SURGERY. UNDER CHARGE OF W. B. ROGERS, M.D. Professor of the Principles and Practice of Surgery and Clinical Surgery, Prostatic Irritability and Enlargement-A Sequence of the Hemorrhoidal State. Jelks (Med. Times, vol. 27, no. 1) says our experience with prostatic troubles, and our attempts to relieve or ameliorate, be the procedures however mild or radical in their nature, have been met with uniformly unsatisfactory results, save the small number which have survived most formidable operations. He then reports three cases operated by him, in which prostatic irritability and enlargement was relieved by the operation for hemorrhoids. The first of these occurred in a man aged 35, who had suffered several years with obstinate constipation, hemorrhoids, and an enlarged and irritable prostate. Thorough dilatation of the bowel displayed a number of hemorrhoids in a more or less inflamed state. One of these, the last tied off, was at the base of the prostate, and the tie taken upon it was the signal of a marked nervous shock. Operation entirely relieved this patient of all symptoms of prostate or rectal troubles, and of their attendant symptoms and sequelæ. A second case was that of a man aged 60, who had suffered for a number of years with enlarged prostate. Dilatation of bowel revealed numerous pile tumors in a varying state of inflammation. One of these was a large, red tumor under the base of the enlarged prostate. The tie taken upon the tumor was a signal of a marked influence on the nervous system, although the patient was apparently thoroughly etherized. Patient duly recovered, and has since been greatly relieved of all his trouble. A third and similar case was also relieved by operation. In order to elucidate the important rôle played in the causation and aggravation of symptoms in and about the rectum and its contiguous organs, Jelks appends to his report the following brief review of anatomical relationship: The blood supply is derived from: first, superior hemorrhoidal, a branch of the inferior hemorrhoidal; primary and secondary, branches of internal iliac, which supply the chief amount of blood to all the pelvic viscera. The inferior hemorrhoidal, which is a branch from the internal pudic, passes across ischio-rectal fossa, supplies lower part of rectum, bladder, prostate, perineum and external genitalia. The veins, superior and inferior hemorrhoidal plexuses, anastomose freely with vesico-prostatic nerve supply. This being abundant, is derived from the hypogastric plexus of sympathetic, also a direct supply from fourth anterior sacral nerve, the only part of the alimentary tract supplied direct from spinal system; thus is explained the great irritability and sensibility of this part. The sphincter being supplied from more sources than any other muscle of the body, derives nerve supply from pudic, fourth sacral, and posterior sacral nerve; hence, "in the male, pain in the bladder, penis, urethra, scrotum and prostate may be directly traceable to the rectum as their source." The author says that he does not know that the prostate in any one of these cases has been materially reduced in size, but that the relief of symptoms, and restoration to an apparent normal state of affairs in them, would seem sufficient evidence of the rationale of the procedures referred to, where the hemorrhoids and rectal irritation coexist, having before our mind's eye the intimate relationship (anatomical), the irritant surface, and leading therefrom to the nerve centers, the afferent nerve supply, and thence through the afferent nerves, distributed to the first named, and sympathizing parts or organs. Muscles, nerves, and vessels, each claiming due recognition of importance, while the effect of pressure alone exercised by these tumors upon contiguous parts, should not be lost sight of. Abscess of the Appendix Discharging Through the Umbilicus. Wyeth (Med. Record, vol. 55, no. 2), on account of the rarity with which abscess resulting from appendicitis opens through the umbilicus, reports the following case: M. S., male, 34 years of age, was admitted to the Polyclinic Hospital, September 27, 1898. Three months before admission he had suffered a very severe pain in the right iliac region, the pain radiating toward the umbilicus. This pain lasted about ten days, when the symptoms subsided so entirely that he considered himself in perfect health. About the 10th of September he was again seized with a similar attack which was somewhat more severe than the first. There was great and persistent pain over the abdomen and up as high as the navel, accompanied by high temperatures and several well-marked chills evidently due to septic infection. In three or four days a hard swelling was felt at and to the right of the umbilicus. The patient was at this time seized with vomiting and had also a well-marked diarrhoea. When admitted to the hospital his oral temperature was 103° F.; pulse 100. There was marked tenderness over the central and right lower portions of the abdomen, which was slightly distended. The integument in and immediately about the navel was red and doughy on