PROCEEDINGS OF THE BOSTON SOCIETY FOR MEDICAL OBSERVATION.

O. W. DOE, M. D., SECRETARY.

NOVEMBER 19, 1877. Delirium Tremens. DR. MCCOLLOM read a paper upon this subject which will be published in full in a later number of the JOURNAL.

DR. INGALLS asked the reader if he had ever known any one to die in a first attack of delirium tremens.

DR. MCCOLLOM replied that he knew of only one case of a first attack proving fatal, and that was of a young girl who drank of alcohol to excess. Usually, the more attacks a patient has, the more broken down he becomes and the more liable he is to succumb to the disease.

As regards the use of opium in this affection, DR. FISHER said he had never adopted that treatment on account of his knowledge of its fatal results. At Deer Island, sixteen years ago, he was informed that patients were sometimes removed dead from the padded cells in use there at that time. During the year of his service there he treated his cases in airy rooms in the attic, by a more expectant method, with strict attention to feeding, and no fatal case occurred. As physician to the Directors of Public Institutions he now sees ten or twelve cases a month for purposes of diagnosis only. It is fortunate for these patients that so litt'e treatment is required and that recovery is the rule, since the natural period of the disease has often nearly elapsed before they arrive at a destination where systematic treatment is possible.

Dr. Fisher said that it is highly important to differentiate the varieties of mental disorder from drink in persons arrested, since while the law exonerates a person insane from drink for his acts, and sometimes when simply delirious, it holds him responsible when frenzied by the immediate effects of alcohol, though in this state he may commit acts of violence which he does not afterwards remember.

DR. BOLLES thought from the various methods of treatment which he saw at the City Hospital three years ago that recovery depended much more upon proper nursing and food than upon drugs. One surgeon treated the disease, when complicating surgical injuries, with chamomile tea, and with as good results as by any other method.

DR. WEBBER asked the reader what he thought to be the pathological condition of the brain in delirium tremens.

DR. MCCOLLOM replied that he considered the brain to be poisoned by the presence of alcohol, and in a state of congestion, probably venous.

DR. WEBBER said he thought the condition to be probably a complicated one; that we should take into consideration the want of proper food which the patients usually suffer from. He regarded the pathological condition as one of cerebral anæmia of pure arterial blood, attended with slow circulation, the vaso-motor nerves becoming paralyzed by alcoholic poisoning, thereby producing passive congestion and an insufficient supply of arterial blood; with this is probably also dema.

The attacks are so variable in different persons that statistics regarding treatment are of comparatively little value unless we know the condition of the patient in full. Digitalis in a patient with a good, full pulse from 70 to 80 would not be indicated; but where the pulse is small, rapid, feeble, compressible, and there is a great deal of delirium and excitement following long abstinence, digitalis acts well, in accordance with the speaker's ideas of the pathological condition, by increasing the force of the cardiac impulse, and by contracting the smaller blood-vessels the rapidity of the blood current is also increased. It sends poor blood, to be sure, at first, but the blood flows faster and becomes much better aerated. Tincture of digitalis in a half-ounce dose has sometimes produced sleep within half an hour. Even two drachms has occasionally had the same effect, and almost always after two or three doses. The dose should be graduated according to the condition of the patient; a too long-continued use, a too frequent repetition of the drug, would be dangerous, and should be avoided. Patients who have had five or six attacks have recovered sooner under the use of digitalis than by any other treatment. At the City Hospital only one death has taken place, and in this case the patient had had several attacks previously. In the last and fatal one, as in the others, he had had convulsions of an epileptic character. There was albuminuria. Two doses of digitalis were each followed by sleep, but he subsequently became much excited, vomited food and medicine, and digitalis again given had no effect. After death the kidneys were found much diseased.

DR. FISHER objected to the term "cerebral anæmia" as used by Dr. Webber in reference to a state of passive cerebral congestion, though he had seen it so applied in books. He said that the nerve cells may be in a state of starvation, or suspended nutrition, while the brain as a whole is full of blood. He had found great benefit from digitalis in a case of idiopathic delirium where passive congestion evidently existed.

DR. CURTIS remarked that Gubler thought the state of the brain in delirium tremens to be one of hyperæmia and not anæmia, since during sleep the pupils are observed to be contracted. Langlet, a pupil of Gubler, has recently written a treatise upon this subject, in which experiments are noted which seem to show the condition of the brain to be that of hyperæmia. Dr. Curtis advised the use of less remedies, inasmuch as renal disease is so often a complication, and many drugs, especially mercury, opium, and salicylic acid, are known to act unfavorably in such cases.

