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present condition of the public baths and gymnasia of Boston. — Boston
Medical and Surgical Journal,

Professor Roentgen Declines. — It is now announced authoritatively
that Professor Roentgen has refused to accept the call to the University of
Leipzig to succeed Professor Wiederman, who will retire at the end of this
semester. Professor Roentgen prefers to retain his present position, that of
Professor of Physical Sciences at the University of Wiirzburg. — Medical
News.

In the death of Dr. Charles Fayette Taylor, which occurred at Los
Angeles, Cal., January 25th, the profession loses one who may justly be
termed the strongest force in American influential orthopedic surgery —
now well recognized as a branch of the profession in which the American
medical fraternity can take personal pride.



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I20 The American Practitioner and News.

Special notices*



Tablet Nervitone. — William R. Warner & Co. are introducing a new tablet to
the profession.

The formula comprises active ingredients of a nature well calculated to fill the
want of a good nerve tonic.

Messrs. Warner & Co.*s preparations are so long favorably known that this new
preparation will no doubt receive something more than passing notice. We recall the
introduction some three years ago of Tono Sumbul Cordial (Wm. R Warner & Co.).

The rapidity with which it found favor at the hands of the profession is evidence
that while a great deal is no doubt due to excellence of the formula, it was largely
owing to the fact that all " Warner " preparations have a known therapeutic value and
do just what is claimed for them.

Messrs. Warner & Co., introducing Tablet Nervitone, write : "When the indica-
tions are for a prescription to correct asthenia, neurasthensia or nerve exhaustion,
whether the result of debilitating diseases or excesses, we have in Nervitone Tablets a
remedy which will give satisfactory results. Being a combination of well-known
nerve-tonics and stimulants. Tablet Nervitone will fill a wide field of usefulness in
physicians' prescribing." Many of the so-called tonics contain coca and other sub-
stances calculated to produce that distressing condition termed the "drug habit,"
which necessitates a continuance of the drug or a withdrawal of the remedy at the
expense of great suflfering. Tablet Nervitone should be given a trial.

Sanmetto in Enuresis Diurna et Nocturna. — Some years ago my attention
was called to Sanmetto as a remedy for troubles of the genito-urinary organs, partic-
ularly in men past middle life, and I have had some very gratifying successes with
its use. Recently I was called upon to prescribe for two boys, eight and ten years of
age respectively. Every thing had been tried, including whipping, to break up the
"habit" of wetting the bed at night, and one of them also his clothing in the day
time. It occurred to me that Sanmetto would be worth trying, and to the delight of
every one concerned it has been perfectly successful ; and now for the past six months
and twelve mouths respectively, these boys have been entirely cured of this unfor-
tunate " habit." Undoubtedly the trouble was due to irritability of the prostate and
mucous membrane of the bladder; hence the prompt and permanent relief afforded
by Sanmetto. I have written these few lines hastily, calling the attention of the pro-
fession to these cases, with the hope that others will try the same remedy for the same
"habit." James A. Stewart, M. D.

Baltimore, Md.

Grateful Testimony.— T'A^ Imperial Granum Co., New Haven, Conn.: Dear
Sirs: I feel assured you have the best food preparation on the market I had a
son, a soldier, come home low with typhoid fever. I used the Imperial Granum and
it acted like a charm. He is now well. It allays inflammation, reduces fever, quiets
the patient, and is a great blessing. I wish you a happy Christmas.

Newport. : M. D.

I TAKE great pleasure in offering my testimony to the great value of Cactina Fil-
lets, in cases of weak and irregular action of the heart I have used them for four
years and have never been disappointed in them. They not only stimulate the heart,
but improve that organ permanently. I find them very useful in all cases of typhoid
fever and pneumonia.

Kent, lud. C. B. Matthews, M. D.

I HAVE used Peacock's Chionia and find it very effective. I shall continue to pre-
scribe it in my practice.

New York, N. Y. A. P. Dalrymple, M. D.



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THE



American Practitioner and News.



