lege Clinic on the 23d of May, 1878, with excessive | flow of urine. He was a dyspeptic, troubled with flatulency and occasional vertigo, and a feeling of soreness in the limbs and across the abdomen and the back. There was no cause to which the inordinate flow of urine could be directly traced; he stated that the weak back of which he complained, and his other symptoms, began with chilly sensations about a year before; but the flow of urine has been coming on for two years. He was found to have tubercular deposits, not extensive, at the apices of both lungs. It was impossible to get him to measure accurately the amount of urine passed in twenty-four hours; he kept a record of the night urine, and it was frequently eight pints. It was of low specific gravity, and contained neither sugar nor albumen The man was placed on fluid extract of ergot, half a drachm three times daily, which was subsequently increased, and he was directed to take nourishing food. In two weeks' time he had greatly improved, the soreness was entirely gone, and the quantity of urine largely decreased; how much he did not ascertain for us by measurement, but he was not obliged to rise at night nearly so often. On account of the dyspeptic symptoms, a mixture of five minims of tincture of nux vomica, ten of dilute phosphoric acid in compound infusion of gentian, was now administered three times daily, and the ergot no longer steadily used. He continued to do better and better until July 15; the urinary flow being no longer a prominent feature of his case, when he discontinued his visits. The lung affection had not increased. CASE VI.-W. H. S., thirty years of age, applied at the Medical Clinic of the Jefferson Medical College, in October, 1879, on account of great weakness and excessive flow of urine. There was an old history of syphilis, a more recent one of severe malaria, contracted in the spring of 1878 in Texas, and which had broken out again in April of 1879. He was very pale and weak, had lost much flesh, and complained greatly of pains throughout the body, and especially through the limbs. But his chief disturbance was from the quantity of water he passed, some days not less than fourteen pints, six pints of which were voided at night. We made him measure the urine for three consecutive days; the record was eleven pints, ten pints, ten pints. This was on a varied diet; he had tried a restricted diet, such as a diabetic patient would employ, and no change was perceptible. The record of the three days alluded to was below his usual average. The urine was very pale, of specific gravity 1006, free from sugar or albumen. He was very thirsty, but thought he passed more fluid than he drank. The extreme flow had existed for a month. He was somewhat dyspeptic, with a tendency to constipation; the spleen was decidedly enlarged, the liver somewhat so, and he complained of tenderness over these organs, especially over the spleen. Just before he had malarial fever his horse fell on him, bruising his left side, since which time he has always had pain and some soreness there. Nothing else abnormal was discovered; the skin appeared to be acting fairly well. He was placed on a full diet and on ergotine, which, however, was soon exchanged for half a drachm of fluid extract of ergot three times daily. He did not improve; indeed, about a week after this treatment was begun, he passed, November 10, sixteen pints; 11th, eighteen pints; and in twelve hours of the 12th, twelve pints. An attempt was made to increase the dose of the fluid extract of ergot, but it did not suit his stomach, and we returned to the use of ergotine, in three-grain doses three times daily; while, for the constipation, an occasional pill at night was administered, consisting chiefly of small quantities of podophyllin and aloes. 13th, the urine was sixteen pints; 14th, twelve pints. This improvement slowly went on, and with it the man's general condition became better. 20th, lactate of iron was in addition prescribed. The urine on the 26th had been reduced to eight pints in the twenty-four hours, and at about this it remained until December 7, when the record was seven pints. The lactate of iron was now stopped, while the ergotine was continued, and gradually increased to six grains three times daily. A tonic mixture containing th of a grain and 15 m. of tincture of the chloride of iron was also given three times daily; but from this, on the 21st, the strychnia was omitted. December 16, the record was five pints in the twenty-four hours; 21st, the same. The specific gravity rose with the decreasing quantity; diminution of the spleen was noted, and continued improvement in general health; the soreness and the pains had nearly gone. 31st, he passed four and a half pints; January 5, 1880, he felt himself well enough to go to work, still voiding that amount of urine, or some days a little more. On the 15th, he reported that he was quite able to do his work, was gaining flesh, but that his appetite was failing, and that the bowels, notwithstanding occasional purgative pills, were costive. He thought the ergotine was disagreeing with him, and it and the iron mixture were stopped; the urine had not increased in quantity, nor returned to a low specific gravity. One-thirtieth of a grain of strychnia, with five minims of dilute muriatic acid in glycerine and water, was given three times daily, and the laxative pill already mentioned at bedtime. February 1, was gaining, the soreness of the limbs was nearly gone, the appetite was good; he passed four pints of urine daily, or rather less. A pill was required every night to ensure a movement the next morning. 