J. A. (Joel Asaph) Allen.

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part at any rate, by the infiltration of the membrane with tubercles.

It is stated that palliative treatment should always precede
operation. The writer takes the view that, given such a case as
the one here presented, no time should be lost in tentative efforts

L Th« writer removes, in addition, such nodules as have not already broken down.
a Hemyg : Die Heilbarkeit der Larynx-Phihlse. Stuttgart, 1887, p. 67.
8. Cong. loternat. de Laryngol. Milan, 1880.

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with palliative measures. Not that it is useless to rub in lactic
acid alone,^ but the formation of scar tissue is so much quicker
and firmer when the parts have been first thoroughly scraped.
Gratifying results are obtained by menthol used in the same
way.' The writer's experience would justify the use of the
curette in almost every case when ulceration can be made out ;,
unless, indeed, the case has gone on to extremity. It is pretty
generally laid down as a safe rule that, with extensive involvement
of the epiglottis, instrumental interference is bad practice. In
such cases palliative measures alone should be resorted to, includ-
ing the hydrochlorate of cocaine in the form of a spray.
21 West North Street.


Bt frank J. THORNBDRY, M. D.,
BeiDODStrator of Bacteriology^ University of BoflTalo.

'< Regurgitation at the tricuspid orifice is generally secondary to^
mitral stenosis or regurgitation ; primary disease of the tricuspid
valves, however, is not infrequent."

The above statement is made by Dr. Wm. Pepper, in his
admirable System of Medicine, where he devotes no less than
three pages to the discussion of this disease. The valvular lesions-
which lead to tricuspid insufficiency are similar to those whicb
produce mitral insufficiency. The valves are thickened, shrunken,
and opaque ; the papillary muscles are shortened and thickened.
The valves of the cordse tendine© and columnse carneaB may rup-
ture ; in either case, acute and extensive insufficiency results.
Acute endocarditis of the right heart is rare in adult life, but when
it occurs the tricuspid orifices are its primary and principal seat.
The first effect of tricuspid regurgitation is dilatation of the right
auricle ; following this there will be more or less hypertrophy of
its walls. As soon as the valves in the subclavian and jugular
veins are no longer able to resist the regurgitant current, jugular
pulsation follows. The tributaries of the inferior vena cava, and
the organs to which they are distributed, become greatly engorged.
The liver may present pulsation and, later, assume a nutmeg charac-
ter in consequence of the continued, chronic congestion. The

1. Krause : Berlin Klin. Woch., 1885, Vol. XXII., p. 488.

S. Rosenberg; : Therap. Monatsh^ft, 1888. Nos. 7 and 8. C. H. Knight : Journal Ameri-
can Medical Association, 18Q0, Vol. XIV., p. 89.

8. Read before the Buffalo Academy of Medicine, OjtoberSl, 1898.

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skin takes on a dingy yellow hne, which, combined with the cyano-
sis, gives a pecaliar greenish tinge that is only met with in heart
disease. The condition which I designate cyanotic induration^
occarring more often under other circumstances, may also be
present in this disease. This gives rise to a gastro-intestinal
catarrh, or, perhaps, hemorrhoids, which, with ascites, speak for con-
gestion within the abdominal cavity. The spleen becomes enlarged,
ordinarily. The kidneys often show cirrhotic changes. Edema of
the lower extremities and general anasarca may develop. The
obstruction to the systemic circulation may cause hypertrophy of
the left ventricle, by an extra amount of work being thrown
upon it. Then we have disease of the left ventricle consecutive
to that of the right heart.

The symptoms in tricuspid insufficiency, whether the disease be
primary or secondary, are for the most part those which pertain
to derangements of the abdominal viscera. There may also be
present palpitation, cardiac dyspnea, and irregularities in the force
and rythm of the heart action.

Gastro-intestinal disturbances are very common. The latter
comprise dyspepsia, nausea, vomiting, or hematemesis. There may
be constipation or hemorrhoids. The urine is often high-colored
and scant, sometimes containing albumin or casts. Cephalalgia,
dizziness, and vertigo may, be present as indications of cerebral
congestion (passive), and there is a peculiar mental disturbance,
which Pepper regards as characteristic of tricuspid insufficiency.

