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and night, with bichloride solution, 14,000, and nitrate of silver, ten grains to the ounce once a day and yet the trouble advanced, and in a week's time the second cornea became affected. At that time Dr. Burnett suggested the use of formalin and he applied it at once. There had been some sloughing, but the day after applying formalin the slough had disappeared and the ulcer was clear. There had been a great deal of chemosis, and the ulceration threatened to destroy that eye as it had the other. He scarified the conjunctiva and continued to use formalin, 1-60, once a day and 1,500, instead of the bichloride every hour. Under this treatment the chemosis disappeared and the eye improved. This was only one case, to be sure, but he felt confident that formalin had saved this patient from blindness. At the same time that the improvement was noted he had changed from atropine to eserine in the treatment, and he did not know what effect this had had.

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Dr. Burnett, in closing the discussion, said that he had had no idea of precipitating such a debate on antiseptics. He had thought that formalin was known to all surgeons and was being used for what it was worth. He did not claim that it was the best preparation yet known, but he did think it had some properties which none other possessed. He had not, fortunately, observed the effect upon instruments which Dr. Forwood spoke of, possibly because he did not use it in such strength, as he had done. He did not disinfect his instruments with formalin-he always boiled them-but simply kept them aseptic in a solution of formalin. He used it I2,000, and in that strength it did not affect the skin to any great extent. As to its penetrating effect, he believed it had greater power in a weak solution than any other antiseptic. He was glad to hear Dr. Forwood's statement of its efficacy in disinfecting sponges, but he believed that general surgery would benefit by this more than opthalmic surgery. It was not his purpose, in presenting this paper, to advocate the discarding of cleanliness, and he hoped Dr. Thompson would not abandon it, but would try formalin in connection with it. Its pow

er of penetrating mucous tissue was what led him to try it in diseases of the conjunctiva. Bichloride did not reach them, and be believed that formaldehyde would.

MEETING OF APRIL 8, 1896.

Dr. S. C. Busey, President, in the Chair. SPONTANEOUS RUPTURE OF AORTA FROM ATHEROMA.

Dr. D. S. Lamb presented a specimen consisting of the arch of the aorta and adjacent organs of the mediastina. The lumen of the aorta was dilated and the inner coat showed extensive atheroma. Just beyond the origin of the left subclavian artery was the apex of a triangular rupture, running downwards longitudinally one inch and with a base one inch wide; from this base there extended transversely to the right 1-5 inch another rupture, also triangular in shape, its apex to the right, its base to the left and one-half inch wide. The rupture extended through all the coats. The resulting hemorrhage had distended the mediastina, to a thickness just above the diaphragm of three inches. The lungs were collapsed; right pleura distended with dark blood and a small quantity in the left.

The patient was a white man, age 76, who had retired from business about twenty years before and lived a quiet life with but little exercise. His appetite was good and he became somewhat fat. His health was generally good except for occasional pains which he thought to be rheumatic and for which he took colchicum with relief. In 1893 he had a left hemiplegia from which he almost completely recovered. March 14, 1896, he had sudden severe pain in the region of the heart, but deeper seated; pain in the back between the shoulders but no tenderness; pulse sixty and regular; arteries somewhat inelastic; no dyspnoea;

no rise of temperature. Gave morphia hypodermatically with relief of pain and sleep. Sixteenth, pain recurred. Gave anodyne with relief. He now slowly improved, the surface however remaining pale and he was unable to stand alone. By the nineteenth he had nearly recovered his usual comfortable condition when about 10 p. m. he had a recurrence of pain much more severe than the others and died in five minutes.

The necropsy showed the conditions described; the heart weighed seventeen ounces, slightly enlarged and fatty; atheroma of whole length of aorta with some atheroma of aortic and mitral valves. A microscopical examination by Dr. Walter Reed, Army Medical Medical Museum, showed extensive infiltration of aortic coats with blood, part of it undergoing organization. The kidneys showed chronic diffuse nephritis and slight amyloid change.

There were here three distinct paroxysms of pain with equally distinct intervals. The last paroxysm corresponded doubtless to the hemorrhage into the pleural sacs; but why the rupture of all the coats did not cause speedy death in the first place seems unexplained.

FORMALINE AS A DISINFECTANT. Dr. Wm. Forwood presented a jar of sponges disinfected with formaline; also a couple of instruments which had been immersed in formaline over night and that showed the characteristic deposit of oxidation.

DISCUSSION.

Dr. Thos. E. McArdle, said, of course if formaldehyde gas does no more than sterilize sponges it will be an important contribution. Dr. Forwood has submitted some instruments which were kept in formaline and have become coated with a deposit, but I wish to assure the members that with a bit of cotton the coating can be rubbed off, and the instrument will look cleaner than before.

