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Orcian ; nlt-rect C- 
 
 International Clinic Week 
 
 AT THE 
 
 New York Polyclinic Medical 
 School and Hospital 
 
 DURING THE 
 
 International Surgical Congress 
 April, 1914 
 
 
 fa~**~* Y "^**"^* 
 
 New York 
 
 '''Jlijwfei.'. I'l ■■'., .- 'IF 
 
International Clinic Week 
 
 AT THE 
 
 New York Polyclinic Medical 
 School and Hospital 
 
 DURING THE 
 
 International Surgical Congress 
 April, 1914 
 
 ALFRED C. JORDAN, M.D. 
 
 EUGENE HERTOGHE, M.D. 
 
 BENJAMIN MERRILL RICKETTS, M.D. 
 
 JOHN A. WYETH, M.D. 
 
 JOHN A. BODINE, M.D. 
 
 ALEXANDER LYLE, M.D. 
 
 WILLIAM SEAMAN BAINBRIDGE, M.D. 
 
 New York 
 
INDEX 
 
 PAGE 
 
 INTRODUCTION ------ 5 
 
 Tuesday, April 14 
 
 "CHRONIC INTESTINAL STASIS —INTERNAL 
 PHOTOGRAPHY AS AN AID TO DIAG- 
 NOSIS, ILLUSTRATED." -• - - 7 
 
 ALFRED C. JORDAN, M.D., Cantab, M.R.C.P., Med- 
 ical Radiographer, Guy's Hospital, and Royal Hospital 
 for Diseases of the Chest, London. 
 
 Wednesday, April ij 
 
 "THYROID DEFICIENCY," LECTURE AND 
 DEMONSTRATION, WITH STEREOPTI- 
 CON PICTURES." 29 
 
 Dr. EUGENE HERTOGHE, Member of the Royal 
 Academy of Medicine, Belgium. 
 
 Thursday, April 16 
 ''INTRATRACHEAL INSUFFLATION." - - 78 
 
 BENJAMIN MERRILL RICKETTS, M.D., LL.D., 
 Cincinnati, Ohio. 
 
 Friday, April 17 
 
 FOUR CLINICAL LECTURES, PROFESSORS OF 
 SURGERY, NEW YORK POLYCLINIC 
 MEDICAL SCHOOL AND HOSPITAL: 
 
 I "FRACTURES AND BURNS." - - 89 
 
 JOHN A. WYETH, M.D., LL.D. 
 
 II "OPERATIONS FOR INGUINAL HER- 
 
 NIA UNDER LOCAL ANESTHESIA." 93 
 JOHN BODINE, M.D. 
 
 III "FRACTURES." ----- 95 
 
 ALEXANDER LYLE, M.D. 
 
 IV "CANCER." 100 
 
 WILLIAM SEAMAN BAINBRIDGE, Sc.D., 
 M.D., CM. 
 
INTRODUCTORY NOTE. 
 
 In an editorial entitled, "A Notable Surgical 
 Clinic," Dr. Thomas L. Stedman, editor of the 
 Medical Record, said in part : "In the issues of 
 the Medical Record for September 19 and 26 a 
 large amount of space available for original 
 communications has been given to papers read 
 and reports of clinics held at the New York 
 Polyclinic during the week of the International 
 Surgical Congress which met in this city last 
 spring. In honor of this Congress the Faculty 
 of the Polyclinic requested the surgical staff of 
 the institution to open its doors to the visiting 
 members of the profession, and to arrange a 
 series of lectures and clinics. Accordingly, on 
 four days of that week the surgical lectures and 
 demonstrations were given which have here 
 been reproduced for the benefit of our readers. 
 
 "This was the first occasion on which the In- 
 ternational Surgical Congress had met in this 
 country — in fact the first time it had been held 
 elsewhere than in Brussels, the city of its birth. 
 One can but wonder where the next Congress 
 will meet and when — when indeed the enmities 
 and hatreds engendered by this European strife 
 will have become so far dulled that any really 
 international meeting will be possible, even of 
 medical men. These are wont to boast in their 
 gatherings, in the intervals of war, that science 
 is truly international, untinged by jealousies of 
 race and nation, but when war comes they find 
 that after all blood is thicker than water and 
 love of country is more compelling than love of 
 science." 
 
 When the Surgical Staff of the New York 
 Polyclinic Medical School and Hospital arranged 
 for the "International Clinic Week," in honor 
 of the members and friends of the International 
 Surgical Congress, they had no thought that 
 perhaps the Empire City of the Western World 
 might witness the unforeseen ringing down of 
 the curtain for a time upon the corporate life 
 of this body of distinguished surgeons who, in- 
 
dividually and collectively, have accomplished 
 such splendid work for science and for 
 humanity. 
 
 This, however, may be the case, — not, per- 
 haps, because "the love of country is more com- 
 pelling than the love of science," but because 
 of the years of reconstruction, of privation, and 
 of general disheartenment that must of neces- 
 sity follow the unfortunate struggle which now 
 engulfs the major part of the world, and which, 
 in truth, affects deeply the whole world. 
 
 For all these reasons we are glad to respond 
 to repeated requests for the perpetuation, in 
 convenient form, for those who attended the 
 International Surgical Congress and the Inter- 
 national Clinics held at the Polyclinic, the lec- 
 tures and clinics held on that occasion. 
 
 We venture, however, to express the hope and 
 the belief that when the present conflict of na- 
 tions shall have ended the medical world will 
 find itself once more united in the earnest effort 
 to alleviate human suffering and to render more 
 and more impossible, through the development 
 of a higher brotherhood, a repetition of the 
 tragedies now being enacted. 
 
CHRONIC INTESTINAL STASIS. 
 
 By ALFRED C. JORDAN, M.D., CAMB., M.R.C.P., 
 
 I HAVE the honor to address you on one of the most 
 fascinating and far-reaching branches of medical 
 study; a vast realm that has been opened up by the 
 genius and insight of our great surgeon, Sir. 
 Arbuthnot Lane. 
 
 Intestinal stasis is a chronic disease due to the 
 absorption of poisonous substances from the ali- 
 mentary canal. The disease itself may be so in- 
 sidious as to escape notice, while a complication may 
 produce severe and urgent symptoms, and compel 
 instant attention. In this way we have hitherto 
 lost sight of the fundamental disease— the stasis — 
 and we have fixed our attention on the complica- 
 tion, regarding this as a primary disease. 
 
 The general signs and symptoms of intestinal 
 stasis are too well known to require a detailed 
 description. A full and most graphic account is 
 contained in Sir Arbuthnot Lane's recent paper 
 {Practitioner, March, 1914) . 
 
 I am concerned with the radiological demonstra- 
 tion of the changes found in cases of intestinal 
 stasis. When first I took up this work I was handi- 
 capped by the belief that the patient must be "pre- 
 pared" for the bismuth meal by giving him purges 
 and enemata, and that he must take his bismuth 
 in the form of a "meal" while fasting. Many radi- 
 ologists adhere to this mode of preparation still, 
 but I am perfectly sure that once they have made 
 up their minds to abandon it they will never return 
 to it. 
 
 The best way to give the bismuth is in the form 
 of an emulsion to be taken about an hour after an 
 ordinary breakfast. The reasons for this were given 
 fully by me in a recent paper {Brit. Med. Jour., 
 
 Copyright, William Wood & Company. 
 
November 22, 1913). In the vertical posture the 
 emulsion is seen to pass through the esophagus 
 rapidly, and to fall at once to the great curvature 
 of the stomach. The patient then lies on the couch 
 on his right side to allow the bismuth to fill the 
 pylorus and duodenum. After a minute or so he 
 lies on his back, and is examined with the fluorescent 
 
 Fig. 1. — Simple ileal stasis, taken on the couch 37 hours 
 after a bismuth meal in a woman aged 40 suffering from 
 advanced cystic disease of the breasts. 
 
 screen. In the normal case the duodenum is small 
 and short, its vertical portion measuring 2 3 /4-3l/4 
 inches; in a few seconds a duodenal peristaltic wave 
 starts near the top of the duodenum, and carries 
 before it the whole contents of the duodenum with- 
 out delay through its four parts and on to the 
 jejunum. At the end of three or four hours there 
 is no longer any bismuth in the stomach or duo- 
 denum; the whole of it is in the lower abdomen, 
 partly in the lower coils of the ileum, partly in the 
 cecum and ascending colon. In perfectly normal 
 cases the lower ileal c.oils lie above the pelvic brim, 
 and there is never a very large collection of bismuth 
 in these coils, the passage through the ileocecal 
 valve being free. One of the very earliest effects 
 of stasis is to cause the lower ileal coils to drop 
 into the pelvis. There is then a long rise from the 
 pelvis to the cecum. Spasm of the ileocecal valve 
 occurs, and adds to the difficulty. The last inches 
 
Fig. 2. — Great stasis in the large intestine, with elongation 
 of the pelvic colon, taken on the couch 80 hours after a bis- 
 muth meal in a woman aged 46 suffering from advanced 
 cystic disease of the breasts. There was also extreme ileal 
 stasis, and the patient showed all the usual signs and symp- 
 toms of chronic intestinal stasis. 
 
 of the ileum become hypertrophied to a thick cord 
 which is easily felt. In many cases the weight of 
 the overloaded cecum and ileum causes a constant 
 pull on the mesentery of the ileum whenever the 
 patient is upright ; a thickening then appears in the 
 mesentery at the point where the pull is greatest. 
 The point of greatest strain varies from case to 
 case; often it is within an inch of the ileocecal 
 valve (Fig. 14) ; sometimes it is in the right iliac 
 fossa about four inches from the valve (Figs. 4, 5, 
 and 19) ; in other cases again it is just above, or 
 just below the pelvic brim. 
 
 It is clear, then, that the ileal kink is not the 
 primary cause of the ileal stasis, although the kink, 
 when present, aggravates the stasis, at any rate in 
 the upright posture. I find there is still much mis- 
 
understanding on this point. It is the ileal stasis 
 which produces the kink, by pulling on the mesen- 
 tery of the ileum. Some of the worst cases of 
 ileal stagnation occur in feeble women, and in them 
 a kink may never appear (Fig. 1). In such cases 
 there is often extreme dropping of the large intes- 
 tine, the cecum occupying the deepest part of the 
 pelvis. The ileal contents have not then to negotiate 
 a rise to the cecum ; the difficulty must be enhance* 
 by the ileocecal valve, which gets into a state of 
 spasm seldom fully relaxed. 
 
 Fig. 3. — Taken on the couch after a bismuth meal in a 
 woman aged 47, showing the duodenum and the plyoric por- 
 tion of the stomach. The woman suffered from severe glyco- 
 suria ; at the age of 30 she had exophthalmic goiter for six 
 months. The screen showed active gastric peristalsis with 
 plyoric spasm. The duodenum was dilated, and showed 
 strong "writhing" peristalsis with repeated return of the bis- 
 muth from the third to the second part of the duodenum, only 
 traces of bismuth having entered the jejunum at the end of 
 15 minutes. C, P, cardiac and pyloric portions of the stom- 
 ach ; Py., pylorus a, b, c, d, the four parts of the duodenum ; 
 U, the umbilicus. (See also Figs. 4, 5, and 6.) 
 
 With regard to the large intestine I propose to 
 say little, except incidentally to explain its effect 
 on other parts. In normal cases the bismuth begins 
 to enter the cecum in three to four hours ; in six to 
 eight hours it has reached the middle of the trans- 
 verse colon ; in eight to ten hours the splenic flexure, 
 and in eighteen to twenty-four hours the rectum. 
 At this stage (twenty-four hours) there is usually 
 bismuth in all parts of the large intestine, fairly 
 evenly distributed. At the end of forty-eight hours 
 all the bismuth should have been evacuated. The 
 delay in the large intestine in stasis is often ex- 
 treme, and after one hundred hours there may be 
 
 10 
 
little bismuth beyond the splenic flexure. Un- 
 doubtedly a good deal of toxic absorption occurs 
 from the stagnant contents of the large intestine, 
 
 Fig. 4. — Taken on the couch 9 hours after the same bismuth 
 meal. There was still a large amount of bismuth in the 
 stomach — kept back by the pyloric spasm. The terminal coil 
 of the ileum was tortuous and thick-walled ; it was firmly 
 fixed in the right iliac fossa (Lane's kink). The appendix, 
 seen beneath the cecum, was freely movable, and appeared 
 healthy. 
 
 Fig. 5. — Taken 23 hours after the same bismuth meal, 
 showing the ileal kink as before with extreme ileal stasis, the 
 lower ileal coils being still well filled with bismuth. 
 
 11 
 
Fig. 6. — Taken on the couch 47 hours after the same bis- 
 muth meal ; i.e. at a time when all the bismuth would have 
 been evacuated in a normal case ; the transverse colon dips 
 vertically into the deepest part of the pelvis, and no bismuth 
 has advanced beyond the middle of the transverse colon. 
 After 95 hours no bismuth had been passed, and very little 
 had got beyond the transverse colon. A few days later dia- 
 betic coma supervened, and the patient died. 
 
 but the greatest harm arises from the damming 
 back of the contents of the ileum, these ileal coils 
 becoming infected with microbes from the cecum. 
 The ileum is sterile in health, and is not equipped by 
 
 Pig. 7. — Atheromatous elongation and dilatation of the 
 aortic arch, in a "stasis" subject. The dotted line is in the 
 long axis of the heart, more oblique than normal in conse- 
 quence of the aortic elongation. No tissue escapes the dele- 
 terious action of the intestinal toxins. 
 
 12 
 
Fig. 8. — Stomach and duodenum, taken on the couch after 
 a bismuth meal in a man aged 47, suffering from mucous 
 colitis and a rheumatoid left hip. Both had persisted for a 
 year. There had been no symptoms referable to the stomach 
 or duodenum. The first part of the duodenum is much di- 
 lated and tensely filled, ending below in a blunt point beyond 
 which no bismuth was seen to pass. The obstruction was 
 due to spasm set up by a duodenal ulcer (in the position of 
 the arrows). C, P, cardiac and pyloric portions of the stom- 
 ach ; Py., pylorus ; a, the first part of the duodenum ; U, the 
 umbilicus (see also Figs. 9-12). 
 
 Nature to deal with microbic invasion, while the 
 large intestine can cope with a considerable amount 
 of bacteria. 
 
 The absorption of poisons into the circulation 
 
 Fid. 9 — Showing the pyloric end of the stomach and the 
 dilated first part of the duodenum in the subject of Fig. 8. 
 
 13 
 
Fig. 10. — Taken on the couch 6 hours after the same 
 bismuth meal, showing ileal stasis. There was still a little 
 bismuth in the stomach, and the dilated first part of the duo- 
 denum (a) was again shown well filled with bismuth en- 
 trapped above the ulcer (arrows). U, umbilicus; the X 
 marks the ileocecal entrance. 
 
 enables these poisons to gain access to every organ 
 and tissue of the body, and no tissue escapes their 
 baneful influence. Thus we get many of the gen- 
 eral symptoms of stasis; the headache and de- 
 pression, the aching muscles and joints, the un- 
 
 Fig. 11. — Taken 9y 2 hours after the same bismuth meal, 
 showing the same conditions as Fig. 10 (q.v.). The appendix 
 appeared healthy. 
 