Of especial importance in this disease is the possible disastrous
consequence of the assumption of the horizontal posture, as illus-
trated by the following case. The patient taking the recumbent pos-
ture may become cyanosed, and, remaining long recumbent, stupor,
coma, and even death may supervene. This fact may be called
upon to explain why people are sometimes found dead in bed with
heart disease, the case being, perhaps, one of this peculiar type.

According to Dr. Pepper, in no other form of valvular disease is
the area of cardiac impulse so markedly increased as in extensive
tricuspid insufficiency. This area sometimes extends from the nip-
ple to the xyphoid cartilage, and it may reach as high as the second
right intercostal space. Not only the jugular veins pulsate, but
also those of the face, arms, hands, and even of the thyroid gland
and mamma. The apex beat of the heart is indistinct, and there is
commonly epigastric pulsation. Sphygmographic tracings of the
pulse show it to be dicrotic.

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280 thoenbury: tricuspid insufficiency.

The area of cardiac dulness, as revealed by percussioD, some-
times reaches to the second intercostal space. Auscultation elicits
a murmur which is synchronous with, or takes the place, of the
first sound of the heart/ It is superficial, of low pitch, blowing,
soft, and heard best directly over the valves between the fourth
and sixth ribs.

The distinctive features of this murmur, as compared with that
due to aortic or pulmonary stenosis, or to mitral regurgitation, are,
first, its location ; second, its character ; third, its point of
maximum intensity near the base of the ensiform cartilage, and,
fourth, the absence of any associated accentuation of the second
sound. The presence of jugular and epigastric pulsation are what
give weight to the diagnosis in this disease.

Tricuspid Regurgitation (after Galabin) a, a, anadicrotic wave synchronous with the
auricular systole, and caused by reflux into the large veins.

In connection with this presentation of the subject, I desire to
report the following case of tricuspid insufficiency, with autopsy :

S. G., male, cet. 35 years; single ; an American; a farmer by occupa-
tion. He gave the following history : had rheumatism four years ago, and
was now suffering from " heart and liver disease.''^ There had been
progressive weakness for the past six weeks, which, together with
shortness of breath and irregular hearts action, necessitated dis-
continuance of work. There had been edema of the feet and general
anasarca, which subsided under treatment. Present condition : patient
fairly well developed, of medium height and weight ; physique, poor ;
expression of countenance, haggard ; pulse, very feeble and irregular ;
area of cardiac impulse enormously enlarged, and its outlines imper-
fectly defined. Patient was intensely dyspneic, and suffering from great
mental anxiety. He had walked a longdistance prior to coming under
observation. He now laid down, and, upon assumption of the horizon-
tal position, immediately died.

Autopsy, fourteen hours after death, revealed the following con-
ditions : body that of an adult male, about thirty-five years of age,
well developed ; poorly nourished. Rigor mortis is present. Some
post-mortem staining. Thoracic organs: heart enormously hyper-
trophied, especially upon its left side. Right auricle and ventricle very

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much dilated. The tricuspid (right auriculo-ventricular orifice)
•extremely enlarged, admitting the tips of four fingers, the valves being
incompetent. Ante-mortem clots were foimd in the ventricles of the
left side. Liver, intensely congested ; lungs, hyperemic and edematous.
Other organs normal.

469 Delaware Avekub.

(sfiaioaf S^eportxft,


Professor of Surgery, Niagara University, and Surgeon to the Sisters' Hospital.

In a paper on Arthrectomy of the Knee-joint, read before the
Medical Assoeiation of Central New York, on June 2, 1891, I dis-
cussed the importance of the early discovery and prompt removal
of the local tuberculous focus in the epiphysis, before the joint
had become permanently injured by perforation of the focus
directly into the joint, or by extension of the tuberculous process
through the periosteum and synovialis. The main symptoms of a
local focus, in its early stage, near the epiphyseal cartilage, are
diminished extreme extension and flexion, while the motion is free
in the middle ranges, slight atrophy and commencing muscular
contractions, starting pains, increased surface temperature and
pain on tapping over a circumscribed area. Where such symp-
toms are present, any delay is dangerous, and painting with tincture
of iodine, the universal remedy for obscure bone and joint affec-
tions, is worse than useless. There is but one thing to do, t. «., to
incise down to the bone over the painful area, trephine the epiphy-
sis, and remove the local focus with a sharp spoon. The quickness
with which these patients recover by this treatment is as astonish-
ing as it is gratifying. I do not know of anything that gives me
more pleasure than the early discovery and removal of such a local
focus. The years of sufferings, with resections and amputations
as a final resort, which I have saved these unfortunate patients, are
quite large. The same symptoms may accompany a chronic osteo-
myelitis in the diaphysis of the long bones, particularly in those
bones which, as in t^e hip and shoulder joints, have the epiphysis
completely surrounded with the synovial capsule. The original