Since the matter was discussed here last week I have been experimenting with formaldehyde in all strengths from one struments in this strongest solution and per cent to forty-five per cent. I put inleft them in three days, and when I took them out the coating on them was very thick but could be rubbed off very easily. I noticed, also, that with this strong solution-forty-five per cent-the hands were rendered numb, but without tingling as when we use carbolic solution, and I think that formaldehyde gas will have a position, which it will retain, as an antiseptic. What I do not understand is, that if it is the formaldehyde. gas which is efficacious, as Dr. Forwood claims, why, in the very strong solutions which I used for three days the instruments were not affected except where they were moistened by the solution. The deposit does not appear on the parts which are not submerged, but only on those that are.

Dr. Forwood: The result of my experiments with formaline as a surgical disinfectant amounts simply to this: that it is an excellent thing for sterilizing sponges. Aside from that it will play no part.

Dr. McArdle: How about its use in sterilizing cat gut, silk, etc?

Dr. Forwood: I said in my remarks on the subject when it was before the Society that formaline might be used for this purpose, but that there were so many better ways of doing it that it was not worth while to use formaline. Boiling with bicarbonate of soda is much

better.

TRANSPOSITION OF VISCERA.

Dr. T. Morris Murray presented a young man in whom there was a complete transposition of the thoracic and abdominal viscera.

DISCUSSION.

Dr. C. H. A. Kleinschmidt, said: It may not be uninteresting to know that transposition of the viscera occurs very frequently in the lower animals. In my physiological experimental work I had two rabbits in which the viscera were transposed. The post mortem showed that there was complete transposition of all the viscera.

TRANSACTIONS OF THE MEDICAL SOCIETY OF

THE DISTRICT OF COLUMBIA.

PUBLICATION COMMITTEE:

W. W. JOHNSTON, M. D., GEO. M. KOBER, M. D., JAS. D. MORGAN, M. D.

ACUTE ANTERIOR POLIOMYELITIS.

BY TALLIAFERRO CLARK, A. B., M. D.

When we consider that a sudden elevation of body heat attended with vomiting, in very young children, subsiding with the same suddenness as the outset, may be occasioned by apparently slight irregularities of diet, or by exposure, it is not to be wondered at that we often fail to recognize the incipiency of acute anterior-poliomyelitis. It is the writer's firm belief the earlier the diagnosis, to gether with the institution of appropriate treatment, the greater will be the curtailment of the area finally paralyzed. Therefore, it is partially the purpose of this paper to impress upon the general practitioner the necessity of ever being on the watch for this common and insidious affection, when called upon to prescribe for a child, under three years of age, presenting symptoms characteristic of no particular malady.

The onset is usually sudden. The litThe lit tle patient has fever, vomiting and often convulsions. The fever, as a rule, is not high but may reach 105° F. The child is restless, fretful and occasionally presents some hyperesthesia along with

spinal pain. The latter are rather complications than symptoms, being dependent upon congestion of some portion of the sensory tract and involvement of the spinal meninges repectively.

The onset in some cases is exceedingly obscure. The writer readily recalls the case of a child, four years old, with slight talipes varus. The mother could give no history of an acute attack, incidentally calling attention to the child during a professional visit to herself. is thus seen that the initiatory symptoms are not characteristic, and are present at the outset of many of the affections of childhood.

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Within an hour to several days, from the onset, paralysis, more or less extensively distributed, is observed. This paralysis presents several peculiarities. First, it develops with great rapidity, depending, of course, upon the acuteness of the attack. Second, it is flaccid in character and, as a rule, without sensory symptoms, consequently there is no disturbance of bladder or bowel. This latter fact is also due to the part played by

unstriated muscular tissue in these acts, and which is never involved in uncomplicated anterior-poliomyelitis. Third, this paralysis may be divided into more or less definite stages: (1) A period of extension, in which there is an increase in the area paralyzed. This usually lasts several days. The writer recalls a case in which the increase of paralysis was so extensive that death resulted from paralysis of the muscles of respiration. (2) The stationary period. In this the paralysis, after reaching the acme, remains without change for a few days or several weeks. (3) The period of retrogression, lasting for months and finally merging into the chronic stage. In this period there is gradual regain of control over those muscles that are paralyzed only temporarily. Lastly, there is a peculiarly constant selection of certain groups of muscles finally paralyzed. The most frequently affected groups are the extensors and peronei of the leg and, therefore, the most usual deformity is a talipes equino-varus. In the arm it is the deltoid: in the fore-arm, the extensors with resulting wrist drop.

The affected muscles are not only paralyzed, but atrophied, and are markedly altered in their action in response to an electrical stimulus. The atrophy is immediate, and it is stated by some observers to be more rapid in development than that following section of a nerve.