DR. JEFFRIES referred to two or three instances of threatened delirium tremens in which a good cathartic seemed to act as a prophylactic.

Case of Pleurisy.-DR. BOWDITCH referred to the case of pleurisy in a young girl, reported at the last meeting, and said that it had been progressing very favorably, even as well as the one of nine months' duration. The last part of the fluid drawn seemed to be of a sero-purulent character. Dr. Bowditch said he considered the case at that time to be even more serious than if it had been pus alone, as the former requires other aspirations, and generally affords a more unfavorable prognosis than clear serum or pus. He said he was gratified to find upon a microscopic examination that only very few pus cells could be seen, but cholesterine in a large amount, which was probably the cause of the sero-purulent-like color.

Case of Poisoning. - DR. BUNDY reported the following case of poisoning: A gentleman took by mistake a large dose of a liniment, the amount taken representing three grains of morphia, two thirds of a grain of atropia, and forty drops of tincture of aconite root. Mustard given as an emetic produced no effect. Two drachms of sulphate of zinc, administered half an hour after the poison was taken, produced emesis in three quarters of an hour. The stomach-pump was subsequently used, and the patient recovered. The liniment was put up in a common white bottle, and Dr. Bundy suggested that apothecaries should be requested to use for all poisonous preparations blue glass bottles with a rough exterior.

Hysteria in a Male. — DR. BOLLES reported the following case. A young man was suddenly attacked with almost complete (hysterical) coma, and was found in that condition in bed one morning, occasionally sobbing, but not responding to any questions, nor to pricking, pinching, or touching the conjunctiva. Pulse varied from 100 to 120. Temperature 100%. There was free perspiration. He passed urine of a light color in large quantities. He improved a little on the next day, but subsequently relapsed, and remained so for four days. The attack was brought on by some "amatory misunderstanding," and subsided immediately on reconciliation taking place, leaving a condition of exhaustion for several weeks.

Arsenical Poisoning. - DR. BOWDITCH reported a case of arsenical poisoning in a boy three years old, from sleeping in a room the walls of which were covered with arsenical paper. The symptoms were impaired digestion, nausea, diarrhoea, a roughened tongue, pallid countenance, and general depression of strength. The papers on examination showed the presence of arsenic. Dr. Bowditch thought it should be a penal offense for any one to sell arsenical paper, but on the contrary the law at present allows such to be sold, and he believed it to be sold by all paper dealers.

DR. INGALLS said that Dr. F. H. Brown offered a petition to the legislature last year to prohibit the sale of arsenical papers, and that he with others appeared before a committee in support thereof. They had secured the signatures of representatives of nearly all the district and many of the local societies in the State in furtherance of their petition. Many specimens of paper were shown and proofs presented of the amount of arsenic contained in a large proportion of those which are in common use. There were also proofs shown of the deleterious and dangerous effects of such papers when placed upon the walls of sleeping and other inhabited rooms.

Although the petitioners had attended two sessions of the committee and had given ample testimony regarding the necessity of preventive legislation, the committee had declined to recommend such action. The committee had admitted the desirability of protection to the community, but considered that such action as was suggested would bear too severely on the makers and venders of wall and other papers.

Cancer of the Spleen. DR. BOLLES showed a specimen of cancer of the spleen, taken from an elderly lady who had cancer of the breast removed three years ago and a second operation two years later. There was also cancer of the lungs and liver.

Anal Speculum and Modified Urethrotome. -DR. CURTIS showed an anal speculum made of block tin, in the form of a cross, and easily closing up like an umbrella. He also showed a modification of the urethrotome of Civiale, combining the exploring bulb and cutting blade, with a series of movable bulbs varying in size from eighteen to thirty-five of the French scale.

DECEMBER 3, 1877. Cases treated by Bleeding. -DR. HAYDEN read a paper upon this subject, reporting five cases.

DR. WEBBER said he had seen at the City Hospital two cases of oedema of the lungs complicating Bright's disease speedily relieved by the use of jaborandi; in one case, in which the patient was considered hopelessly sick and not expected to live but a short time, the lung became nearly clear after one drachm of the fluid extract of jaborandi had been given. This was repeated on the third and fourth days with still more decided benefit. The patient's life was prolonged several weeks, and he was relieved of great discomfort. Dr. Webber added that the subcutaneous injection of muriate of pilocarpine, one third of a grain, acted promptly, producing profuse diaphoresis, which commenced in five, ten, or fifteen minutes; in cases of extreme urgency this might be used with great advantage. In one of the two cases referred to above the patient swallowed the saliva, which caused vomiting and subsequent exhaustion, which was so great as to require stimulants; this was afterwards avoided by directing the patient to allow the saliva to run out of his mouth.