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pathological condition, the chronic osteomyelitis, is often over-
looked, and the patients treated for joint rheumatism or tubercu-
lous joint affections. Yet, a careful examination would show that
the joint is perfectly free in the middle ranges and not tender by
crowding the joint surfaces together, while the upper or lower
third of the diaphysis is thickened, tender on pressure, and doughy
in consistency. The^accompanying muscular atrophy and dimin-
ished motion simply show that the osteomyelitic process has
extended near the joint, and that this prepares itself for the inev-
itable perforation by becoming more or less obliterated. To illus-
trate these points, I take the liberty to publish a few of the quite
numerous cases I have seen :


Case IV. — Alice Goodrich, aged 7 years, entered the hospital
on August 18, 1893, with the following history : she sprained her left
knee by a fall on the ice, last Winter, but recovered perfectly. A few
weeks ago her mother noticed that she limped and could not extend
the left leg completely. She became peevish and fretful, and cried at
night. At the examination the left knee was seen somewhat swollen,
on account of moderate hydarthrus. A distinct doughy swelling was
seen over the internal condyle of the tibia, with increased surface tem-
perature and great tenderness on tapping and pressure. Motion in the
middle ranges of the joint was free and painless, but forced extension
and flexion was very painful. Some atrophy of calf and contraction of
hamstring muscles apparent.

A curved incision was made over the internal condyle of the tibia,
the periosteum elevated, and a small opening discovered in the bone,
through which tuberculous granulations were sprouting out The
opening was enlarged by chisel, and a cavity discovered as large as a
hickory nut, and filled with bone detritus and tuberculous granulations.
The cavity extended up near the joint cartilage. It was scraped and
packed with iodoform gauze under an antiseptic bandage.

August 22d, patient discharged to her home. The cavity was kept
open for four weeks, and then healed rapidly. The hydarthrus disap-
peared in short order, the motions in the knee became free and normal,
and she is now in perfect health.


Case V.— William Garllng. aged 20, Walcottsville, N. Y.. entered
the hospital on May 23, 1893, on crutches, and unable to use his right
leg. He was struck on right knee by a horse three weeks previously.
There was seen considerable swelling and apparent expansion of
internal condyle of right femur, with increased local temperature and

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pain by pressure and tapping. Complete extension and flexion of the
knee-joint was impossible, but motion in middle range was painless.
Under narcosis, the internal condyle of the femur was trephined. The
periosteum was found thickened, and easily peeled off. The condyle wa&
found in a state of softening and congestion, without any distinct cavity.
The osteoporotic bone-tissue was gouged out, leaving a healthy cavity
as large as a small walnut. The cavity was plugged with iodoform-
gauze, under an antiseptic bandage.

June 4th, wound dressed ; looks healthy. Patient can bear con-
siderable weight on the foot.

June 10th, patient discharged. He can walk without crutches, and
has no pain in the knee, which appears normal as far as motions are
concerned, but he presents a distinct genu-valgum on the right side,
evidently the result of the enlargement of the internal condyle on
account of the acute inflammation.


Case VI.— William D., aged 27, Hamnrondsport, N. Y., clerk,
entered the hospital on September 20, 1893, with the following history :
three years ago the patient had a severe attack of gonorrheal rheuma-
tism, from which he recovered. He has complained for one year of
pains under right shoulder, expectoration, cough, and some night-
sweat, and has lost considerably in weight.