"NEC TENUI PENNA,



Vol. XXVII. Louisville, Ky., February 15, 1899. No. 4

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the
fiewest possible words, or his reader is sure to skip them ; and in the plainest possible words, or his
reader will certainly misunderstand them. Generally, also, a downrisrht fact may be told in a plain
way ; and we want downright facts at present more than any thing else.— Ruskin.



©riginal Clrticles^



ANEURISMS.*

BY W. O. ROBERTS, M. D.

Professor of Surgery and Clinical Surgery in the University of Louisville.

This patient, Mr. J. P., is thirty-four years of age, with a good
family history. He has had typhoid fever and gonorrhea, but not
syphilis. He worked at the coopers' trade from boyhood up to four
years ago, when he gave up his trade and did practically nothing for
two years ; he then took a position as carrier of brick and mortar for
house-builders. He has been a moderate drinker all his life, but drank
a great deal while not at work.

In August, 1897, he began suflfering with cramps in his right leg;
these cramps were worse at night and when the patient was on his feet.
About a month after the cramps were first noticed, while rubbing his
limb he detected a swelling in the popliteal space of the right leg.
This tumor was about the size of a guinea-egg. It gradually but stead-
ily increased in size]until he appeared at my clinic at the University of
Louisville, in December, 1897. At that time the mass almost com-
pletely filled the popliteal space. Pulsation very expansile; bruit very
distinct. The foot and leg below were markedly edematous ; the knee
was semiflexed and could not be completely extended. The patient
walked on his toes with the aid of a crutch and cane. He was put to
bed on December 19th preparatory to operation.

On December 21, 1897, two days later, at my clinic at the Univer-

^ Patient presented and report read before the Louisville Mcdico-Chirurgical Society, January 77,
1899. For discussion see p. 127.

10



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122 The American Practitioner and News.

sity I ligated the femoral artery at the lower angle of Scarpa's triangle ;
a catgut ligature was used. Immediately on tying the artery the pul-
sation in the tumor ceased, and it has never recurred.

The patient was kept at the University Infirmary about one month,
at the end of which time the tumor had diminished in size to about one
third of its original volume. It was then quite solid ; the edema of the
foot and leg had entirely disappeared, and the leg could be completely
extended. He was then discharged as cured, and I saw nothing more
of him until a few days ago. Upon examination I find the tumor
entirely gone and the leg in good condition. Pulsation of the posterior
tibial artery in the lower third of the leg can be felt. The foot of the
aflFected side is more susceptible to the influence of cold than the
opposite foot. Barring this, the patient says he sees no diff*erence in
the two legs.

Case 2. I have another case operated upon last December. This
man is sixty-five years of age ; he is a colored man with a good family
history so far as he knows. Until thirty-five years of age he worked
on a farm, then as a teamster in the city for about six years, and since
then he has been driving a hack or baggage wagon. He gives no his-
tory of syphilis ; has been a steady drinker of whisky for the past ten
years, taking from three to five drinks a day. About a year ago, while
rubbing his knee with a liniment for supposed rheumatic pains, he dis-
covered a small lump about the size of a partridge egg in the popliteal
space of the right leg. It was at first painless ; gradually increased in
size and became painful and tender to the touch.

About six months later the foot and leg began to swell ; the tumor
gradually but steadily increased in size and became more painful,
especially at night, or when on his feet. Edema of the foot and leg
increased in proportion to that of the tumor in the popliteal space.

When he appeared at my clinic December 14, 1898, the foot and leg
were very edematous, and the tumor not only filled the popliteal space
but extended a short distance above it. Expansile pulsation and bruit
were very marked. The knee was flexed almost at right angles, and
could not be extended. I was little afraid on account of the great
swelling that there might possibly be some destruction of the struct-
ures of the knee.

On December 14, 1898, I ligated the femoral artery at the same
point as in the other case, after having kept the man in bed two or
three days preparatory to the operation. The patient, on coming from



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The American Practitioner and News. 123

under the influence of the anesthetic, noticed immediate and complete
relief of pain in the limb, caused by the aneurism, and the only dis-
comfort complained of afterward was some numbness of the foot and
leg. He was kept in the infirmary for three weeks, at the end of which
time there was marked diminution in the size of the tumor, and it was
quite firm. The edema below had entirely disappeared. Without our
knowledge or consent he left the infirmary at the end of three weeks
and walked to his home, about three squares distant. Improvement
has been steady since then, and now the tumor is about half as large
as it was at the time of the operation. There has been no return of the
pulsation or bruit.

