attendance

ordinary upon the sick does not affect the attendants. I admit this fact, but the attendance is not so prolonged, nor so close as in families. Let any one who has doubt about the clinical evidence bearing upon this point read the little brochure of Webb. The fact is that tuberculosis is so common with us, that we have almost ceased looking for the immediate cause in any case, especially if relationship gives us a chance to attach the blame to heredity. I believe, however, that there are hundreds who have by inheritance that peculiarity of pulmonary soil which favors the development of the tubercular disease, who would not show it unless they were brought into contact with those already affected. Whether all cases require such a transmission of germ we do not know.

In what manner is it probable that the disease is communicated? It has been claimed that bacilli have been found in the breath; but it is, perhaps, more probable that the communication in most cases is by dried sputum, which becomes diffused in the atmosphere. We have abundant proof that tuberculosis can be readily communicated to animals little liable to it, for example dogs, by causing them to inhale for an hour or two a day an atomized solution of the sputa of tuberculous patients. (See the experiments of Tappeiner and others in substantiation of this statement).

So then, I say that the appearance of tuberculosis of the lungs in countries where it was previously unknown, with the ingress of people from countries where it was common, the marked increase in the disease in the neighborhood of health-stations resorted to by the tuberculous, the personal history of the development of cases in our midst, and experimental work with the sputa, all point strongly to the probable communication of the disease under favorable conditions, and make it not only incumbent upon us, in case of pulmonary tuberculosis in a family, to establish precautions against communication of the disease, but makes us criminally negligent in failing to do so.

These

What precautions shall we take? pertain (1) to the patient ;(2) to the quarters he occupies; and (3) to the exposed attendant.

The patient should be made careful in the disposal of his sputa, either to deposit them in a cup in which some germicide has been placed, or if the patient is feeble and obliged to use cloths let them be destroyed before any drying occurs. It would hardly seem to be necessary to warn respectable patients not to spit about them carelessly, yet I have seen with respectable people the most utter indifference in this regard. I have seen a patient with hemoptysis lying in bed on his back letting fly his expectoration in every direction, so that the bedding, floor, aud walls of the room were well covered with sputa. I have seen a beautiful prima donna of the opera spit right and left over a handsome hotel carpet. Neither of these patients was American. I have, however, seen an American, a distingushed citizen, afterwards United States Minister to one of the European Courts, sit in the office of a distinguished consultant, aud squirt a sickly stream of tobacco-juice between his teeth, over a fine straw carpeting just laid.

For disinfection of the spit-cups, Dr. Ernst informs me that a five per cent. solution of carbolic acid is the best. Corrosive sublimate does not answer, as it coagulates mucin, and does not reach the bacilli at all.

In regard to the room we should secure change of air by every known device, and as long as possible by a daily removal of the patient from his room, for the purpose of thorough ventilation. Clothing and bed-linen should be frequently changed. The absolute value of antiseptic sprays for the room in such cases we know not, and the use of these which are offensive in themselves should not be recommended. But such as are pleasant to the patient and attendant would be of service at least in counteracting the disagreeable odor which attends the last stages of pulmonary disease.

In regard to the exposed persons, let it be said that from the moment tubercular disease is dis

covered, another person should not occupy the same bed, not only for the sake of the exposed person, but also that of the patient, who will rest much more comfortably alone. Sleeping in the same room should also be forbidden, as we seem to be more susceptible to all infectious diseases during sleep. The attendant should have daily exercise in the open air, and, if a relative, an occasional complete change, if possible. In case of any failure in health, this should be insisted upon, and although the physician cannot always prevent self-sacrifice on the part of friends, he can often modify it. At any rate he should not feel that relief of his patient was his only duty, but that his duty extended to the surroundings of his patient, and required that these should be arranged with due regard to the protection of relatives and friends.

If there is any decided hereditary tendency to the disease, relatives should, if possible, be prevented from any attendance upon the sick, and at once put upon proper hygiene.

ORIGINAL ARTICLES.

CYSTIC ENLARGEMENT OF THE VULVO. VAGINAL GLAND.

BY B. F. BAER, M. D.

This case is specially interesting because of the size of the tumor, and of a mistaken diagnosis which had been made.

The patient, thirty-six years of age, married, but sterile, presented herself at the Polyclinic, and stated that she had "a rupture which would not go back," although she had been kept upon her back as long as two days at a time, and had been bandaged and compressed until she could no longer endure the suffering. Truss after truss had also been adjusted, but all to no purpose. On inquiry, it was learned that, about one year before coming under ob servation, she noticed a small lump near the posterior commissure of the vulva, correspond ing with the location of the vulvo-vaginal gland. It was painless, and gradually increased from below upward. At the time

she presented herself it was as large as a duck's egg. During the first nine month's of its presence it produced no symptoms, except slight inconvenience from the swelling, but about three months before coming under my notice the tumor began to occasion difficulty on account of its size, and the friction produced in walking, and from a most interesting symptom, namely, obstruction to the flow of urine. During the act of micturition the urine would flow regularly for a short time, and then it would suddenly cease, to be followed by great pain. By an effort she could again start the flow, and then it would again abruptly stop. During the last few months, the tumor had so increased in size as to approach the symphysis pubis.