palpation. Wyeth saw him for the first time on September 30th, and recognized what was believed to be a suppurative appendicitis, the abscess cavity of which was pointing at the umbilicus, through which there was a very slight discharge of pus. Introducing a probe, it passed into the cavity of the abscess. The patient was put under an anesthetic and an incision made, which gave discharge to quite a quantity of pus and to two or three small hard fecal concretions or enteroliths, such as are not infrequently found in the appendix. The subsequent history of this case as far as the appendicitis was concerned was uninteresting. His condition improved to such an extent that on October 10th, at his request, he was discharged, as he desired to spend his convalescence at his home in New York. Just as he was walking out of the building he suffered the rupture of a vessel in the brain and died quite suddenly from compression of the brain. The gangrenous stump of the appendix was found in the abscess cavity which had opened through the navel. OPHTHALMOLOGY. UNDER CHARGE OF A. G. SINCLAIR, M.D. Professor of Diseases of the Eye, Ear and Throat, Memphis Hospital Medical College ; Ophthalmic, Aural and Laryngeal Surgeon to St. Joseph's Hospital, Memphis, Tenn. The Ocular Symptoms of Hysteria and Nervousness in Children. Saenger (Die Ophth. Klinik) spoke before the Medical Society of Hamburg upon hysteria and nervousness in children, in which he laid stress upon the ocular symptoms and their relation to functional nervous disturbances. He distinguished three groups of nervous disease in children, and in all found certain symptoms in the organ of vision. 1. Neurasthenia. Out of 30,759 cases of eye disease from the polyclinic, there were 1029 children with nervous asthenopia, which is not often recognized and often remains the principal symptom. Conjunctival or accommodative asthenopia has nothing to do with this. It does not come from central origin, but may be more often referred to retinal causes which are connected with a deficient nutrition and lessening of the visual substance, as has been shown by Wildbrand. 2. Hysteria. Blepharospasm of long duration, without appreciable eye affection, may occur in this condition, which may sometimes show as a form of ptosis. Hysteric ptosis is common enough, but hysteric amaurosis is less common. 3. The Combination of Neurasthenic and Hysteric Conditions. In children this group shows itself ordinarily in connection with photophobia and weakness of the eye for near point, pain, etc., diminished visual acuity, and concentric contraction of the field of vision; also a neurasthenia of the eye, which Michael has called hysteric stigmata. The causes of these symptoms in children between 10 and 14 years of age are seen by Saenger to be in too much forcing work at school, poor hygienic surroundings, in anemic children of the poorer classes. These ocu lar symptoms are plain, as the eye is one of the first organs affected.—[Ann. Oph. Hysteria Combined with Reflex Paralysis of the Pupil. Oppenheim (Zeitsch. f. Pract. Aerzte) says that there have been few cases in which, during an hysterical attack, paralysis of the pupil has been observed. Cases are more rare in which this symptom appears with the attack. In all of these cases the paralysis of the pupil has disappeared. In Oppenheim's case it has remained for fifteen years, and should not be denominated hysterical, as fifteen years before the patient had brain syphilis, which was cured by inunction. This case is especially interesting, as since this time this person has had no further indications of syphilis. Amblyopia aud Amaurosis in Pregnancy, Labor and Childbed. Silex (Monatsch. f. Geburtshülfe v. Gynekologie) has never seen pure amblyopia caused by pregnancy, and has found no case in the literature free from doubt. The amaurosis of pregnancy, etc., is most commonly due to uremia following acute nephritis or disease of the kidney of pregnancy, and is a toxic symptom. Albumin alone is seldom found without conscious changes. Amaurosis of an hysterical, epileptiform and apoplectic nature is likewise rare. In five out of six cases of amaurosis observed by Silex, there usually remained a pupillary reaction to light. The arteries were not narrowed. This is contrary to the angiospartic theory of eclampsia. The prognosis of pupillary paralysis is favorable. If the visual acuity does not return soon to normal after an uremic attack with amaurosis, there is likely to be complicating retinitis. This retinitis. may readily return during a following pregnancy. Silex had not seen such a return of the amaurosis in any of his cases, but it has been observed by other authors. The treatment of the amaurosis is that of the eclampsia and retinitis.. Atropin Conjunctivitis. Mark (Budapester Med. Chir. Press) says that in Schulek's clinic the borat of atropin is used. Atropin conjunctivitis is supposed to be caused by bacteria in old solutions. Mark cites two cases from Ahlstrom, and also two original cases, in which sterile aseptic atropin solutions had caused conjunctivitis. This he ascribes to individual