With the exception of the skin, which is frequently a serious obstacle to the proper correction of the deformity, a dexterous operator may divide subcutaneously all the structures that are divided in the open operation, but the great danger of adopting the subcutaneous method is that something may be left intact that should be cut to obtain the end desired. After lowering the heel by section of the tendo Achilles and severing the posterior ligament of the ankle-joint if necessary, the surgeon is confronted with the task of turning that part of the foot in front of the mediotarsal joint outward and bringing the plantar surface downward. To accomplish this it is necesarry to divide certain structures which offer resistance, and even after all the structures are severed which are advised to be cut in the Phelps' operation, there is still strong resistance to the correction of the deformity. Those who possess the necessary instruments, such as the Grattan osteoclast or some other variety of wrench, can by main force complete the rectifying process by tearing the resisting structures, but this is done at the expense of a great deal of crushing of the foot and consequently a much longer time is required for recovery. I have for some years taught my classes that the open operation would prove a failure in their hands if their incision did not open up the mediotarsal joint; that it will not suffice to sever only those structures which text-books advise should be cut in that operation; that we must cut the astragaloscaphoid ligament and in some severe cases the plantar ligaments also. Unless this is done the anterior part of the foot is brought around with difficulty, and when the splints are removed the foot will be apt to relapse into its vicious position. It is of the utmost importance that the incision in the mediotarsal joint should be continued until, if necessary, we reach the outer border of the flexor brevis digitorum muscle, when it should stop in order to avoid severing the external plantar artery. If resistance still offers, the remaining structures can readily be broken with the hand. When the wedge of new tissue is interposed between the bones forming the inner half of the mediotarsal articulation it is almost an impossibility for the deformity to recur. If the patient has arrived at the walking period, it has been my observation that it is not necessary to keep him under observation for the ordinary length of time-several years. The weight of the body in that case helps to keep the member in the corrected position so that the patient can safely be dismissed shortly after the deformity has been corrected. The ordinary methods for developing the weakened muscles should be resorted to and those will be found to be much more effectual if the foot can be trusted to retain its place without the application of mechanical appliances. When I discharge my patients after operating by the open method, I have for some years been able to get along with an ordinary shoe, and my relapses have been very few. I have seen an operation done in which the operator thought he was performing the Phelps' operation, wherein the heel was not sufficiently brought down after section of the tendo Achilles when the deltoid and astragaloscaphoid ligaments were not cut and when an effort was made to bring the foot around to the corrected position after only the tendo Achilles, anterior and posterior tibial tendons, and the abductor pollicis muscle were severed. In such cases, as the foot is brought around with a great deal of difficulty, the deformity cannot be overcorrected as it should be, and after the dressings are removed it is sure to recur. After an operation performed in this manner I have seen feet relapse before the plaster was dry. Many objections have been urged against the open operation among which may be mentioned, the fear of the occurrence of flat-foot, the danger of the skin at the edges of the wound rolling in and leaving a painful condition, and the existence of a tender scar after granulation has taken place. All these objections in my cases have been found groundless. When relapses occur it will usually be found that the open operation has been improperly performed; some of the resisting structures have been left intact. Some surgeons have been profuse in denouncing the open operation on general principles, but I doubt if they are prepared to offer us anyhing better or more effectual. THE MANAGEMENT OF TRACHOMA.* BY CHARLES H. BAKER, M. D., BAY CITY, MICHIGAN, TRACHOMA is a contagious disorder of the eyes produced by a microorganism, the growth of which causes the development of rounded granules in the conjunctiva. That the disease is contagious is undeniable. Its presence so often among soldiers crowded in barracks; lumbermen in camps; inmates of almshouses; and among members of a family, from using the same towels and basins and beds, proves this assertion. SATTLER claimed to have discovered a diplococcus smaller than the gonococcus, both in the granules and in the secretion, which in a pure culture would produce the disease in human eyes. His theories, though denied by some, have been confirmed by many good observers; and treatment, applied in accordance with the discovery of this investigator, has proven most successful in controlling the disease. There is much variation in the descriptions and divisions of trachoma as made by different authors. Some make two general classes, follicular conjunctivitis and trachoma proper, claiming that the different results of treatment under the old methods demonstrate two distinct affections; others subdivide still farther and describe different stages of the same disease which may be either acute or chronic from the first. A complete description of the clinical appearances of trachoma may be found in any general work on