 14 
 
healthy skirl, etc. The glands suffer early, one of 
 the first changes due to stasis being in the 
 breasts, which become nodular. The condition of 
 the breasts is a very good index for gauging the 
 progress of a "stasis" patient while under treatment. 
 In neglected cases chronic cystic disease appears in 
 the breasts, and finally they become cancerous (Figs. 
 1 and 2). Other glands suffer, and the pancreas is 
 found to be hard and nodular in operations for sta- 
 sis. Cancer of the head of the pancreas may be the 
 
 Pig. 12. — Taken 26 hours after the same bismuth meal, 
 showing evidence of mucous colitis, the latter portions of the 
 transverse colon, and the whole of the descending and iliac 
 colon being in a state of tonic contraction, and holding only 
 an irregular thin line of bismuth, mixed with mucus. The 
 iliac colon is firmly fixed in the left iliac fossa at one point, 
 constituting a well-marked "last kink" (Lane). 
 
 last stage in the history. The suprarenal glands 
 probably suffer a similar change, and many cases of 
 glycosuria result from changes in the pancreas and 
 the suprarenals (Figs. 3-6). The pigmentation of 
 the skin of stasis subjects is probably due to supra- 
 renal changes. Other ductless glands are affected; 
 the thyroid gland atrophies, or else undergoes 
 changes leading to exophthalmic goiter. The sur- 
 est proof that these diseases are due to stasis is the 
 fact that they clear up — permanently — on the cure 
 of the stasis, whether by operation or by treatment, 
 
 15 
 
Atheromatous elongation, and later dilatation of the 
 aortic arch occurs at an early age in the subjects of 
 intestinal stasis ; this change is easily recognized by 
 radiology, and is capable of accurate measurement 
 (Figs. 7 and 15). The walls of the aorta evidently 
 share the deterioration of all the tissues. It is in- 
 teresting to speculate how far changes in the pitui- 
 tary gland, leading to raised blood pressure, act as 
 the exciting cause of the dilatation of the aorta. 
 Rheumatoid arthritis is a frequent result of stasis, 
 and is relieved permanently on the abolition of the 
 stasis (Figs. 8 and 24). 
 
 Fig. 13. — Typical chronic ulcer of the lesser curvature in a 
 woman, aged 58, taken on the couch after a bismuth meal, 
 showing the depressed base of the ulcer, and the tight spas- 
 modic constriction of the circular fibers of the stomach over 
 the ulcer. As usual there was persistent spasm at the py- 
 lorus, with dilatation and dropping of the pyloric portion of 
 the stomach. The duodenum was elongated and dilated, es- 
 pecially its first part ; it showed marked "writhing" contrac- 
 tions, with repeated regurgitation, only small amounts en- 
 tering the jejunum in spite of the strong duodenal peristalsis. 
 After 24 hours fully one-third of the bismuth was still 
 in the pyloric portion of the stomach. C, P. cardiac and 
 pyloric portions of the stomach ; U, umbilicus ; Py., pylorus ; 
 a.b.c, first, second and third parts of the duodenum. The 
 arrows indicate the persistent pyloric spasm, resembling or- 
 ganic stenosis (see also Fig. 14). 
 
 The microbes which have entered the stagnant 
 ileum from the cecum ascend to the upper reaches 
 of the small intestine. Thus the duodenum becomes 
 infected, and the ducts which open into it cannot 
 escape infection. In this way we get the gall- 
 bladder infected; it becomes distended, and gall- 
 stones are formed in it. 
 
 This brings us to another aspect of stasis — one 
 of the most important of all, and the one which is 
 
 16 
 
still most open to doubt by the medical public, al- 
 though the facts are so clear that there is no room 
 for doubt. I refer to the effects of intestinal stasis 
 upon the duodenum and the stomach. In studying 
 this part of the subject radiology is able to give the 
 greatest assistance, and the changes revealed by a 
 bismuth meal are most striking and characteristic. 
 I have already described the appearance and be- 
 havior of the normal duodenum. In stasis the state 
 of affairs is quite different: the duodenum is much 
 too large ; its vertical part measures 4, 5, or even 6 
 inches in length instead of 2%-3 1 / 4 inches, as in 
 
 Fig. 14. — Taken on the couch 47 hours after the same 
 bismuth meal,, showing- bismuth still present in the pyloric 
 portion of the stomach and in the depressed base of the ulcer. 
 There was an ileal kink ; the appendix was normal. There 
 was great stasis in the large intestine, and at the end of 72 
 hours most of the bismuth was still in the cecum, the ascend- 
 ing colon and the dropped transverse colon. (Confirmed by 
 operation by Sir Arbuthnot Lane, and all the symptoms — both 
 general and those due to the gastric ulcer — relieved by 
 "short-circuiting" the ileum into the rectum. The stom- 
 ach was not touched. Six months later she was at work, 
 feeling quite well.) P, pyloric portion of stomach; II., ileum; 
 S. F., splenic flexure ; I. C, iliac colon. The X marks the 
 ileocecal entrance. 
 
 healthy subjects. These measurements are taken 
 orthodiagraphically, so they are strictly comparable. 
 The duodenum is also much wider than normal; 
 often it is double the normal width. Its first part in 
 particular is often greatly dilated. The increased size 
 of the duodenum is not the only change, though it 
 is a sufficiently striking one. Far more remarkable 
 is its altered behavior. It fills well with bismuth 
 (provided the conditions be arranged suitably), but 
 it does not empty itself into the jejunum with a 
 single peristaltic wave as in normal cases; the 
 
 17 
 
Fig. 15. — Taken on the couch after a bismuth meal in a 
 woman aged 60, showing a carcinoma of the stomach. The 
 x-ray appearances are those of chronic ulcer in caricature. 
 The wire marks the outline of a tumor which was felt. The 
 duodenum was dilated, and showed well-marked "writhing" 
 contractions. The aortic arch showed considerable athero- 
 matous elongation, and slight fusiform dilatation. C, P, 
 cardiac and pyloric portions of the stomach ; Py., pylorus ; 
 a, b, c, first, second and third parts of the duodenum ; U, 
 umbilicus. Undoubtedly the tumor originated in a chronic 
 ulcer of the lesser curvature, though the deviation from the 
 typical form is considerable, the tumor being a large one. 
 
 "static" duodenum shows excessively powerful peri- 
 stalsis, wave after wave passing along its four 
 
 Fig. 16. — Cancer of the pelvic colon, taken on the couch 96 
 hours after a bismuth meal in a man aged 56. I. C, iliac 
 colon ; the arrows show the seat of obstruction in the pelvic 
 colon. 
 
 18 
 
parts; one has only to look at it to realize that it is 
 working against an obstruction; the bismuth is 
 driven down to the lowest part of the duodenum, 
 and often well on into the fourth part, only to re- 
 turn again, time after time, to the vertical part as 
 each wave passes over. The whole duodenum alters 
 in form continually during the occurrence of this 
 phenomenon, giving the appearance of "writhing." 
 In severe cases this "writhing" peristalsis continues 
 hour after hour, a single spurt of bismuth finding 
 its way through to the jejunum every ten minutes 
 or so. The duodenum seems never to tire. Of 
 course it should be understood that all stages occur 
 between the normal duodenum and the extremely 
 dilated, writhing duodenum of severe stasis. 
 
 What proof have we that the static duodenum is 
 
 I Opaaue 
 _£.tteTncz 
 
 Rec turn. 
 
 Fig. 17. — Taken after Pig. 16, the rectum having been 
 filled with barium fluid, to show the obstruction in the pelvic 
 colon. 
 
 due to the downward pull on the commencement of 
 the jejunum caused by overloading of the lower ileal 
 coils? The proof is manifold and complete. In the 
 first place the downward pull on the jejunum can be 
 observed at operation. The top of the jejunum, 
 moreover, is found empty, and often it is the sub- 
 ject of torsion, the effect of the duodenojejunal 
 kink being increased greatly by this torsion. The 
 radiologist, while examining the duodenum, can 
 actually see the bismuth forced into the fourth 
 part of the duodenum, almost up to the junction 
 with the jejunum ; eventually some bismuth is 
 forced through, and then the radiologist can see 
 
 19 
 
Fig. 18.— "Diverticulitis" of the pelvic colon in a man 
 aged 54. Severe symptoms, including albuminuria and a high 
 blood pressure, were relieved by the operation of "short- 
 circuiting" carried out by Sir Arbuthnot Lane. 
 
 that the jejunum passes down vertically at its com- 
 mencement. A few hours later he is able to con- 
 vince himself that there is stasis in the lower coils 
 of the ileum. Few things in medicine are more 
 constant; if we find a distended duodenum we are 
 certain to find ileal stasis, and conversely, if we 
 find a normal duodenum, with free duodenojejunal 
 junction we are most unlikely to find any material 
 amount of stasis in the lower ileum. The proof is 
 more perfect even than this: there is a definite 
 
 Fig. 19. — Ileal kink in a man aged 57, taken on the couch 
 10 Vi hours after a bismuth meal. (See also next Fig.) 
 
 20 
 
quantitative relation between the amount of ileal 
 stasis and the amount of duodenal distention; thus 
 a high degree of duodenal distention will be found 
 associated with great ileal stasis, while slight duo- 
 denal distention goes with slight ileal stasis. Of 
 course the proportion is not mathematically accu- 
 rate, but it is nearly enough so to furnish clinching 
 proof of the dependence of duodenal distention on 
 ileal stasis. 
 
 The distended duodenum causes no subjective 
 symptoms, but if it is congested the patient be- 
 comes aware of its presence at once; he feels pain 
 in this region, and there is tenderness to pressure 
 over it; the tenderness is often attributed to the 
 gall-bladder. If the duodenum has become infected 
 
 Fig. 20. — Taken 47 hours after the same bismuth meal, 
 showing obstruction by bands just beyond the hepatic flexure. 
 (Confirmed by operation.) 
 
 with microbes from the stagnant ileum we shall 
 probably get ulceration in the duodenum (Figs. 
 8-12). No normal duodenum gets ulcerated; a 
 chronic duodenal ulcer occurs only in the distended 
 duodenum of chronic intestinal stasis. It follows 
 that one cannot have a duodenal ulcer without ileal 
 stasis, and this accords entirely with my experience. 
 The distended duodenum has a very definite ef- 
 fect on the pylorus, which closes tight to prevent 
 reflux from the overfull duodenum. The pylorus 
 gets into a state of permanent spasm (Fig. 13), its 
 contents become too acid, and this leads to a further 
 increase of the spasm, for physiological experiments 
 
 21 
 
have proved that no acid can enter the duodenum 
 without setting up an immediate tight closure of 
 the pylorus. There is delay in the emptying of 
 the stomach, and this organ is overloaded and di- 
 lates. The great curvature drops, and the trans- 
 verse colon, also heavy with the weight of its stag- 
 nating contents, drops with it. Thus we get an 
 abnormally great strain on the lesser curvature, and 
 especially on the two "ligaments" of the stomach — 
 the pylorus and the esophagus. A chronic ulcer is 
 apt to appear at the pylorus, this part being accessi- 
 ble to the microbes which infect the "static" duo- 
 
 
 • 
 
 7 , 
 
 
 
 
 
 
 D 
 
 
 .9 
 J 
 
 e 
 
 
 
 
 • Caecum 1 
 
 - , ^rr t 
 
 -, 
 
 
 
 
 
 
 
 Fig. 21. — Cancer of the ascending colon in a man aged 57. 
 There was a movable tumor in the position marked by a 
 wire. A thin streak of bismuth ran along the outer side of 
 the ascending colon, the tumor being attached to the inner 
 wall. The appendix (normal) is shown well filled with bis- 
 muth. 
 
 denum, or, if the pylorus drops, the point of great- 
 est strain is shifted toward the esophagus, and the 
 ulcer appears at some point along the lesser curva- 
 ture (Figs. 13 and 14). 
 
 With the appearance of an ulcer in the stomach 
 the acidity of the gastric contents increases still 
 more, and the pyloric spasm becomes so severe and 
 constant as to simulate organic stenosis (Figs. 13 
 and 14), and the radiologist must be very wary in 
 the manner of carrying out his investigations to 
 avoid this pitfall. 
 
 The ar-ray appearances of chronic ulcer of the 
 lesser curvature are quite characteristic, especially 
 on the couch. The depressed base of the ulcer fills 
 
 22 
 
with bismuth; the raised margins of the ulcer are 
 shown, and there is a tight hour-glass constriction 
 of the stomach over the region occupied by the ul- 
 cer, so that the stomach appears divided into two 
 parts, separated by a narrow isthmus (Fig. 13). 
 An important point to remember is that this hour- 
 glass constriction is permanent except during gen- 
 eral anesthesia. The radiologist must bear this in 
 mind, lest he diagnose a cicatricial contraction, and 
 the surgeon must not forget it, for when operating 
 
 Fig. 22. — Taken 11 hours after a bismuth meal in a woman 
 aged 35, short-circuited a year previously by Sir Arbuthnot 
 Lane. Showing the termination of the ileum, and the rectum 
 fu'l of bismuth. Some bismuth had run up to the splenic 
 flexure ; the following morning this had come down again. 
 II., ileum ; I. C, iliac colon ; the X marks the union between 
 the ileum and the rectum. 
 
 under general anesthesia he does not see a constric- 
 tion, and he may not realize that the stomach will 
 be drawn in again at the seat of the ulcer as soon 
 as the patient has recovered from the anesthetic. 
 I have seen a surgeon make his gastrojejunostomy 
 opening at the level of a chronic ulcer of the lesser 
 curvature and the result was promptly fatal. 
 
 If we were to make an artificial hour-glass con- 
 striction in a healthy stomach we should expect the 
 pyloric portion of that stomach, beyond the con- 
 striction, to become small (for it would never be 
 properly filled), just as the entire stomach becomes 
 
 23 
 
small in cases of stricture of the esophagus. The 
 fact is exactly the apposite in chronic ulcer of the 
 lesser curvature; the pyloric portion of the stomach 
 is always large and dropped (Fig. 13) ; in the most 
 extreme cicatrical hour-glass stenosis of the stomach 
 the great curvature may be in the pelvis in the up- 
 right posture. This affords the most striking con- 
 firmation of the fact that the chronic ulcer of the 
 lesser curvature occurs, not in a healthy stomach, 
 but in the enlarged stomach produced by constant 
 pyloric spasm. 
 
 Fig. 23. — Taken 5 hours after a bismuth meal in a woman 
 aged 26, nine months after colectomy. All the bismuth is in 
 the rectum except traces in the last four inches of the ileum. 
 The duodenal distension and the pyloric spasm had been re- 
 lieved almost completely. 
 
 The symptoms caused by these chronic gastric ul- 
 cers are often vague and difficult to interpret clin- 
 ically, and they are not often diagnosed correctly ex- 
 cept by the rc-ray method, when the diagnosis can 
 be made with certainty as a rule. One of the 
 dangers of leaving these ulcers untreated is due to 
 their tendency to become malignant after a time, 
 and I have a number of instances of carcinoma of 
 the stomach exemplifying various stages in the 
 transition from a typical chronic ulcer to an ex- 
 tensive malignant growth. The x-ray appearances 
 are those typical of a chronic ulcer, but with more 
 or less deviation from the typical picture due to 
 the malignant involvement (Fig. 15). 
 
 24 
 
Thus intestinal stasis is shown to be an impor- 
 tant cause of cancer, not only in the stomach, but 
 also in the pancreas, the liver and bile-ducts, and 
 in the breasts. Cancers occur also in the large in- 
 testine as the result of stasis ; this is readily shown. 
 In the rectum (Figs. 16 and 17) and in the cecum 
 (Fig. 21) the long-continued irritation of stag- 
 nant feces is responsible for the growth; in the 
 hepatic flexure region and in the first part of the 
 transverse colon immediately beyond the hepatic 
 flexure fecal accumulation is often due to bands 
 continued down from the lower surface of the 
 
 Fig. 24. — Rheumatoid arthritis ; a disease frequently seen 
 in the subjects of chronic intestinal stasis. The cancellous 
 tissue of the bones is rarefied. The joint trouble subsides 
 permanently on the relief of the stasis. 
 
 liver over the pylorus and gall-bladder (Fig. 20). 
 These bands are found in a fair proportion of 
 stasis subjects. The iliac colon, again, is often 
 tied to the left iliac fossa by bands, these being 
 the first to form in the body. These bands some- 
 times cause obstruction and lead to a condition of 
 chronic congestion with yielding of the bowel-wall 
 between the bands and the production of the dis- 
 order known as "diverticulitis" (Fig. 18). Follow- 
 ing upon this long-continued obstruction we may 
 get the appearance of a cancer in this region. 
 
 Needless to say the bearing of all this new knowl- 
 edge on treatment is of the greatest importance. 
 
