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December 29, with no improvement, the tumor having gradually increased in size.
Case III (Curetment, Trachelorrhaphy, and partial Resection of both Ovaries) left the hospital December 26, with an entire subsidence of all previous symptoms.
Case IV (Osteomyelitis) left the hospital December 23, with a small healthy granulating wound.
Case V (Removal of both Long Saphenous Veins for Relief of Recurring Ulcers of both Legs) was discharged from the hospital January 17, 1904, with wounds all healed and a marked general improvement. This has been our experience in a large majority of cases that we have operated upon in this manner.
Case VI (Tendoplasty) was discharged December 25, with a stight evidence of the return of flexure.
CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC MEDICAL
SCHOOL AND HOSPITAL.
STATED MEETING, NOVEMBER, 2, 1903. THE PRESIDENT, JAMES HAWLEY BURTENSHAW, M. D., IN THE Chair.
REPORTED BY JOSEPH A. ROBERTSON, M. D., SECRETARY.
READING OF PAPERS. Doctor FREDERICK H. DILLINGHAM read the paper of the evening, which was entitled “Alopecia Areata.” In part it is as follows:
Alopecia areata should only be used to designate a disease where the hair falls out in one or more patches which increase in size by spreading at the periphery and leave a bald area without any apparent inflammation of the skin. In a majority of cases the disease is confined to the scalp, and after the hair stops falling out the patch may remain stationary or new hairs, which are usually at first fine lanugo hairs, appear at the margin or in the patch. While the disease is progressing the hair at the margin is loose, with atrophied roots, and can be easily pulled out. The skin shows no signs of inflammation, is smooth, shiney, and slightly depressed. There has been a great difference of opinion as to the etiology, some claiming it to be a trophoneurosis and others parasitic. There is no question but that there are a number of cases of alopecia occurring as the result of shock or injury to a nerve, but they do not have the definite clinical history that characterizes alopecia areata and should not be called such, but designated as alopecia neurotria. Simply because an area is devoid of hair it should not be called alopecia areata.
The manner of spreading at the periphery, the inflammatory process in the corium, the fact that the loss of hair does not follow a nerve distribution and the number of epidemics reported seem to be conclusive evidence that the disease is parastic and slightly contagious under favorable conditions. Although a number of different organisms have been found, none of these have been proven to be the cause of the disease.
Salourand claims it is caused by the same bacillus that is found in seborrhea but it is also present in comedones of acne. He also claims that it only occurs after puberty, which does not explain the many cases in children. Crocker and Hutchinson believe it to be related to ringworm, but there is no proof.
The disease which will cause the most difficulty in diagnosis is rirgworm of the scalp, in which the patch is inflamed, the baldness is not complete, and there are characteristic, short, broken-off hairs, with short ends. In doubtful cases the microscope will decide. In favus the yellowish crusts, incomplete baldness, inflammatory symptoms and atrophy will enable one to make a diagnosis.
The prognosis is almost always good if the disease has not lasted long enough to destroy the hair follicles. If acne has been properly treated for two months and there are no lanugo hairs, the chances are that the hair follicles have been destroyed and there will be permanent alopecia.
If there is any defective condition of the general health, it should be corrected, but aside from this, internal treatment is useless. Besides a large number of drugs, Roentgen rays, Finsen light and radium have been used. Chrysarobin will give the best results in most of the cases, but it should not be used on the face or over too large a surface at one time. It is best employed with vaseline, fifteen grains to the ounce, and it is well not to use too strong a preparation at first. We aim to produce a mild dermatitis in order to obtain the benefit of the emigration of the white blood corpuscles and destruction of the organisms. The preparation should be thoroughly rubbed in with considerable friction every night for a week and then discontinued in order to ascertain if the disease is still progressing. After the alopecia has stopped spreading, stimulating applications with massage should be used to bring an increased blood supply to the part and aid in the nutrition of the new hair.