14th, he reported continued improvement; for four days the amount of urine passed was not more than when he was in health, and he had discontinued measuring it; the strychnia was only given twice daily, the pill alternate nights. As the same favorable report continued March 1, with the addition of the statement that he felt as well as he ever had, the medicines were gradually abandoned. April I, he was in as good condition as when last seen; the strychnia had been entirely stopped for a week; the laxative pill was taken every third or fourth day. On June 14, after hard work, he had a slight relapse. The urine, which had remained normal in quantity, increased to eight pints in twenty-four hours; the tired feeling in the limbs returned. But the relapse was of short duration; it readily yielded to the former strychnia prescription, taken twice daily, and by the 20th he was again well. The strychnia was, however, continued for a month. August 1, 1880, he had not taken the remedy for two weeks; he remained well, and so he has until now. When we look at these cases, we find five recoveries out of the six, and in two the patients have been since under observation, and it is positively known that the recovery from the disorder is lasting; of the other three, it is most likely that such is the result. In the case in which the treatment did not succeed, ergot was only tried, though in decided doses, for about a week, and, as it produced no effect, and there was a pulmonary complication, it was exchanged for strychnia, under which the patient did better, although not rapidly. The evidence of improvement in all in which improvement follows, is not only seen in the decreased flow of urine and its increased specific gravity, but in the better nutrition, the lessened thirst, the altered state of the skin, and in the subsidence of a symp tom to which I shall call particular attention, and which the analysis of these and others of my cases has impressed on my mind,--the pains in the limbs and body, and the feeling of soreness without tenderness: It is not my object to discuss here matters of general pathological and clinical import, but rather to bring forward the results of a special plan of treatment, or I should do more than merely touch upon this point; I should also do more than merely speak, in passing, of the connection with pulmonary disease, which two of the cases exhibited. In one there was a catarrhal pneumonia, in another a tubercular affection; and I have lying before me the notes of two others, the first of which, beginning with catarrhal pneumonia, I had the opportunity of following subsequently, to the autopsy, with pneumonic phthisis. Here the lung affection followed the polyuria. In the case described in this paper (Case V.) it was the same; at times the reverse appears true. There seems to be more than coincidence in the occurrence; and the matter, both with reference to chronic catarrhal pneumonia and phthisis, is well worthy of careful analytical study. The treatment under discussion is not a difficult one to carry out. Here and there a stomach rebels, and the continuance in sufficient doses becomes impossible. Then, too, we may not be able to keep the ergot up long enough to effect the cure alone, though long enough to have practically broken up the disorder, for the urine does not again decidedly increase. Under such circumstances, as in Case VI., I have found strychnia an admirable remedy to follow the ergot treatment with, either as a permanent or temporary substitute; in other instances, wherever the ergot is continued, cod-liver oil becomes a good adjunct. The dose of ergot must be a decided one at least one drachm of the fluid extract three times daily; better still, if well borne, twice that quantity. Case VI. took in place of ergot three grains of ergotine, increased to six thrice daily. But, on the whole, I prefer the ergot itself in extract. I have never seen any disagreeable consequences from the doses mentioned; never dilated pupils, markedly slower pulse or breathing, or vertigo. Some headache, and perhaps an aggravation of the existing constipation, are, besides any gastric disorder, the only unpleasant signs of the impression of the medicine. It takes generally about one week for it to show a decided influence. As to the mode of its action, it is chiefly by the contraction of the capillaries; but where? in the kidneys or in parts of the nervous system, in ganglionic or cerebro-spinal nerve centres? Most likely in the centres. But our knowledge of the exact