 I propose to say but little concerning treatment, 
 
 25 
 
and only in its relation to radiology. Having ascer- 
 tained the existence of stasis in a particular case, 
 and the presence of one or more of its complica- 
 tions, the question will always arise — should we go 
 to the root of the matter and deal with the stasis, 
 or should we apply our treatment to the complica- 
 tion, — the end result of the stasis — e.g. a gastric 
 or duodenal ulcer. The answer is simple: — leave 
 the end result alone if you can, i.e. if it is not 
 causing stenosis, or becoming malignant, or im- 
 pacted in the case of gallstones. If you treat the 
 end result {e.g. by performing a posterior gastro- 
 jejunostomy for ulcer) you will give your patient 
 temporary relief which may be great, but you will 
 not cure his stasis. Or again, if you merely remove 
 his appendix, which has become (secondarily) con- 
 gested or kinked, no lasting benefit will result. In 
 proof of this I would mention the very large num- 
 ber of patients sent to me for investigation by the 
 x-rays at some period after one of these operations 
 had been performed. They are sent to me because 
 they are not cured; they are suffering from the' 
 general symptoms and signs of stasis; or perhaps 
 some other complication has arisen, e.g. colitis. 
 
 The rational treatment of stasis is directed to 
 the abolition of the undue retention of the con- 
 tents of the lower ileum and the large intestine. 
 In slight cases this may be done by the adminis- 
 tration of liquid paraffin to accelerate the progress 
 of the feces through the large intestine, and by 
 a spring support for the lower abdomen, to pre- 
 vent the dropping of the large intestine and the 
 lower coils of the ileum, and to obviate the evil 
 consequences of an ileal kink if there be one. 
 
 In severe cases of stasis, too advanced to gain 
 sufficient relief from the above treatment, operative 
 measures are needed; short-circuiting the ileum, 
 near its lower end, into the rectum, and making a 
 kink in the iliac colon above the short-circuit to 
 prevent or diminish the regurgitation of the ileal 
 contents from the rectum into the descending colon. 
 Often there is already a well-developed kink in this 
 region (Fig. 12), or there is a slight kink which can 
 be made more effective at the operation. In some 
 cases, where the large intestine is very unhealthy, and 
 would cause flatulent distension and other trouble 
 if left, Sir Arbuthnot Lane now removes the whole 
 big bowel above the short-circuit opening at the 
 time of the first operation. Formerly he would do 
 this at a subsequent operation if it proved neces- 
 
 26 
 
sary; with increased experience, however, one is 
 now able to judge, in a particular case, whether 
 the big bowel must be removed, or may be retained. 
 All the details of the operations have been de- 
 scribed by Lane, and are now well known and are 
 practised extensively by a number of prominent 
 surgeons throughout the world. 
 
 We come now to the results of the radical treat- 
 ment of stasis from the radiological standpoint: 
 Can we show, by radiology, that the stasis has been 
 relieved? Certainly we can; in a successful case 
 the whole bismuth meal is in the rectum after 6 or 8 
 hours (Fig. 23). The stasis has been cured. If 
 the large intestine has been left there may be some 
 bismuth in the descending colon for a few hours 
 (Fig. 22), but as soon as the patient has an evacu- 
 ation this comes down and is passed with the rest. 
 Some of the cases in which the bismuth passes back, 
 not merely into the descending colon but right back 
 to the cecum, are those in which the subsequent re- 
 moval of the big bowel becomes necessary on account 
 of flatulent distension and tenderness due to the 
 irritation set up in the bowel wall by the retention 
 of lumps of secretion in the big bowel. 
 
 The question will be asked, what is the effect 
 of the radical cure of stasis upon the distended duo- 
 denum? If the explanation ascribing the "static" 
 duodenum to the downward pull on the upper jeju- 
 num be the true one, then the cure of the ileal 
 stasis should abolish this downward pull, and should, 
 therefore, relieve the duodenal distention. Does 
 it do so? Yes. I have reinvestigated a large num- 
 ber of patients after short-circuiting, at varying 
 intervals, from three weeks to several years, and 
 the general conclusions are as follows: The duo- 
 denal obstruction, as shown by "writhing" contrac- 
 tions, and repeated return of the bismuth toward 
 the pylorus, are relieved at once by the 3 or 4 
 weeks recumbency following the operation, and do 
 not come again even after the patient has resumed 
 ordinary conditions of life and work. The duo- 
 denum does not return at once to its normal size, 
 but gradually — in the course of months — it becomes 
 smaller and shorter, though in old, neglected cases 
 the duodenum tends to remain permanently more 
 "baggy" than normal; but the chief point is that 
 the duodenum never again becomes distended; it 
 is no longer found full of bismuth; its outlines can 
 be sketched only by observing small quantities of 
 bismuth as they pass through it — which they do 
 
 27 
 
without delay — into the jejunum. No photograph 
 of the "cured" duodenum can be taken, in marked 
 contrast to the state of things before the opera- 
 tion, when a most striking photograph of the dis- 
 tended duodenum is readily obtained. 
 
 Another proof of the efficacy of the radical treat- 
 ment is shown in the stomach, which loses its con- 
 stant pyloric spasm, so that the rate of emptying 
 of the stomach becomes normal, or nearly so with- 
 in a few months after the operation. This was 
 exemplified to me in a most striking way recently 
 when I reexamined a woman six months after she 
 had been "short-circuited" by Sir Arbuthnot Lane. 
 Before the operation she had furnished one of my 
 most striking instances of the distended, "writh- 
 ing" duodenum, and scarcely any bismuth had left 
 the stomach after 6V2 hours. Now (6 months 
 later) the whole of the bismuth was in the rectum 
 after six hours, a little having run up the descend- 
 ing colon, and the whole had been evacuated within 
 24 hours. The duodenum could not be photo- 
 graphed, the bismuth passing through it, little by 
 little, without difficulty, so that the duodenum was 
 never seen filled with bismuth, in striking contrast 
 with its behavior before the operation. Thus the 
 patient has been relieved of all the signs and symp- 
 toms of stasis, and her stomach and duodenum 
 have been put out of danger; the duodenum is no 
 longer infected with microbes from the stagnant 
 ileum, and the duodenal distension and overloading 
 of the stomach have been rectified. 
 
 I have given details of other aspects of stasis in 
 a contribution to the International Journal of Sur- 
 gery, for April, 1914, with a series of skiagrams il- 
 lustrating many of the changes due to the disease. 
 
 Much progress is being made on both sides of 
 the Atlantic in our understanding of Chronic In- 
 testinal Stasis, but there is still scope for search- 
 ing inquiry by surgeons, clinicians, radiologists, 
 pathologists, and in fact all medical workers, in the 
 realm which has been discovered by the far-reach- 
 ing observations of Sir Arbuthnot Lane. 
 
 Here, in the New York Polyclinic, I see earnest 
 investigators at work on the stasis problem. Dr. 
 Quimby is attacking it from the radiological side, 
 Dr. Hayes and others from the medical and patho- 
 logical standpoint, while Dr. William Seaman Bain- 
 bridge is getting brilliantly successful results from 
 the application of surgical measures to the relief 
 of chronic intestinal stasis. 
 
 28 
 
THYROID DEFICIENCY. 
 
 By E. HERTOGHE, M.D., 
 
 ANTWERP, BELGIUM. 
 
 CORRESPONDING MEMBER OF ROYAL ACADEMY OP MEDICINE OF 
 BELGIUM. 
 
 Myxedema in the severe form was discovered and 
 first studied in England. It is now a well-known 
 pathological entity all over the world and of it I 
 could say nothing but what you know perfectly well. 
 But I will insist upon the mild forms because they 
 are not so well outlined and very often escape the 
 attention of the medical man. I called it when I de- 
 scribed it for the first time 1899 1 mild myxedema, 
 myxedema frustum, or benignant chronic hypothy- 
 roidism. The conception of mild myxedema was at 
 first strongly opposed because the symptoms were 
 so numerous, that is to say, because the sympto- 
 matological range was so great and extended to 
 every organ of the body. Just lately Dr. Leonard 
 Williams of London has said: "The idea of benig- 
 nant chronic hypothyroidism is simple enough, but 
 the symptomatology is a perfect maze." This is 
 not the fact, provided we begin with a clear under- 
 standing of the lesion caused by thyroid want. 
 
 If we knew exactly the function of the thyroid 
 gland we would no doubt be able to deduct imme- 
 diately the symptom of a diminished or impov- 
 erished secretion; but we do not. However, we 
 know something. We know that without the thyroid 
 stimulus no cell, whatever it may be, can attain 
 its morphological perfection — the perfection needed 
 for good work, muscular, nervous, connective, 
 glandular, or bone. The proof thereof is that a 
 child born with congenital want or a child deprived 
 completely by an operation of its thyroid gland 
 does not grow, or grows very little. Give it a 
 few doses of thyroid extract and it will begin to 
 develop; stop the supply and immediately progress 
 is stopped. 
 
 We know something more: When a cell has done 
 its duty for some time it decays, it is no longer 
 desirable. It must be taken to pieces and elimi- 
 nated through various channels — bowels, kidneys, 
 
 (Reprint from the Medical Record.) 
 29 
 
lungs — especially under the form of urea. When 
 thyroid supply is scarce the carrying away of the 
 cellular waste matter is slow and incomplete — 
 mucin, fat, and other principles accumulate on the 
 spot, and there form an infiltration and edema of 
 a special kind — hard, non-depressible — and there- 
 from comes the name of myxedema. 
 
 Infiltration Is the Constant Lesion of Thyroid 
 Deficiency. — It may be obvious or it may be slight, 
 but it is always there. If a patient, swollen with 
 this special edema, takes thyroid extract he im- 
 mediately eliminates a great quantity of urine and 
 urea. He loses in weight, the cellular waste matter 
 is carried away, and when he has got rid of the 
 whole residual stock you may give him doses ten 
 times stronger and he will lose no more. We may 
 sum up and say, thyroid secretion is necessary to 
 the building up and to the dismantling of our 
 tissues — of all our tissues ; and, therefore, the want 
 of it finds an echo in all our organs without any 
 exception. 
 
 All the infectious diseases of early age and of 
 later on fall heavily on the vitality of the thyroid 
 gland. Acute rheumatism of the joints has a 
 most nefarious influence and causes even after 
 years the outbreak of severe forms of myxedema. 
 And, what is more, all the great causes of patho- 
 logical disturbance, tuberculosis, syphilis, paludism, 
 alcoholism, chronic starvation, and consanguinity 
 hit their first blow on the thyroid system, and the 
 thyroid deficiency thus brought on comes down 
 fatally on the offspring. 
 
 The child shown in Fig. 1 is a remarkable in- 
 stance of hereditary syphilis and thyroid weak- 
 ness. The father married shortly after having 
 contracted syphilis. The result you see here — 
 growth stopped, cretinous appearance; observe also 
 the result of medication. 
 
 If we had seen such a patient some ten or fif- 
 teen years ago we would have no doubt diagnosed 
 hereditary syphilis, but there would have ended our 
 healing power — neither iodine nor mercury would 
 have restored the child to normal growth and 
 health. But now that we know that the growth 
 has been stopped on account of the syphilitic toxin 
 having dried up the thyroid well, we act in conse- 
 quence and have a successful medication, that shows 
 the usefulness of the hypothyroid notion. 
 
 The litle girl shown in Fig. 2 is a case of thyroid 
 weakness caused by hereditary paludism. The 
 
 30 
 
mother while pregnant underwent several attacks 
 of intermittent fever. She herself had a weak 
 thyroid. The paludic poison added to her natural 
 disposition had the result of impairing the thyroid 
 powers of the child, and it was born a cretin. This 
 case looked at as merely paludic was hopeless. 
 Seen in the light of thyroid weakness we get a 
 good result. 
 
 The boy shown in Fig. 3 was twenty-one years 
 old. He was a perfect dwarf, absolutely childish, 
 and without any intellectual development. Mother 
 healthy. Father died from pulmonary consump- 
 
 Fig. 1. — Hereditary syphilis, a, Arrest of growth, age 10%, 
 height 3 ft. 2y 2 in. ; b and c, influence of thyroid feeding 
 after 1 and after 2 years. 
 
 tion a few days before the child was born. This 
 may be considered as a case of hypothyroidism and 
 tuberculous heredity. 
 
 Let us bear in mind that we are inheritors of 
 a great number of generations. Our blood is a 
 mixture of good and bad qualities that our fore- 
 fathers have left us while struggling with in- 
 numerable causes of diseases of all sorts. From 
 all this we may conclude that thyroid weakness is 
 very frequent, at least in a mild form. 
 
 Now I must say that thyroid weakness is not 
 synonymous with cretinism. Incomplete forms will 
 go very well with a fairly active and busy life; 
 some of these patients are indeed very intelligent. 
 I wish to draw your attention to these social forms 
 because they are very common, and because the 
 exact knowledge of them enables us to grasp the 
 cause and decide the successful treatment of a 
 
 31 
 
large number of pathological conditions for the 
 occurrence and treatment of which we are other- 
 wise unprepared. 
 
 We will now follow up the idea of infiltration 
 which is brought on by thyroid insufficiency, and 
 consider the consequences in various tissues of the 
 body. 
 
 Muscles. — The cell loaded with fat and mucin is 
 increased in size so that its contraction is delayed 
 in onset and slow in execution. Muscular action 
 then becomes painful, accompanied by stiffness and 
 dread of movement. The connective tissue sheath 
 
 a b c d 
 
 Fig. 2. — Hereditary paludism. a, Arrest of growth, age 8 
 years, height 2 ft. 10 in. instead of 3 ft. 10 in. ; b, c, d, influ- 
 ence of thyroid feeding, after 1,2, 5 years. 
 
 which supports the contractile elements and con- 
 nects the muscles with the tendons, aponeuroses, 
 and articular ligaments is equally infiltrated, and 
 this adds to the difficulty of movement. This ap- 
 plies alike to non-striped and voluntary muscle. 
 
 This muscular infiltration shows itself subjec- 
 tively by rheumatoid pains, which must not be 
 confused with rheumatism, due to causes with 
 which we are not here to be concerned. The state- 
 ment made by some writers that thyroid extract 
 cures nodular rheumatism, chronic or otherwise, 
 should, therefore, be accepted with reserve. Thy- 
 roid extract relieves pain in the muscles, joints, 
 and ligaments only in so far as this depends on 
 thyroid deficiency ; that is, it is due to the specific 
 myxedematous infiltration, and it acts only by 
 causing absorption of that infiltration. We must 
 
 32 
 
remember that thyroid extract is essentially a spe- 
 cific and can act favorably only where there exists 
 an inactivity, or weakness of the thyroid. 
 
 Let us take another example. The nerve cell, 
 whatever may be the degree of myxedematous ca- 
 chexia, is never destroyed as in a hemorrhagic focus 
 or embolic necrosis. Its nutrition and excretion 
 are simply hindered. It is infiltrated and at the 
 same time compressed by the infiltration of its 
 supporting connecting tissues. The transmission 
 of motor, sensory, and voluntary impulses is thereby 
 delayed but not abolished, and the reflexes are slug- 
 gish but present. 
 
 The discomfort of the nerves shows itself by 
 neuralgias and even by shooting pains of a neuritic 
 character; the distinction between these two kinds 
 of pain being well known to the patient. Cardiac 
 pain is also present with radiations into the bra- 
 chial plexus simulating attacks of angina. 
 
 The central nervous system exhibits early evi- 
 dence of infiltration, however slight it may be. In 
 well-marked myxedema, vertigo, dizziness, noises 
 in the ears, headache, migraine, loss of memory, 
 mental confusion, depression, melancholia, loss of 
 consciousness, loss of balancing power, sudden 
 falls, somnolence, attacks of coma, which may be 
 confused with the serous apoplexy of Bright, with 
 all the more probability that there is usually some 
 albuminuria. 
 
 In mild myxedema the list is not so formidable. 
 One should remember the morning headaches and 
 tendency to migraine, vertigo, and noises in the 
 ears. 
 