RUPTURE OF THE URETHRA. DOCTOR CHARLES H. CHETWOOD: This boy, nine years old, fell astride the edge of a barrel. The accident was immediately followed by swelling and ecchymosis of the perineum and scrotum, which extended down the inner side of the thighs. On examination the bladder could be felt slightly distended toward the brim of the pelvis. Gentle effort to introduce a soft rubber catheter was unsuccessful. The diagnosis was complete or incomplete rupture of the urethra. The patient was anesthetized, but it was impossible to gain entrance to the bladder through the urethra. Perineal section was then performed. The distal end of the tube was found without difficutly, but not until the perineal opening was distended with boric acid solution was it possible to distinguish and grasp the proximal end. The ends were sutured together and a small catheter introduced through the perineal wound. Three days later the catheter was removed and the patient urinated without trouble. Twenty-four hours later, under anesthesia, a catheter was passed through the meatus into the bladder and tied in position for three days. At the end of two weeks cure was complete. PROSTATIC HYPERTROPHY AFTER GALVANO-PROSTATOMY
(CHETWOOD). DOCTOR CHETWOOD: This man is sixty-three years old, and a pedler by occupation. His principal complaint had been that he was compelled to urinate at least every half hour, day and night, which was accompanied and followed by considerable pain. Urinary symptoms of that character, occurring in a man of such age, would naturally suggest prostatic hypertrophy, causing vesical insufficiency and cystitis. The examination of this patient bore out this hypothesis. While the prostate proved to be only moderately enlarged, the bladder contained seven ounces of residual urine, and the Thompson searcher, introduced into the bladder, recognized an obstruction at the urethral orifice in the nature of a bar. Operation was performed on February 27, 1903. Perineal section, followed by digital examination of the bladder showed a tight vesical orifice, an elevated and hypertrophied median fold and a deep bas fond. This bar was incised with the galvanocautery instrument in two places, each being three-quarters of a centimeter in length, forty-five seconds being allowed for each cut. A perineal tube was then introduced and left in place for five days, at which time it was removed and in a few days the patient began to urinate through the natural channel. He was pronounced cured in three weeks. Summing up this method of operating, it may be said that it is essentially one of drainage, the aim being to effect, as nearly as possible, the reestablishment of the normal condition of bladder drainage, with the minimum amount of risk, the greatest dispatch, and without removing more of the prostate gland than is necessary in order to accomplish this purpose.
TWO CASES OF SKIN DISEASE. DOCTOR VICTOR C. PEDERSEN: I desire to report two interesting cases of skin disease, one of scaling papulosquamous syphilide, some of the lesions of which resemble psoriasis; and the other a generalized nummular psoriasis, strongly suggesting syphilis at first sight. The histories of the patients are as follows:
Case 1.-A male, twenty-two years old. Eight months ago patient had a chancre, which left behind the typical indurated scar on the prepuce. Nearly three months afterwards a rash appeared on the skin and the man consulted a physician, who prescribed antisyphilitic remedies, which were taken in an irregular manner for a short time, resulting in a more or less complete disappearance of the rash. About three weeks prior to his appearance at the New York Hospital, about the middle of October, an outbreak occurred with greater virulence and wider dissemination. When first seen at the New York Hospital he presented a generalized papulosquamous scaling rash all over the body. Some of the lesions, especially near the elbows and shoulders, were so large and the
scales so profuse as to strongly suggest psoriasis. Differential diagnosis was made by the presence of typical mucous patches in the mouth and typical lesions of syphilis on the palms of both hands and soles of both feet. Tonics, mercurial inunctions and ascending doses of iodid of potash in aboui three weeks caused practically all of the small lesions to disappear and only the large ones remained. The character of these larger lesions is still somewhat suggestive of psoriasis, and the case is presented for its interest, and for differentiation by the members of the society between the two diseases.
Case II.-A male, twenty-four years old. About five weeks before he applied for admission to the New York Hospital, Out-Patient Department, a generalized scaling rash appeared all over his body. In this case the lesions were frankly those of psoriasis, but resembled those of syphilis somewhat in being comparatively small and in being scattered everywhere over the body excepting on the soles and palms. The diagnosis was made through the absence of sole and palm lesions and of lesions in the mouth, and likewise by the distinctly psoriatic condition of the backs of the hands. Three weeks of treatment nad caused the scaling to practically disappear, and the color of the underlying skin had assumed a much more healthy appearance. The treatment had been simple, consisting in simple diet and regular physical exercise and ascending doses of Fowler's solution of arsenic, with chrysarobin ointment, about ten per cent, applied to small areas of the body in turn, from night to night, and ten per cent boric acid ointment applied to other parts of the skin to keep the scales as soft as possible.