pathology of diabetes insipidus is too uncertain to speculate much on the manner in which a drug affects it. Then, too, there are classes of cases in which ergot is not likely to do much good; those, for instance, with a distinct cerebral lesion. But here, the character of the lesion will make much difference. Thus, in Case III., where it was probably meningeal to a great extent, the effect was very good. In degenerative diseases of the fourth ventricle, and brain tumors pressing there or else | where, ergot is not likely to be of benefit. But this is mere surmise; for we know nothing as yet from direct observation, as we do of cases of polyuria dependent on gummata cured by mercurial inunction' or by iodide of potassium. In instances of excessive flow of urine associated with renal disease, ergot only acts temporarily or not at all. We have at present under observation at the Pennsylvania Hospital, a man (August S., Men's Medical) who came in passing 225 ounces of highly albuminous urine. He has been voiding a large quantity for three years, with one decided intermission. At first he was dropsical, but this was early in the case, and before the excessive flow, which at one time reached 300 ounces. He is now passing 182 ounces after a two weeks' treatment with ergot, increased gradually to half a drachm of the fluid extract of ergot eight times daily; belladonna did no better. Ergot has been in the last few years tested by others than myself, and I shall analyze such of the recorded cases as I have met with. Dr. Tyson' publishes a failure. The drug was given in sufficient doses, one drachm of the fluid extract three times daily, increased to two drachms. It answered well for a short time, but not permanently, and its use was exchanged for gallic acid, which did better, although it is not known whether the improvement was sustained. On the other hand, ergot has been successfully employed by Sydney Ringer, Murrell, Rendu, Saunders, and McClellan. The The Sydney Ringer's case was a very marked one of the disease. It happened in a man thirty-eight years of age, of temperate habits, in whose family there had been many cases of consumption. quantity of urine varied from 9 to 22 pints. patient was much troubled with thirst, loss of appetite, dry skin, and constipation. The disease was uninfluenced by quinia, cod-liver oil or jaborandi. But on three occasions the quantity of urine was greatly reduced by ergot. Thirty minims of the liquid extract every third hour, was the dose last employed. The urine was in twenty-four days brought down to a pint and a half daily. The man has been seen after the lapse of four and a half years,‘ the urine is normal in quantity, and he is strong and well. In a case reported by Murrell," the patient, a lad, had first taken belladonna with advantage, but without a permanent result. He was subsequently placed on ergot in aggregate daily doses of two drachms, kept up fully for a month, the quantity of urine falling from 3174 cubic centimetres to from 1700 to 1983 c. c. daily. The patient ultimately died from hemorrhages away from the hospital, and after a prostrating sea voyage. The improvement in the urinary secretion, it was thought, was permanent. Rendu details a case of polyuria cured by the administration of powdered ergot, at first given in doses of 50 centigrammes for six days, and sub 1 Mosler. Virchow's Archiv, LVI. 2 Transactions of the College of Physicians of Philadelphia. Vol. II., 3d Series, 1876. 3 British Medical Journal, December 25, 1875. 6 4 Wm. Murrell, ib. May 8, 1880. Ibid., January, 1876. Bull. Soc. Clin. de Paris, 1879, vol. ii, p. 8, and La France Médicale. sequently of a gramme. The affection followed a fall into the sea. Valerian had been found to be useless, and atropia did not suit, and was soon discontinued. Saunders' has given us the history of a woman fifty-three years of age, who became so enfeebled by the excessive flow of urine, from sixteen to twenty pints in the twenty-four hours, and the constant thirst, that she was unable to attend to her household duties; the skin was dry and harsh, the bowels excessively constipated. She suffered greatly from pains in the back and side, and had been ailing for two years. Fluid extract of ergot, one drachm three times a day, reduced the urine so rapidly that it alarmed her. The remedy was kept up for two or three months; a few relapses being occasioned by its unauthorized discontinuance. A perfect recovery took place, and when last seen, she had been in excellent health for months. Fifty-seven cases are now on record, or rather that which I now relate makes this number complete, and from this array certain conclusions may be drawn as to the wisdom of resorting to the procedure, and the propriety of considering it one of the legitimate resources of the surgical art. Mr. A. E. Barker,' writing in April of this year, declares that the number of cases on record up to that time was 54; that of these 26 recovered and 28 died; that lumbar operations show rather better results than those through the abdomen; and that in 11 out of the 54 