no barrier to the success of such suggestion, as I have repeatedly observed.

Hypnotism is not necessarily exhausting to the patient, as has been claimed. On the contrary, if his nervous energy is not wasted by suggestions which produce fatigue or disgust, he feels refreshed upon awakening, as from ordinary sleep. The dangers of hypnotism, as far as they exist elsewhere than in the imagination of its opponents, are due almost always to an improper use of the method. Certainly as employed for the cure of alcoholism, there are no dangers to be feared from it which are at all comparable with those arising from a continuance in habits of intemperance.

Dr. Arthur being unavoidably absent the following extract from the report of the Surgeon General of the Army for 1895 was read by Dr. G. W. Adair, U. S. A., Washington Barracks, D. C.

"Capt. W. H. Arthur reduced the statistics of alcoholism at Vancouver Barracks by dealing with drunkenness as with acute poisoning. He reported as follows:

"The report of the Surgeon-General for the year ended June 30, 1892, mentions this post as having out of all the Army the highest rate of admission to sick report for alcoholism.

The number

of cases of simple acute alcoholism that appeared at sick call and during the day, when I first assumed charge of this hospital, was unusually large, and resulted in the laying down of certain rules in an effort to discourage drunkenness as far as it was in my power. No man is taken on the sick report or excused from any duty unless, in my opinion, his condition would make it actually dangerous for him to keep at work. I may say here that such cases are, in my experience very rare, and that a mistaken pity for a man suffering from the effects of a

debauch is liable very often to lead a too indulgent post-surgeon to excuse him from duty when the guardhouse, and not the hospital, is the proper place for him. I am confident that this mistaken kindness has done a great deal in the past to encourage drunkenness. Each man who has reported at the hospital in any stage of simple alcoholism is treated as a case of alcoholic poisoning, taken immediately to the operating room, his stomach emptied by the use of the stomach pump, and thoroughly washed out with warm, two per cent soda solution. After this he is given a bowl of hot beef extract, with cayenne pepper, allowed an hour's rest, after which he is generally perfectly able, however unwilling, to do his duty. If the weather is severe, either very hot or very cold, it might not be safe in his depressed condition to force. a man to work out of doors immediately after this procedure, but at this post the extremes are not great, and it has in no case resulted prejudicially to the patient. Occasionally some resistance is met with, but two, or at most three, able-bodied hospital corps men and a perforated wooden gag, such as comes with the stomach pump, will, with patience and determination, overcome almost any ordinary opposition. I have found for this purpose the gum elastic stomach tube in the old-fashioned stomach-pump case, connected with Allen's surgical pump, work very satisfactorily. The ordinary soft rubber lavage tube is too easily collapsed, and is more difficult to introduce when there is resistance.

The effect of this treatment has been uniformly excellent. The stomach emptied of its irritating contents and cleansed of the thick, tenacious mucus that is always present in such cases, is much less irritable and rarely rejects the beef extract which is given immediately; the nervous symptoms improve at once,

Of

I

and sedatives administered by the mouth have a far more prompt and lasting effect and in almost all cases the craving for liquor is very much diminished. course cases may occur which are two serious for such summary treatment. have not met with any myself, and have used the stomach pump with good effect in cases even of delirium tremens and alcoholic coma. These cases, of course, are promptly tuken into the hospital and treated as dangerously sick men. The deterrent effect of this treatment is excellent. It is, of course, not agreeable, though no one can deny that it is perfectly rational and merciful.

In the past

ten months but one man has been admitted to the hospital for alcoholism. There are, no doubt, other factors that enter into the production of this marked change in the post in two years, but I am confident that this method of treating alcoholism as poisoning, has been a very important, if not the principal one. I may add that in but one case has it been necessary to use this treatment on the same man more than once.

DISCUSSION.

Dr. Adair said: Among the various methods of managing the alcohol habit, I believe that hypnotic suggestion will take a prominent place. My experience is limited in its use for the alcohol habit to two clinical lessons given by Captain Bushnell of the Medical Department of the Army. I had heard through the laity of Dr. B's success with the method, and from previous acquaintance with one of his patients could testify that the cure in that case might well be called remarkable.

So when chance duties brought us together at a little post in the Wind River Mountains, I solicited an exposition. of his methods.

The doctor himself, was no enthusiast, and his patients were in no sense imaginative, neurotic or hysterical. He practiced upon

frontiersmen-cattlemen, miners and soldiers. His first case was a member of a large cattle company

whose partners came to the doctor to see if something more could not be done. The patient was universally esteemed and a valued member of the firm, but his habits were such that they would be compelled to sever business relations with him if he could not be cured. The doctor told them that he had already tried every method with which he was familiar but that he had recently read an article on hypnotism, that he had no experience with the method, but, as a last resort, he was willing to give it a trial. He made the proper suggestions and after seven daily sessions the patient could not take whiskey in his mouth without vomiting. After several months, the patient came back to solicit a modified treatment to enable him to take an occasional drink with the boys. With such a frame of mind and such social surroundings, it is clear that no cure can be permanent, as a new tolerance can be developed in time.