On examination, I found an elastic tumor making compression upon the urethra, and the mechanical interference was at once explained. When the bladder became full, the effort to empty the organ overcame the obstruction from pressure of the mass for a time, but as soon as the straining ceased the urethra would be again suddenly closed by the tumor. It required considerable force to displace the tumor so as to see the urethra. The tumor was not tender on pressure, and there were no signs of inflammatory action about it. There was marked fluctuation, and its size was not affected when the patient was in the recumbent position. The inguinal canal was empty, and there was nothing in the shape or character of the tumor which would indicate that it contained intestine. The diagnosis lay between hernia and hydrocele of the labium major, both of which are exceedingly rare, and abscess or cystic enlargement of the vulvo vaginal gland, although the tumor was much larger than any I had ever seen from the latter cause. I advised its removal by extirpation, because my previous experience in the treatment of this disease has taught me that radical measures are necessary. The patient entered the hospital,and in the presence of the Polyclinic class I proceeded to operate. An incision was made at the lower and inner surface of the tumor, my intention being to try to enucleate it entire.

But the cyst was ruptured by the effort, and a yellowish fluid escaped, of the consistency of thick cream, but without odor. I next passed my finger within the collapsed sac, and found that it occupied a very extended surface-from the upper portion of the labium down to the ischio rectal space. The secreting surface or membrane was very thick. It was not likely, therefore, that anything short of removal of the gland would effect a per

manent cure.

This has been my experience with these cases, as I have said. But hemorrhage is sometimes great, and this has caused most authors to advise simply evacuation of the fluid, and injection or packing with iodine, or some other agent, to destroy the surface. It will be remembered that the gland is in close relation with the transverse perineal artery below, and with the bulb of the vestibule at its upper extremity. When, however, the organ is diseased and hypertrophied, the blood vessels become greatly enlarged, as during pregnancy, making this locality much more vascular. Then the gland, as the result of its increased size, extends much further up, and becomes surrounded by the network of veins called the bulb of the vestibule, and there is closer contact with the vessels at the lower surface of the gland.

In pursuance of my original plan, I endeavored to separate the sac from its close attachments with the handle of the scalpel; but this I was unable to do, and I was compelled to dissect it out with the edge of the knife. The extent of surface was much greater than I had anticipated even, and the hemorrhage very considerable; that from the arteries was controlled by ligation, but I found great difficulty in checking the venous. Hot water and compression failed, and I was finally compelled to pack the cavity with pledgets of cotton saturated with Monsel's iron, and supplement this with pressure supplied by vaginal tanpon and with a compress held in position by means of a "T" bandage. The dress. ing was permitted to remain in position twenty-four hours (there being no untoward symptoms), when the bandage and compress

were removed. I now ordered the constant application of lead-water and laudanum, which gave great comfort, as the parts were hot and somewhat swollen. Very little pain was complained of, however.

The next day a part of the packing was removed, and a little more each day after-as much as came away easily. Irrigation with carbolized water every four hours, and the constant application of the lead water and laudanum, constituted the after-treatment. At the end of a week the last pledget of packing came away, and in another week the patient left the hospital, the wound having almost entirely healed. I was much gratified with the rapid recovery, for I feared that there might be extensive sloughing and granulation.

The operation occurred some months ago. The patient is entirely cured.

In simple retention cysts I have succeeded in curing the case by incision and packing. In abscess of this gland, treatment of that kind will usually be sufficient. One word in regard to the cause of these cysts. In the present case I do not know the cause. A common cause is injury from coition or from child-birth, the former most commanly. It sometimes occurs as a result of the first coition. There is no doubt that some of the cases have a gonorrheal origin, but I do not believe that this cause is as common as is often stated.

PYOPNEUMOTHORAX OF NINE MONTHS' DURATION.

BY DR. JUDSON DALAND.

Through the kindness of Dr. Osler I am able to present this case to-night.

John L, æt., thirty-two, printer, single. Father died suddenly at the age of thirty-six, cause unknown. Mother died at fifty-nine of valvular disease of the heart. An only brother, aged thirty-four, living and well. Two maternal aunts died of phthisis. No other case of phthisis in the family. As a child he was always weak and nervous; was never robust. He suffered from no special

disease until the age of twenty-two, when he contracted syphilis. In 1880 he was operated upon for varicocele, and from that time until 1885 suffered from repeated attacks of articular rheumatism. About this time the removal of a corn from the ball of the left foot was followed by an abscess, which discharged a tablespoonful of pus daily for four months, and healing was not completeed until six months later.

In the midst of apparent good health, his present trouble began abruptly in January, 1885, with huskiness of the voice; slight dry cough soon becoming frequent, and accompanied by mucous expectoration. Two weeks after the appearance of the cough he was awakened from sleep by a pulmonary hemorrhage, which continued more or less for a month, and then gradually decreased in frequency until July, 1885, since which time they have occurred only at long intervals. These attacks of hemoptysis would vary in frequency from four daily to one in two weeks; and in amount, from one to eight ounces. During this time he continued at work, though he noticed that it excited renewed attacks of bleeding, as would also the act of stooping to the floor.

