rassment from being obliged to do so by gas- herent to the sac of the hernia, and conlight.

nected with the cæcum by a narrow, elongated portion or pedicle. But it does not exhibit so well the part of the cæcum which was engaged in the stricture, as the ridge of

very plain at first, soon became obliterated.

CASE III.

Upon opening the sac it was found to be filled with an unusual mass of intestine, which, after careful examination, we made out to be the vermiform appendix, very constriction which surrounded it, and was much enlarged and strangely altered in appearance. This was closely adherent to the sac all round, and at every part, and had Albert Graham, colored, single, aged 22, to be separated before we could discover the native of Ohio; robust, healthy man; height, seat of strangulation. This was accom- 5 feet 9 inches; weight, 160 lbs. For several plished without difficulty, simply by being slow and careful, using mainly the handle ofnal hernia of the right side, for which he slow and careful, using mainly the handle of years he has suffered from an indirect inguithe scalpel, with only now and then a touch of the edge; there was no bleeding. When this had been done it was found that a very small portion of the cæcum had been forced

has worn a truss. On two occasions before the present, the hernia has come down, and was returned with difficulty. Sept. 25, 1879,

past the internal ring and was tightly stran-early in the morning, while about his orgulated. The stricture was divided; the intestine, which was strongly congested, but nothing more, and the liberated appendix.

from the surface of which there was no oozing, were returned, and the wound dressed

in the usual way. The operation lasted half an hour The patient recovered consciousness in due time, rallied well at first, but soon sank again into a very feeble condition, and died in twenty-four hours, of pure weakness. At the post mortem not the slightest evidence of peritonitis was found, no internal hemorrhage, in fact nothing whatever to ac count for death, which must have resulted from simple asthenia.

The part of intestine implicated in the hernia was removed, cleansed, stuffed with cotton, and a photograph taken, from which the accompanying wood ent has been made

Strangulated Hernia of Apendix Vermiformis.

This shows very plainly the appendix, with its lower enlarged portion, which was ad

7

dinary duties, the intestine came down in spite of the truss, and soon began to give him great pain. A physician was called at A. M., who put the patient under ether, and tried to reduce the hernia by taxis, but after more than an hour's manipulation was obliged to desist, without having accomplished the reduction. He was then brought to the St. Francis Hospital of Starling Medical College, being still somewhat under the influence of ether. On arriving at the hospital he seemed to be in the most agonizing and unendurable pain, which prevented his standing upright, and it was with difficulty he was undressed and got into bed. I saw him at 10.30 A. M., and after having him profoundly etherized attempted reduction, both in the ordinary and the completely inverted position; this effort was protracted for twenty minutes, and failed. I then had him taken before the class of Starling Medical College, and operated at 11 A. M. It was not till the operation that I discovered that the hernia was of the congenital kind. stricture which was at the neck of the sac was divided, and the intestine, which was deeply congested, almost purple, was returned. In closing the wound I first passed a strong, deep suture completely through the pillars of the ring on each side, and closed the rest of the wound with superficial sutures and the usual bandage. He was returned to his bed, and a grain dose of opium, or its metric equivalent, ordered every two hours, unless he was completely free from pain. Evening, patient comfortable, free from pain; pulse 80, temperature 99.

Sept. 26th.-Patient had a comfortable.

night, no fever, no tenderness except imme- line, these occurrences have been frequent diately about the wound. Appetite fair; enough to make me fully alive to this dandressing not disturbed; opium continued at ger, and desirous of emphasizing it for the longer intervals. benefit of others. The second case here reSept. 27th.-Complains of pain from the corded is a very interesting and instructive pressure of the bandage, which was removed; one. First, it shows how important it is in wound healthy and closing; slight oozing of all persistent abdominal derangements to exsanious fluid; no fever, no tenderness. amine the usual seats of hernia, despite, it There was nothing to note in the patient's may be, the denials or reluctance of our pacondition after this. His freedom from un- tients. No doubt a neglect of this precaupleasant symptoms was remarkable, temper- tion has often led to disastrous reature never over 101°, pulse not over 90 at sults. any time after the first day. He was kept usual in bed for about ten days, the wound healed kindly, with very little discharge. The su perficial sutures were removed in four days, the deep one in eight.

Oct. 11th he was discharged well, and recommended to wear a truss for a while.

REMARKS.

