighteen years of age, tall, slender and rather anemic, consulted me in the summer of 1896. He reported that for eight or ten years he had daily on defecation had hemorrhages from the rectum. Proctoscopy revealed a bleeding pedunculated tumor about the size of a Malaga grape, pendant from the roof of the second rectal chamber and situated about fifteen centimeters from the anal verge. He had no other anal or rectal lesion. Assisted by Dr. Hubert L. Spence, I quickly removed the polypus by means of the cold snare. The hemorrhages at once disappeared and the patient grew robust within a few months. These are a few of many cases which demonstrate the value of the routine practice of proctoscopy in all cases of proctica. 1077 Prospect Street REPORT OF AN OBSTETRIC CASE AND ONE OF AMAUROSIS IN CHRONIC INTERSTITIAL NEPHRITIS BY D. S. HANSON, M. D., CLEVELAND ULY 21, 1892, I attended Mrs. M., aged about 22 years, in her first confinement. The examination showed the pelvis to be slightly contracted in conjugate diameter. After a somewhat prolonged labor a living child, somewhat small, was delivered with forceps. The mother made a good recovery November 4, 1894, I saw her in her second confinement. The child was in the first position and the pains vigorous, but the head only engaged after several hours. The patient by this time was considerably exhausted, and as the fetal heart-action was growing more rapid I deemed it advisable to use forceps, but failed to deliver. I sent for Dr. R. We administered chloroform and only succeeded in delivery after more than two hours constant work. The child was very large and dead. The mother's perineum was ruptured and an immediate operation was done for its repair. The recovery was tedious, and she has since been extremely nervous, but otherwise in good health. Early in July this year she again consulted me for a very severe pruritus vulvae, stating that she expected to be confined again about August 7 In view of the last experience I advised her to have labor induced about two weeks before the time expected. July 24, assistd by Dr. L., we introduced a sound into the uterine cavity and filled the vagina with a tampon, and found the latter (vagina) in an unhealthy condition, several plaques of membrane being adherent to inflamed patches of mucous membrane. The sound remained two full days but not a single contraction resulted. She became extremely nervous, the heart was rapid, she ate nothing, and as the tampon began to have some odor and the temperature became elevated one degree, I concluded to remove both the tampon and sound. I then told her that I would do nothing more but wait until time for delivery, administer chloroform, turn the child and all would yet be well. August 20 the labor began and as soon as the cervix was thoroughly dilated under anesthesia we succeeded easily in doing a podalic version and delivered a healthy boy. The mother did nicely for seven days, then she had a mild septic fever which quickly subsided under uterine irrigation. I wish to say that the strictest care was taken in the way of antisepsis in the attempt to produce premature labor. The chief interest in the case is that the sound failed to do what was expected. The said failure was probably a fortunate thing for both mother and child. August 16, 1898, I was called to see William T., aged 53 years. He has had bronchial asthma for a number of years and for several years during asthmatic exacerbations would have slight albuminuria. About two years ago the presence of albumin in the urine became constant and after several weeks treatment showed no improvement. His general condition was so good that he took no treatment from that time until the present date. His present complaint is of headache every morning for the last two weeks which however disappeared after taking a cup of coffee. This morning it had increased in severity until he was in extreme agony. He was dazed and semiconscious. When asked to show his tongue he allowed his mouth to remain widely open, and otherwise showed lack of comprehension of what was said to him. During the afternoon he had five clonic convulsions which were relieved by full doses of chloral and a calomel purge. In the evening his mental condition was much improved, but he was blind, and could not see the lighted lamp. The next morning he could see the windows; in the evening he could count fingers. The field of vision was not contracted in either eye. The vision rapidly improved so that in two days he could see to read. No opthalmoscopic examination was made but in all probability retinal hemorrhages were present. At the present writing the urine is in sufficient amount but does not contain enough solids, (specific gravity 1.010). Under the use of potassium iodid and Ernst Mineral Water he is slowly improving. Excepting slight swelling of the ankles, no edema has been present at any time. 1419 Broadway A CASE OF THROMBOSIS OF THE INTERNAL JUGULAR VEIN FOLLOWING SYSTEMIC INFECTION. E BY H. L. SPENCE, M. D., CLEVELAND ARLY last March I attended a youth of sixteen during a five days' illness, of which intermittent fever, preceded by a severe chill, frontal headache, and general myalgia were about the only symptoms worthy of remark. On the sixth day his temperature, which at no time had exceeded 103°, became normal, and convalescence seemed assured. For the slight constipation present calomel, followed by effervescent salines, was given, which, with quinin in small doses, rest in bed, tepid bathing, and a bland, sterile diet comprised the treatment. Lastly, a tonic of quinin, iron, and strychnin, was ordered and the boy discharged, his mother being instructed |