 Even the bone does not escape the consequences 
 of thyroid defect. Every surgeon knows that in 
 certain persons fractures unite imperfectly or not 
 at all, and thyroid extract is given to avoid com- 
 plication. If one carefully examines such patients, 
 those at least who benefit by it, there will always 
 be found some more symptoms of thyroid deficiency. 
 
 Cartilaginous tissue also gives clear evidence of 
 this specific cellular infiltration. On moving the 
 joints which are stiff and painful the application of 
 the hand detects a peculiar sensation resembling 
 the crackling of crushed snow which is almost 
 pathognomonic. This is well felt in the knee joint. 
 Sometimes the patient himself feels and hears a 
 crepitation in the joints of his cervical vertebrae. 
 These joint symptoms were described first by 
 Professor Verriest in connection with a case of 
 
 33 
 
myxedema shown to the Royal Academy of Medi- 
 cine of Belgium in 1886." 
 
 These painful affections of the joints improve 
 very slowly and are the last symptoms to disappear. 
 An ecclesiastic, after several months' treatment for 
 very pronounced myxedema, still complained of the 
 stiffness of his knees which rendered ritual genu- 
 flection very difficult, but which ultimately com- 
 pletely disappeared. This delay in functional restor- 
 ation may perhaps be explained by the slowness of 
 the nutritive exchanges in cartilage. 
 
 The glandular tissues which play so important 
 
 Fig. 3. — Hereditary tuberculosis, thyroid weakness. Arrest 
 of growth ; influence of thyroid feeding, after %, 1, and 2 
 years. 
 
 a part in the organism also present infiltration both 
 of their secreting elements and the supporting con- 
 nective tissue. The secretion of sweat is com- 
 pletely abolished. 
 
 There is considerable congestion of the liver, 3 
 the hepatic cells secrete badly, while the canaliculi 
 are compressed. Bile passes into the circulation, 
 causing the characteristic amber color of the skin. 
 Biliary calculi are also common. 
 
 The scanty intestinal secretion along with the 
 muscular weakness of the visceral walls causes ob- 
 stinate constipation, which in turn leads to fermen- 
 tation with the formation of an abnormal quantity 
 of gas, thus producing meteorism and abdominal 
 distention with noisy eructations from the stomach. 
 
 The alterations of epidermic and epithelial cov- 
 erings deserve special notice. The insufficiently 
 
 34 
 
nourished epidermis undergoes early desquamation; 
 the hair falls prematurely. In milder cases the hair 
 is poor, brittle, and becomes early grey, while the 
 beard is thin and straggling. The nails are striated 
 and brittle, and in severe cases split and destroyed. 
 The teeth are almost always in a deplorable con- 
 dition, exposed, decayed, and covered with a green- 
 
 Fig. 4. — Hypothyroids alopecia ; thyroid insufficiency. Influ- 
 ence of thyroid feeding. 
 
 ish tartar. The gums are red and irritated, form- 
 ing polypoid projections between the teeth. The 
 eyebrows are thinned, especially in their outer 
 thirds, giving the face a somewhat silly expres- 
 sion. The eyelashes are also shed, leaving the eye- 
 lids unprotected against the erosive action of the 
 tears. This blepharitis of thyroid origin is some- 
 times seen in old persons. In a case which had re- 
 sisted all other means of treatment, a radical cure 
 was obtained in a few days by the local applica- 
 tion of adrenalin and the administration of thy- 
 roid extract. The whole skin is thickened, infil- 
 
 35 
 
trated, cold, and easily attacked by such affections 
 as eczema, psoriasis, and alopecia. The eczematous 
 condition of the scalp in young infants, known as 
 the "milk crust," which is alike the despair of 
 mothers and doctors, yields rapidly to a few doses 
 of thyroidin combined with arsenic, when this af- 
 fection is associated with thyroid defect, and the 
 same can be said of psoriasis and of certain forms 
 of alopecia. 
 
 The little boy pictured in Fig. 4 had lost all his 
 hair. I should never have suspected thyroid de- 
 ficiency in this case if the mother had not evidently 
 been under thyroid distress. The result of thyroid 
 treatment on growth and alopecia is well shown. 4 
 
 The mucous membrane of the mouth, lips, tongue, 
 nose, pharynx, larynx, ear and esophagus are also 
 infiltrated. 
 
 The vaginal mucous membrane is softened and 
 infiltrated, giving on digital examination a sen- 
 sation similar to that of the commencement of 
 labor. Similar changes produce disturbances of 
 phonation, deglutition and hearing. 
 
 The swelling of the fauces and esophagus may 
 actually prevent swallowing in some cases. 
 
 In very severe cases of advanced myxedema, at 
 the approach of death, the enormously swollen 
 tongue tends to fall backward so that the air does 
 not enter the trachea, although the respiratory 
 movements of the thorax continue; the condition 
 being identical with that seen during anesthesia in 
 similar circumstances. After five or six of such 
 false inspirations a spasm of the tongue .and 
 pharynx occurs which again allows the entrance 
 of air. Normal respiration is thus reestablished 
 for a time, till again interrupted and restored as 
 before. This condition may be mistaken by an in- 
 experienced observer for a type of Cheyne-Stokes 
 respiration. 
 
 Endothelial tissues share in the general feeble- 
 ness. They are shed prematurely, and such cavities 
 as the gall-bladder and also the urinary bladder 
 are unprotected from the irritating action of their 
 contents. The gall-bladder becomes sensitive, even 
 painful, while the mass of desquamated epithelium 
 may become the nucleus of a calculus. Biliary 
 lithiasis is itself frequent in myxedema, and occurs 
 to a less extent in the milder forms. 
 
 The bladder being constantly denuded of its 
 epithelial lining is more than usually sensitive to 
 the irritating action of the urine, and this alone 
 
 36 
 
is responsible for many cases of nocturnal enuresis 
 in children. An examination of the urine in these 
 cases shows the presence of a large number of 
 squamous epithelial cells from the bladder. When 
 closely studied these children present signs of thy- 
 roid weakness, and their parents, especially the 
 mother, often exhibit a more or less advanced de- 
 gree of thyroid defect. As the children grow up 
 the activity of the thyroid gland increases and 
 these troubles disappear. In girls a trace of them 
 frequently persists as pollakiuria or frequency of 
 micturition. 
 
 A most constant symptom of myxedema is a 
 lowering of the temperature. This may be due to 
 the decreased or less active combustion of fats and 
 
 Ej 
 
 
 4 %*M 
 
 \ 
 
 
 
 
 Fig. 5. — Severe myxedema before and after treatment. 
 
 mucin, or perhaps to the infiltration of the heat- 
 regulating center in the brain. If one suddenly 
 administers large doses of thyroidin to a myxe- 
 dematous patient, at the time he has a large quan- 
 tity of infiltration ready to be oxidized, one may 
 observe a considerable elevation of temperature, 
 which may even be mistaken for fever. This is 
 probably due to the ultra-rapid combustion of these 
 accumulated materials. 
 
 The lowering of the body temperature is per- 
 ceived by the patient. It is subject to diurnal vari- 
 ations, being specially noticeable in the afternoon 
 about 4 or 5 o'clock, in the form of violent shiv- 
 ering, starting with the sensation of cold water 
 thrown on the back. These symptoms may be mis- 
 interpreted and treated by the useless administra- 
 tion of quinine. In slight myxedema this feeling 
 of cold is present in a lesser degree. The patient 
 is in a state of habitual chilliness, showing itself 
 in women and children by constant coldness of the 
 hands and feet, and the condition known as "dead 
 
 37 
 
finger" — pallor, stiffness, and insensibility of one or 
 more digits. 
 
 Let us consider the effects of the infiltration on 
 a complex mechanism, such as the cardiorespi- 
 ratory system, where the different elements we 
 have just studied are associated with one another. 
 
 We have to remember the paresis of the cardiac 
 muscle, of the external respiratory muscles, and 
 of the diaphragm; the painful infiltration of the 
 nervous ganglia at the base of the heart, added 
 to the disturbances of its central innervation; the 
 infiltration of the pulmonary tissue, the bronchial 
 mucous membrane of the respiratory tract, and 
 consider the consequences. 
 
 The dyspnea presented by some patients suffer- 
 ing from severe myxedema may surpass all de- 
 scription. They can with difficulty climb a short 
 flight of stairs, even with a rest by the way; they 
 arrive in the consulting room absolutely breath- 
 less and supporting themselves by the furniture, 
 indicating by signs their inability to speak till 
 they have recovered breath. 
 
 In mild cases the oppression is less marked. It 
 may be intermittent and presented only on the 
 occasion of unusual exertion, corresponding to an 
 increased demand on the thyroid gland which is 
 weak already. The condition is then readily mis- 
 taken for an attack of asthma, and many so-called 
 asthmatics are certainly suffering from thyroid 
 defect. Certain French writers have reported some 
 unexpected cures of asthma by thyroid extract, 
 and while admitting that the patients presented 
 symptoms of thyroid weakness they persist in de- 
 scribing such cases by the term neuroarthritic. 
 That is not logical; we should rejoice to see the 
 word arthritism, which no one understands and 
 which is so often used as a cloak for ignorance, 
 disappear from the medical vocabulary. 
 
 Another example: Consider the gastrointestinal 
 system — the muscular walls are slow and lazy, in- 
 testinal secretion scarce, therefrom arises consti- 
 pation. Microbes find their way to the peritoneum 
 and even kidneys; the peritoneum protects itself 
 by false membranes which in time will grow into 
 bands, bringing on kinks and their consequences. 
 In hypothyroid patients these pericolitic adhesions 
 nearly always exist and are even found in very 
 young children, which is not to be wondered at 
 — hypothyroid disposition being nearly always 
 hereditary. 
 
 38 
 
I would be delighted if my supposition concern- 
 ing the question of intestinal stasis should prove 
 to be correct. It would perhaps bring into a 
 brighter light still the ideas that Sir Arbuthnot 
 Lane in England and Professor Bainbridge in 
 America have promoted and implanted at the price 
 of a most daring and incessant effort. 
 
 Sexual System. — The thyroid gland plays an im- 
 
 Fig. 6. — Severe myxedema before and after treatment. 
 
 portant part in the development and functional 
 activity of the sexual organs, especially in females. 
 It superintends the growth and general develop- 
 ment of the sexual organs. Absolute cretins never 
 come to puberty. In mild forms of thyroid in- 
 sufficiency the uterus remains infantile and small; 
 menstruation begins late in life. Sometimes the 
 posterior wall of the womb does not grow as quickly 
 as the anterior, and therefrom comes retroflexion. 
 This is by no means a rare condition in very young 
 girls. Profuse menstrual bleeding is often seen 
 in such cases and is attributed to retroflexion. As 
 a matter of fact, the excessive bleeding is caused 
 by the infiltration of the uterine mucous lining, by 
 the defective contractility of uterine muscular 
 cells and by the hemophilic condition of the blood. 
 In thyroid defect hemophilia is quite a classic symp- 
 tom. Profuse oozing may be brought on by almost 
 a mere scratch. 
 
 It is a well-recognized fact that thyroid defi- 
 ciency falls, in nine-tenths of the cases, on females. 
 The reason thereof is easily given: The thyroid 
 has a great influence on menstruation, pregnancy, 
 
 39 
 
lactation, and even uterine involution after child- 
 birth. When the thyroid is normally active the 
 menses are normal; when weak, menorrhagia sets 
 in. The weaker the thyroid the greater the loss 
 of blood. We very often come across these cases 
 of menorrhagia even in very young girls, and we 
 are at a loss to understand the meaning of this 
 distressful condition. We do not know what to do 
 to prevent it. If we can put aside such causes as 
 fibroids and cancer, we will always think of thyroid 
 deficiency. 
 
 A large quantity of thyroid stuff is wanted dur- 
 ing the menstrual period, and during that time can- 
 
 Fig. 7. — Severe myxedema before and after treatment. 
 
 not be given to the general keeping up of the 
 body. We often see women who at ordinary times 
 have a decent supply of thyroid secretion run, 
 short during the menses, and show then, and then 
 only, the usual signs of thyroid defect. Headaches 
 (migraine) are almost classic symptoms at that 
 time. Many women have muffled voice, which is 
 the result of temporary infiltration of the vocal 
 chords. Extreme lassitude, pains in the back, ob- 
 stinate constipation, all go along in that line of 
 symptoms. 
 
 It is not necessary to dwell on the good effects 
 of thyroid medication under such circumstances. 
 A few doses of thyroid extract will act as a power- 
 ful tonic and reduce to a considerable extent the 
 anemic influence of the menses, and reduce con- 
 siderably the loss of blood. 
 
 In pregnancy the thyroid becomes enlarged and 
 throws into the blood an unusually large quantity 
 
 40 
 
of secretion, thereby suspending menstruation and 
 protecting the fertilized ovum against the harm 
 which would result from menstrual activity. This 
 action of the thyroid should be. remembered in 
 cases where chronic abortion has exhausted all 
 other forms of medication. We may assert that 
 thyroid extract has proved in scores of cases an 
 excellent remedy for otherwise inexplicable ster- 
 ility. A great many women who have taken thy- 
 roid extract with a view to reduce their obesity 
 have been surprised by becoming pregnant in the 
 course of this medication, and this unexpected re- 
 sult is due to the thyroid inhibition of menstrua- 
 tion. After childbirth the maternal system is sud- 
 denly relieved; a large amount of thyroid secre- 
 tion is still in store. Part of it will be given to the 
 muscular and nervous exertion of labor itself and 
 another part goes to the involution of the uterus. 
 The heavy muscular walls of the womb have to de- 
 generate into fat and be oxidized, and this can- 
 not be done without the interference of the thy- 
 roid stimulus. 
 
 Finally, lactation claims a good deal of thyroid 
 stuff. It has been proven by experiments on ani- 
 mals that thyroid extract works upon the mammary 
 glands and increases the quantity of milk. Women 
 who have a good lactation have also a quick involu- 
 tion of the womb. After weaning, the thyroid 
 gland is now fairly exhausted. Most of mothers 
 grow fat at that time. Menstruation takes advan- 
 tage of this deficiency and comes back. Thyroid 
 medication may be useful in such cases where lac- 
 tation is scanty and where menstruation has a 
 tendency to return before the physiological time. 
 This is indeed the only way we have to increase 
 the mammary secretion. 
 
 The mucous lining of the vagina is also infil- 
 trated, and under examination gives the impres- 
 son of incipient labor. A good many patients have 
 been curetted for hemorrhagic endometritis who 
 were in reality deficient in their thyroid powers. 
 
 I acquainted Professor Bainbridge when he was 
 in Antwerp with these facts. Being a gynecologist 
 as well as a surgeon, he said he would make a care- 
 ful study of hypothyroid menorrhagia. I am glad 
 to say, and he announced it before the Academy, 
 that he is now convinced that this is absolute truth. 
 He has cured a number of cases already with thy- 
 roid feeding, to the astonishment of those who 
 had previously curetted the uterus without reliev- 
 
 41 
 
ing the menorrhagia. Much more might be said 
 about thyroid secretion, indeed volumes have been 
 written on the subject. My friend, Dr. Sajous of 
 Philadelphia, knows about it, and his work on in- 
 ternal secretion has not said all. 
 
 The usefulness of thyroid medication is con- 
 spicuous in delayed development of the sexual or- 
 gans, infantile uterus, infantile retroflexion and 
 excessive menstruation. In some cases of sterility 
 and repeated abortion it will prove to be a success- 
 
 Fig. 8. — Mild myxedema, showing the loss of heir. 
 
 f ul treatment. Slow involution of the uterus after 
 childbirth and wavering lactation will also find here 
 powerful help. 
 
 From what we have stated it is evident that 
 the best way to understand mild myxedema is to 
 have a clear conception of the more severe form. 
 The more severe form, when properly treated, 
 gradually progresses through the milder forms to 
 become finally imperceptible even to the most ex- 
 perienced eye. So also, after successful treatment, 
 a myxedematous patient, left to himself, gradu- 
 ally relapses, the milder symptoms being the first 
 to return, followed by those of increasing severity, 
 so that the disease reconstructs itself under your 
 eyes. These symptoms of the milder form of the 
 
 42 
 
disease are precisely those which should be most 
 clearly impressed upon your memory. 
 
