nostril being almost completely occluded. I told him the only thing to do was to break it and insert a tube until healing took place, but so far he has refused interference. The other case was similar in character, and was treated by Dr. Rodman. The external appearance of the nose was apparently normal, but just as in the first case there was a deviated septum which more or less completely occluded one nostril. Where the parts are crushed, it is a very good thing to get the external appearance of the nose as perfect as possible, but nearly always along the line of fracture a deviation of the septum occurs, and later more or less complete occlusion of the nostril. Dr. James B. Bullitt: In this connection I desire to report a rather infrequent injury. A railroad man. at West Point, Ky., in trying to load some sheep into a car, found them rather unruly, and grasped one while his partner was driving the others; one of the sheep made a leap and landed on the malar bone of the man who was trying to hold one of the animals. The injury was followed by some pain and swelling. The man came to Louisville a few days afterward, when the swelling had subsided to some extent. He complained of pain just at the junction of the malar with the frontal bone, although at that time nothing wrong could be felt with the fingers. At the junction of the zygoma with the malar bone there was a distinct indentation, where the malar bone had been driven in. At the junction of the malar bone with the superior maxillary, over the infraorbital foramen, a very distinct bony point could be felt where the point of the malar bone had been driven up beyond the superior maxillary. The man had a typical paralysis or interference with the inferior orbital nerve, and anesthesia therefrom extending on the nose and over the whole of that side of the lip, and over the gum on that side of the upper jaw. The bone was absolutely fixed at the time he appeared; the deformity was not very marked. To a man in his station of life the deformity amounted to very little, and practically the only inconvenience he suffered was anesthesia along the distribution of the nerve. It was deemed best to let him alone and see if the nerve would not right itself after a time. I believe from what I can find in textbooks, where the subject is dismissed rather summarily in most of them, the only treatment suggested is, in case of an external wound, to try to pry up the bone, then attempt to hold it in its place; or in a case of the kind reported, where there is no external wound, to make a punctured wound and go in with. a corkscrew arrangement and catch the bone and pull it out. This man had one more feature worthy of mention, and that was a dropping of blood and mucus, as he expressed it, into his mouth. The only way in which I see this could be accounted for was that there must have been a hemorrhage into the antrum, and then by filling up of the antrum and by change of position of the head this had escaped through the normal opening into the nose, and then dropped from the nose into the throat. Dr. Dabney was kind enough to illuminate the antrum for me, and on this side there was a distinct opacity, as much as you would ordinarily find in empyema of the antrum. This does not mean that the antrum was necessarily filled with blood, as after an injury of this kind the infiltration might be sufficient to cause this amount of opacity. There was little to be seen in the way of subcutaneous hemorrhage. At the corner of the eye there was apparently none. Beneath the eye there was some at the end of three days. There was no external wound and no interference with sight. I would like to ask what is the proper name for this injury. Manifestly it was not a fracture in the sense that there was separation at the point of articulation. Dr. H. H. Grant: My observation of injuries in this region has been such as to lead me to conclude that Dr. Bullitt's treatment of the case was entirely proper. Wherever there is an injury in this situation, such as to cause much displacement of the bones, there are usually injuries to the soft parts or to even the brain itself that are of more importance, and there is very little to be done. If the deformity had been neath the zygoma, and, after pulling it outward into place, to hold it there by tying the suture around an external splint of glass or other inflexible material. But in depression of the malar bone, as in this case, such procedure would manifestly be impossible of application. BY DR. J. M. MATHEWS. sufficiently marked to make it worth while to endeavor to replace the fragments, it might have been accomplished by the method suggested by Matas, who passes a curved needle armed with a heavy piece of silver wire beneath the zygomatic arch, brings the needle out again, and then makes traction on the wire in such way as to draw the bone into place, where it had been displaced THE TREATMENT OF PRURITUS ANI. by a blow of this kind. This perhaps would be simpler and make less traumatism than the application of a hook or a corkscrew, and in many instances it appears to answer a very satisfactory purpose. In the great majority of cases, however, it is hardly worth while to do any more than was done by Dr. Bullitt. It is also generally understood that traumatism communicated in this way to the peripheral nerves usually produces paralysis and anesthesia, which is a temporary lesion, and in the course of eight or ten months, at the outside, the majority of such conditions recover. If they are not repaired in this time and the manifestations still persist, it is usually a permanent paresis, something of the character we see in Bell's paralysis. My experience has been, if these lesions do not disappear in eight to ten months, the effect becomes perma nent. Dr. Wm. Cheatham: Dr. Bullitt's theory as to the source of the hemorrhage is very plausible, yet it may have been due to some other cause. Dr. James B. Bullitt: Hemorrhage persisted for ten days, or at least for this length of time the man would occasionally spit up some blood, which he said dropped down into his throat. Dr. Wm. Cheatham: Most of the discharges from the antrum go forward instead of backward, and if there had been hemorrhage into the antrum, it would most likely have shown itself in the nose rather than in the throat. Hemorrhage might have been into some of the other sinuses. Dr. James B. Bullitt: In response to Dr. Grant, I take it the procedure ascribed to Matas would not be at all applicable to an injury of this nature. Where the zygoma has been fractured