The narration of cases in medicine and suris almost always more or less interest gery ing and instructive; and in no class of cases is this more so than in strangulated hernia. For the variations encountered are so numerous, and often unexpected, that no amount of text-book, or systematic instruction is sufficient that the man of physic may be thoroughly furnished, and he often feels the need of experience of his own, or an acquaintance with the recorded experience of others to guide him in the darkness. This must be my excuse for recording the foregoing cases.

The first case illustrates the connection of

hydrocele with congenital hernia, and shows the necessity of care in examination, lest the more prominent and obvious phenomenon hide one less evident perhaps, but more important. It also shows, what cannot be too often insisted upon, the danger of delay, and of repeated unsuccessful attempts at reduction, which have done more than everything else together to increase the mortality of herniotomies. In my own experience, I have known one instance where the intestine was ruptured in the effort of reduction, as demonstrated by post mortem examination. Another where, probably, the same result took place, the patient having an abscess with fæcal contents, of which she died; no post mortem. And still another, where there was an abscess, from which, after a week of dan gerous and almost desperate symptoms, the patient slowly recovered. As my experience has not been particularly extensive in this

The case also illustrates the unand extraordinary things. sometimes found in herniæ; for an enlarged and altered processus vermiformis, adherent in the sac, was a thing not to be anticipated or known beforehand. Of more practical importance is the fact that the adherent intestine had to be separated before the strangu lation could be reached. Where the symptoms of strangulation are plain, and only in be undertaken, nothing but an insuperable such a case would an operation be likely to obstacle should prevent our finding and relieving the stricture. Both these cases show how dangerous strangulated hernia may be in old people, and how prompt our treatment needs to be under such circumstances. last case illustrates forcibly the advantages tal powers have been unduly taxed, or local of early interference, before the patient's vimischief done by delay and the resulting interference, which, the more protracted it is, the more likely to be rude and violent. Well

The

might Amussat declare that he would rather operate on a hernia that had never been brunt of a disaster that other agencies had touched than be called in only to bear the rendered inevitable, and which he was expected to avert. These practical points for which the cases are related might be drawn easiest learned, and short articles most likely out at greater length, but short lessons are

At a former discussion held in Port Huron, the non-contagionists were ably represented by Dr. McLane, of Sarnia.

gan for the last five orix years, in malig- Among the prominent advocates of this view nancy as well as in prevalence. The registra- is the ex-President of this Society, our friend tion report of each year contains an exhibit and associate, Dr. McColl. of the fifteen principal causes of death with the mortality from each, and up to the issue of 1873, the last published, diphtheria has never been in the exhibit. In our discussion From the lack of a sufficiently large aca year ago on this subject, I made the state- cumulation of facts by which to decide these ment that when the returns for 1878 should differences of opinion, we are obliged to be compiled, they would show for that year rely on negative evidence to bolster up our a mortality of not less than 500, making it theories. For instance, in my own case, I the third on the list, the place usually occu- have studied diphtheria some, and my obpied and disputed by typhoid fever and pneu- servations point toward a certain set of conmonia. I now estimate that the returns of 1879 will show a mortality of 900 from diphtheria, giving it the place next to consumption, as the second principal cause of death in the State of Michigan.*

It is the most formidable of acute diseases It is so sudden and unexpected in its attack, so rapid in its course, so revolting, so loathsome and mortal in its character, so capricious and uncertain in its results in cases supposed to be free from danger, that there are few diseases more dreaded by the physician, and the fact that he knows so little what to do demoralizes him still further.

clusions, but I am to remember that these are drawn from a comparatively small number of observed facts. They may then be founded merely on coincidences. More facts may compel me to change every one of them, but in the meantime I must believe and act according to the light that I have.

At present, then, I believe that diphtheria is a self-limited, self-protecting disease, always originating from personal infection.

It is not necessary now to mention the grounds for this classification, for it is something that we have been over several times, and is pretty familiar to us all, but if the position is attacked in the discussion of this paper, I will take note of the arguments and traverse them seriatim.

CAUSATION.

In the community the fear that a fatal out break of the disease causes, is not like that produced by an epidemic of small-pox, that always leads to well concerted and vigorous measures for isolation and stamping out; it is instead a benumbing, paralyzing fear that leads to no such efforts. This is owing to the fact that the sequence of the disease, being often hard to trace, there is not a general belief in its contagiousness, and the result is a feeling that there is a blind chance at work that it is useless to resist. Such a state of mind, like the fatalism of the Orientals, lends no hearty support to measures for would the diphtheria. Bad drainage is

effective isolation and disinfection.