cases, over one-fourth of all reported, an incorrect diagnosis had been made. H. Braun, writing in August, cites 56 operations. Of these 28 were laparotomies, with a result of 18 deaths and 10 recoveries; and 28 were lumbar sections, with 9 deaths and 19 recoveries. The pathological conditions which have heretofore called for the operation, have been neoplastic growths, such as cysts, fibro-cysts, and sarcomas; cancerous disease; floating kidney; calculus; hydronephrosis; tuberculous kidney; and fistulous connection between the ureter and the uterus, or vagina. by Hüter upon one of four years, and by Thornton upon one of seven years. Of these only two cases recovered, Jessop's and Thornton's. Surgeon Ely McClellan,' U. S. A., treated a case successfully with ergot that had been uninfluenced by full doses of quinia. It was only of some weeks' standing when seen; but the patient passed from twenty to twenty-four pints of urine daily, of It has repeatedly been performed upon very young specific gravity of 1008, and the inclination to uri- children; for example, by Czerny upon a child nate was at night so urgent that he was almost eleven months old, by Kocher upon one two and a deprived of sleep. Inordinate thirst, impaired ap-half years old, by Jessop upon one of the same age, petite, and serious constipation were also very troublesome symptoms. Fluid extract of ergot, in half drachm doses, was administered every four hours.. At the end of the first week, the amount of urine had sensibly diminished; at the end of the second week, it was reduced to one-half, and the thirst had almost disappeared. The remedy was then given three times daily for two weeks longer, when all the symptoms disappeared. Seven months after treatment had been suspended, the man remained well, passing forty-seven ounces of urine daily, of specific gravity, 1020. On the whole, then, ergot makes good its claim to confidence in the treatment of diabetes insipidus. That it always succeeds, even when faithfully used, will not happen. But it is pleasant to be able to confront the statement of so recent and distinguished a writer as Senator, that "the prognosis of diabetes insipidus is, in respect to recovery, very doubtful," with the array of cases here brought together. EXTIRPATION OF THE LEFT KIDNEY ON BY T. GAILLARD THOMAS, M.D., Ir may now be safely assumed that the operation of nephrectomy, or extirpation of the kidney, is one of the recognized and legitimate procedures of surgery. That this operation is one of necessity, and that without a resort to it, lives which by it could be saved, would necessarily be lost, no one can doubt who examines, even in the most cursory manner, the literature pertaining to the subject. 1 St. Louis Courier of Medicine, October, 1880 I now proceed to give the history of the case which has called forth this paper. Mary P., a native of Germany, 21 years of age, a pale and rather delicate person, was admitted to my service in the Woman's Hospital, October 13, 1881. Upon examining her I found in the abdomen a soft and obscurely fluctuating tumor, about as large as the uterus at the eighth month of utero-gestation. This was centrally placed, fell well down into the pelvic cavity, was perfectly movable, and was not tender upon pressure. The patient gave evidence of no special or peculiar symptoms, except that of very severe and constant pain in the abdomen. Her suffering was so great that she declared that she could no longer tolerate the tumor, and must have it removed. I saw no reason to suppose the tumor to be other than ovarian, and arranged for ovariotomy on the 15th of October, the patient being at once put upon preparatory treatment. The operation was performed on October 15. As soon as the abdominal walls and peritoneum were cut through, I passed in my finger, discovered between the tumor and the symphysis pubis a large coil of intestine, and at once felt convinced that the growth was not of ovarian origin, though as yet no suspicion of its real nature entered my mind. There was so much solid material about it that I had to enlarge my incision before I could puncture with the trocar. When I did so, six pounds of an amber-colored fluid poured away, the appearance of which led me to ask an assistant who was collecting some of it in a vial for examination, whether it was 1 Lancet, April, 1881. * Deutsche Med. Wochenschrift, 31, p. 421, August, 1851. not urine. Now for the first time the thought of hydronephrosis presented itself to my mind. It was found, however, not to be urine. I found the tumor everywhere adherent, and recognized the fact that to remove it, it would be necessary for me to tear it out of its bed. As I proceeded, a large number of ligatures became necessary, and a good deal of blood was lost. Professor A. C. Post now suggested that a mass at the upper extremity of the tumor looked like the kidney, and, upon examination of this, it was found to be so. I now included all the emulgent vessels and the ureter in one ligature, severed the mass, and dropped the ligated portion back into the abdominal cavity. The patient