years of age. From her twentieth to twenty-eighth year she was anemic and continued to have constant headaches, pains in joints, and swelling of legs. When thirty-one years of age she suffered a sudden shock, from which time her heart's action became intermittent and she had a frequent sense of intense precordial pain. She was examined in 1891, and a distinct mitral regurgitant, together with a double basic murmur, was recognized.

She reported that in the spring of the year her cardiac symptoms were always most severe. The heart action was always most intermittent at that time, so as to make her feel faint very often during the day. She could not sleep, and the precordial pain was accompanied by the sense of impending danger and death. She tried rest and mountain air for three summers, with only temporary improvement.

She came to Nauheim in 1894.

From July 7th to 29th she took fifteen thermal saline baths, temperature varying from 32% to 32° C.; duration, ten to twenty minutes.

From July 30th to August 6th she took six thermal effervescent saline baths; temperature, 31° C.; duration, eight to twelve minutes.

Although she left Bad-Nauheim, having gained eighteen pounds in weight, yet the conscious improvement began only a fortnight after she reached her home. She remained well the entire year, passed the spring without any symptoms, and when I examined her in July, 1895, she had a feeble mitral regurgitant murmur, but a perfectly regular heart.

She repeated her treatment the next year, 1896, and reported herself able to go about her duties all the year without hindrance.

OPHTHALMIC SURGEON TO ST. MARY'S HOSPITAL, TO THE HOUSE OF THE GOOD SHEPHERD, ETC., PHILADELPHIA.

It is not my purpose this evening to go into the different forms, nor to enter into a study of the etiology of the various kinds of iritis, but I desire to call the attention of the Society to a case of simple plastic iritis recently treated at the eye clinic of St. Mary's Hospital, not on account of its rarity, but because its history is typical of a number of cases of neglected

disease which are seen at every hospital.

G. D., aged thirty-two, came to the clinic, March 17, 1896, with the following history: Always had good vision until one week previously, when he awoke one morning with considerable pain in the right eye and intolerance of light; nevertheless, he managed to work that day and the next, his eye being protected by a shield. On the evening of the second day, the pain being then very great and the eye greatly congested, he applied to an apothecary who gave him some drops, presumably sulphate of zinc solution. It is needless to say that the drops aggravated all the symptoms, and after two visits to the apothecary, he came to the eye clinic at St. Mary's Hospital.

1 Read before the Phila. Northern Med. Soc., October 16, 1896.

On examination a typical case of iritis was found, the iris firmly adherent to the anterior capsule of the lens, the anterior chamber filled with flaky lymph, and the media so obscured that it was difficult to see the fundus. No deeper inflammation had, however, as yet set in.

The

As I have said, this history is not at all unique, and I am sorry to add that it is not always apothecaries who commit these blunders. Yet of all the inflammations to which the human body is liable, iritis should be the one most readily recognized. whole progress of the disease is exposed to view and the symptoms are characteristic and well marked. Certain cases of iritis might be mistaken for more serious eye troubles, such as glaucoma, but there is no excuse for the mistake of supposing it to be simply a conjunctivitis or "cold in the eye,'' as was apparently done by the worthy apothecary in the case which I have related.

It com

The pain in iritis is very characteristic. mences with a heavy deep pain as if the eyeball was being pressed upon by the fingers and this pain grows more and more severe as the inflammation progresses and is accompanied by shooting pains which usually radiate along the branches of the fifth nerve. Supra-orbital neuralgia is thus a prominent symptom, but it is accompanied by the deep pain in the eyeball itself. Gradually the pain becomes more and more neuralgic, intense paroxysms coming and going and increasing toward night. Frequently these are accompanied by flashes of light. All these symptoms are of intra-ocular pressure, and an active inflammatory process. The pain is totally different from that of any inflammation, however severe, external to the eyeball.