 The weakness of the thyroid gland is usually 
 hereditary, and it is rare that one does not find 
 traces of milder defect among the ascending, de- 
 scending, or collateral relations of a person suffer- 
 ing from well-marked myxedema. One must in- 
 quire carefully into the family history; it will 
 be found an inexhaustible source of information 
 regarding symptoms which will render one more 
 
 Fig. 9. — The same patient as in Fig. 8 after treatment. 
 
 familiar with the milder cases of hypothyroidism. 
 
 In doubtful cases treatment by thyroidin forms 
 the touchstone whether for mild or severe myxe- 
 dema. Many persons suffering from the milder 
 forms do not appear stout or swollen, but may 
 even be quite spare in body, the infiltration in such 
 cases predominating in the internal organs. If 
 under small doses of thyroidin such a person loses 
 weight with simultaneous improvement in his gen- 
 eral condition, one may assert the existence of in- 
 sufficient secretion of the gland. 
 
 Let us now study some cases of advanced myxe- 
 dema, and, to facilitate the task, permit me to in- 
 dicate the course I myself followed at the begin- 
 ning of ray studies on the subject. I confess that 
 
 43 
 
when I first found myself in the presence of a 
 case of myxedema I knew nothing about it. I had 
 neglected this part of my medical studies, believ- 
 ing I should never encounter what was then con- 
 sidered a pathological rarity. Myxedema, which 
 meant nothing to me in 1883 when I finished my 
 university course, interested me as little ten years 
 later, when circumstances forced me to concern 
 
 Fig. 10. — Mild myxedema — Loss of eyebrows. 
 
 myself with it, and to recognize it without having 
 suspected its existence. 
 
 In 1894, while in attendance at the house of M. X., 
 he confided to me that he was much concerned about 
 the health of his wife. He informed me that she was 
 64 years of age, had been married at the age of 20, 
 and had had no children. She had been delicate all her 
 life, but recently her condition had been so much worse 
 that he feared a fatal issue was rapidly approaching. 
 In spite of this she absolutely refused to consult a 
 doctor. She was indifferent to all that went on around 
 her, this apathy being combined with an invincible dis- 
 inclination to all physical exertion. Speech was la- 
 borious to her, being slow, faulty, and indistinct, so 
 that usually despairing of making herself understood, 
 she cut short all attempts at conversation. Her only 
 
 44 
 
desire was to'be left at peace, free from all emotion or 
 anxiety. 
 
 Soon after her marriage Mme. X. had a miscarriage. 
 Her menstruation had always been profuse and the in- 
 tervals between the periods much shortened; the men- 
 strual loss was so great that the blood soaked through 
 the mattress to the floor. She also bled easily after 
 
 Fig. 11. 
 
 -Severe myxedema with loss of hair, 
 after treatment. 
 
 Before and 
 
 Fig. 12. — Profile of the patient shown in Fig. 11. 
 
 slight injuries, a simple scratch being followed by pro- 
 longed oozing. These repeated hemorrhages had pro- 
 duced a state of pronounced anemia shown by the pres- 
 ence of marked pallor and weakness. The hemorrhages 
 were regarded as the original cause of her con- 
 dition. At the age of 35, while driving in an open car- 
 riage Mme. X. was caught in a heavy shower of rain 
 which soaked her to the skin. Following this she took 
 cold and suffered from a well denned attack of acute 
 articular rheumatism, from which she recovered but 
 had never since been free from pain. From that time 
 her condition was attributed to the rheumatic attack 
 by herself and her friends. 
 
 Such was the information given me by the husband, 
 and at his request Mme. X. consented to see me. My 
 diagnosis was instantaneous — it was evident that Mme. 
 
 45 
 
X. was suffering from an attack of Bright's disease 
 in its last stage (Fig. 5). The face was swollen, the 
 eyelids were edematous, leaving only a narrow space 
 between them, the lips were thick, everted, and bluish 
 in color, the speech was slow and drawling, the voice 
 having a strange, deep, croaking tone, while the gait 
 was awkward with slow and indecisive movements. I 
 communicated my opinion to her husband and in- 
 timated my fear that a fatal termination was threaten- 
 ing from uremia. M. X. was not surprised and told 
 me that all the doctors previously consulted had been 
 of the same opinion. I then examined the urine and to 
 
 Fig. 13. — Severe myxedema ; baldness of the nape 
 
 my great astonishment it contained only an insig- 
 nificant quantity of albumin — about 1% grains to the 
 ounce. There was no renal epithelium present, but 
 squamous cells from the bladder were abundant. I 
 was much embarrassed at finding a case of Bright's 
 disease which had reached the stage of threatened 
 uremia practically without change in the urine. Next 
 day I explained to M. X. that the case was somewhat 
 unusual, and asked his permission to keep the patient 
 under observation for ten days in order to make a 
 further examination, to which he willingly agreed. 
 
 I could then examine the patient at leisure. The 
 heart presented no appreciable change, though the 
 pulse was slow. The kidney region was painless on 
 palpation so far as it was possible to examine it, for 
 Mme. X., while not obese, was short and stout, weighing 
 204 lb. Her lower limbs did not appear notably swol- 
 len and though large were not out of proportion to her 
 
 46 
 
body. Her temperature was rather low and she com- 
 plained of cold although it was the end of May and a 
 large fire made the room uncomfortably warm. The 
 patient told me that she always felt the cold most in- 
 tensely about 4 o'clock in the afternoon, at which time 
 she felt as if cold water had been poured on her back, 
 causing her actually to shiver. She soon became tired 
 during my examination and even fell asleep while I 
 talked to her, complaining of extreme lassitude and 
 rheumatic pains throughout the whole of her body. 
 
 Having discovered all this I had advanced no further 
 than before. That a woman 64 years of age should be 
 
 ■*#*" 
 
 Fig. 14. — Same patient as in Fig. 13 after treatment. 
 
 sleepy, chilly, easily tired and suffer from rheumatism 
 was neither very extraordinary nor was it pathog- 
 nomonic. Five days had passed, when chance, — the 
 Providence of doctors, — came to my assistance. M. X. 
 informed me that he was expecting an early visit from 
 his wife's cousin who suffered from a very troublesome 
 goiter which at times threatened to suffocate her. He 
 also told me that I might be consulted by her and, 
 should alarming symptoms occur, I might even be 
 asked to remove the tumor. Now goiter is a rarity in 
 Antwerp and for my part I had never seen a single 
 case and was rather worried at the prospect. 
 
 My situation was truly awkward, the old lady ap- 
 parently had Bright's disease but without albuminuria 
 and seemed to be at the point of death without present- 
 ing a single positive symptom which I could lay hold 
 of; — and then this cousin must needs come from the 
 other end of Austria possessed by the desire to be 
 
 47 
 
Fio. 15. — Severe myxedema. 
 
 operated upon for a tumor which she would a hundred 
 times better have had removed in her own country, 
 where they are accustomed to similar exploits. 
 
 I returned home in a state of great anxiety and felt 
 a real relief on finding on my table a large parcel con- 
 taining the treatise on surgery in 8 volumes by Duplay 
 and Reclus which had just been published. I turned 
 to the article on goiter by Broca. Oh, yes ! goiter could 
 certainly be removed: it was not easy, but with de- 
 
 Fig. 16. — Same patient as in Fig. 15 after treatment. 
 48 
 
Fig. 17. — Severe myxedema, before and after treatment. 
 
 termination and a score of artery forceps it could be 
 done. Then there were complications — one must not 
 divide the recurrent laryngeal — must guard against 
 hemorrhage and sepsis. And this was not all, — one 
 must beware of removing the whole of the thyroid 
 gland — for this was followed after a short interval by 
 a special cachexia which Kocher had named "Cachexia 
 strumipriva" and Reverdin had called "Post-operative 
 myxedema." This was becoming more and more in- 
 teresting. 
 
 Thus when the patient had escaped from the dangers 
 of the operation, hemorrhage, and sepsis, just when 
 we might expect him to enter upon convalescence, a 
 very strange condition gradually disclosed itself, char- 
 acterized by the following symptoms: — lassitude, 
 feebleness, clumsiness, heaviness of the limbs, pain in 
 the arms, legs, neck, and shoulders, swelling of the 
 
 Fio. 18. — Profile view of the same patient shown in Fig. 17. 
 
 49 
 
face and puffiness of the eyelids. The eyes become 
 sunken, the activity of the brain diminished and men- 
 tal effort dulled. Then there came an extraordinary 
 phase: "The urine is almost always normal, to the 
 astonishment of the early observers who expected from 
 the appearance of the face to discover albumin. And 
 again another phrase: — one of the most remarkable 
 phenomena is a sensation of cold, which is almost con- 
 stant. 
 
 Truly Mme. X. presented a complete picture of these 
 
 Fig. 19. — Severe myxedema with predominance of rheumatoid 
 pains before treatment. 
 
 symptoms. She had the false suggestion of albumin- 
 uria without the presence of albumin, and the general 
 swelling of the body. Like the patients operated upon 
 by Kocher, Reverdin, and Bruns, she had the drawling 
 voice, the sluggish attitude of body, the thinned hair 
 and eyebrows, the swollen mucous membranes, and the 
 difficulty in swallowing. Her tongue appeared too 
 large for her mouth, the floor of which was swollen 
 and raised till it suggested a double ranula. Even her 
 ocular conjunctiva was edematous and prolapsed while 
 her complexion was amber-yellow with patches of red 
 on the cheeks. She had also the low temperature with 
 
 50 
 
subjective sensations of cold — but indeed Mme. X. 
 presented all the symptoms described in post-operative 
 myxedema and if so she must suffer from spontaneous 
 myxedema. 
 
 At last my diagnosis was made. On the following 
 day I verified the presence of the hard, nondepressible 
 edema extending over the whole body and some other 
 symptoms which I had not previously recognized. I 
 then informed her husband of what I had discovered 
 and that I was prepared to commence treatment at 
 
 Fig. 20. — Same patient as shown in Fig. 19, after treatment. 
 
 once. M. X. was too polite to say that he did not be- 
 lieve me, though his face plainly showed his incre- 
 dulity, but he followed my instructions to the letter. 
 
 The result exceeded my hopes. After three weeks 
 treatment the bodily and mental transformation was 
 so complete that she would no longer have been recog- 
 nized as the same woman (Fig. 5). The edema of the 
 tongue, of the lips, and of the eyelids disappeared as 
 if by enchantment and the face assumed an intelligent 
 expression. The patient then went to the country 
 where the treatment was continued by the local doctor, 
 who gave me valuable assistance. I did not see her 
 
 61 
 
Fig. 
 
 21. — Severe myxedema, cachectic stage, three days 
 before death. 
 
 again for over two months by which time she had 
 completely recovered, that is to say the absorption 
 of the infiltration had been complete. 
 
 If you now ask me what we have to learn from 
 this observation as regards mild myxedema, and 
 on what point it helps our knowledge of this con- 
 dition, I would first direct your attention to the 
 metrorrhagia which is presented by the history of 
 the patient. As a rule thyroid weakness shows 
 itself by the presence of metrorrhagia which is 
 sometimes appalling in its amount. The adminis- 
 tration of thyroidin moderates these losses, and 
 if large doses are given one may even completely 
 
 52 
 
suppress menstruation, as in the same way com- 
 plete amenorrhea is not infrequently present in 
 cases of exophthalmic goiter. Women with feeble 
 thyroids conceive readily, but abort as readily in 
 consequence of the onset of profuse bleeding which 
 carries away the fertilized ovum. I do not mean 
 to say that a woman suffering from thyroid weak- 
 ness cannot go to full term, as from the beginning 
 of pregnancy the thyroid gland undergoes hyper- 
 trophy with increase in size and in the amount of 
 its secretion. In fortunate cases this increased 
 activity is maintained throughout pregnancy and 
 forms an effectual protection to the embryo against 
 the menstrual return. Such women tell you that 
 their health is better when pregnant. The in- 
 creased activity of the gland continues during lac- 
 tation, and such patients instinctively prolong suck- 
 ling beyond the physiological period. After wean- 
 ing, the symptoms of thyroid weakness reappear 
 and certain authors have even discovered in pro- 
 longed lactation a cause of myxedema. Thus when 
 you encounter cases of profuse menstruation in 
 which you can exclude such ordinary causes as 
 fibroids, cancer, or placental remains, think of pos- 
 sible thyroid defect and search for other symptoms 
 of this condition. 
 
 Think of it also in those disheartening cases of 
 repeated abortion, in which the administration of 
 thyroidin will often permit a pregnancy to go to 
 term when all other rational means of treatment 
 have failed. 
 
 I would in the second place direct your attention 
 to the rheumatic pains from which this patient 
 suffered. In almost all cases of severe myxedema 
 one finds that the patient at some period of life 
 has passed through an attack of acute articular 
 rheumatism. This affection can itself cause grave 
 disturbances of the thyroid gland, the congestion of 
 which in the course of acute articular rheumatism 
 is a classic symptom. I believe, however, that its 
 influence is usually limited to producing an aggrava- 
 tion of a pre-existing thyroid weakness, thus bring- 
 ing to light symptoms hitherto unnoticed. The 
 metrorrhagia from which Mme. X. had suffered 
 before the occurrence of her acute rheumatic attack 
 supports this view. The chronic rheumatic or 
 rheumatoid condition is almost always associated 
 with mild myxedema, and its occurrence should be 
 carefully inquired into, especially when met- 
 rorrhagia is also present. These pains, which are 
 
 53 
 
often complicated by neuralgia, tend to assume a 
 characteristic form and course, to which I will now 
 refer. The most frequent rheumatoid pain ex- 
 perienced in mild myxedema is that affecting the 
 back between the shoulder blades, and is most 
 severe in the morning on rising, after the chilling 
 and inanition of the night. Driven from bed by the 
 pain, these patients rise absolutely worn out, as if 
 they had slept on a hard uneven mattress. The 
 pains subside gradually during the day, owing to 
 the warmth produced by food and exercise, and dis- 
 appear completely in the evening after a good meal 
 with plenty of wine. Such patients are strongly 
 attracted to the use of alcoholic stimulants. 
 
 I have already stated my opinion as to the low- 
 ered temperature and the subjective feeling of cold, 
 so I need not insist further on this point. The 
 hard, cold hand of a patient suffering from severe 
 myxedema is very characteristic, and in the milder 
 forms coldness of the extremities is usually present, 
 though to a less degree, as I have already stated. 
 
 Among the symptoms presented by Mme. X., one 
 of the more interesting was the special character 
 of the voice and speech. The voice was deep, rough, 
 and croaking, with an indescribable quality which 
 when once heard could not be forgotten. This 
 symptom is caused by the infiltration of the vocal 
 chords and the pharyngeal mucous membrane, and 
 is present in a less marked degree in milder forms 
 of hypothyroidism. In women with feeble thyroids 
 the voice is slightly hollow or muffled. Sometimes 
 this is only occasionally present, as during men- 
 struation, when a considerable part of the thyroid 
 resources is employed in the inhibition of the men- 
 strual function. We will not consider further the 
 case of Mme. X., though interesting from the stand- 
 point of our subject, but will bear in mind as lead- 
 ing symptoms the metrorrhagia, the recurring abor- 
 tions, the rheumatoid pains, the feeling of chilliness, 
 and the alteration of the voice. 
 
 After my attendance on Mme. X., I reproached 
 myself for having so long neglected to inform myself 
 as to the diseased conditions of the thyroid gland. 
 During my ten years of practice I must have already 
 met with these cases of apparent Bright's disease; 
 I had treated them, and they had disappeared and 
 been forgotten. Surely I had heard somewhere a 
 voice similar to that of Mme. X., but when? and 
 where? On racking my brains, I remembered that 
 one day I had been summoned as an expert before 
 
 54 
 
Fig. 22. — Myxedema, severe form, before and after treatment. 
 