I would have had this patient here to-night but he lives in the third
story, and I did not care to have him climbing up and down stairs. He
is able to walk about the house in comparative comfort. 1 saw him
this morning and examined him carefully with Drs. Bloch, Butler, and
Ballon; the tumor is firm and solid. He can perfectly extend his leg;
the edema has entirely disappeared below ; there is no pulsation in the
tumor, and it has diminished in size at least one half. I expect to show
the man before this Society at its next meeting.

I bring these two cases before the Society and report them in order
that they may be added to similar cases that I have already reported.
I have so far had the most marked success with the Hunterian opera-
tion for aneurism ; in fact, I have never seen a case in my own practice
or that of my friends where failure to cure the aneurism has occurred.
Success has followed every operation, and in one of the cases that I
have already reported the aneurism extended nearly up to Scarpa*s tri-
angle, and ligation was of the external iliac artery.

The operation performed upon these two men (the Hunterian) is
not so popular as it used to be, judging from modern literature, and its
place is being taken by the operation of Antyllus, that is, extirpation
of the tumor, after having ligated the vessel above and below. The
following extract is from An American Text- Book of Surgery:

" The special advantages of extirpation of the aneurismal sac over
proximal ligature, compression, or any other method are the removal
of danger of emboli which might cause gangrene, the absolute perma-
nency of the cure, the absence of secondary hemorrhage, the freedom
from sepsis, and finally the lessened mortality. The mortality of prox-
imal ligature has been placed by Delbet at eighteen per cent, that of
total extirpation of the sac at eleven per cent ; the occurrence of gan-



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1 24 The American Practitioner and News.

grene after proximal ligature about eight per cent, after extirpation
only three per cent. RansohoflF collected twenty-eight extirpations of
major aneurisms of the extremities without a single death."

These statistics are surprising. I may have struck a fortunate lot
of cases, since all resulted in perfect cure. In the one last reported
to-night I hardly expected a favorable result, owing to the size of the
tumor, the very marked edema below, and inability on the part of the
patient to get his leg at more than a right angle. I was apprehensive
that it had gone too far to be benefited by this operation, but the result
I believe will be a perfect cure.

LOUISVII^LE.



LITHOLAPAXY: REPORT OF CASE.

BY A. H. BARKLEY, M. D.

The operation for stone resolves itself into two procedures — crushing
or litholapaxy and lithotomy or cutting. Litholapaxy is an operation
that is almost devoid of danger, and should be given the preference in
all cases if possible, and I believe that there are very few cases in
which this method can not be employed.

It has many advantages and few disadvantages. It is much more
preferable to lithotomy for the following reasons: (i) No cutting is
necessary, unless the meatus be very small, and this is a trivial matter,
and no open wound for infection is made ; (2) it can be employed at
nearly all ages ; as is well known it gives a lower mortality at the
extremes of life than any other operation ; (3) the patient suflFers little
if any after the operation, and is up and about in a very much shorter
time than after lithotomy ; (4) the mortality at all ages is much lower
after it than after lithotomy, as Thompson collected nine hundred
and thirty-two cases operated on by litholapaxy, perineal section, and
supra-pubic cystotomy ; of this number, eight hundred cases by lithola-
paxy, with forty-six deaths ; one hundred and fifteen perineal sections,
with forty-three deaths, and seventeen cases of supra-pubic cystotomy
with forty deaths.