Not less characteristic are the objective symptoms. Before any lymph is thrown out which is apparent to the eye, the iris is discolored and contracted and be

gins to lose its power of movement; the pupil loses

its shiny blackness, there is deep ciliary injection, and a dull appearance of the cornea. The immobility of the pupil is almost pathognomonic. If we ex

clude certain nerve troubles which in no other way resemble iritis, immobility of the iris and contraction of the pupil necessarily indicate some morbid process going on in the iris itself. When the disease has progressed to the formation of lymph and apparently the entire fixation of the iris, there can be absolutely no doubt of the nature of the disease, but even in the very early stages there is little excuse for a mistaken diagnosis.

educated eye there is marked difference in the congestion which accompanies iritis from that resulting from any other cause. It is so with the other symptoms set down in books. There is one condition, however, which may occasionally puzzle the physician who has had little experience in eye troubles. I have seen cases of glaucoma in elderly people which were complicated by an inter-current attack of iritis, and in these cases the symptoms of iritis are to a certain extent masked by the presence of glaucoma ; and again, in inflammatory glaucoma there is frequently an exudate from the pupillary edge of the iris. While the acuity of vision is lost in both diseases, the decrease is much less in iritis than in glaucoma, and to the educated touch, as a rule, the tension of the ball furnishes a ready guide to diagnosis. The fact that iritis may occur during the progress of glaucoma should make us cautious in the treatment of the former disease in elderly people, where there may be a history of approaching glaucoma. In serous iritis we should also be on our guard, lest in curing the iritis we increase the blocking up of the canals of the ciliary body and thus increase the glaucomatous condition.

In my opinion it is a matter of very little practical importance to determine whether an iritis is rheumatic, scrofulous, cachectic, or syphilitic in origin. As far as the treatment is concerned the same course is adopted in my practice, whether the patient confesses to syphilis or not. Of course, if iritis occurs during the progress of a rheumatic attack, or if there is a distinct history of rheumatism or gout, then remedies directed to these conditions should be employed, but taking the average case of iritis, with which we are all so familiar, the treatment should be conducted on the same general grounds, no matter what we have concluded the etiology to be.

The treatment of iritis has progressed but little since the early days of ophthalmology, and for the simple reason that if adopted early, the old fashioned treatment is eminently satisfactory. As in the days of our fathers, it consists essentially in the free exhibition of mercury, of local sedatives and derivatives, and in the free use of atropin. Mercury is best administered by inunction, the system thus rapidly coming under its influence. It should be remembered that the general condition of those attacked by iritis is usually poor, and that the stomach is not rarely irritable, and the digestion impaired. Internal medication should therefore be avoided as much as possible, except so far as is useful to build up the system and correct disorders of digestion. The use of mercury should be pushed to the point of tolerance. "Gently touch the gums," is the good old rule which is probably not very far wrong. Iodid

of potassium is of little use in the earlier stages of the disease, but must be used after the inflammatory stages have passed, and when the mercury has been pushed almost to the point of salivation. If, unfortunately, your patient should object to inunctions, then some other form of mercury than the ointment must be used, the protiodid or bichlorid internally, or, better still, the subconjunctival injections as used by Abadie.

Local treatment to reduce the inflammation is very efficacious. I usually employ the Hurtelope or Swedish leech applied to the temples. Hot water fomentations applied to the eyeball are useful in allaying pain, and possibly in lessening the congestion, and should be freely used at frequent intervals and as hot as can be borne. A boric acid solution should also be employed.

But the chief treatment is the use of atropin, which should be administered both early and late, and in sufficient strength to thoroughly dilate the pupil, and at such frequent intervals as to maintain the dilatation. In the early stages the use of a solution of four grains to the ounce of the sulphate of atropin, applied every four hours, or even more frequently, is necessary to bring about this result. I have found good effects from combining cocain with the atropin in the earlier stages; it lessens the pain and aids in the more rapid dilatation of the pupil. After full dilatation has been obtained the cocain may be dropped, but the use of atropin, until all inflammation of the iris has disappeared, is absolutely imperative. lutely imperative. In uncomplicated cases, which are seen at an early stage, the progress is very favorable. With neglected cases, complications are very liable to occur. The most simple is posterior syne

chia, which is altogether too frequently seen in eyeclinics, but it is unnecessary at this time to more than refer to the fact that most serious complications are more liable to follow neglect or maltreatment.

I have been greatly struck by the tolerance of mercury evident in many cases of iritis. I have seen numbers of cases which, as far as I could determine, were non-syphilitic, which bore readily the absorption of two to three drachms daily of mercurial ointment, for weeks, and even months, with no symptoms of ptyalization. In these cases, the mercury was continued until the eye whitened and the evidence of deep injection lessened. Mercury, in these cases, acted as a powerful tonic, the general health improving even more rapidly than the inflammation subsided, and it is in these cases that the most successful results are seen. I have already referred to the necessity, in many patients, of attending to the general health. As the majority of cases of iritis occur in patients whose systems have been run down

by the presence of syphilitic or other poisons, the Turkish bath is especially useful, and tonic treatment should never be neglected.