Dr. John E. Walsh said he had been in the Washington Asylum at the time. that the Keeley cure first came into prominence, and fifteen or twenty cases were put under treatment. They were old chronic cases who took the treatment of their own free will. The treatment consisted of hypcdermatic injections of strychnia, gr. 1-60, and chloride of gold and sodium, gr. I-20. These were given four times a day, supplemented with elixir of iron, quinine and strychnia. After this treatment had been continued for two or three weeks nearly all the patients returned to their former bad habits. Of those who did not relapse one did not want to drink and another refused to take the hypodermatic injections but took the medicine by the mouth for a very short time and remained sober for four years. From time to time those who were taking the treatment in the hospital were offered whiskey and they nearly all took it, and he thought there was very little hope for a man who would drink poor-house whiskey.

Dr. Tuckerman, of Cleveland, said that he regarded the craving in alcoholism as due to a deficient excretion of the kidneys, and the value of strychnine and the value of every other remedy.

used for this purpose, rested largely in the fact that they promoted excretion from the kidneys, and as that excretion came up the nervous tension diminished. He had used atropine but did not like it, for he had had some accidents from its

use.

He remembered one man, to whom he gave atropine, he developed delirium from which he never recovered. He believed there was something to be said in favor of mental suggestion. His plan of treatment was to give a hypodermatic dose of strychnine with one-eighth grain of pilocarpine to start the sweat glands and the kidneys. He then gave a solution of strychnine 1-60 gr. and tr. strophanthus one minim, with directions to take that amount followed by a cupful of hot water every hour, and oftener if necessary. When the craving came on this could be taken every half hour and usually, when there was a desire to reform, the mere fact of having something to take to tone them up—seemed to assuage the desire for alcohol. There

seemed to be something in the capsicum treatment tincture of capsicum and fluid extract of lupulin, in equal parts, a teaspoonful pro re nata-but he thought it was too violent for the average stomach. Altogether he had come

to look upon the treatment with strychnine, pilocarpine and strophanthus as the best.

Dr. Wm. C. Woodward said there was an attempt being made to force a Keeley Institute on the District in an official form. A bill was pending in Congress to establish an asylum for inebriates, and the agent of the Keeley Institute in the District was pressing the Commissioners to enter into a contract

with him to take care of such patients as might be sent him by the District au

thorities. The bill was sent to the Health Officer for a report; such report was made recommending that, until the treatment was fully described, the proposition be not entertained. The agent sent a reply to this, but omitted two very important particulars. He stated in a general way, that when patients were admitted, they were given two or three days of preparatory treatment, but details of such treatment were omitted. Later on he referred to the fact that the

patients were given "internal treatment," and so dismissed that subject. This letter was naturally returned to the agent with a request that he supply the omissions.

Ectopia vesicæ, exstrophy or extroversion of the bladder, is a congenital defect in which there is an absence of the anterior wall of the bladder, together with a corresponding defect in the lower part of the abdominal parietes and usually of the symphysis pubis, the ureters generally opening and discharging the urine directly upon the external surface. The penis is nearly always epispadiac and small, and the clitoris is divided into two parts; or there may be an absence of both penis and clitoris. In the male the deformity prevents procreation; but in

the female the reproductive function is generally not impaired, and cases of parturition are on record, notwithstanding the external genitals are very imperfectly formed.

As to the manner in which the deformity is brought about, little seems to have been attempted by way of an explanation. Samuel G. Shattock's explanation is, that the cloacal invagination of the surface which normally lays open the lower end of the rectum and the lower end of the uro-genital sinus, does in these cases, by an undue exten

sion forwards and upwards, lay open the anterior wall of the uro-genital sinus and the anterior wall of the bladder as well. Should the undue extension occur to a lesser degree, there would be epispadias; if greater ectopia vesica. For, although epispadias may occur without ectopia, ectopia never occurs without epispadias.

In 1805, W. H. Coates, surgeon Fifth Dragoons, reports in the Edinburgh Medical Journal, a case of exstrophy, which occurred in his practice four years before. It was a female child and one of twins. No attempt was made to remedy the defect. He says his case was similar to one reported by Dr. Baillie in 1793; that there were several cases on record, but that few were reported with sufficient accuracy. This latter statemert holds good even now, for Howe, who operated in 1890, says he read over everything written by surgeons, who had operated, but received little satisfaction.

In 1851 Mr. Lloyd, of St. Bartholomew's, attempted to remedy the defect by passing a seaton from the bladder to the rectum, but the patient died of peritonitis.

In 1851 M. Jules Ronx made the first attempt to remedy the defect by plastic surgery.

