junction with the proposed treatment. I do insist, however, that the physiologic and chemic make-up of our salines applied in the various forms of baths with the customary tub massage warrants the assertion of a pronounced speedy effect. While these baths must not be considered the paramount curative agent in the treatment of this special disease, they are at least to be regarded as a most powerful auxiliary resource in balneo-therapeutics.

The chief curative medication and the very foundation for the ultimate success in the treatment of this disease belongs to and consists in the application of well known powerful inorganic germicides and mineral alteratives in different forms of administration, assisted by surgical, mechanical, balneo-therapeutic, hygienic, dietetic and other remedial measures at our command. I refer to mercury in its various chemical composition and mechanical application. If we take into consideration the fact that we today admit the gravity of gonococcic infection with its destructive sequela and nefarious complications, and regard it quite as dangerous to health and life, and likely to produce just as severe pathologic conditions as in syphilis, we must meet and combat such a foe with the strongest and most formidable therapeutic weapons at our command. Ordinarily recognized remedies and methods may be satisfactory and sufficient in the milder cases, but in the more complicated and graver ones, in which ankylosis of the joints, atrophy and contraction of muscles, inflammation of nerves, partial paralysis, endocarditis, and locomotor ataxia threaten the health and welfare of the patient, medicines of the salicylate group, coal-tar derivatives, opiates, iron, and strychnia are only to be looked upon as skirmishers.

My first experience in the treatment of gonorrheal rheumatism with such drugs always proved unsatisfactory in severe complications, no matter how successfully the urethral involvements were controlled. If in conjunction with all these auxiliaries, mercury was too timidly administered, because of much antagonism from the profession as well as the laity, the unsatisfactory results achieved in the treatment always would awaken the thought and impress upon my mind that cell destruction must necessarily still go on in consequence of insufficient mercurial application, the same not counteracting or overcoming the destructive propensities and force of these toxic factors.

The timidity and laxity in prescribing fully and courageously these so-called powerful alteratives seems to have been instilled into the minds of many, because of the indiscriminate and empirical application of the same in former decades and even centuries, and in some medical quarters the practice still prevails, causing some practicians and clinicians to condemn and abruptly stop their use, simply in consequence of insufficient knowledge of the physiologic action and effect, a faulty comprehension of the correct application of the drug and an occasional scare pertaining to a casual idyosyncrasy, productive of a salivation, stomatitis, or alleged "bone-ache" occurring in some patients. I have yet to see, with the possible exception of about two per cent. of the patients who have been under treatment, any deleterious effects produced in the patients suffering from gonorrheal arthritis by the correct and scientific use of mercurial preparations. No disturbances of the kidneys, bladder, stomach, mouth, or other organs were observed in the patients who underwent treatment years ago and who were subsequently examined. I do not wish to state that ill effects are not possible. Those patients, however, who

were successfully treated with the addition of a course of methodical bathing escaped any of the unfortunate aftermath.

One patient under treatment some years ago for a severe gonorrheal rheumatism, involving the knee- and ankle-joints, which were partially ankylosed, thickened and swollen, having also atrophy and contractions of certain muscles, together with pain in both sciatic nerves, when it was explained to him that mercurial applications were extremely necessary with the addition of a course of methodical bathing, pleaded very earnestly and seriously that the use of mercury in former years for the cure of a syphilitic infection had caused the rheumatic conditions he was now suffering from, and that he was extremely averse to its further use, being under the impression that more of its administration would certainly stiffen him entirely. When informed that the baths would not permit any such condition, he very reluctantly consented to its application. Old indurations denoting the remnants of ulcerated syphilides made apparent the former existence of a luetic infection. Microscopic examination of the discharge from the urethra showed the presence of gonococci and convinced me of the fresh intrusion of bacteria.

The skepticism in this patient was soon buried beneath an avalanche of returning health, and within a few months all abnormal conditions of the joints, muscles, nerves, et cetera, gradually disappeared. The action of mercury seems to be mitigated in some way, when applied with the assistance of minerals baths. Very rarely do we meet with disastrous or annoying results from its application.