In conclusion, I have only to impress upon you the facts that iritis is readily recognizable and is a most tractable disease if taken in time. The treatment is simple and effective, and there is no reason why nearly every case of iritis coming under competent care should not make a good recovery.

MENTAL COMPLICATIONS FOLLOWING SURGICAL OPERATIONS.

66

BY J. T. WILSON, M.D., OF SHERMAN, TEXAS.

THE subject of mental disorders produced by or following surgical operations has not been discussed to any great extent, and until within the past few years only a passing notice has been given it. Dr. T. Gaillard Thomas reported six cases to the New York Academy of Medicine in April, 1889. He could find only twenty cases recorded previous to that date, and states that prior to 1887 there was nothing in the way of literature on the subject." After Thomas called attention to this complication, quite a number of cases were reported, but I find in my investigations in this field very few complete histories accompanying these reports. This important part of the subject has been much neglected, and therefore a study of the literature is somewhat disappointing. The various mental disorders of traumatic origin, if I may use the expression, are not so rare as is supposed, and I presume every surgeon has met with cases during his career. They are sufficiently frequent to elicit careful consideration and special study in order that they may be prevented, or properly treated, when they have developed.

It is a strange fact that while surgical operations will sometimes cause serious mental disturbance, on the other hand, these same operations will sometimes cure them, and especially is this the case with some melancholiacs. Many females laboring under attacks of melancholia caused by some disease of the genital apparatus, have been cured when relieved of the physical defect by operation; others have been much improved, and yet others have received no benefit.

The question may very properly be asked, why a surgical operation should produce an attack of insanity. This can no more be answered satisfactorily in every case than can the question why some persons become insane from the many other causes to which it is attributed; for in most cases these mental complications are a surprise, and no good reason can be given why they should follow; in others, however,

1 Read before the Southern Surgical and Gynecological Association at Nashville, Tenn., November 10, 1896.

a logical explanation might be arrived at. If the patient is a high-strung, nervous individual, easily excited and unable to bear pain, the great and increasing dread of the anesthetic, or the thought of the operation, or both, will so affect him that he will lose control of the will-power, and the explosion will come after the operation and reaction from anesthesia. In many of these cases, probably a majority, there is an hereditary taint or a strong neurotic tendency. I think it has been the observation generally that females are more subject to these mental outbreaks than males, not because they cannot endure pain with equal fortitude, but because they are, as a rule, more nervous, more excitable, and more susceptible to the extremes of mental emotion. Nervous explosions, traceable to operations upon the female genitalia, are of comparatively common occurrence, because a greater number of operations are now performed in connection with these organs than upon other portions of the body; but this sequel is by no means confined to operations upon these parts. Polk has stated that he preferred not to operate upon patients who had previously shown an abnormal mental activity.

To anesthesia has been ascribed the cause of the trouble in some instances, but in these cases it is very likely that there is an insane temperament in the background. Anesthetics, too, may complicate the case by their effects upon various organs, which may combine with the other causes to produce a mental perturbation. Every anesthetic produces a more or less powerful depressing effect upon the heart. Cases are frequently recorded in which albuminuria has been discovered after chloroform and ether-anesthesia, the urine previously having been free from albumin. I have myself observed a hyperemia and torpidity of the liver, with febrile excitement and mental exaltation, following chloroform anesthesia. Chloroform and ether produce more or less anemia of the brain, or a venous stasis which may be very slow in being relieved; the patient may be feeble, and the delayed recovery from the effects of the anesthetic may end in confusional insanity. A very nervous person is liable to suffer from great dread of the operation, and often resists the anesthetic, or becomes wild and uncontrollable under the attempt to administer it. He often requires a greater quantity and it takes longer for him to become anesthetized, which has a more depressing effect. He remains for a greater length of time under its influence, and when he recovers from it labors under greater prostration; the shock is more profound, and prolonged nausea and vomiting may follow. He loses self-control, fears that he cannot recover, and, becoming absorbed in these thoughts with such in

tensity, in his already weakened nervous and physical condition, his mind gives way. From my researches, I learn that it is very rare for the patient to recover from the effects of the anesthetic with this mental disorder established, or evident to the observer; but it may come on suddenly or gradually within twentyfour, thirty-six, or forty-eight hours; or several days or weeks may elapse before its complete develop

ment.