 55 
 
the Civil Pensions Commission, the administrative 
 body to which the servants of the State apply when 
 on account of infirmity they wish to claim their pen- 
 sion before the retiring age or when it is necessary 
 to retire them. It decides in accordance with the 
 advice of the medical experts. 
 
 A professor of solfeggio in the Antwerp Conserva- 
 toire had appeared before us. His condition was so 
 lamentable, so profoundly cachectic, that my colleague 
 and I requested the President to send some one home 
 with him lest he should fall in the street. The strange, 
 hoarse, croaking voice of this man whose occupation 
 was the teaching of singing to children, was so irresist- 
 ibly comic that commissioners and doctors alike had 
 great difficulty in keeping their gravity. The medical 
 examination did not take long and the verdict was 
 explicit — Bright's disease in its last stage with uremia, 
 and he was at once retired on pension. 
 
 I searched for and found the singing master who 
 was still alive, and whom I now recognized to be suffer- 
 ing from myxedema. I show here his photograph be- 
 fore and after treatment (Fig. 6). I informed the 
 Minister of the error, who sharply rebuked the Com- 
 mission for a mistake made through no fault of theirs. 
 The board then had the patient examined afresh by 
 other doctors, who discovered nothing wrong with him 
 as he no longer presented the least sign of myxedema. 
 The proposal to retire him was withdrawn, and his 
 voice having now recovered, he was able to resume his 
 class with a brilliancy to which he had been long a 
 stranger. He was at this time 55 years of age. Before 
 treatment was begun his whole face was swollen, espe- 
 cially the eyelids, the space between which was reduced 
 to a mere slit. He also suffered from rheumatic pains, 
 a constant feeling of cold, and continual dyspnea. The 
 skin was dry, thin, and scaly, the epidermis covered 
 with fine lozenge-shaped wrinkles. The whole body 
 was heavy, clumsy, and infiltrated with a firm resistant 
 edema. He complained of invincible somnolence, de- 
 pression, and weariness of life. The infiltration was 
 rapidly absorbed under treatment, his weight falling 
 from 169 lb. to 136 lb. in two months, at the end of 
 which period the second photograph was taken. 
 
 Here for the first time dyspnea appears as a 
 leading symptom of myxedema. The patient had 
 suffered from it for a long time, and in my former 
 notes of his condition I found it occupied an im- 
 portant place. His walk was slow and difficult, and 
 he required to support himself by the furniture, 
 making signs that he could not speak for want of 
 breath. In mild myxedema this breathlessness is 
 constantly present, though to a less degree, only 
 showing itself on walking rapidly or uphill, and is 
 usually accompanied by palpitation. Sometimes the 
 breathlessness is intermittent, like the insufficiency 
 of the thyroid secretion on which it depends, and is 
 then liable to be mistaken for an attack of asthma. 
 
 56 
 
The gratitude of this singing master was all the 
 greater that he had been restored to his duties and 
 escaped the misery of a premature pension. He 
 told me that one of his friends, a police agent, who 
 had been put upon the retired list ten years before, 
 suffered from the same condition as himself. This 
 was rather too much — to have myxedema diagnosed 
 by a patient who had only just recovered from the 
 disease. 
 
 I called on the police agent whose appearance be- 
 fore and after treatment is shown in the photographs 
 (Fig. 7). He was suffering from very advanced myxe- 
 dema and though only 42 he appeared much older. The 
 photograph shows the degree of cachexia at which he 
 had arrived. His whole face was infiltrated, the eye- 
 
 Fig. 23. — The patient shown in Fig. 2 after 14 years of 
 treatment. 
 
 lids being so swollen that the eyes could be opened 
 only with the greatest difficulty, while the thickened 
 lips resembled those of a negro. The complexion was 
 amber yellow with bright red patches on the cheeks. 
 The trophic changes in the hair were striking, the fore- 
 head presented a band of brown pigmentation and 
 there were similar marks on each side of the neck. The 
 head was too heavy for the infiltrated muscles and 
 ligaments of the neck so that it fell forward and the 
 patient could raise it only by throwing the trunk back- 
 wards. He complained of rheumatism and a perpetual 
 feeling of cold, huddling himself night and day under 
 thick bedclothes. The breath was offensive, the teeth 
 bad, the gums red and inflamed. Speech was much 
 impaired. On replying to a question he opened his 
 mouth widely, so that the motions of his tongue could 
 be plainly seen although he uttered no sound, and it 
 was only after a lengthy effort that the words were 
 slowly formed. His weight was 152 lb. of which he 
 
 57 
 
lost 22 lb. under treatment with the simultaneous im- 
 provement of all his symptoms. The loss of weight 
 in this case amounted to 18, 28, and even 35 ounces a 
 day. His hair grew again rapidly, muscular con- 
 tractility was regained so that he could again raise 
 his head, and he was delighted to find his self-con- 
 fidence return, complete recovery being attained in 
 about two months. 
 
 This case directs our attention to the trophic 
 changes of the hair, teeth, and gums. In the milder 
 type of myxedema the hair may also be shed early, 
 though more frequently it becomes prematurely 
 grey. The destruction of the teeth and the chronic 
 alteration of the gums is also observed, though to a 
 less extent. 
 
 Fig. 24. — Mild myxedema in the mother of the patient pictured 
 in Figs. 2 and 23. 
 
 Whatever the type of myxedema, the baldness 
 very constantly presents a special distribution, the 
 hair being first shed in the frontal region, then on 
 the nape of the neck, giving the appearance which 
 is well shown in Figs 8 and 9. The loss of the hair 
 in the eyebrows is early and constant, even in mild 
 myxedema, and has been called the eyebrow sign. 
 It is not so easily concealed as the baldness of the 
 scalp, and it gives to the patient's face an air of 
 perpetual astonishment. 
 
 Fig. 10 is the portrait of a woman aged 24 who had 
 suffered from uterine hemorrhage since her confine- 
 ment, four months previously, for which she had been 
 packed and curetted several times. The absence of 
 the eyebrows is striking, and though the frontal bald- 
 ness had been artfully concealed, she at once suggested 
 to me a case of insufficient thyroid secretion. She 
 
 58 
 
suffered much from migraine and also from occipital 
 headaches; she was always cold, while her menses 
 were always very profuse. Under thyroid treatment 
 the hemorrhage ceased in a fortnight. 
 
 A very interesting case of myxedema is shown in 
 figures 11 and 12. There was marked loss of hair 
 which in addition to the usual situations had affected 
 the sagittal line, but the baldness was concealed by the 
 presence of black crusts which covered the whole scalp, 
 the eyebrows were also markedly affected. This pa- 
 tient might be classed as an advanced case of myxe- 
 dema and the result of treatment was very striking. 
 She had always been tired, constipated, and somnolent. 
 She was never free from rheumatic pains and became 
 breathless on the slighest exertion. Her face was in- 
 filtrated, the eyelids and lips being specially swollen. 
 Under thyroid extract she rapidly lost 22 lb. in weight 
 and after four months treatment, was completely 
 changed both morally and physically, having regained 
 
 Fig. 25. — Mild myxedema, before and after treatment. 
 
 courage, strength, and cheerfulness. She even became 
 coquettish and would not believe that her appearance 
 had been as in the first photograph. 
 
 The patient shown in Figs. 13 and 14 is a good 
 example of the effects of thyroid weakness on the 
 hair and eyebrows. She was only 39 years of age, but 
 appeared much older. The face was swollen, amber 
 yellow in color, with patches of red on the cheeks. 
 The trophic changes had chiefly affected the hair and 
 teeth, the nape of the neck being almost bald. She 
 complained of a constant sensation of cold, obstinate 
 constipation, and pains all over the body, which she 
 attributed to rheumatism. She presented also the 
 drawling voice with its characteristic intonation. Her 
 weight was 154 lb., of which she lost 22 lb. in the 
 course of treatment. 
 
 The patient presented in Figs. 15 and 16 was 42 
 years of age. Fourteen years before, as the result 
 of a chill, she suffered from swelling of the hands and 
 feet with albuminuria. She was treated for Bright's 
 disease, but did not recover her health, dragging on in 
 a weak, exhausted, somnolent condition, with pains in 
 all her limbs. Becoming pregnant she suddenly im- 
 
 59 
 
proved considerably, due to the stimulation of the 
 thyroid gland by her condition. This improvement 
 lasted throughout pregnancy and was maintained dur- 
 ing lactation, although she nursed her infant for two 
 years. After weaning him she gradually relapsed into 
 her previous condition, again becoming apathetic and 
 depressed while the rheumatic pains returned with in- 
 creased severity. The eyebrows were very thin, the 
 features swollen, while the pale yellow complexion 
 recalled that usually associated with albuminuria. She 
 suffered from constipation and headache, her teeth 
 were decayed, and she presented attacks of shivering 
 during the evening which were attributed to fever. 
 
 Pig. 26. — Severe myxedema before treatment 
 
 All these symptoms improved under treatment, her 
 weight at the same time falling from 143 to 138 lb. 
 
 The patient shown in Figs. 17 and 18 was only 39 
 years of age. He was a cigar maker, who had been 
 unable to work for six years, owing to his fingers 
 haying become stiff and clumsy. He had taken to 
 drink and he and his family had fallen into extreme 
 poverty. He was positively ugly, and the boys of the 
 district, who knew him under the name of Ravachol, 
 followed him on the street. I literally picked him out 
 of the gutter and kept him under observation for a 
 week before commencing treatment. His appearance 
 is well shown in the illustrations. He complained of 
 pain in the spine, a constant feeling of cold and in- 
 superable fatigue, and was melancholic, depressed, and 
 extremely miserable. His hair was unaffected, except 
 
 60 
 
in the occipital region, which was bald. During the 
 week before treatment was commenced he excreted on 
 an average 323.4 grains of urea per day, which in- 
 creased under thyroidin to an average of 477.4 grains 
 per day, during the first week, with a further increase 
 during the second week to 677.6 grains per day. In 
 consequence of the absorption of the infiltration his 
 weight fell from 167 lb. to 138 lb. His urine contained 
 an extraordinary number of spermatozoa, this symp- 
 tom persisting for a whole month, when it suddenly 
 ceased. He rapidly recovered as shown by the illus- 
 tration, and he not only regained his health but also his 
 self-confidence, so that he resumed his work, at which 
 
 Fig. 27. — The same patient as in Pig. 26, after two months* 
 treatment. 
 
 he was expert, and after some months sailed for Amer- 
 ica in quest of a better situation. He obtained work 
 at once, and is now himself an employer, and has made 
 money. Every two or three years he returns to Europe 
 to express his gratitude to me. 
 
 Soon after the cure of the singing master and the 
 police agent I remembered that at the beginning of 
 my career I had treated a woman of whose peculiar 
 voice I was reminded by that of these two patients. 
 She had left town, but at last I discovered her. In 
 those days she had suffered from rheumatism in- 
 volving all the body, the muscles being stiff, hard, 
 and painful. The joints were also swollen, the gait 
 
 61 
 
stiff and awkward, while the pains in the back were 
 very severe. I had formerly treated her by every 
 means I could think of, without benefit. On her 
 reappearance I found that she was really suffering 
 from myxedema — as you will see by the photographs 
 before and after treatment (Figs. 19 and 20). The 
 puffiness of the face, the swelling of the lips, espe- 
 cially the lower one, the loss of the hair of the 
 scalp and eyebrows, the redness of the cheeks on a 
 yellow skin, the drawling, croaking voice, the dry 
 wrinkled skin, and the desquamation of the scalp 
 
 Fig. 28. — Severe myxedema. 
 
 left no doubt as to the diagnosis. Under thyroid 
 treatment the infiltration rapidly disappeared. The 
 general pain and stiffness also disappeared steadily, 
 though slowly, along with marked breathlessness, 
 to which she had always been subject, and which I 
 had formerly attributed partly to obesity and partly 
 to pulmonary emphysema. Finally all these symp- 
 toms were completely abolished, but on the patient 
 ceasing treatment the pains gradually returned, to 
 cease again on the administration of thyroidin. 
 This woman had suffered from these rheumatic 
 symptoms for so many years that she had become 
 resigned to them, and sought advice only when the 
 
 62 
 
pain in the back or the swelling in the wrists or 
 knees became unusually severe. The pain was then, 
 as later, simply a manifestation of defective thyroid 
 secretion. 
 
 Let me now record a case illustrating the dis- 
 orders of the liver associated with defect in the 
 thyroid gland. The patient shown in Fig. 21 was 
 a women suffering from myxedema in its last stage. 
 She died three days after admission to my ward 
 without it being possible to begin thyroid treatment. 
 On post-mortem examination the gall-bladder was 
 
 Fig. 29. — The same patient as in Fig. 28, after treatment. 
 
 found much enlarged, distended to the bursting 
 point, with marked thinning at its upper pole. It 
 contained a large gallstone, which permitted the en- 
 trance but not the escape of the bile. I was much 
 impressed by this observation, and later in cases of 
 myxedema, whether mild or severe, I examined for 
 tenderness of the liver and especially of the gall- 
 bladder. Very frequently, not to say always, a pain- 
 ful point was found in this region, which disap- 
 peared during treatment. Although the presence of 
 a calculus in the gall-bladder is a common occur- 
 rence in the post-mortem room, I have dwelt on it 
 and shown this photograph in order to emphasize 
 
 63 
 
the frequent presence of disorders of the liver in 
 myxedema, of whatever type. In this affection one 
 should always think of congestion of the liver and 
 the possible presence of calculi or biliary sand in 
 the gall-bladder. The amber yellow coloration of 
 the skin, so characteristic of myxedema, is only an 
 attenuated jaundice and depends on biliary dis- 
 turbances. 
 
 Fig. 22 is that of a woman 40 years of age, 
 suffering from well-marked myxedema. Her father, 
 who was dead, had suffered from rheumatism and al- 
 
 Pig. 30. — Mild myxedema with atrophy of the optic nerves. 
 
 buminuria. She had six children; the eldest daughter 
 was subject to metrorrhagia, while two of the sons had 
 suffered very severely from acute articular rheuma- 
 tism. Her appetite had completely gone, she suffered 
 from menorrhagia, with headaches and frequent at- 
 tacks of shivering. Her temperature taken in the 
 mouth was only 96.2° F. There was great swelling 
 of the face, but the hair was well preserved and the 
 teeth in good condition. She suffered from melan- 
 cholia and apathy with difficulty of thought, speech, and 
 action. After six weeks' treatment at the Institute 
 she was discharged so changed in appearance that she 
 would not have been recognized. Since then she had 
 continued her treatment, but only very irregularly. 
 When she neglected it too long the first symptoms of 
 relapse were a feeling of weight at the stomach, diffi- 
 
 64 
 
culty in stooping, tenderness over the liver, and a 
 distaste for meat. After an unusually long period 
 of neglected treatment she sent for me in haste one 
 night and was found suffering from biliary colic. The 
 urgent symptoms yielded to oil and morphine and later 
 under thyroidin she made a complete recovery. 
 
 I have said that an excellent means of becoming 
 acquainted with the slighter degrees of myxedema 
 is to study the morbid characteristics of the ascend- 
 ing, descending, or collateral relations of patients 
 suffering from the more severe type, the weakness 
 of the thyroid gland being essentially hereditary. 
 
 Fig. 31. — Same patient as in Fig. 30, after treatment. 
 