was then put to bed, and the ordinary treatment after ovariotomy was ordered. For the first three or four days she suffered such severe pain at the epigastrium that morphia had to be used hypodermically very freely for its control, and the temperature showed a tendency to rise. As the importance of the case, however, calls for a day to day history, I avail myself of the notes of the house surgeon of the hospital, Dr. Andrew F. Currier, to whose assiduous and intelligent care I feel greatly indebted. On the 16th, at noon, the temperature was 102°, but by the douche, applied after Kibbee's method, which I invariably employ after ovariotomy when the temperature becomes exaggerated, it was reduced to 100%. The pulse during this day ranged at about 100. On the 17th, the morning temperature was 1021⁄2°; the evening, 100%, being kept down by the douche. Pulse, same as yesterday. 18th, morning temperature, 100°; evening temperature, 10134°. Pulse ranged at about 100. 19th, A.M., 100°; P.M., 101°. 20th, A.M., 1000; P.M., 994°. 21st, A.M., 9934°; P.M., 101°. 22d, A.M., 994; P.M., IOI. After this the patient progressed very favorably, and, with the exception of a mural abscess, presented no troublesome symptom, and at the present date, one month from the time of operation, she is up and fully convalescent.. The gross appearances of the tumor were these. The whole mass, fluid and solid, weighed 101⁄2 pounds. The tumor growing from the capsule of the kidney on the convex surface of the organ, bent it over backwards so as to make this surface concave, and to render the portion on which was the hilus convex. The structure of the kidney appeared to the naked eye entirely healthy. The tumor was submitted for examination to Dr. Welch, the pathologist of the hospital, and the following is his report of it: "That portion of the kidney to which the tumor was attached was not sent to me, nor did I receive any of the fluid from the main cyst. The remainder of the kidney, and the greater part of the tumor, however, came into my hands. "The growth is partly solid and partly cystic. The solid part is said to have weighed, when removed, 41⁄2 pounds, and the fluid 6 pounds. There is a main cyst, the size of which about equals that of a child's head. A part of the wall of this cyst has been removed, and was said to be closely adherent to the kidney. The rest of the tumor consists in greatest part of dense, white, glistening tissue, in which appear many cysts, varying in size from a pea to a hen's egg. "In the dense stroma there are also many patches presenting a yellowish, translucent, gelatinous appearance, and composed of a wide-meshed tissue, infiltrated with serous-looking fluid. These oedematous-looking patches resemble the so-called geodes of the fibro-cystic tumor of the uterus, and from these geodes can be clearly traced the development of the cysts. "The fluid contained in these cysts is of a yellowish or reddish-yellow color, and spontaneously coagulable. Whitish coagula were found floating in the fluid of all the cysts opened. The microscopical examination of the fluid showed the coagula to consist of finely fibrillated fibrin, and, in addition, revealed the presence of leucocytes and red bloodcorpuscles in moderate numbers. (Unfortunately, I am not able to report the characters of the fluid in the main cyst.) "The dense stroma, of which the solid part of the tumor is mainly composed, consists of fibrillated connective tissue containing branched cells. fibrillated basement substance in most places preponderates over the cells. "In the gelatinous patches (geodes) the fibrils of connective tissue form a loosely interlacing meshwork, containing serum and numerous leucocytes, with some branching cells. The appearance is that of mucoid tissue, but no reaction for mucin could be obtained with acetic acid. In the development of the cysts, the tissue in these patches acquires a looser and looser texture, the meshes become wider and wider, the interstitial fluid increases in amount, until a cavity with smooth or slightly vigorous walls is formed. "The walls of the cyst are not lined by epithelium, but simply by the surrounding connective tissue. "The exterior of the tumor presents a somewhat lobulated appearance, and is apparently covered over a part of its extent by peritoneum. "The tumor is to be regarded as a fibroma in which cysts have developed, either by mucoid metamorphosis of the fibrous tissue, or by distention of the interstices of the connective tissue by lymph." USE OF PLASTER-OF-PARIS IN THE TREATMENT OF CLUB-FOOT. BY P. S. CONNER, M.D., PROF. OF ANATOMY AND CLINICAL SURGERY, MEDICAL COLLEGE OF OHIO. THAT the deformity of club-foot may be corrected, it is necessary (1) that the distorted parts be put in normal position, and (2), that they be kept there; and, just in proportion as any plan of treatment accomplishes these indications, it is a proper one to be employed. Every one knows that in the great majority of congenital cases it is possible, during a variable but quite considerable time after birth, by manipulation, to bring the foot