It is not always after a grave operation that these sequences occur. I have seen a violent outbreak in a patient from whom a small fatty tumor was removed. This patient, however, had had a previous attack of insanity.

There may be disease of some of the other organs, or their functions may be interfered with. The inebriate, and persons long addicted to the drug-habit, do not bear operations well, as a rule, and these conditions may be put down as predisposing causes of mental alienation after shock from surgical operation.

66

Savage of London read a paper before the British Medical Association, at its fifty-fifth annual meeting, in which he states that "in persons who are predisposed to insanity, intoxication with mineral, vegetable, or organic poisons, and the use of alcoholic or anesthetic inhalations, may be followed by acute delirious mania, from which the patient may recover or may lapse into dementia, or even to the progressive paralysis of the insane." Dent attempts to show that mental impressions may be produced in three ways: by anticipation, by actual operation, and by after-effects." Mairet thinks, "first, that it is in those individuals who are predisposed by heredity or other grave causes-alcoholism, infectious diseases, etc.—that surgical operations give rise to insanity; second, in the constituent elements of an operation that might act on the brain were two most important factors, namely, the anesthetic, and the degree of surgical traumatism, with its after-effects, of which disturbed nutrition plays a very important part; and third, when predisposition also is considerable, the anesthetic alone may produce insanity, or it may result even after minor operations. It is, of course, necessary to take into consideration the mental state of the patient prior to the operation, especially in those graver ones where questions of life or death are frequently involved."

All diseases that have a tendency to exhaust or impair the nutrition of the nerve-centers weaken the mind and render it less able to withstand the great strain it may be called upon to sustain. Poorly fed, badly nourished subjects come under this head.

The antiseptic drugs used for dressing wounds have been accused of causing mental disturbance, but I have never seen a well-authenticated case from this cause. Septic absorption is sometimes an ac

The mental derange

companiment, if not a cause. ment from septicemia, pure and simple, can, however, usually be differentiated from others.

The manifestations of mental disorders following surgical operations are not different from the same disorders produced by other causes. They usually occur in the form of confusional insanity, mania, and melancholia, while very rarely we may have paranoia and dementia. We can only classify the different manifestations of insanity by their symptoms.

The mind has a powerful influence over the functions of the organs of the body, which, in turn, when interfered with, will react upon the brain and nervous centers. The outbreak may be sudden, and may begin with wild delirium; more frequently it comes on gradually, showing itself as a delusion that cannot be dissipated, and this is followed by incoherent conversation. The patient becomes restless, and is troubled with insomnia. Impatience is succeeded perhaps by violent excitement, which passes beyond control except by the employment of absolute force; or there may be only fixed delusions and insomnia, which occur in many cases, and are often the first symptoms to attract attention to an abnormal condition of mind. On the other hand, the patient may become quiet, or morose, and refuse to speak, or to notice his surroundings. notice his surroundings. There may be a moderate rise in temperature, or it may be subnormal. In the violent form, there may be a higher temperature, increased pulse-rate, dry, coated tongue, loss of appetite, and impaired digestion and constipation, with more or less loss of physical power. Acute mania is generally accompanied in the beginning by febrile excitement. If the patient is violent and restless, and laboring under great nervous tension, the functions being all interfered with, the temperature is liable to rise with the excitement and fall with its subsidence.

In septic poisoning, and in the toxemias, we always have a greater or less degree of febrile movement. Sometimes after a violent outbreak, with continued excitement for several days, signs of exhaustion appear, and stupidity and coma gradually

come on.