 I have shown in Fig. 2 four photographs of a child 
 who suffered from severe myxedema, and presented 
 marked delay in her physical and intellectual de- 
 velopment. When first brought to me in November, 
 1896, she was 8 years of age, and she measured 
 only 2 ft. 10 in. in height, instead of 3 ft. 10 in., 
 the normal average for her age, though she was 
 comparatively heavy, her weight being 33 pounds. 
 The expression of the face was that of well-marked 
 myxedema; the face itself was swollen with the 
 characteristic red cheeks on an amber yellow skin. 
 The dystrophy had not involved all the tissues to 
 the same extent, those of epidermic origin being 
 relatively intact. The hair was black and thick, the 
 
 65 
 
eyebrows were well marked, while the teeth were 
 healthy, an exceptional event in myxedema. The 
 bones, on the other hand, were severely affected, 
 the femora were curved, the tibiae and fibula? showed 
 advanced signs of rickets, and the feet were short 
 and flat. The belly was large — a characteristic of 
 this affection — and presented an umbilical hernia. 
 The false ribs had been carried outwards by the 
 distention of the abdomen — a change more apparent 
 in the second photograph, where the belly has been 
 
 Fig. 32. — M. A., severe myxedema ; before treatment. 
 
 reduced by a year's treatment. Her intelligence was 
 but slightly developed. Her temperature was very 
 low, even in summer, and in winter it became ex- 
 tremely so, there being great difficulty in keeping 
 her warm. She throve badly, and was extremely 
 constipated. There could be no doubt as to the 
 cause of the condition — a congenital weakness of 
 the thyroid gland. 
 
 The patient's mother had suffered from several 
 severe attacks of malarial fever in the course of her 
 pregnancy, and had been obliged to leave the low- 
 lying village where she lived and come into town 
 for her confinement. Four years previously, before 
 she lived in this low-lying district, she had borne a 
 
 G6 
 
son, now 12 years of age, who was slender and 
 delicate. A second child had died of some abdominal 
 condition at the age of five months, the third being 
 the patient with whom we are now concerned. 
 I have often observed that for the production of 
 a severe case of congenital myxedema the associa- 
 tion of at least two grave defects in the parents is 
 necessary, as, for example, the coexistence of 
 syphilis and tuberculosis; gout or diabetes, com- 
 plicated with tuberculosis or syphilis ; or, again, the 
 
 Fig. 33. — M. A. after two months' treatment 
 
 coincidence of alcoholism and syphilis. The mother 
 was therefore carefully examined to discover the 
 defect which, joined to malaria, had produced such 
 a complete degeneration in the fetus. She suffered 
 from severe migraine, was very constipated, her 
 liver and gall-bladder were tender, and her men- 
 strual loss was excessive. She also complained of 
 transient rheumatoid pains in her muscles, which 
 became aggravated during the cold season. She was 
 dull, depressed, almost melancholic, and presented a 
 low temperature, frequent breathlessness and pal- 
 pitation. Her complexion was pale yellow, like that 
 of the child. Vertigo, tinnitus, and muscae volitantes 
 were also present. 
 
 G7 
 
The clinical picture was that of the simpler forms 
 of thyroid defect. Without being myxedematous 
 she evidently suffered from thyroid weakness. The 
 malarial poison had done the rest, and the mother, 
 unable to furnish the fetus with the necessary 
 amount of thyroid secretion, gave birth to a cretin. 
 
 The little patient quickly responded to treatment 
 by thyroidin. After a year her appearance had 
 much improved, as seen in the second photograph 
 (Fig. 26). At the beginning of treatment the 
 thyroid extract appeared to disagree with the 
 
 l r io. 34. — M. A. after 14 months' treatment. 
 
 patient, causing vomiting in the morning, before 
 breakfast, but in spite of this its administration 
 was continued. During the first year she gained 
 5V2 inches in height, while the rachitic deformities 
 greatly improved but did not entirely disappear. 
 The distended abdomen assumed more natural pro- 
 portions, the umbilical ring closed, and the neck 
 became more slender. The expression of her face 
 became more inquiring and thoughtful. Her prog- 
 ress during the second year was less satisfactory, 
 as she unfortunately suffered severely from whoop- 
 ing-cough, which lasted five months. The increase 
 in height amounted to only 2*4 in., but all traces 
 
 68 
 
of rickets had disappeared from the limbs. The 
 third photograph (c) shows her appearance at the 
 end of the second year. 
 
 The action of infectious diseases on the activity 
 of the thyroid gland has been well known since the 
 work of Marcel Gamier. 5 He states in connection 
 with a case of whooping-cough which proved fatal 
 by bronchopneumonia: "The thyroid gland was 
 completely transformed, (on post-mortem examina- 
 tion). The coloring matter was almost entirely 
 absent; the vesicles were empty; the thyroid cells, 
 
 Pig. 35. — Sister of M. A. — Myxedema. 
 
 more or less raised towards the interior of the 
 cavity, did not fill it, and there was no cellular 
 proliferation, so that the thyroid tissue appeared 
 like a fine network between the meshes of the con- 
 nective tissue, which were closer than usual. There 
 was in this case an arrest of the colloid secretion, 
 a state of athyroidism." Gamier attributes these 
 lesions to the bronchopneumonia rather than to the 
 whooping-cough, but we may remark that whoop- 
 ing-cough is almost constantly complicated by 
 bronchopneumonia, and it certainly was so in the 
 case of our little patient. One is not then astonished 
 at the slight progress made during the second year, 
 
 69 
 
and it is worthy of note that whooping-cough 
 showed itself able to lower the secretory activity, 
 even in this child, apparently destitute of an active 
 thyroid gland. I believe that however degenerate 
 it may be, the thyroid gland, even in the most con- 
 firmed cretinism, never loses entirely its secretory 
 power, as the complete absence of thyroid secretion 
 from the blood causes death in a short time. 
 
 In the course of the second year the parents be- 
 came much alarmed at the appearance of a defect 
 in speech, which they attributed to the treatment. 
 I have seen several similar cases in analogous cir- 
 cumstances. The child had great difficulty in articu- 
 lation, the first syllable being specially hard to utter, 
 so that she panted, gasped, and twisted herself 
 about. Soon, however, this disturbance ceased 
 spontaneously. During the third year the patient 
 gained 2 1 /2 inches in height. 
 
 The progress in the fourth year was also unsatis- 
 factory, the treatment being irregularly followed 
 and even interrupted for some months. There was, 
 however, a gain of IV2 inches. After a serious 
 admonition the parents became more attentive, and 
 in the course of the fifth year the child's growth 
 showed a distinct improvement, the increase in 
 height amounting to Z x /z inches. The fourth photo- 
 graph (Fig. 2d) shows the patient as she appeared 
 after five completed years of thyroid treatment. 
 During that period she had gained 15% inches in 
 height, her lower limbs were straight and well 
 formed, and the most trained eye could no longer 
 detect the slightest indication of thyroid defect. 
 
 This case confirms the ideas which wa have long 
 expressed on the etiological unity of several morbid 
 states which have been attributed to very diverse 
 causes. Such conditions as infantile obesity, 
 rickets, the slender type of infantilism, anangio- 
 plasia, chondrodystrophy, myxedema, the arrested 
 growth in congenital syphilis, the arrest and delay 
 of growth associated with alcoholism, tobacco 
 poisoning, malaria, and tuberculosis, are all due in 
 their last analysis to the same cause — a lesion of 
 the thyroid gland. Syphilis, tuberculosis, alco- 
 holism, chronic malnutrition, and consanguineous 
 marriages alike deal their first blow at the thyroid 
 gland and alter its secretion in various directions. 
 Does not the perfect recovery from the rachitic 
 changes in our little patient show us that this con- 
 dition is due to an alteration in the thyroid gland? 
 Thyroid extract is essentially a specific and can 
 
 70 
 
benefit only the lesions which come within its sphere 
 of influence. 
 
 The different morbid influences which we have 
 just enumerated do not all affect the thyroid secre- 
 tion in the same manner. This secretion is very 
 complex in its composition, containing nucleins 
 associated with phosphorus, iodine (Baumann), 
 arsenic (A. Gautier), and even bromine. The 
 thyroid gland is liable to injury from several direc- 
 tions, and from this results the great variety of 
 trophic disorders which are the echo of its im- 
 pairment. 
 
 To return to the patient, I may state that she 
 continued to grow till 21 years of age, when she 
 measured 4 feet 9 inches in height. Her appear- 
 ance at the age of 24 is shown in Fig. 23. 
 
 Her mother's portrait is shown in Fig. 24, her 
 hair is silvery white, but she now finds herself 
 healthier than fourteen years ago. Since the meno- 
 pause, the thyroid secretion, which during her re- 
 productive life was devoted to the inhibition of 
 menstruation is now fully available for the general 
 nutrition of the body. She still suffers, however, 
 from breathlessness and rheumatic pains, and when 
 these symptoms become troublesome she takes thy- 
 roidin for a time with beneficial effect. 
 
 Let us now take an example of mild myxedema 
 occurring in a descendant of a patient presenting 
 a more severe type of myxedema. 
 
 The patient shown in Fig. 25 was the daughter of 
 the singing master whose case I have previously de- 
 scribed. The woman was 40 years of age. At all times 
 her menstruation had been profuse and exhausting and 
 she suffered much from migraine and dullness in the 
 head, while her hair had come out freely. When 
 closely examined her face presented a slight degree of 
 swelling, she was tired, worn out, somnolent, with an 
 urgent desire to sleep. At the time she complained of 
 sciatic pains in the left leg. Her hands were large, 
 cold, bluish red in color and were covered with chil- 
 blains in winter. Under very small doses of thyroidin 
 the swelling of the face disappeared, and the other 
 symptoms ceased, including the shooting pains in the 
 left sciatic. This case forms a good example of mild 
 myxedema. 
 
 Finally, let me give an example where the study 
 of the collateral relations of the patient has been 
 of great value. 
 
 The venerable ecclesiastic shown in Figs. 26 and 27 
 suffered from well-marked myxedema. He was the 
 priest of a parish in the neighborhood of Antwerp, and 
 having visited his church, which was of archeological 
 interest, I heard him preach. He stood by the steps of 
 
 71 
 
the altar painfully supporting himself with both hands 
 on the communion rail. His speech was so defective 
 that I could not understand a word of his discourse. 
 Then he mounted the steps of the altar, very slowly, 
 and with great difficulty, leaning on the shoulder of 
 the server. There was no doubt as to the diagnosis, 
 he was suffering from well-marked myxedema. I had 
 the satisfaction of quickly restoring him to health, as 
 may be seen in the photograph. This patient, as you 
 may imagine, had been previously treated in various 
 ways in the course of a disease which had lasted ten 
 years. He was much troubled by great thickening 
 of the nasal mucous membrane, for which he consulted 
 a specialist, who nimbly removed a portion of his tur- 
 binals, at the price of an alarming hemorrhage. 
 Myxedematous patients are very .hemophilic. The 
 operation had no beneficial result for the patient. 
 
 I inquired into the state of health of his brothers 
 and sisters. One of the latter lived with him, she was 
 very thin and had a pronounced nasal voice with 
 marked hypertrophy of the mucous membrane of the 
 nose. This was in her the only symptom of thyroid 
 defect. Another sister was married and presented the 
 appearance shown in Fig. 28. She was as myxedema- 
 tous as her brother the abbe. Under treatment sne 
 quickly and completely recovered her health. (Fig. 29.) 
 But this was not all. 
 
 The abbe had a brother aged 54, who for ten years 
 had suffered from an obscure condition characterized 
 by weakness, anemia, and progressive exhaustion 
 (Fig. 30). Along with the loss of strength his vision 
 had gradually failed which had been attributed by 
 well-known specialists to white atrophy of the optic 
 nerves. Three years before, on his return from an ex- 
 hausting journey, he suffered severely from headache, 
 then suddenly collapsed and became unconscious with 
 complete loss of motion and sensation. This state of 
 coma lasted three days and on recovery he remembered 
 nothing that had taken place, but presented no loss 
 of functional power. He continued to suffer from 
 weakness and exhaustion and his eyesight became 
 steadily worse, so that when I saw him two years later 
 he was almost blind. White atrophy of the optic 
 nerves has been recorded several times in the course of 
 myxedema, but I believe that this is purely a coinci- 
 dence, and that there is no causal relation between 
 these two affections. If the alteration of the optic 
 nerves was caused by the specific myxedematous infil- 
 tration, vision would return under the influence of 
 thyroid treatment, as we have seen that the most pro- 
 nounced changes of the nervous system due to this 
 cause are capable of complete restoration. The attack 
 of coma which the patient had presented had placed 
 his medical attendants in a serious difficulty. As there 
 was no history of syphilis, the diagnosis appeared to 
 lie between a tumor, hemorrhage, and embolism of the 
 brain, serous apoplexy being excluded by the absence 
 of albuminuria. I confess, if I had not previously 
 seen the abbe and his sister, I would not have suspected 
 thyroid weakness in this case, but once my attention 
 was directed to this possibility it was easy to confirm 
 the diagnosis. The low temperature, the yellowish pal- 
 lor and slight swelling of the face, the fine and scanty 
 
 72 
 
beard, the breathlessness, and extreme weakness all 
 pointed to this conclusion. Even the attack of coma, 
 hitherto so difficult to explain, fitted in with this 
 opinion in a very simple manner. As the result of an 
 harassing journey there was produced an abnormal ex- 
 haustion of the resources of the thyroid gland in a 
 patient in whom they were already very restricted. 
 This had caused a severe and sudden infiltration of 
 the nervous centers, producing an attack of coma. The 
 immobility secured by the unconscious condition of the 
 patient permitted the recovery of the secretory activity 
 of the gland, and the consequent absorption of the in- 
 filtration, so that the coma passed off without leaving 
 any paralysis or loss of function. On being submitted 
 to thyroid treatment, this man regained strength, 
 color and self-confidence, his appearance being shown 
 in Fig. 31. The anemia completely disappeared, but 
 his eyesight did not improve nor could it be expected 
 to do so. 
 
 A last example showing the utility of an inquiry into 
 the family history is the case of M. A., whose photo- 
 graph is shown in Figs. 32 to 34. This is the most 
 severe case of myxedema which I have yet met with, 
 and also that which I have most closely studied and 
 the treatment of which I followed from day to day. 
 When I first saw him, the patient was 63 years of age. 
 As you see by his photograph, he was much infiltrated 
 and weighed 221 lb., although he ate very little, having 
 a distaste for all food, especially meat. He suffered 
 much from breathlessness and was incapable of the 
 slightest exertion. Three years previously he had had 
 an attack of epistaxis, which lasted five days and 
 threatened to prove fatal, when the bleeding was ar- 
 rested by an injection of antidiphtheritic serum. Soon 
 after this he became suddenly comatose for a period 
 of eight hours. As he had long been known to suffer 
 from albuminuria, and had been treated for Bright's 
 disease, the coma and epistaxis were naturally attrib- 
 uted to the renal affection and regarded as signs of 
 uremia, while the dyspnea, intellectual dullness, head- 
 aches, vertigo, and noises in the ears were believed to 
 be due to the same cause. This interpretation must 
 be admitted to be both scientific and logical. He also 
 suffered from nocturnal incontinence of urine which 
 caused him great distress. He rapidly improved under 
 treatment, his appearance after two months being 
 shown in Fig. 33. At this stage he was still 
 weak and his features were somewhat haggard, but 
 the fierce expression they had assumed was quite mis- 
 leading as the man was amiability itself. His appear- 
 ance after fourteen months' treatment is shown in 
 Fig. 34. He has become a little stouter, but is 
 in complete possession of all his faculties and his face 
 well reflects his character as he shows extraordinary 
 energy in the management of his affairs. His recovery 
 was absolutely complete. Some idea of the extent of 
 the myxedematous infiltration may be obtained by a 
 study of the loss of weight presented by this patient. 
 His original weight was 221 lb., which was reduced 
 in the course of two months' treatment to 163 lb. He 
 thus lost 48 lb., or about 23 per cent, of his total weight 
 in sixty days, being at the average rate of nearly 13 
 ounces a day. 
 
 73 
 
I naturally inquired into the family history and 
 found that about ten years previously the patient's 
 sister had died in a state of coma following great 
 fatigue on the occasion of a removal. She had 
 formerly had an attack of coma and had for some 
 years presented albuminuria and been treated for 
 Bright's disease. A photograph of this sister is 
 reproduced in Fig. 35. You will observe that it 
 has been carefully retouched in order to supply 
 the absence of the eyebrows and that the photog- 
 rapher has unsuccessfully endeavored to reduce 
 the swelling of the face and neck. It is certain 
 that this woman suffered from myxedema and that 
 the apparent Bright's disease, including the fatal 
 attack of coma was due to myxedematous infiltra- 
 tion. Suitable treatment might have saved her 
 as it saved her brother. 
 