About October 17, 1885, he suddenly experienced severe pain in the right chest, with cough and high fever, intense orthopnea, etc. The shortness of breath moderated, and the pain disappeared in two weeks, but he was confined to his bed for three months.

When admitted to the University Hospital, March 12 1886, he was markedly emaciated, having lost twenty-two pounds during the previous eight months. The chest presented a remarkable prominence, composed chiefly of the second piece of the sternum and attached cartilages. Immediately below the prominence there is a deep depression. This deformity has nothing to do with his present trouble, as it has existed from infancy. The apex beat is diffused, and can be plainly seen and felt in the seventh intercostal space in the midaxillary line. Respirations are chiefly thoracic; expansion over upper part of right chest scarcely visible, and is absent at the

base; over left base the expansion is increased. The thorax is long and narrow; intercostal spaces lessened; ribs more oblique, and in places overlapping; inferior costal angle acute. Vocal fremitus normal over left lung, dimin. ished over right upper lobe, and abolished at base. Percussion note over right chest tympanitic down to the nipple, below which there is dulness. The recumbent position will lower the upper line of dulness four inches. All over the left lung the note on percussion is hyper-resonant. Auscultation of right chest shows well-marked metallic phenomena, namely, occasional metallic tinkling, amphoric breath sounds, amphoric echo of cough and voice, Hippocratic succussion splash, and bell tympany. All over the left lung a greatly exaggerated respiratory murmur can be heard. The liver is displaced downward, and the heart to the left. A musical systolic murmur can be distictly heard all over the precordia, and is carried to left. Since then the heart has returned almost to its normal position, and this murmur has disappeared.

On the 21st,of March, 1886, the dyspnea became more marked, temperature 101° F., and severe pain referred to the depression in the lower part of the chest. The expectoration of eight ounces of blood seemed to give partial relief. The next day sixty-eight ounces of sero-pus were withdrawn by aspiration, with immediate relief to the breathing. In January, 1887, ten ounces more were removed, and in March an equal amount of pure pus was obtained. It required just one year for the sero-pus to become pure pus. Careful percussion immediately after the operation, and repeated again the following day, failed to show any lowering of the upper level of the dulness. After the last thoracentesis, about two weeks ago, when ten ounces of pus were again removed, it was noted that the upper level of the liquid fell one inch. A few hours later subcutaneous emphysema occurred around the puncture and spread over most of the right chest. This was due to the escape of gas from the pneumothorax.

Comparing his condition now with what it was fifteen months ago, it would seem that

the dyspnea is less, that the chest has retrated, and that the amount of liquid is less. This opinion is based on the fact that the heart and liver have returned almost to their normal position. The sputum is chiefly mucus or muco-purulent, small in amount, and contains a few bacilli. ·

From a careful study of the symptoma tology and sputum,it would seem that this patient at first had phthisis of the right lung, and that ulceration into the pleural cavity occurred in October, 1886; this was followed by pneu. mothorax, which quickly became a hydropneumothorax, and he now has a pyopneumothorax with a pulmonary fistula.

The slowness of the change from serum to pus is very unusual, and the absence of hectic fever is probably due to an altered condition of the pleura, rendering it non-absorbent. The recurrence of subcutaneous emphysema after thoracentesis is rather uncommon, and the disappearance of the musical systolic murmur is very interesting.

All authors upon this subject are of the opinion that in from sixty to eighty per cent. of all cases the cause of this condition is phthisis, and next in frequency stands emphy. sema. The other possible causes, such as gangrene, emphysema, rupture of subpleural abscess, are of such rare occurrence that they may be considered medical curiosities.

I beg leave to ask the following question: In view of the probable phthisical condition of the compressed lung what would be the best treatment?

The patient referred to is in an adjoining room, where I shall be glad to demonstrate the physical signs to any one interested.

-The craze for obstructing research on the grounds of cruelty to animals, is crossing the ocean and afflicting our own shores. Dr. Leo Sommer, although having the sanction of the mayor and Board of Health to experiment upon the dogs in the New York city pound with hydrophobic inoculation, was prevented from so doing by the agents of the society for the prevention of cruelty to animals. We must be Anglo-maniacs, even in respect to dogs.

1. There are three different theories in regard to ovulation and menstruation: (a) That ovulation is under the dependence of menstruation; (b) that menstruation is under the dependence of ovulation; (c) that they are both under the dependence of the central nervous system. No matter what may be our opinion, there are certain facts that must be admitted. Menstruation is a function that has a periodical return, and ovulation does not of necessity follow it; it is independent of menstruation. This is based on clinical and anatomical facts. Leopold's work is based on the examination of ovaries taken from women who died during their menstrual periods, and he saw that he could always find Graafian follicles about to break or else already broken. The same observation was made by Lawson Tait, who operated between the monthly periods. M. Porak has given