and driven in, it is feasible to pass a needle armed with a stout suture be There is a class of patients that annoy us all very much which fall under the domain of special surgery, the physician as well as the surgeon meets them, that is, pruritus ani. Every work on surgery possesses a special chapter devoted to this subject, and works on rectal surgery contain elaborate chapters on the subject. When you come to the treatment of this very annoying, distressing affection, you will find they all advise that it be treated medically; some lotion, some ointment, some simple procedure; and I must confess that in this class of patients no procedure of that kind ever did any material good, in my experience. Just before I left for the Denver meeting I had two very bad cases of this kind one was a physician hailing from the extreme northwest, who told me that he had tried all the remedies he could think of, or that had been prescribed by others for the affection, which did him no good, and he, like all other patients of this character do, said that he would much rather have some real surgical affection, undergo some severe surgical operation in that he might be cured. He was willing that I should do any thing that would promise relief, because he said life was a misery. This man I cured by application of the actual cautery. chloroformed, and I used the cautery extensively, beginning at the anus, or just inside the anus, and extended cauterization up for two or three inches around in every direction, bearing down on the cautery so much so as to destroy considerable tissue; but I found the after-effect, in the convalescent state, that he suffered a great deal of pain, as you will imagine he would, because it was nothing more nor less than a deep He was blister with necrosis of tissue and sloughing. But he has written me since his return home, saying that it was a radical cure. The other case was a man sent me from Hornellsville, N. Y. His was a very peculiar case. He came to see me one day, and some ladies waiting in the office told me that a wild man had called, and said he would return later, perhaps in the course of an hour or two. He soon came back, and I thought myself that he was insane. He was crying, and in detailing his case to me said he had been suffering from this pruritic affection, as he called it, for several years; that he had had all manner of treatment; that on a previous occasion some surgeons had given him chloroform and divulsed his sphincter muscle. And in this connection I will say he was suffering from partial incontinence of feces from the effect of divulsion of the sphincter muscle. He said if I was not positive I could do him any good, he would rather I should not attempt it. In the same breath he said if he did not get well, that he would commit suicide. He was thirty-five years of age, a business man, and said that he could not attend to his business because of the intense agony he suffered; that it interfered with his business; when he had the disposition to scratch himself, he was forced to do so, even in the presence of ladies; that he could not sleep; that his life was a torment; that he believed he was going insane. Several authors report cases of insanity resulting from pruritus ani. I had one case of this kind which was reported to this society several years ago. The patient was a Jew, who went insane and was confined in the asylum at Lakeland and died there, and I am satisfied the cause of his insanity was pruritus ani. I said to this man, I believe I can cure you. I sent him to the Norton Infirmary about noon one day, and late in the afternoon, or perhaps in the evening, I received a telephone message stating that the patient was acting very queerly, and asking me what was the matter with him, if he was crazy, etc. I answered that the patient was all right; that I would see him in the morning. He was chloroformed the morning of the second day after being put in the Infirmary, and I made a circular incision, including a radius of about three inches, going up on the perineum and back as far as the sacrum laterally. Then I made a careful dissection, I would say of the skin, but we can not very well dissect the skin, it was the tissue, to the depth of one-quarter of an inch, going down to the rectum; dissecting it loose and pulling it down to the extent of nearly an inch, it was cut off. I simply twisted the bleeding vessels, and did not unite any mucous membrane, as there was nothing to unite it to, of course. This made a very extensive wound. The man remained in the Infirmary about four weeks. From the moment I made the incision to the present time he has never itched a particle, and he was comfortable the next day after the operation. He cared nothing for pain, and as he remarked, I could do all the cutting I desired, the application of acids, hot irons, etc., and it would be a pleasure to him compared with the agony he suffered from pruritus. Therefore being free from itching, he told me that he was never so happy in his life. There never was after the operation the least disposition to itch or scratch. I kept him here until the entire wound had healed, until skin had grown freely over it, then he was allowed to go home. I heard from him since, and he says he has been perfectly and radically cured. Now, I believe some of the authors at least, perhaps the majority of them, take the position that pruritus is the result of irritation caused by a discharge of some kind from the rectum, therefore is but a symptom for instance of hemorrhoids, internal fistula, proctitis, etc. I do not believe it. I believe that the itching, you might call it, resulting from a discharge from the rectum is easily cured; it would get well of itself by curing the cause of the trouble. The vast majority of cases of pruritus I have met with have never been associated with any other rectal disease; there has not been a discharge such as is spoken of by most authors. Therefore I have always believed that there was an irritation, per se, of the peripheral nerves themselves, brought about I do not know how, and that by destroying them, as by the actual cautery, or by dividing them, as by incision, that we could cure this peristent and often longstanding pruritus. Therefore I recommend to my surgical friends that when they meet cases of this character, that they do not waste time by using local applications, but subject the patient to surgery. I do not mean the simple cases, but the persistent cases, such as the two I have reported. I prefer careful dissection to the application