Three weeks ago he noticed a slight pain in the right shoulder,
which has since steadily increased. He describes it as a dull, aching
pain, continuing day and night, and the shoulder feels as if there was a
heavy weight resting on it. He has been feverish since, lost his appe-
tite, and had night-sweats. He has been treated at home for inflam-
matory rheumatism with salicylates, but without any benefit.

On examination, he looks pale and suffering. The examination of
the lungs does not reveal anything abnormal. There is a diffuse swell-
ing of the upper third of the humerus, while the shoulder- joint itself
seems rather smaller and the acromion more prpminent than normal^
on account of atrophy of the deltoid muscle. Limited motions of the
joint and crowding the joint surfaces together are not painful, but rais-
ing and rotating the arm are very painful. The skin is reddish, the
surface temperature increased, and the humerus, in its upper fourth,
feels thickened and is very painful upon pressure. Temperature, 100 ;
pulse, 96. The diagnosis in this case was so evidently that of a bone
affection in the neighborhood of the shoulder joints, that I decided on
immediate operation. Under narcosis, an incision, four inches long,
was made along the anterior margin of the deltoid muscle. Under the
muscle a collection of tuberculous granulations was found, but the
bone seemed normal here. Another incision was then made aloDg the
posterior margin of the deltoid, where the same tuberculous granula-

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tioDS were found. The perioBteum was here thickened, and easily
peeled off. The medullary cavity of the humerus was chiseled open,
just below tuberculum major, and found in a state of tuberculous degen-
eration, with softening and numerous foci of tuberculous material and
small pus-cavities. The disease extended into the head of the humerus,
which was gouged out with a sharp spoon, and down the shaft for
about three inches. The joint was not opened. The cavity was
plugged with iodoform-gauze, the anterior incision closed by sutures,
and an antiseptic bandage applied.

He improved very rapidly, the wound was dressed once a week in
the same manner, and he left the hospital for treatment in his home,
October 5th. October 25th his wounds were all healed ; there was still
«ome stiffness in the joints, for which passive motions were recom-
mended. He had gained twenty-five pounds in weight, and was in per-
fect health.


Case VII.— Mrs. Murphy, 66 years of age, residing at Lockport,
N. Y., entered the hospital on June 20. 1893. She.had complained for
five years of rheumatism in her left shoulder ; eighteen months ago
«he noticed a slight stiffness and pain in the left shoulder. It grew
worse gradually, and interfered greatly with her work. She was
treated by various physicians for rheumatism, but without any benefit.
About one year ago, the pain became more severe and of a dull,
aching character, and the movements of the shoulder became very
limited. Blisters, liniments« and an ti- rheumatic remedies were again
tried unsuccessfully. At last, the joint was aspirated and a turbid
fiuid removed. Later on, two incisions were made and a similar fiuid
evacuated. The incisions made did not heal, and continued to dis-
•charge a thin, watery fiuid. Worn out by pain, she entered the hospi-
tal on June 20, 1893.

On examination, the region of the left shoulder was seen uniformly
enlarged and swollen, the muscles, above and below, greatly atrophied.
An unhealthy-looking sinus, discharging a thin, watery pus, was seen
in front about an inch below the acromion. Motions were very limited
■and painful, but a good deal of looseness and grating of the joint was
noticed. Under narcosis, the sinus was enlarged and the finger could
then easily be introduced into the joint, where a large sequestrum
could be felt. The joint was thereupon resected, Langenbeck^s anterior
incision being used, and the head of the humerus removed at the sur-
gical neck. The head was found in a state of caries, the cartilage had
disappeared, and soft tuberculous-looking granulations covered the
denuded surfaces. A large sequestrum was found in the joint, repve-
«enting the whole glenoid process of the scapula. The osteitic process
had evidently commenced here and then invaded the whole joint, just

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as would heve happened in case number six, if it had not been discov-
ered and promptly operated. The diseased synovial capsule was there-
after removed. ' The long head of the biceps had completely disap-
peared. The long anterior incision was closed by sutures, and a
drainage-tube inserted through an incision at the lowest posterior
angle. The wound healed by first intention, the tube was removed on
July 10th, and the old patient left the hospital, on July 18th, in good
health and with a quite useful arm.

November 20, 1893, she had gained twenty-two pounds in weight,
feels well and is able to use her arm in her daily work. A small fistula
is still left through which occasionally a little pus is discharged.