The treatment in general covers possibly a period of from four to twelve weeks. The result of a critical physical examination plus an analysis of the blood, urine, et cetera, governs the mode of procedure. Twelve to thirty-six mercurial inunctions of sixty grains each daily, or as many daily intramuscular injections of the bichlorid salts (varying from one-sixteenth to one-fourth grain) given at the option of the physician and consent of the patient, are recommended. Personally I prefer the inunction applied to the skin (as recommended by VON SIEGMUND) inasmuch as they do not subject the patient (who is already suffering from rheumatic and neuralgic pains) to more unnecessary torture from painful nodules, resulting from the hypodermatic method. Mineral baths are administered every day under the guidance of trained masseurs and doucheurs, who perform their duties under orders and occasional supervision. Suppurative joints are tapped or opened when it is necessary; those swollen and effused are treated palliatively and those with partial or complete ankylosis are left to nature until a greater power of resistance and return of secretory functions have been reestablished. This is facilitated by the daily bath, hepatic stimulants at bedtime, the ingestion of some saline mixture taken in the morning before breakfast, alkali treatment combined with salicylates, bitter tonics (columbo) and carminatives three or four times daily to promote assimilation and secretory action, moderate exercise if the patient is capable, fresh air and sun baths if possible, and a strict attention to a rational dietary regime individualized in conformity with chemico-physiologic laws leading to a speedy rehabilitation of the metabolism. Harm and annoyance and sometimes excruciating pains are inflicted upon patients when attempts to break up joints and lesions are inaugurated too early or at the onset of treatThe saine may be said of forcible massage. No patient with an already weakened constitution can withstand those onslaughts and severe

ment.

*

shocks extended to the organism by such unskillful treatment; and the results are generally stiff joints for the remainder of life.

All other abnormal conditions are to be carefully nursed into a healthy state, if the auxiliaries can aid in making this possible: and especial attention is paid to the treatment of the urethral tract and its various complications by such surgical, mechanical, and therapeutic means as are today recognized and promulgated by the foremost writers and clinicians, embracing the use of sterilized warm or cold steel sounds, deep urethral injections of silver salts, protargol, et cetera, enlarging the meatus, milking the prostate gland, removing sinuses, fistulas threatening the perineal and perirectal regions, the ingestion of balsamic and other palliative preparations, or at times leaving the local affection entirely alone. Tonics are also given in later stages of the treatment if deemed necessary.

That powerful sulpho-iodo-bromo-salines exert a most marked and beneficial influence in assisting to arrest and destroy these gonococcic ptomains and toxins, is evinced daily by the rapid improvements manifested in the treatment of this disease. Concerning the mode of action of mineral waters, when a body is immersed in one of these mineral baths, the skin separates two salt solutions of unequal concentration, one being the blood serum and the other the mineral water proper. According to the physical law of osmosis an equalization of these two salt solutions will be sought. The baths, through the process of absorption, supply the deficient blood salts lacking in such patients and at the same time the powerful alterative effect and action of the sulphur, iodin, bromin and other mineral ingredients also absorbed in the general circulation, tend to hasten cell proliferation and eliminate from the system all waste matter by their lymphagogic action. The stimulation also imparted to the skin, peripheral nerves, the nervous and the circulatory systems in general, while the bath is being taken, assists very materially in eventually establishing normal metabolic functions of the organisms.

CIRCULAR RUPTURE OF THE IRIS.

BY OVIDUS A. GRIFFIN, B. S., M. D., ANN ARBOR.

LATE DEMONSTRATOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF MICHIGAN.

[PUBLISHED IN The Physician and Surgeon EXCLUSIVELY)

Of late, several interesting papers have been presented reporting instances of radial iritic lacerations, but finding, aside from iridodialysis, little mention of circular ruptures of the iris in our principal works on ophthalmology, I beg to report a case of this rather unique condition.

On June 13, a man, fifty-six years of age, called at my office for treatment, presenting the following history: One year ago the patient's left eye became greatly inflamed, which, judging from the symptoms given, was a case of iritis attended by the formation of an hypopyon. He consulted a physician in a neighboring city who advised an enucleation which was performed after an interim of a few days. The operation was successful and the recovery uneventful.