into its natural place; and, could it be sufficiently long and steadily held there by the hand of parent or nurse, rectification of the deformity would almost to a certainty result. What can be substituted for such gentle yet efficient hand-pressure? Ordinary bandages and adhesive plaster strips have been employed, and, in many cases, with advantage; but not infrequently they have been found insufficient, and the adhesive strips often very much irritate the delicate skin of the foot and leg. As a rule, club-foot apparatus are not applied until the child is a few or several years old, when the deformity has become quite well developed, and when frequently strongly contractured tendons and more or less altered jointsurfaces much complicate the case. Against all the Against all the forms of these mechanical appliances several objections lie. In the first place, oftentimes they are badly adjusted, and in the majority of instances they do not maintain the correction made when they are applied; next, making pressure generally upon only a limited number of points, their use is very apt to be followed by local irritations, with resulting ulcers or callosities; again, they are expensive, and often require much repairing, and very many club-foot patients are the children of poor parents. to see a single case in which the growth of the foot HOSPITAL NOTES. Recognizing the existence of these disadvantages, I have, for several years past, been experimenting with the plaster-of-Paris, recommended long ago by Little; the youngest subject upon which it has been applied being two weeks old. The success which has attended these experiments leads me to believe that this method of treatment may, in many cases at least, be advantageously employed. The application of it is easy; an ordinary plaster roller being ON THE TREATMENT OF FRACTURES OF THE UPPER turned over the foot, ankle, and the lower half of EXTREMITIES, IN THE BOSTON HOSPITALS. the leg. In quite young patients a layer of cotton (Specially reported for THE MEDICAL NEWS.) may with advantage be laid on, and the bandage IN general, it may be said that plaster or other imput over it; in older ones the latter should be placed movable dressings are almost never used in the treatdirectly on the skin. The thickness of the covering ment of fresh fractures in the Boston hospitals. Stiff must of course vary with the amount of deformity and glue, or dextrine, are, however, applied in a large bandages of either plaster, silicate of potash, starch and existing muscular power. Before the plaster majority of cases later on in the treatment, when begins to set, the foot is to be brought as near its the union of the fragments has become somewhat firm, normal position as can be done without causing any and the swelling has subsided. Ether is given when decided pain, and held in place until the hardening reducing fractures of the thigh, and in other cases is complete. Great care must be taken not to where there is difficulty in overcoming the displacement attempt too much at first. Preliminary tenotomy is of the fragments, or in making an accurate diagnosis. to be made or not, according to circumstances, but Simple fractures of the humerus, in its upper third, is seldom required in young subjects. At each sub-wire, gutta-percha, felt, or two layers of rather coarse are treated by means of a shoulder-cap, made either of sequent dressing more and more rectification is to be effected. Removal of the bandage will be required ordinarily in from three to six weeks, and the treatment, so far as I have been able to determine, must be continued for from six to eighteen months, and afterwards either a half boot with stiffened sides or the usual club-foot shoe worn, the former being generally sufficient to prevent any reproduction of the deformity. Two objections have been made to this method of treatment; first, that the dressing is a heavy and clumsy one, and second, that the proper development of the foot will be prevented. If properly applied, the weight of the plaster bandage is not so great as to prevent ready use of the limb if the patient is old enough to run about; and I have yet gauze, with plaster well rubbed into it. This is moulded to fit the shoulder, a pad is placed in the axilla, coaptation splints are applied to the inside, back, and front of the arm, and the wrist is placed in a sling. Simple fractures of the middle third are treated by a shoulder-cap extending well down towards the elbow, coaptation splints, and a sling for the wrist. Sometimes, in addition to the above, an internal angular splint is applied to the elbow. Simple fractures of the lower third are put up on an internal angular splint; and this splint is also used for all fractures about the elbow, whether above, through, or below the joint, except those of the olecranon. opinion that, in many cases of fracture of the humerus Dr. Ingalls, of the Boston City Hospital, is of the near the elbow joint, the best treatment is to make traction with the arm extended, instead of being flexed around an internal angular splint; and he intends to |