Case VIII. — Andrew Steislinger, aged 26, horseshoer, entered the
hospital on June 17, 1893, for the fourth time in two and one-half

The first time, in February, 1891, he had suffered for six months
with pain, stiffness, and swelling of left elbow-joint, and had been
treated for rheumatism. A chronic synovitis, without bone affection,
was diagnosticated. Three large moxies were applied with the thermo-
cautery posteriorly, and a plaster-of-Paris dressing applied. He was
discharged in a few weeks with a normal joint and without pain.

He reentered in July, 1892, wi^h an abscess over the olecranon. It
was found to be dependent on a tuberculous focus in the olecranon,
which was promptly removed, and he left the hospital shortly after
with a normal joint again.

He entered the hospital again in February, 1893. At that time the
whole joint was swollen, lateral motion, crepitation, and pain on
crowding the joint surfaces together were present. The old focus in
the olecranon seemed well, and as no other could be discovered, he was
considered to suffer from a tuberculous synovitis, pure and simple.
Injections of iodoform and glycerine (twenty per cent.) were used, and
he improved quite remarkably for a time, although he was not perfectly
recovered when he left the hospital. In April a fistula formed, which
had discharged since. I did not see him again until he entered the
hospital on June 17, 1893, in a much worse condition. The elbow-
joint was greatly swollen, with muscular atrophy above and below,
great lateral mobility with crepitation, intense pain by crowding
the joint surfaces together. The joint was flexed to an angle of 120
degrees, and scarcely any flexion was possible. Two sinuses were found,
one leading down to the head of the radius, another into the old focus
in the olecranon.

Under narc/osis, resection of the elbow was performed by posterior
median incision and subperiostally. The humerus was sawn off
immediately above the condyles, the bones of the forearm just beneath

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the head of the radius. The whole capsule was removed, the cavity
packed with iodoform gauze, the wound sutured except iu the center,
and an antiseptic dressing applied, and over that a plaster-of-Paris
dressing, the arm being secured in a right angle. By examination of
the removed epiphysis, another local focus was found in the internal
condyle of the humerus. It had perforated into the joint and done
the damage. June 22d, wound dressed, gauze removed.

June 27th, wound almost healed. Splints with hinges applied
and surrounded with plaster-of-Paris dressing, passive motions com-
menced, and patient discharged to his home.

October 25, 1893, the final result is very excellent. He can actively
fiex and extend his arm to almost normal, pronation and supination
normal, very little lateral motion in the joint. He has taken up his
work of shoeing horses and is able to work well with his resected arm.
As a matter of safety, he still uses an apparatus with two lateral
hinged splints.


Reported by WILLIAM C. FRITZ. M. D.,
Of Resident Staff Buffalo General Hospital.

Mr. p., aged 2.S ; single ; printer by^ccupation ; born in United States.
Patient was admitted to the Buffalo General Hospital during the ser-
vice of Dr. W. C. Phelps, May 18, 1893, where he gave the following
history :

On May 17, 1893, he fell, striking on his right temple ; shortly
after this his left eyelid began to swell, and very soon the eye was
•completely closed. This swelling extended downward, involving the
cheek, lip, and cellular tissue of neck. On entering the hospital the
patient -was slightly cyanosed, suffering from dyspnea, almost entire
loss of voice, and expectorating a moderate amount of frothy material.
On physical examination, the uvula was found to be about the size of a
hickory nut ; left tonsil, pillar of fauces, 'and left side of glottis were
very edematous. During the following night the swelling began to
-extend to the right side of the face, at the same time subsiding where it
had first appeared. On examination of chest, lungs and heart were
found normal.

Next day. May 19, 1893, after some of the acute symptoms had dis-
appeared, the family history was obtained as follows : his paternal
grandmother died with edema of the glottis. His father was insane
six months before death, the cause of death being abscess of the lungs.
His mother is alive and well. One aunt had an edema which appeared
and disappeared at various times. Two of her children died with
«dema of the glottis. Patient had two brothers and two sisters. One

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siBter is comparatively healthy, the other is troubled with edema of the
glottis, and both his brothers died with this form of edema. This
makes a total of eight persons in the family who have suffered edema.

Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 29 of 78)