About six months later, the patient's remaining eye became mildly inflamed, photophobic, and painful, especially at night. The pupil, which his daughter says was always large, now became smaller, though regular in outline. After about a week the symptoms disappeared, but returned within a month only to vanish again after a few days. During

the attacks, the patient says, his vision was variably dimmed. This periodicity of inflammation continued for six months, when a severe form developed from "catching cold", so the patient thought, though he presented evidences of a syphilitic history. Again he called upon his former physician, who diagnosed the condition as "glaucoma" and accordingly made instillations of eserine-judging from the patient's description of the medicine; for each application of the "red drops" caused intense pain and made the pupil smaller and irregular above, so his attendant observed.

The next day the patient called at my office and, upon examination, the following points were noted: Visual acuity was five-twelfths, tension slightly increased, pericorneal injection with some chemosis, iris lusterless, fresh hyperemia, pupil not responsive to direct or indirect light reflexes, irregular and elongated in the horizontal, together with a small, triangular aperture situated above nearly filled with blood-which conditions are

shown in the accompanying sketch. A large, firm posterior adhesion was present at the upper angle of the rupture and several synechiæ at the lower pupillary border. Under atropin and calomel the extensive adhesions were broken after an interim of five days. After twelve days mydriasis and physiologic doses of potassium iodid, the inflammation subsided and his vision returned nearly to normal. The iris was now allowed to resume its position, when it was found that the rupture had healed, leaving naught but an irregularity of pigmentation to mark its position.

As no history of trauma could be elicited, the damage wrought must have been due to the myotic action of the drug upon a tissue weakened and rendered friable by the long existing inflammation, as large shreds of the iris were left adherent to the anterior capsule, after the separation of

superior synechia. An interesting point in the case is the fact that one of the factors productive of the laceration was also instrumental in its repair, as the synechia above the rupture was the last to disappear, thus bringing the edges of the wound into apposition as the mydriasis progressed. 340 SOUTH STATE STREET.

TRANSACTIONS.

NORTHEASTERN DISTRICT MEDICAL SOCIETY OF MICHIGAN.

STATED MEETING, PORT HURON, JULY 25, 1901.

THE PRESIDENT, PHILLIP A. KNIGHT, M. D., IN THE CHAIR.
REPORTED BY A. HENRI COTÉ, M. D., SECRETARY.

DISCUSSION OF PAPERS.

DOCTOR SAMUEL K. SMITH read a paper entitled "Placenta Previa.” (See page 394.)

DOCTOR PLATT: The paper is instructive. It records the procedure in handling the cases that the essayist has met, and conveys an idea as to what should be done when dealing with this comparatively rare condition, although, as DOCTOR SMITH has remarked, if like cases should occur again in his practice, the former course of palliative treatment would not be repeated. I am perfectly satisfied that in managing placenta previa a physician errs in making delay after the second hemorrhage. I have encountered five or six cases, in three of which I was called at a late period, when it was absolutely necessary to perform an operation. The death rate as regards the mother has been nil, but all the children have been lost except one, which I worked over twenty minutes to resuscitate. have recently read of four cases of threatened postpartum hemorrhage in which adrenal extract was used. In one case of postpartum hemorrhage the flow is said to have ceased entirely upon the employment of this preparation.

I

DOCTOR WILSON: I have never had a case of complete placenta previa. I have seen the placenta attached to the side. I delivered a primipara yesterday afternoon, gestation being in the seventh month. The patient was taken with a severe hemorrhage about noon yesterday. Her husband came for me and said his wife had a severe hemorrhage. I repaired to the house and found that the bleeding was due to dilatation of the uterus, and detachment from the edge of the placenta. The hemorrhage had ceased and I thought I would await events. Three hours later the man called and said his wife was flowing severely and wanted me to come to the house again. Upon examination I found that labor had begun. The head of the child was impinged upon the edge of the placenta and there was not very great hemorrhage. I saved the child by applying instruments and the mother was resting quietly this morning at 5 o'clock. I always deliver immediately when confronted with this condition.