DISCUSSION. Doctor FREDERICK H. DILLINGHAM: With regard to Case I, I think most of the lesions are syphilitic. On the patient's back are a large number of lesions which are undoubtedly syphilitic, and those on the front portion of the body resemble these, but in syphilis there is atrophy or less of tissue. Sometimes the lesion is too small to be recognized with the naked eye, but if there is loss of tissue, it cannot be psoriasis. It leaves the skin perfectly normal, except often pigmentation disappears. The speaker made a diagnosis of syphilis and psoripheral eczema of the scalp.
Doctor EDWARD L. KEYES, Junior: The case reminds me of a patient, about twenty years of age, who came to me with psoriasis all over his body. The case was supposed to be psoriasis, as the lesions were characteristic, and although the question of syphilis was mentioned, there was no history and no evidence of a primary lesion. More psoriatic lesions appeared, characteristic ones of the palms of the hands and soles of the feet. This seenied to point to syphilis, and the patient was put on mercury and the lesions promptly disappeared.
Doctor PEDERSEN: I brought the patient before the society because, three weeks ago, when I first saw the man, he was put on syphilitic treatment and the improvement was marvelous. This morning, however, a colleague at the New York Hospital and myself failed to agree on the diagnosis, I considering it syphilitic and my colleague claiming that the patient presented a combined lesion.
SUBPHRENIC ABSCESS. Doctor John A. BODINE: This patient, a man, thirty-five years old, came to me with a history of pneumonia, occurring six weeks before. The disease kept him in bed for thirteen days, and he had been up and about for eight days, when pain and fever returned. He was referred to me with a diagnosis of encysted empyema. Sweating, emaciation and septic facies were present, and on the right lower side of the chest there was a well-marked bulging. Respiratory signs were absent in this locality. To verify the diagnosis, a hypodermic syringe was inserted in the upper part of the bulging mass, between the seventh and eighth ribs and pus was withdrawn. A section of one and one-half inches was made in the ninth intercostal space, care being taken not to go through the diaphragm. There was no pus, but the liver and diaphragm could be felt intervening. The needle was inserted again, between the seventh and eighth rib, and pus was withdrawn. A second incision was made at this point, and when the pleura was reached six or eight ounces of clear serous fluid was found. When the finger was inserted into the second opening a dome-shaped mass was found rising over the liver. The lower border of the lung was defined and a fluctuant subdiaphragmatic abscess diagnosticated. The diaphragm was incised with a knife and eight or ten ounces of pus withdrawn. A drainage tube was carried through the lower wound. The fever has entirely disappeared and the patient is on the road to recovery.
DISCUSSION. DOCTOR MORRIS MANGES: To make a positive diagnosis in these cases is impossible. Absence of pneumococci might have given the clue to the origin of the subphrenic abscess. There is no part of the body in which one is more liable to err than in the lower portion of the pleural cavity in the recognition of fluid. There is nothing which Auid cannot simulate. It was Leyden who pointed this out in 1887, and gave to it the name pyothorax subphrenicus. Since then a number of cases have been reported as secondary to pneumonia, but in such cases pneumococci are usually found in the pus from the subphrenic abscess. Another condition which makes differential diagnosis difficult is abscess of the liver as differentiating this same condition from secondary effusion into the pleural cavity. In almost every case one finds the localized point of tenderness over the liver, and this indicates where the aspirating needle should enter. In abscess of the liver the dullness and flatness is higher in the axillary line than it is anteriorly, and respiratory conditions are present which are absent in empyema.
UNITED COMPOUND FRACTURE OF THE TIBIA. Doctor LESTER L. Roos: I desire to present a patient who, four weeks ago, fell in the street. Examination revealed a compound fracture of the tibia, with two simple fractures of the fibuia. The patient is sixty-seven years old, and has suffereci from locomotor ataxia for eighteen years. For twelve years he was treated with silver nitrate. Four weeks after the accident there was no sign of healing in the frac