In 1853 Richard, modifying Nelaton's operation for epispadias, operated by turning in a flap from below the umbilicus, with its skin surface towards the bladder, and covered this flap with skin. taken from the scrotum. The operation induced peritonitis which proved fatal.

In 1858, Prof. Joseph Pancoast of Philadelphia, performed the first successful operation for exstrophy of the bladder. However, the patient died some months later from another affection.

In 1859, Dr. Daniel Aryes published an account of a successful operation, which he performed the year previous. A

plastic cast of this case is in the Army Medical Museum.

Holmes employs two flaps. A flap from one side of the groin is covered by a flap from the opposite groin. The cutaneous surface of the first flap is turned towards the bladder, and the raw surfaces of the two flaps are brought together. Wood's method is similar to that of Holmes, except that he employs three flaps instead of two. The first flap is taken from above, and covered with two lateral flaps.

In 1874, Dr. John Ashurst, Jr. reports an operation for exstrophy, resulting in death in thirteen hours.

In December, 1885, Prof. Treudelenburg, of Bonn, published his first case, treated by division of the sacro-iliac synchondrosis, which permits the approximation of the pubic symphysis. Later the bladder cavity is made to dilate and resort to flaps is seldom necessary.

The writer has collected all the cases reported in this country and the British. Isles since Ashurst reported his table of 38 cases in 1874. Of the twentyseven collected, sixteen were males and eleven females. All but four were operated upon. Of the twenty three operations, two were reported as successes; two as failures; five resulted fatally, including two who died some time after the operation; and nine were improved. In five the result was not stated. Of the three which resulted fatally, two died of purulent pyelitis and the other one of uræmia, the result of suppression of urine. Including the five, in which the result was not stated, with those improved, we have 30.4 per cent of failures. The four deaths and four failures in the thirty-eight cases, reported by Ashurst, gives 21.0 per cent of failures.

This is not a very favorable showing, and yet a careful reading of the cases reported, is sufficient to convince one that

the results, as exhibited by the tables, are far too favorable. It would appear as if some operators, in applying the term successful to the results of their efforts to remedy this defect, mean simply that the patient was successful in surviving the operation.

Porter says the surgeon should continually keep in mind the main result for which he is striving, viz, a free drainage of urine; otherwise the ordinary results of obstruction will follow, which are dilatation of the ureters and destruction of the kidneys. Dr. Walter Reed, in a paper read before this Society last winter, clearly shows that pyelitis and other infective processes of the kidneys and ureters are not likely to take place unless there is some obstruction to the flow of urine. It, also, has been shown that healthy urine is not infective and does not interfere with the healing of wounds. Hence, it would seem that if an aseptic operation were performed and free drainage secured, fatal results could be avoided. It is, mainly, because the writer believes that a more thorough appreciation of the conditions will lead to better results, that he wishes to call attention to the following fatal cases including that seen by himself.

March

In 1877 Champney reports a case of exstrophy of the bladder, in a female child, born February 14, 1877. It took the breast well until March 7th. 12th, at night, it had convulsions and died at noon March 13th. The post mortem was performed the day after death.

Both ureters were much dilated at various points, and there was no obstruction. The pelves of both kidneys were markedly dilated, but their tissue was healthy. There was spina bifida of the last two sacral vertebræ. The same author, in an article written in 1880, calls attention to a paper by Alexander James, on "Hydronephrosis in connection with

reports the death of three boys, who had been subject to eneuresis. The first boy, aged eight years, had phymosis the result of an injury. He had an attack of diarrhoea followed by coma and death. The amount of urine had not been ascertained, but it was pale and of low specific gravity, 1010, containing renal cells. and a trace of albumen. The autopsy showed the muscular coats of the bladder thickened, no cystitis, no stricture of the ureter or urethra, but both ureters and the pelves of both kidneys were greatly dilated and there was double hydronephrosis. The other two boys had eneuresis produced by some abnormality

of the prepuce. They had similar

symptoms and died in the same manner as the first boy. Dr. James says that irritation of the prepuce causes the bladder to contract frequently and violently, damming up the urine in the ureters, which results in serious obstruction, dilatation and hydronephrosis. Dilatation of the ureters and kidneys is a sign of gradual and incomplete obstruction.

Champney says this view receives remarkable confirmation from the state of the ureters in cases of exstrophy of the bladder. In exstrophy the ureters are always lengthened and dilated, and with them, the kidneys.

In 1886 Edward H. Bennett reports an operation on a female child, four years old. Before the operation the flow of the urine was guttatim, but after the operation it became squirting and at intervals. The child grew thinner and weaker. Vomiting set in, and later became. constant, resulting in death. Post mortem showed death to be due to purulent pyelitis, brought about by chronic stricture at the orifices of the ureters. The vagina, uterus and ovaries were of normal size. In 1887 W. H. Walling reported an operation, performed by Prof.