of the actual cautery. In this connection I desire to say that there is one class of patients who suffer from pruritus whom I do not believe should be subjected to this method of treatment, and that is the tuberculous patient. They often have pruritus, and if we remove that much tissue, the wound might prove an indolent one, it might refuse to heal, and consequently the patient would be put in a very distressing condition. Certainly the operation I have described. will be the means of curing this very intractable condition in many instances where various other measures have failed. I have never heard of the operation being done, and have never seen the report of such a case. I will also state that the last patient was also cured of incontinence of feces by the operation. DISCUSSION. Dr. F. W. Samuel: The cases reported by Dr. Mathews are especially interesting to me. I believe I have seen but one case of chronic persistent pruritus ani which absolutely failed to get relief from local treatment. It has been my belief heretofore that pruritus was a symptom, and always associated with some other rectal trouble. The operation described is an extensive one, and is a new procedure to me. I have recently been looking over Kelly's work on Gynecology, and he recommends incision and dissection of the skin over the labiæ and pubes for the cure of chronic, persistent pruritus vulva, which is also quite an extensive operation. I simply refer to this in connection with the report Dr. Mathews has made. J. G. SHERRILL, M. D., Secretary. Treatment of the Vomiting of Pregnancy. Bacon (American Journ. of the Med. Sci., June, 1898) publishes three cases of hypermesis gravidarum where he induced premature labor without curing the vomiting, and which all ended fatally. He quotes Cohnstein's statistics, embracing two hundred cases, of which 40 per cent only were cured by abortion. From his experience and from an examination of the literature of the subject, he draws the following conclusions: (1) The abnormal irritability of the nervous system, including, the vomiting center, is to be allayed by keeping the patient in a horizontal position, by attention to the skin, bowels, and kidneys, using rectal and, if necessary, hypodermic injections of normal saline solution. (2) The hysterical condition so often present should be controlled by strengthening the will and influencing the dominant ideas of the patient. (3) All sources of peripheral irritation should be discovered and treated. (4) In extreme cases subcutaneous saline injections serve the three-fold purpose of (a) diluting the blood and raising blood pressure; (b) eliminating toxins through the renal and intestinal emunctories; (c) furnishing two most important kinds of food. (chlorides and water). He reports a case in the ninth week of pregnancy and in a desperate condition, where the hypodermic injection of a quart of salt solution twice a day, combined with washing out the stomach every morning and rectal injections of salt solution four times a day, produced immediate improvement. The vomiting ceased. after the second injection, and food retained, though the patient. eventually died of tetanus (? from an infected hypodermic puncture). Laborie in France has also used this method with excellent results. (5) Induction of abortion is never indicated. At a stage when it is safe and efficient, it is not necessary, and in extreme cases it adds greatly to the danger and rarely stops the vomiting. THE LOUISVILLE JOURNAL ..OF.. but rather be content to watch the brilliant operations done in the operat SURGERY AND MEDICINE. ing room. We must not forget that Didactic versus Clinical Teaching. In looking over the curriculum of many medical schools, one would conclude that the day for didactic teaching had passed. But when attention is directed to the questions propounded by the different examining boards each year to students desiring to practice medicine, the natural query is, how are students to be prepared for such examinations unless the principles as well as the clinical phases of disease are taught the student? Certainly the laboratories and clinical demonstrations are not to be underestimated in the least, but it must be remembered by all those concerned that a full knowledge of all that pertains to either medicine or surgery can not be taught in this way. Any college that attempts to teach all that is essential to the practice of surgery by giving clinics in the amphitheatre is bound to receive the stamp of incompetency from the profession. The same can be said of any faculty that is content with its professors of medicine giving only clinical lectures. It is a well known fact to the medical teacher that students are too eager to watch the sensational part of a clinic to pay much attention to the principles that are taught, or attempted to be taught, during the lecture. Indeed, to read some catalogues, one would be forced to believe that it was no longer necessary to teach the principles of any thing, the student is a student in fact, and must be instructed in the very principles of both medicine and surgery, and that in a didactic way. There should be in every medical college a Chair of Principles of both medicine and surgery, as well as a chair devoted to clinics in these separate branches. The Ladies' Home Journal. There is no publication in America that deserves more praise than The Ladies' Home Journal. It is suited alike to the man of business, the professional man, and the home circle. Its articles are always from the most talented of authors, and are of great worth. Indeed, nothing trashy is ever admitted to its columns. Clean, pure, and instructive are its characteristics, and every family is the better off that has The Ladies' Home Journal as a visitor. The editions are a marvel of beauty, and the work should be encouraged by a subscription from every household. By so doing the family circle is made happier and every member profited. The nation should be proud in having within its borders such a splendid family journal. AT the meeting of the Section on Diseases of Children of the American Medical Association, held at Denver, Colorado, June 7-10, 1898, it was moved and carried unanimously that "a memorial committee" be appointed to commemorate the late Joseph O'Dwyer, with suitable powers, etc., to collect such moneys and to act with other bodies for the same purpose. The committee is composed of the following: Dr. Louis Fischer, New York City, Chairman; Dr. J. P. Crozer Griffith, Philadelphia, Pa., and Dr. F. E. Waxham, Denver, Colo. |