idiosyncrasy. He had one patient in whom one drop of atropin solution would each time produce an intense conjunctivitis. The causation, in conjunctivitis from atropin, is its effect on the vessels and nerves of the membrane, which lowers the tone of the vessels; so by this means a catarrh may arise from slight irritation. Graefe has shown that this drug produces anatomical changes, and the irritability of the conjunctiva is much greater. If the membrane is saturated with atropin, an extra drop may cause intense inflamma-tion, and this irritability may last many months. NOSE, THROAT AND EAR. UNDER CHARGE OF RICHMOND MCKINNEY, M.D., MEMPHIS. The Nature and Significance of Chronic Tonsillar Abscesses. Before the Berlin Medical Society at a recent meeting (Med. Press & Cir., vol.. 67, no. 3013), Treitel presented a paper of extraordinary interest, taking as hissubject a consideration of the nature and significance of chronic tonsillarabscesses. It was known that chronic suppuration in any part of the body constituted a danger to the whole system. Fraenkel first pointed out the danger of tonsillar abscesses. Later, cases became known where articular rheumatism had commenced in the tonsils, and a similar relation was observed with regard to other diseases, cryptogenetic pyemia, for instance. In simple angina, microorganisms, such as streptococci, might enter the blood and set up disease in a locus minoris resistantiæ. The question now arose whether pathogenic germs could pass through the tonsils without setting up local inflammation. It appeared as if this were so; at least, the local inflammation was unnoticed, according to Fraenkel, in a case where death occurred from streptococci, in which they were found in the tonsils, but without inflammation thereof. It was a question whether the intact mucous surface of the tonsils would allow them to pass, and in most cases this would be destroyed in places. Generally there was swelling of the gland, and later a tonsillar abscess which could be the starting period for general suppuration. These abscesses were usually so small as not to be dis- tinguishable during life, as they did not lead to general swelling of the tonsils. The question would often arise as to whether these abscesses were primary or secondary. In some cases, however, their primary nature was evident. The speaker then related the following case: A man, 63, had often formerly suffered from tonsillar abscesses, and more recently hoarseness and shortness of breath had come on. A few days before, difficulty of swallowing had presented itself. On examining the throat no symptoms of acute inflammation were observed. The laryngoscope showed edema of the glottis, of the arytenoid cartilage, and of the aryepiglottic folds. The troubles got worse in spite of ice and other applications. Tracheotomy was performed. A foul abscess was then discovered around the cricoid cartilage and the patient died. The autopsy revealed chronic tonsillar abscesses. As regarded treatment, this could only be prophylactic, as the small abscesses could not always be discovered. In case of recurrent inflammation he advised splitting the tonsils, and careful attention to cleanliness of the mouth. Dr. A. Fraenkel said that septicemia was a tolerably frequent disease in his wards; that the source of infection was always sought for, and but rarely found, but when found was mostly in the tonsils. During life nothing could be found in the tonsils; the center of disease was generally discovered only after death. A woman in the thirties was admitted into hospital with bad jaundice and pyemic fever. Nothing abnormal was discovered at the heart beyond a short systolic murmur. The abdomen was swollen, the liver enlarged, but nothing abnormal in the fauces. He thought it might be a case of pyelophlebitis arising from perforation of the vermiform appendix. Death took place in forty-eight hours. The autopsy showed small abscesses in the tonsils and commencing ulcerative endocarditis. In another case a pericardial effusion could be traced back to a primary tonsillar abscess. An interesting observation had been made that day. In a case of sepsis that had been diagnosed during life by examination of blood, there was a large splenic tumor and continuous fever. The incubation blood showed sepsis, streptococci in such numbers that speedy death might be expected. The autopsy showed that the point of entrance was the genital tract, following abortion. Dr. Benda objected that Treitel had grouped two things together that pathologically should be kept separate: 1. A group of infections, the point of entrance of which was often difficult to discover, as generally only a few microorganisms were formed at first, but which afterward multiplied in the circulation. 2. Actual pyemia, when a spot was always found where a thrombosis had taken place, in which the germ had developed. Fraenkel's case was one of valvular inflammation, set up by streptococci, when, as a rule, the exit point of these streptococci was difficult to determine; in that case, streptococcus thrombi were found in the small veins of the valves. |