The chief disadvantages to litholapaxy are, (i) wounding the blad-
der and uretha, (2) leaving fragments of stone behind to form a nucleus
for another stone, and (3) requiring a little longer time, and the blades
of the lithotrite may become clogged. Wounding the bladder and



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The American Practitioner and News. 125

uretha can be avoided, I believe, in nearly every case, if proper care is
taken to inject sufficient quantity of water to distend its walls, and the
greatest care exercised after the stone is seized to see that the instru-
ment is freely movable ; if the uretha has previously been sufficiently
dilated, no harm is likely to result unless the instruments are carelessly
used, or with an undue amount of force. The leaving of a fragment
behind may in the vast majority of cases be avoided if the washing
has been thorough and the canal dilated suflBciently. I have seen quite
large fragments pass after operation without the patient suflFering any
inconvenience. The bladder should be thoroughly searched for frag-
ments, both at the end of the operation and several months later. The
time required is a little longer than is required for lithotomy, but this
is of little importance when we consider the short time in which one
recovers from the operation. The clogging of the blades may be obvi-
ated by using the fenestrated instrument.

Mr. N., aged forty-nine, white, came to me on January 5, 1899, and
the following history was obtained : About ten years ago he began to
have trouble in passing his water ; paid little attention to it at the time,
thinking it would pass oflF; for a period of three months he apparently
was better, but at the end of this time he again had trouble and passed
some mucus, which alarmed him, so he consulted a physician, who pre-
scribed Lithia tablets. He continued to have trouble from time to
time, taking first one thing and then another without eflfect. About
four months before he consulted me he passed several small stones,
ranging in size from a pea on down ; he also complained of his water
stopping suddenly, which could be relieved when he got in the recum-
bent position ; he could feel the stone when he was subjected to any
jarring. He also complained of pain at the end of his penis after uri-
nation; defecation was also painful.

I sounded his bladder with a Thompson stone-searcher and
detected a stone, the diameter of which measured approximately one
and a fourth inches; only one stone could be found.

The examination disclosed nothing of importance with reference to
the bladder, no cystitis or inflammatory trouble whatever being present.
I advised him to allow me to dilate his uretha so it would admit the
lithotrite and tubes, and if crushing was not successful to do median
lithotomy. He agreed, so on January 8th he came to my office ; I
passed No. 15 American sound ; on loth I passed Nos. 15 and 16 ; on
the 13th he took Nos. 16 and 17; on i6th Nos. 17 and 18 were passed



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1 26 The American Practitioner and News.

I found it necessary to cut the meatus to No. 22 American ; on the 19th
I passed Nos. 18 and 19 ; on the 22d Nos. 19 and 20, and on the 24th
Nos. 20 and 21 sounds were passed. He was taking an alkaline diuretic
all the time and suflFered no inconvenience from the rapid dilatation, and
only once did his urine contain any mucus and look cloudy, which
was very promptly relieved by ten-grain doses of boric acid three or
four times a day for two or three days.

On January 25th I operated on him; after he was anesthetized I
passed No. 21 sound ; after this his bladder was thoroughly irrigated with
three-per-cent boric acid solution, leaving from eight to twelve ounces
of the solution in. The lithotrite was introduced into the bladder and
the blades opened and closed two or three times before the stone fell
within its grasp ; finally the stone was seized and broken. The fragments
were broken as they would fall within the blades ; it was with some dif-
ficulty that some of the pieces were found.

I found the stone was very. soft, and could be crushed by pushing
the male into the female blade. Only three or four times did I apply
the pressure aflForded by the screw.

After repeated crushings Biglow's washing-bottle and tubes were
used. A No. 18 American curve tube was passed into the bladder and
connected to the bottle, filled with warm boric acid solution, three per
cent ; pressure on the rubber bulb caused much debris to fall into the
glass bulb below. The lithotrite was again used, and the bladder was
given its final washing, and from six to eight ounces of boric acid solu-
tion was left in the bladder.

The patient was removed from the operating-room; he reacted
nicely. There was no acceleration of the pulse or rise in temperature
following the operation; he was allowed up on the following Monday;
he passed some small fragments; on Tuesday I searched his bladder
and found no fragments ; he went home on Wednesday, one week
after the operation. I have seen the patient since his return home,
and he does not have to get up at night to empty his bladder, and feels
entirely free from any of the disagreeable symptoms he had prior to the
operation.

Through the kindness of Prof. Alfred Peters, of the State College,
some of the stone was analyzed ; he says it is composed of cystin, which
is of course rare. The fragments collected weighed 350 grains.

Lexington, Ky.



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The American Practitioner and News. 127



Heports of Societies.