There can be no difficulty about the diagnosis of mental disturbance, or an attack of genuine insanity, after surgical operations; the manifestations are plain enough, but we cannot always be so positive about the classification of the trouble. It is not difficult either, as a general thing, to distinguish insanity from the delirium of septicemia, for while there are cases of insanity that are probably the result of septic poison, as has already been stated, they can generally be discriminated. The antecedent history is of value in these cases. If there be no hereditary history of insanity, nor a history of a previous at

tack, there being no organic disease present, and the subject being robust and of good constitution, the prospect for recovery of both mental and physical health is fair. If, however, there is an hereditary, or strongly neurotic tendency, and the patient is in feeble health, the danger is great. Digestive disturbances, feeble pulse, and a tendency to stupidity and coma are always very grave symptoms. The cases of so-called confusional insanity of some modern writers, when there is no organic disease, or septic complications, usually recover after certain lapse of time. Under these conditions the affection is entirely functional, and is not generally dangerous to life. Acute mania, if it does not exhaust the patient, is less unfavorable than melancholia; the former is rather more dangerous to life, while the latter tends to a permanent impairment of the mind. The percentage of recoveries from dementia is small.

The danger to life from insanity, after surgical operations, is probably greater than from any other cause, except malignant disease. My own experience, both from observation and study of a comparatively limited number of cases, has taught me that the prognosis is not very favorable, as a majority of the cases terminate in death, or permanent mental alienation. Any mental disturbance, coming on after a surgical operation, in a patient who had not suffered from a previous attack, I should look upon with apprehension. Those systems which are poisoned by chronic alcoholism, or by the use of drugs, do not seem to have the power of resistance that persons do who are free from the effects of these depressing influences. In view of the light we now have upon this subject, the knowledge gained from personal experience, and from the literature bearing upon it, it is the duty of the surgeon to have this unfortunate complication in mind whenever he decides to perform a surgical operation, whether it be a minor or major one. Cases of sufficient number are in evidence to prove the danger from even the most trivial operation, and he should always be on his guard. In obtaining the histories of our surgical cases, the antecedent mental and nervous peculiarities should be taken into account. We should be extremely careful and watchful of those patients upon whom we operate who have an hereditary tendency to insanity, and of those who are unusually nervous, and who submit to an operation with great dread and even protest. Careful preparation should be given them in the way of cheerful surroundings, reassuring conversation, nerve sedation, and plenty of sleep, before the operation. Urgent operations cannot be delayed, but the patient can be placed in the best possible physical and mental condition in the short time given for preparation. There are some operative cases in

which every moment's delay is a menace to life, and the very best must be made of the surroundings. We should do what we can to fortify the patient with hope, and should calm his fears; should avoid making a great display of instruments in his presence, and avoid having too many in attendance. The anesthetic should be administered in a separate room from that in which the operation is to be performed, when this is practicable. When there is no special hurry much can be accomplished by gaining the confidence of the patient; make him even anxious for the operation. Prepare his system, and his mind, and relieve him of the great dread of the anesthetic. Impress those with whom he is in constant contact with the importance of cheerfulness in his presence, and with the necessity of keeping his mind from dwelling. upon the ordeal through which he must pass. Encourage him to look forward to it as the only probable means of deliverance from his malady. Much can be done in this way to increase the powers of resistance to any complication that might arise. I believe that by such careful preparation we will be able in many cases to ward off this most unfortunate sequel.

CLINICAL MEMORANDUM.

A CASE OF DIPHTHERIA TREATED WITH ANTITOXIN; SUBSEQUENT DEATH FROM ACUTE ASCENDING PARALYSIS.

BY G. M. WELLS, M.D., U.S.A.,

FORT MASON, CALIFORNIA.

ON May 8, 1896, I was called to see a male child, eighteen months of age, suffering from diphtheria. He was a little below the average size, but had previously been healthy. At that time the temperature was 98° F.; pulse a little above 100, but quick and weak; respiration accelerated and shallow; appetite poor; bowels constipated; profuse acrid discharge from nose; faint, sweet odor from breath; glands about lower jaw enlarged, hard, and tender; both tonsils enlarged, with a dirty, grayish-white membrane covering them and the pillars of the fauces, a part of the soft palate, and the lower part of the uvula, and that part of the throat not covered with membrane was excessively red. During the next three days the case pursued a regular course, gradually growing worse, but the child continued to take a fair amount of nourishment. On the afternoon of the 11th the temperature was 101° F. and the pulse 160, weak, irregular, and thready. There was great exhaustion, and the color was bad. The bowels and bladder had been evacuated regularly and without difficulty. There was some difficulty in swallowing. The throat was very sensitive, and bled on the slightest touch. The tonsils were greatly enlarged, and there was great swelling and tenderness of the glands about the jaw and neck. The membrane had extended into the posterior nares, had covered almost all