diseases of the eye, and the only reason for discussing the etiology and diagnosis in the present article is that the difference and the reasons for the different management may be apparent. Treatment, according to many early and some late writers, is of two kinds; first, soothing, applicable in the acute stage and in exacerbation, to allay irritation and reduce excessive inflammation; and second, stimulating, suited to the chronic stage, for the purpose of inciting sufficient inflammation to cause absorption of the granulations through the lymph channels and the blood. According to the newer theory of a direct contagious element, antiseptic treatment is required, and therefore, each case should be managed on the principle of securing removal of the irritative cause, after which the conjunctivæ should be thoroughly disinfected. The whole matter is thus simplified. Trachoma is only one disease, and may be either acute or chronic. It is of germ origin and consequently requires antiseptic treatment. In the acute stage pain and smarting can be relieved by the use of a two to four per cent. collyrium of cocain and boric acid, being careful to use crystallized cocain hydrochlorate. The collyrium tends to shorten * Prepared for the BAY COUNTY MEDICAL SOCIETY. this stage, both by the mild antiseptic and astringent action of the boric acid and by the contracting effect of the cocain on the engorged bloodvessels. The patient may also apply to the lids a saturated solution of boric acid-either very hot or very cold. Once daily the surgeon should evert the lids and apply to the conjunctiva with considerable friction a solution of chlorid of mercury, one to one thousand or one to six hundred strong. A pledget of cotton twisted on an applicator is best for this purpose, absorbing the excess with another damp pledget. Excessive pain will be prevented if an eight per cent. cocain solution is dropped into the eye before the application of the sublimate. The friction, if sufficiently forcible, will in this stage usually cause a slight capillary oozing which is beneficial for reducing congestion. Before granulations have distinctly formed this is all the treatment necessary and prompt results may be confidently expected in six to twelve days. Some cases will pass into the chronic stage in spite of remedial measures, and together with those first seen in this stage will be considered under the second division of treatment. The presence of distinct granules in the conjunctiva marks the advent of this stage, whether it is the sole pathologic change, or the disease has advanced until cicatrices have formed or papillary enlargements occur, or there is pannus, blepharospasm, et cetera. The granules, which are nests of germs, must be emptied. Several methods are in vogue for this purpose, as picking open with a broad needle, thermo- or galvanocauterization, scrubbing with a stiff brush, grattage, and expression with the finger nails or with different kinds of forceps. Whatever method is employed for emptying the granules this must be thoroughly done. After having tried the various processes the writer has found Knapp's roller forceps the best, both because of the possibility of reaching all the granules and because general anesthesia is not required. The conjunctiva is well anesthetized with an eight per cent. cocain solution and the contents of all the granules evacuated, paying especial attention to the retrotarsal fold, the angles of the lids and the lower culdesac. As soon as emptied, scrub the lids thoroughly with cotton twisted on a probe and saturated with a one to three hundred solution of bichlorid of mercury, removing the excess with a moist pledget There is seldom much reaction from this strong solutionsuch as occurs being controlled by cold compress and bathing. patients, however, declare on their next visit that their eyes have not been so well for weeks. For the next week or ten days, the everted lids are scrubbed daily with one to six hundred bichlorid solutions, the patient using the cocain and boric acid collyrium, before mentioned, to control irritation. Except in severely complicated cases, the above treatment perfects a cure in two to three weeks. Sometimes expression must be resorted to a second or third time-in fact, as often as granules occur. Most The promptness with which severe pannus and papillary thickening of the conjunctiva usually disappear under this management is a revelation to one who is only familiar with the slow improvement obtained by the use of nitrate of silver, sulphate of copper, lead, tannic acid, et cetera. Since adopting the bichlorid treatment with expression, the writer has almost abandoned the use of silver and has totally given up copper, lead, tannin or zinc in the treatment of trachoma. CRAPO BLOCK. THE ETIOLOGY AND RATIONAL TREATMENT OF DISEASE.* BY GEORGE B. MCCALLUM, M. D., MONROE, MICHIGAN. (published in Che Physician and Surgeon EXCLUSIVELY) ANYONE Conversant with the practice of medicine will not deny the fact that wonderful advancements have been made in therapeutics in the last one hundred years. More real advancement has been made during this time than in any thousand years before. Even the laity know and speak of this. It would take but a few moments to convince the most skeptical. We cannot fail to notice the fact that all this has tended toward the elucidation of etiology and the simplification of treatment. In the centuries gone by little was known of the causes of disease, and that which was believed to be a fact was the result of the wildest speculation and the treatment was crude and often did more injury to the system than the disease itself. In the first part of the century JENNER discovered and introduced vaccination, an almost certain preventative of smallpox, that fell destroyer which well-nigh depopulated England and