DR. C. E. STEDMAN said that he had bled in two out of five cases of puerperal convulsions seen last summer, in both of which were headache, a full, hard pulse, and albumen and casts in the urine. Recovery followed in each A patient suffering from pneumonia attended with orthopnoea and lividity, seemingly almost moribund, was bled to the extent of sixteen ounces, and expressed relief as soon as the blood began to flow. The next day he was out of danger.

DR. INGALLS said that in the early years of his father's professional career it was a custom for many persons of both sexes to "be bled" once and of some twice yearly. The seasons selected for the above-named purpose were early spring and early autumn. Men and not infrequently women would come into what was then called the surgery, and stripping up a sleeve sit down and offer the naked arm for "phlebotomy." This time was and this fashion prevailed about the beginning of this century. Practice for facility in the manipulation of the lancet was by frequent use of the instrument on the veins of a cabbage leaf. It was not a great while before his father began to reflect whether he was doing right to "let blood" for any one who might wish it unless in his own judgment there was reason for it. A hard, quick, and incompressible pulse was an indication for "letting blood;" but unless this was associated with some abnormal physical condition it did not, of itself, warrant the performance of the operation, for he observed that those who had been in the habit of losing blood at certain intervals were apt to have the character of pulse mentioned.

Pathological Specimen from the Urethra. - DR. CUTLER showed a specimen recently removed by Dr. Marion from the female urethra, consisting entirely of

fibrous and elastic tissue, there being no trace of mucous membrane and no blood-vessels to be seen. It was impossible, he said, to state its origin, but he thought it probably came either from one side of the bladder or from the abdominal wall. Dr. Cutler objected to the opinion expressed by some of the members present that it was introduced into the bladder by the patient herself, as the size of the body would contraindicate this, though the absence of any history of considerable constitutional disturbance was a strong point.

DR. MARION gave the following history of the case: The patient, a lady twenty-four years of age, a primipara, was delivered by forceps on September 9th after about fifty hours' labor. The catheter was passed on the 11th, and about three pints of urine withdrawn. From that time until October 16th, when he first saw her, there had been a constant dribbling of urine of a very offensive odor. On examination the mucous membrane of the vagina was red and swollen, and from the meatus was protruding a small portion of this mass, about the size of a grain of wheat. It was removed with considerable difficulty, it being rolled upon itself to fully an inch in thickness. No febrile symptoms preceded her confinement, and she had no puerperal disturbance, so far as could be ascertained from the notes of the physician in attendance or from the family. At the present time the incontinence remains to a considerable extent, she being unable to retain her urine more than an hour at a time, but it is no longer offensive, and she seems to be gaining the control of the bladder slowly.

SAYRE ON SPINAL DISEASE.1

In this volume Dr. Sayre has given a complete account of his treatment of caries of the spine, and of spinal curvature, by the plaster-of-Paris bandage. The minutest details of the application of the "jacket " are carefully laid down, and the process is fully illustrated by numerous photographs and engravings.

We are correct in speaking of the treatment as his, for the idea of adopting this plan and applying it in all cases of spinal disease and curvature originated with or was first brought before the profession by Dr. Sayre. On page 14 due credit is given to Dr. Bryan of Lexington, Kentucky, for having applied a plaster-of-Paris splint to a case of Pott's disease in 1874. But as an account of this application, although witnessed by several physicians, was not published or otherwise made known to our author, previous to May, 1876, he derived no hint from that source.

Experiments to prevent motion of the spine, when affected with caries, and at the same time to allow of locomotion, but without any efficient endeavor to prevent pressure on the diseased vertebræ, have been made at various times. Eulenburg in 1867 or 1868 employed starch or dextrine bandages. Schildbach of Leipsic used, instead of starch, gutta-percha molded to the form. Klopsch used a solution of gutta-percha. Cuirasses made of copper have been employed for the same purpose. To form this cuirass a plaster-of-Paris mold of the trunk was first taken. From this a mold of wax, and on the wax, cop1 Spinal Disease and Spinal Curvature. Their Treatment by Suspension, and by the Use of the Plaster-of-Paris Bandage. By LEWIS A. SAYRE, M. D., of New York. London.