This same doubt concerning the contagious nature of diphtheria exists in the profession, some holding that it always originates in bad sanitary surroundings, such as filth and defective drainage, while others believe that every case springs from a preceding case There are those that mix up the two theories and think that the disease may originate spontaneously and then propagate itself.

*Since making the above estimate, our efficient Secretary for 1877, of deaths from diphtheria, were 593, a basis that, with the rate of increase, will make the mortality for 1879,

of the State Board of Health informs me that the returns

from diphtheria, not less, and perhaps more, than 1,000.

The definition given above says all that is necessary about the causation of the disease. It excludes the idea that filth can produce it, and makes every case dependent on the reception into the system and the subsequent reproduction there of a diphtheria germ or spore, and on no other cause. Ten acres of filth concentrated down to its quintessence, and given in allopathic doses, would bring out the small-pox as quickly as it

equally innocent of causing it, but these and other insalutary agencies will undoubtedly add to its malignancy and death rate.

CLINICAL HISTORY.

None of its family has so short an incubatory stage as diphtheria, it in one case studied by me seeming to be but one day, and in a which is about the mean duration, although recent fatal one it was found to be three, in many cases it is lengthened out to five or six apparently. It is really only the first case in a family that is of much value in determining this point. After a house be

comes full of the poison it is not possible to throat symptoms remain the expression of tell when it is received into the system of the constitutional di ease and the exact the exposed. Cases may be two weeks measure of its gravity.

DIAGNOSIS.

apart, but it does not follow that the stage of incubation is of that length. There can In all our discussions of the subject 1 be no doubt that the insidious invasion of have always spoken of the ease by which the system goes on more rapidly in diph- diphtheria can be diagnosed by its smell, theria than in any other personally infectious which I have contended was pathognomonic disease. After the development of the dis- and distinctive from that of every other ease, the expiration of a week generally de- disease. In these statements I have been termines either convalescence or a fatal criticised by some of our best men, accordresult. Of the latter much the larger num- ing to whom diphtheria gives no distinctive ber of cases are from blood poisoning, but odor to the atmosphere of the room. fully one-fourth are from invasion of the differences of statement do not go in the larynx by the false membrane. Another least to prove that one of us would call a method of dying, later on in the disease, case of disease diphtheria that another would after convalescence seems almost established, not; they only go to prove what a second is by a sudden attack of syncope coming on thought teaches must be true, that like the after some slight exertion of the strength, rest of our special senses the faculty of smell like getting out of bed.

Some part of the mortality from blood poisoning is without question due to uræmia. In a series of twenty cases examined by Dr. McColl, with reference to the existence of albumen in the urine, he found it in every one to some extent, the mean being fully as high as that in scarlet fever. In one of his cases the fatal termination was undoubtedly due to uræmia.

The attention has not been paid to this point that its importance demands, the general impression having been that albuminuria in diphtheria was quite an unimportant and secondary symptom. We are all delinquents in this matter, and much credit is due to our associate for re-calling our attention by his observations to the subject.

These

varies in different individuals. The discrepancy of statement is then entirely a subjective phenomenon, and is no more strange than it is that the same edible substance should be relished by one person's gustatory nerve and be nauseous to that of another.

Our special senses and even general sensibility varies with individuals and races. The pain that would make a white man groan would scarcely make a Mongol scowl. There is no doubt that smell is just as relative as sight or taste. Since we do not see alike nor taste alike, why should we smell alike? We can add to the Latin axiom, "de gustibus non disputandum," and say de smellibus non disputandum.

The assertion that diphtheria can always be recognized by the smell, and that no other The much disputed question between lo- diagnostic is necessary, being unphilosophical calists and constitutionalists is not a it is accordingly retracted, except so far as point of mere idle hypothesis, to be it relates to myself, being retained there in passed over in silence; for, if the doctrine its fullest import. Having never been as yet of local origin in the throat, and subsequent deceived by my nose, you must allow me the general infection, be true, it has a side of privilege of reposing in it the most perfect great practical importance, that simplifies confidence, and you may maliciously add the problem at which we are working. It that you do not wonder at this confidence, must certainly be much easier to find the ap- size being considered any measure of funcpliances to destroy or neutralize the virus tion and utility. while still in the throat before the subse

quent general infection has been produced, than it is to find another set that will be effective to remedy that general infection after it has taken place. The difference would be like that between fighting a fire that has just broken out, and again after the house is wrapped in flames. To the most of us, the

!