Contraction of muscle fibre under electrical stimulation, is produced in two ways: (1) excitation through the motorial end plate or axis-cylinder supplying the fibre: (2) by direct excitation of the muscular structure. The galvanic current only can act in the second manner. Using this current in health, a contraction is more readily produced by closing the current with the negative pole than when it is closed by the positive. Now in anterior-poliomyelitis there is loss of

excitability to the faradic current which may occur as early as the first week. The earlier and more complete this loss, the more hopeless the prognosis with respect to regaining power in the affected muscles. The galvanic current produces contractions more readily, using the positive pole to close the current, than when the negative pole is used. The contractions are wave-like and produced with a milder current than in health. This in substance is the reaction of degeneration.

Owing to the infrequency of fatal cases of anterior-poliomyelitis, its pathology, in the acute stage, was for a long time but little understood. For a clearer understanding, it must be remembered that the microscope reveals the large polypolar cells of the anterior cornua of the cord, arranged not en masse, but into distinct groups. For example, a median group, an internaland external, anterior group. Further

more, each group has a distinct arterial twig coming to it, from the periphery of the cord, derived from the lateral and anterior spinal arteries respectively. It must be noted, furthermore, that the greatest aggregation of these cells is to be found in the most vascular regions of the spinal cord, the dorsal and lumbar enlargements, while, on the contrary, they are most sparsely scattered through the dorsal region, supplying the truncal muscles. This latter arrangement explains why it is comparatively rare to see these muscles paralyzed as a result of the disease in question. It is patent that a very large extent of cord could be affected in this region, yet involve relatively few of these large cells upon which muscles depend for their enervation. When these cells are destroyed, the muscular fibre to which their axiscylinders are distributed become paralyzed and undergo rapid wasting.

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the few cases going to autopsy, in the acute stage, it has been found that the capillaries, just described, become distended and extravasation takes place. The cells become swollen and granular, then follow foci of softening and finally destruction of cell and replacement by fibrous tissue. When this takes place, the muscle fibres supplied by such cells are utterly beyond redemption. It is furthermore found that neighboring groups of cells are compressed by the local extravasation, upon the resorption of which they regain their normal tone and the phenomena of the recessive stages are explained.

In long standing cases, the cord on the affected side is smaller and denser. The medullary sheathes and axis-cylinder of the nerves coming from the diseased anterior cornua, undergo degeneration and later become denser. In the muscles individual fibres become thin and undergo granular degeneration. Within the sheath of the affected fibre are found nuclei, from which, should the destructive process stop, regeneration. may take place. Individually the diseased muscles appear smaller than normal, due to an increase of connective tissue. In some cases, owing to an increase of interstitial fat with hypertrophy of remaining healthy fibres, these muscles present to the eye no loss of volume.

It is worthy of note that the spleen is found enlarged. Of great interest, from an orthopedic standpoint, is the retarded growth of bone-a potent factor in the production of deformity. Ligaments surrounding joints become relaxed, thin from stretching and thus assist in the production of deformities.

The foregoing resume enables us to reason from effect to cause and make clear the lines along which the etiology of anterior-poliomyelitis is to be studied.

The writer sides with the advocates of

the specific germ theory. Many facts may be recited that go far towards substantiating this position. The affection presents all the prominent characteristics of those diseases known to be dependent on zymotic infection. First, we have a sudden onset, fever and a definite course. Secondly, enlargement of the spleen is a frequent concomitant. When we take into consideration that the spleen is the laboratory in which the white blood corpuscles are manufactured, as proven by their excess, relatively, in the splenic vein, then in the splenic artery and, also, by the constant enlargement of this organ in leukæmia: and, furthermore, that the white corpuscles are antagonistic to germ life within the economy, it seems as if this enlargement of the spleen is an evidence of increased activity in the manufacture of agents to combat and eliminate the germs, not only of this affection, but of all the zymotic diseases in which it is so constantly found. Thirdly, the constancy of the morbid findings is another evidence. It speaks of some agent possessing a peculiar selective affinity for the large multipolar cells of the anterior cornua of the cord. In the Medical Record of March 3, 1894, we find the following: "Dr. Redlich, of Vienna, found in the spinal cord of a child five months old, dying of anterior-poliomyelitis, that the blood vessels were the starting point of the disease, and not the supporting framework and ganglionic cells, as was formerly supposed." His conclusions, based upon his findings in this case, were, that the disease is caused by an infective process. According to this, referring to the arrangement of cells and blood supply in the anterior cornua, as just given, if the blood vessels be the starting point, it is very easy to see how one group of cells may be destroyed and others spared, one

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