the Continent of Europe again and again. From 1844 to 1847, we note the introduction in order of nitrous oxide, sulphuric ether and chloroform as general anesthetics, and who can estimate the pain and suffering which their use has prevented? In 1871, SIR JOSEPH LISTER introduced to the profession his antiseptic treatment of wounds by carbolic gauze and spray, which gave birth to a new era in surgery. Among the remedies introduced to the profession in 1870, we may mention eucalyptus globulus, cocoa, grindelia robusta, yerba santa, rhamnus prushiana (cascara sagrada), berberis aquafolium, kava kava, jaborandi, Jamaica dogwood, and manaca, many of which have become invaluable in the treatment of different diseases. In 1883, antipyrin was prepared by L. KNORR, and soon came into general use. This was the first of the coal-tar products. It was followed in rapid succession by acetanilid in 1886, phenacetin in 1887, and sulphonol in 1888. It is almost impossible to estimate the benefits derived from these drugs in the relief of pain, fever and sleeplessness. The effect is prompt and effective with little injury to the system if properly administered. They have nearly superseded the use of opium and its derivatives, and have placed in the hands of the physician a means of relieving pain with little danger of the formation of a drug habit. This review would not be complete without the mention of cocain, that wonderful local anesthetic that has made it possible to perform many minor operations without the production of general anesthesia, which is fraught with so much danger; and iodoform, the surgeon's tried and true friend for more than fifty years; and also salicylate of soda, that blessed boon to the rheumatic. Old remedies have been carefully studied and analyzed; many new derivatives and combinations produced; the lethal and therapeutic effects proved upon the lower animals; and every effort made to rescue materia medica and therapeutics from empiricism, and to establish these branches upon an intelligent basis. Need I take your time in trying to prove to you that this, to a great extent, has been accomplished and that the time has come when a physician prescribing a remedy for a symptom or a disease * Read before the MONROE COUNTY MEDICAL SOCIETY. can give a reason for doing so. Of course, I admit that much yet remains to be done in this line, but the work is advancing with great rapidity. Time will not permit speaking of the discoveries and advancements in physiology, pathology and sanitation, and of the x-ray. We now come to the most important discoveries of the century, which have done much to establish etiology and therapeutics upon a solid foundation. I refer to the advancement in bacteriology made during the last twenty years. In 1866, DOCTOR SALISBURY, of Cleveland, Ohio, began his microscopic researches to find the cause of malaria. This work was continued by KLEBS, and TOMASSI-CRUDELI who made announcements in 1879. LAVERAN, in 1881, published the discovery of what he called osicillaria. malaria, which proved to be the true cause of malaria. It is now called malaria plasmodium, and is a protozoa found in the blood of those suffering from malarial fever. In the same year EBERTH, of Zurich, described the typhoid bacillus. The following year DOCTOR KOCH, of Berlin, first described the bacilli tuberculosi, the cause of lupus, scrofula and tuberculosis. In 1883, the Klebs-Loeffler bacillus, the cause of true diphtheria was observed by LOEFFLER and described by KLEBS. In the same year DOCTOR KOCH announced his discovery of the comma bacillus, the bacillus of Asiatic cholera. The discovery of the bacillus of tetanus was anuounced by RESENBACH, described by M. BONOME and isolated by GIORDANI in 1887. This was followed by the discovery of the plague bacillus by KITASATO and YERSIN in 1894, and by the bacillus of yellow fever, in 1897, by SANARELLI. Similar discoveries have been made pertaining to pneumonia, bronchitis, influenza, dysentery, scarlet fever, measles and smallpox. In. fact, almost every diseased process in the system is now attributed to a microbe. Having established the fact that the cause of almost every disease is a microbe, it would seem as if all that remains to be done in regard to treatment is to discover some remedy which, when administered, will cause the death of that particular microbe, whatever it be, without injury to the system. To all appearances this goal has been reached in diphtheria by the discovery of the fact that the serum of the blood of a horse that has been repeatedly inoculated with diphtheria toxin, if injected under the skin of a patient suffering from diphtheria will arrest the disease, and if injected before the disease has begun will prevent it. This has been established clinically beyond all controversy. Similar efforts have been made with reference to other diseases and with results which, though encouraging, fall far short of the brilliant results of diphtheria antitoxin. Most physicians, however, believe that we have struck a vein which will finally lead to that long-sought goal-the establishment of etiology and treatment upon a rational basis. Far be it from me to belittle in any way these researches and the results of these wonderful discoveries. Those who have been laboring in this direction have been abundantly rewarded for all their efforts by present results. Their names will be handed down to posterity, written high on the pinnacle of fame, and the indications are that their efforts will be crowned with still greater success in the future. There is another view of etiology and treatment, which promises to yield abundant fruit to those who will develop it. The real causes of disease are not from without but from within. The system must be reduced by some other cause before the deadly microbes can begin their |