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.*

Slated Meeting, January ay, 1899, the President, Thomas Hunt Stucky, M. D.,

in the chair.

The essay was read by Dr. W. O. Roberts, subject " Aneurisms."
[See p. 121.]

Discussion, Dr. H. H. Grant: I have had under my personal care
four cases of aneurism of the popliteal artery, in three of which I
attempted to cure the condition by compression with relays of students
to make digital pressure, reinforced by a tourniquet that I arranged for
the purpose. In two or these cases success was attained, with entire
cessation of pulsation and cure of the aneurism so far as I am able to
report at this time. Both patients became entirely well and were sent
away from the clinic. In the third case, a white man, the ligature was
applied without other treatment; he recovered promptly without
event. Two of these patients were under my care about three years
ago. A fourth case very recently, only a few weeks ago, a colored man
about thirty-five years ago, with a tumor as large as a goose egg in the
popliteal space, with but moderate trouble in the leg beyond pain, with
a distinct bruit, marked expansile pulsation, a great deal of pain, but
not much edema. In this case fourteen hours of digital compression
was made by relays of students. It was easy enough to shut oflF the
circulation during compression, but the eflFort was made during the
night and I could not be present at the trial, and the result was not satis-
factory. The next morning I found there was still more or less pul-
sation iq the artery, which increased during the day, and the pulsation
the day following was fully as strong as before. There appeared to
be some hardening, however, in the aneurism, and evidently a partial
clot had formed. Two weeks ago last Monday I ligated the femoral
artery at the apex of Scarpa's triangle, perhaps a little lower down,
pulling outward the sartorious muscle, getting within five and a half
inches of Poupart's ligament. It so happened that the nurse in pre-
paring the patient for operation understood that the operation was to be

• Stenoflrraphically reported for this journal by C. C. Mapes, Louisville, Ky.



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128 The American Practitioner and News.

done in the popliteal space and only prepared that space, so when I
came to ligate the vessel after the patient was anesthetized and on
the table, I found the field had not been properly prepared. The result
of this was the development of a small stitch-hole abscess, which
showed probably a tablespoonful of pus in four or five days. This has
now closed. The patient would be able to walk about the ward,
although it is not yet three weeks since the operation was done. He
is not allowed to do this, but is able to get out of bed on the commode
or sit in a chair without any trouble. There is about half an inch dif-
ference in the size of the foot by measurement across the toes and over
the ankle. He has no pain, and his general condition is entirely satis-
factory. In this case there was a history of syphilis. In two of the
other cases in which this form of aneurism appeared there was also a
history of syphilis. Whether this had any bearing upon the successful
treatment by compression I am unable to say. It is certainly diflScult
to get a satisfactory history of syphilis in the colored man, because he
pays very little attention to the initial lesion, the eruption, etc., and he
is prone to deny that he has had any thing of a serious nature. Still, in
the last case mentioned there was a distinct history of the initial lesion,
although he denied ever having had a secondary eruption ; he had,
moreover, taken a course of anti-syphilitic treatment. In the fourth
case there was no attempt made at compression. In none of these
cases was there a tumor of any great size, not larger, perhaps, than a
double fist, and in the fourth case I made no attempt at compression,
but applied a ligature. All of them have gotten well without any
trouble ; the tumor in each instance has completely gone or was greatly
lessened in size at the time the patient passed from observation. I
have not heard of any of the three cases in a year or more. I do not
know, of course, that they are entirely well, but there is every reason to
suppose they had no recurrence.

With respect to the safety of this treatment, my experience has
been like that of Dr. Roberts, viz., it is attended with little or no dif-
ficulty, and the result is eminently satisfactory. I think excision is not
usually approved by surgeons for small aneurisms ; in those of greater
size, where there is the risk of considerable clot, and greater danger
perhaps of infection, it is perhaps an appropriate step to attempt
excision of the aneurism, but the traumatism of such a step is greater
than that of simple ligation. I think I am not mistaken in saying the
voice of the general profession is against the excision of aneurisms of



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The American Practitioner and News, 129

moderate size ; but in those like Dr. Roberts described, where there is
likelihood of considerable clot, greater risk. of septic infection, the



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