Letting go the plan of the detection of the disease by its odor, the diagnosis between a light, mild case of it and a severe one of common non-specific pharyngitis, with exudation, is not so easy, short of putting the two exudates under high magnifying powers, and finding the micrococcus in one and not in the other. Which of us knows of observations

that prove that microfungous life does not influence the constitutional course of the disexist in the exudate of common pharyngitis? ease by local applications to the throat. Until a diagnostic is found, the only safe What we aim to do, is to kill the false memway will be to look with grave suspicion on brane if we can, and by so doing avoid the every case of sore throat that occurs in a lo- danger of its spreading into the larynx. If cality where diphtheria is epidemic and insist it were not for that danger, it might grow on the necessary degree of caution. In cases there undisturbed till it was ready to peel off of severity there will be plain sailing enough when convalescence began. It is a matter of in making the diagnosis, exclusion being uncertainty how much we can accomplish in limited to cases of scarlet fever, where the this way; but it is reasonable to believe that soreness of the throat is unaccompanied by if the medication is effective the membrane the rash, in instances where epidemics of may be kept from spreading as much as it both diseases exist together-a point of little otherwise would, and life, in some cases, be practical importance. Outside of this there saved. is nothing to exclude, unless it is the first! stages of quinsy from those of diphtheria, later on, the suppuration of the tonsil in quinsy determining which is which.

TREATMENT.

treatment has

After the larynx has been invaded, and death by suffocation is imminent, tracheotomy is the forlorn hope that remains. It may afford a temporary relief to suffering, but it is very seldom that it will save life.

Chorea Paralytica, Aphasia, Amnesia -
Recovery.

BY C. T. SOUTHWORTH, M. D., MONROE.

OVEMBER 5, 1879, I was called

NOVE

to

visit J. B., a farmer, who had always been robust and healthy; wt. 33 years; married, and of temperate habits.

Nothing new in the yet the force of certainty in diphtheria. Many new remedies have in turn raised hopes that were to be disappointed, and some are yet on trial. These new plans of treatment are essentially based on the germ theory of disease, and are really attempts to find by experimentation some substance that On the day previous, at 3 P. M., or thereahas the power of killing the virus of the dis- bouts, while at work brushing a field, he was ease in the blood before it has proliferated attacked with a chill, accompanied with such sufficiently to produce its fatal result. terrible pains in the long bones as to "alSpeaking strictly in terms of the germ the most take his life." Being attacked suddenory, we are endeavoring to find a germicide ly, he found it difficult to reach his house, that will rid the human system of its invad- which was at a distance of about forty rods. ing parasites before that invasion has reached Soon after entering he vomited, ejecting a the limit inconsonant with its preservation. portion of his dinner undigested, and a large The treatment with the benzoate of sodium quantity of mucus of an insipid taste. is one of these new plans that has attracted On the subsidence of the chill, twitching of much attention. It must be thoroughly the arms and legs commenced, still accom tried, and it is for time to say whether or no panied with pain, and gradually increasit will add one more to the list of our baffled ing in violence until 8 A. M., when I was expectations. Sulphur is another drug that summoned. I found him with countenance is on trial. To be effective, it must be pale, anxious and haggard; eyes suffused, crowded into the stomach as fast as that or- watery, and the right pupil fully dilated; gan will tolerate its reception till the system chorea of arms and hands; chronic spasmodic is saturated with it. Permanganate of pot- twitchings of the left leg; of the right leg assium is an article that deserves an oppor- and foot he had partial control; tongue tunity to try its power as a remedy for thickly covered with mucus; pulse, 98, soft, diphtheria. For one, I shall have hopes of very full, with a decided and clear interval

its efficacy till it has been tried and found between the systole and diastole; skin moist useless. There is nothing better for the lo- and clammy; bowels not opened since the cal treatment of the disease than the per- morning previous; urine copious, dark and manganate. Having reached the subject of alkaline; voice sharp, speech difficult and local treatment, it may be remarked that imperfect; entire forgetfulness as to time this is a point on which we are, as a society, pretty well agreed. We do not expect to

and manner of the attack, and up to this hour had been unable to take any nourish