 I need not further multiply examples, but may 
 sum up by saying : 
 
 When you encounter the association of one or 
 more of the following symptoms: Trophic changes 
 in hair, eyebrows, eyelashes, teeth, or gums; an 
 habitual chilliness, biliary disturbances with lith- 
 iasis, dyspnea with asthmatic attacks; menorrha- 
 gia, recurring abortion, hemophilia; melancholia, 
 depression, weariness of life, migraine, vertigo, 
 sudden loss of consciousness, noises in the ears; 
 somnolence, rheumatoid changes in the muscles, liga- 
 ments, or aponeuroses; nocturnal incontinence of 
 urine, pollakiuria, loss of appetite and obstinate 
 constipation — think of a possible deficiency of the 
 thyroid secretion. 
 
 Treatment. — I will conclude with some practical 
 indications as to treatment. The theory of thy- 
 roid defect which I have submitted to you is based 
 on the undoubted existence of an infiltration, the 
 amount of which varies with the degree of defici- 
 ency, but which is always present. This theory 
 agrees with all the known facts and is strongly sup- 
 ported by the complete restoration of the body as 
 the result of treatment. There is no destruction 
 of even the most delicate tissues, since all of them 
 are capable of resuming their functions after the 
 administration of thyroidin. This theory also as- 
 sists us in judging the progress of the patient and 
 explains the various incidents which may be pro- 
 duced in the course of treatment. Thus, the too 
 rapid absorption of the infiltration from the muscu- 
 lar, nervous, connective, or osseous tissue causes 
 
 74 
 
painful phenomena exactly similar to, but more 
 acute than, those experienced during the primary 
 distention. These pains are easily explained by the 
 too sudden shrinking of the walls of the cells, and 
 perhaps also by the increased oxidation of their con- 
 tents. Too intensive a treatment produces violent 
 headaches, neuralgia, anginiform cardiac symptoms 
 which are apt to alarm both the patient and the 
 doctor. Very acute rheumatoid pains also develop 
 in the muscles, tendons, and joints, especially affect- 
 ing the anterior muscles of the leg, the extensor 
 tendons of the foot, and the joints of the toes. I 
 have already spoken of the rise in temperature 
 which occurs in the course of too rapid treatment. 
 
 In the treatment of myxedema, whether mild or 
 severe, let us have the courage to be patient and 
 proceed slowly, as it is unnecessary to cause the 
 absorption of more than 3V2 to 5 ounces of infil- 
 tration per day. 
 
 In adults a dose of 5 grains of thyroidin, cor- 
 responding to an English tabloid of thyroid ex- 
 tract, is quite sufficient, and even this small dose 
 often provokes disagreeable symptoms in connec- 
 tion with the heart, muscles, and joints. Absorp- 
 tion of infiltration should be controlled by daily 
 weighing of the patient. It is found that children 
 tolerate thyroidin better than adults. 
 
 This fundamental treatment should be assisted 
 by the observation of certain dietetic rules. Wine, 
 beer, alcohol in every form, and also tobacco, should 
 be prohibited, because these toxic agents diminish 
 the activity of the thyroid gland, and it is impor- 
 tant to spare that of the patient, however much de- 
 generated it may be. 
 
 Complete rest in bed is also useful during the 
 first period of treatment, because when in bed the 
 thyroid secretion of the patient is not expended in 
 useless muscular action. Certain forms of mild 
 thyroid defect derive benefit from the adminis- 
 tration of small doses of arsenic, iodine, or bromine, 
 because these substances form part of the thyroid 
 secretion. Arsenic is of value in the forms asso- 
 ciated with migraine, while a combination of iodine 
 and bromine benefits the cases of incontinence of 
 urine. A few doses of an active purgative may be 
 required to clear the viscera when loaded after 
 long-continued constipation. 
 
 I need hardly say that I absolutely forbid all 
 cold bathing, but hot baths on the contrary are 
 both useful and pleasant to the patient. 
 
 75 
 
When the infiltration has been absorbed, that is 
 to say, when the patient no longer loses weight, one 
 must endeavor to fix the dose of thyroidin neces- 
 sary to maintain him in health. This varies from 
 1 to 6 tabloids a week, the amount being slightly 
 increased in winter and decreased in summer. 
 When once the patient is cured one should not be 
 alarmed to see him increase slightly in weight, as 
 with the better assimilation an increase of stout- 
 ness is to be expected. 
 
 Finally, it may happen that a case of myxedema 
 comes under observation so late that treatment 
 seems hopeless, the patient having sunk into a state 
 of complete coma, and death seems imminent. I 
 recently saw a woman in whom at times false respi- 
 ratory movements occurred, giving the impression 
 of Cheyne-Stokes breathing in a dying person. For 
 several days two nurses took turns at her bedside 
 in order to support her chin. A metal tube was in- 
 serted between her teeth and connected with a 
 supply of ogygen, and at the same time thyroidin 
 was administered by hypodermic injection. The 
 symptoms rapidly improved, the periods of sus- 
 pended respiration became less frequent, the som- 
 nolence disappeared, and the temperature rose con- 
 siderably — an evident sign of the oxidation of the 
 infiltration. I consider this patient was saved by 
 the hypodermic injections of thyroidin. 
 
 In a case of prolonged coma one would be justi- 
 fied in performing lumbar puncture for the relief 
 of the nervous centers. 
 
 I have now sketched the leading features of thy- 
 roid defect in its various degrees. I have not been 
 able even to enter on a number of interesting points, 
 but I have said enough to enable you to observe 
 around you facts which you have perhaps hitherto 
 not suspected. It is for you to complete these 
 notions, and in order to do so it suffices to think of 
 them. Trousseau has well said that the life of a 
 physician should be a long meditation. 
 
 Just as we search all our patients for tubercu- 
 losis, syphilis, alcoholism, a day will come when 
 a systematic examination will also be made to ascer- 
 tain their thyroid powers and defects. The ques- 
 tion of the internal secretions is coming more and 
 more to the foreground. Innumerable possibilities 
 may arise from it. I must now conclude and thank 
 you for the attention and time you have so liberally 
 given me. 
 
 76 
 
REFERENCES. 
 
 1. Hypothyroidie benigne chronique by E. Hertoghe, 
 Bull. Acad, de Med. de Belgique, 1899. 
 
 2. Bull, de l'Acad. royale de Medecine de Belgique. 
 Series iii, Vol. XX, No. 5, p. 330. 
 
 3. On experimental congestion of the liver see A. 
 Ver Eecke, in "Lesions du foie et des reins chez les 
 animaux ethyroides." Bull, de l'Acad. royale de Med. 
 de Belgique, October, 1897, pp. 666, 686, 698, and 704. 
 
 4. Hertoghe; Myxoedeme franc et fruste de l'enfance 
 Nouvelle Iconographie de la Salpetriere. Vol. XIII, 
 1900, p. 411. 
 
 5. La glande thyroide dans les maladies infectieuses. 
 By Dr. Marcel Gamier, Paris. Georges Carre and C. 
 Naud, 1899, p. 76. 
 
 77 
 
INTRATRACHEAL INSUFFLATION. 
 
 By BENJAMIN MERRILL RICKETTS, M.D., 
 
 CINCINNATI, O, 
 
 As early as the middle of the sixteenth century 
 Vesalius I. recognized the possibility of aerating 
 the blood, after the chest had been opened, by 
 passing a continuous current of air through the 
 lungs; while in 1667 Hook read before the Royal 
 Society a paper entitled, "An Account of an Ex- 
 periment Made by Mr. Hook by Preserving Animals 
 Alive by Blowing Through Their Lungs with 
 Bellows." 
 
 In his experiment, Hook, having laid open the 
 entire thorax of a dog and removed the pericardium, 
 sustained the animal's life, first by reciprocal in- 
 flation and deflation of the lungs, in imitation of 
 normal respiration, and then by means of a con- 
 stant current of fresh air under such pressure that 
 all respiratory movements of the lungs themselves 
 were suspended. Both methods were successful in 
 continuing animation and the pulmonary circulation. 
 
 While mechanical respiration remained a valu- 
 able adjunct of laboratory experiment for almost 
 250 years, its failure as a human resuscitative 
 measure in the practice of such surgeons as LeRoy 
 of France, and Monroe and Dalrymple of Eng- 
 land, forced the scientist, John Erichson, in 1845 
 to conclude that, "In spite of all the improvement 
 and modifications of the technique and the methods 
 of inflation by bellows, mechanical respiration 
 never again came into favor and was speedily for- 
 gotten when the postural methods came into use." 
 
 Marshall Hall was especially severe in his con- 
 demnation of forced mechanical respiration by 
 means of bellows, and until 1887 the postural re- 
 suscitative methods of Hall, Sylvester, Schafer, 
 and Howard were extensively employed. 
 
 On July 23, 1887, Dr. George Edward Fell of 
 Buffalo, N. Y., after all the postural methods of 
 resuscitation had been tried and failed, by means of 
 forced respiration saved the life of a patient who 
 had taken twenty grains of morphine and some 
 chloral hydrate, even after the pupils had dilated 
 
 Copyright, William Wood & Company. 
 
 78 
 
in the la*st stage of asphyxia. Within about three 
 months following, Prof. Dr. Boehm of the Allge- 
 meines Krankenhaus in Vienna saved the life of 
 Dr. Langer by the same method. 
 
 Other successful cases of a similar character 
 followed, and established a new epoch of artificial 
 respiration. In practice Dr. Fell used an espe- 
 cially devised face mask and a trachectomy tube, 
 and later an intubation tube, the invention of 
 Dr. O'Dwyer, connected to a single bellows and 
 provided with a coronet piston exit valve, by the 
 manipulation of which inflation and deflation of 
 the lungs could be made to duplicate normal breath- 
 ing. In one instance, the case of Dr. Williams, re- 
 ciprocal respiration was continued intermittently 
 during four days, with recovery of the patient, and 
 without any untoward pulmonary laryngeal or sys- 
 temic complications. 
 
 It was through the incentive given to artificial 
 respiration by the introduction of Fell's method of 
 "forced respiration," and his adaptation of ether- 
 ization to the technique, that the surgery of the 
 thorax, through its utilization became a possibility. 
 F. W. Parham of New Orleans was the first to suc- 
 cessfully remove a sarcomatous growth from the 
 walls of the thorax, using "forced respiration anes- 
 thesia" by the Fell-O'Dwyer method, for purposes 
 of the narcosis and combating pneumothorax. The 
 operation was performed under reciprocal breath- 
 ing, and the chest walls were closed with the lungs 
 fully inflated. Complete recovery of the patient 
 ensued. 
 
 About 1896 the French surgeon, Tuffier, in asso- 
 ciation with Hallion, after exhaustive intrathoracic 
 experimentation under continuous insufflation, con- 
 cluded that, "the success of this method on ani- 
 mals justified its use in man." In 1902 Matas 
 turned his attention to a solution of the surgical 
 problems involved in pneumothorax. 
 
 Kuhn of Cassel, who had made intubation a 
 specialty since 1895, in 1905 came out with a posi- 
 tive differential method for compensating pneumo- 
 thorax, based on insufflation by intubation. He at 
 first closed the mouth tight, but in 1908 improved 
 his previous technique by introducing two tubes 
 in one, a narrow tube for inbound compressed air 
 and a wider one for the exhaust. After many ex- 
 periments on the human being, Kuhn found it ad- 
 visable to keep the tube out of the trachea, and to 
 stop it just below the larynx. While Kuhn demon- 
 
 79 
 
strated the pulmonary application of anesthesia 
 by intubation to Czerny of Heidelberg, Trendelen- 
 burg of Leipsic, Angerer of Munich, and Lotsch of 
 Berlin visiting each of these surgeons personally, 
 nevertheless the method was not favorably received 
 for use in intrathoracic surgery on the human 
 subject. 
 
 In 1908 Robinson of Boston intubated through 
 the mouth to the bifurcation of the trachea, send- 
 ing in air under pressure through a cannula, and 
 letting the exhaust escape by way of the remaining 
 lumen of the trachea. Later Robinson investigated 
 the Volhard-Sollman method of oxygen insufflation, 
 by means of which, during animal experimentation, 
 life could be sustained without distention of the 
 lungs; but he was distracted from perfecting this 
 or the air-insufflation technique by becoming in- 
 terested in progressive improvements which he 
 made in both the Brauer and Sauerbruch methods. 
 
 Mikulicz, however, must be credited with the 
 first systematic investigation of the physiological 
 problems besetting intrathoracic surgery. At his 
 suggestion in 1903 Sauerbruch began a series of 
 experimental researches, and in 1904 completed 
 cabinets for intrathoracic surgery, using respec- 
 tively positive or negative pressure. 
 
 While Sauerbruch soon discarded his hyperat- 
 mospheric apparatus in favor of his negative- 
 pressure cabinet, Brauer, working independently, 
 developed the first positive-pressure chamber to 
 come into general use. The apparatus devised by 
 Karewski resembled closely that of Bauer, as did 
 also the initial cabinets of Janeway and Green. The 
 devices of Tiegel and Brat-Schmieden were essen- 
 tially of the emergency or laboratory type, although 
 an effort was made to adapt them to the more ex- 
 acting requirements of intrathoracic surgery on 
 the human subject. 
 
 What Carrel has termed the "classical type" 
 (cabinet) of apparatus has found its apotheosis 
 in the new intrathoracic surgical pavilion of Willy 
 Meyer at the German Hospital, New York, in 
 which it is possible to operate differential, positive, 
 or negative pressure at will. 
 
 Until the present popularization of intratracheal 
 insufflation by the Meltzer-Auer technique, what- 
 ever real progress has been made in intrathoracic 
 surgery on the human subject must be credited 
 to the "classical style" of apparatus. 
 
 •In 1908 Meltzer saw Sauerbruch doing intra- 
 
 80 
 
thoracic surgery, and later witnessed some of Willy 
 Meyer's operations at the Rockefeller Institute, 
 and seeing both pleural cavities wide open and the 
 animals continuing to breathe, but not trusting the 
 evidence of his own eyes he went into his labora- 
 tory to verify the experiments. A year later, in 
 association with Dr. Auer, he published an article 
 on "Continuous Respiration without Respiratory 
 Movements." After Meltzer had perfected the 
 technique of intratracheal insufflation in his labo- 
 ratory, Elsberg, with the assistance of Yankauer, 
 developed an apparatus for its use on the human 
 subject, and personally administered anesthesia by 
 this method for a successful thoracotomy performed 
 by Dr. Lilienthal at Mt. Sinai Hospital in 1910. 
 
 Meanwhile, Morriston Davies, after a thorough 
 investigation of all the intrathoracic apparatus and 
 methods in vogue, perfected and used a hyper- 
 atmosheric device, combining both the advantages 
 of the cabinet and intratracheal insufflation tech- 
 niques, and to Elsberg, and Peck (New York) and 
 Davies (London) belong the credit, not only of 
 adapting intratracheal insufflation to the require- 
 ments of intrathoracic surgery, but also of demon- 
 strating its value as a technique of narcosis in the 
 surgery of the head and neck. 
 
 While the "classical type" of the cabinet and 
 intratracheal style of apparatus are in apparent 
 competition for supremacy, still each has its possi- 
 bilities and its limitations, and further clinical ex- 
 perience alone will determine their respective utility 
 in certain definite intrathoracic surgical procedures. 
 
 Physiological Considerations. — Progress in intra- 
 thoracic surgery has depended absolutely on the 
 mechanical control of pneumothorax during the 
 operative procedure. This mechanical control has 
 varied in different methods, from that of Hook, now 
 represented by the Meltzer-Auer technique, in which 
 the lungs for certain periods have been so dis- 
 tended by a constant current of air as to preclude 
 more or less any respiratory movements, to that of 
 Volhard-Sollman, in which the lungs have been 
 allowed to collapse, while a current of oxygen sus- 
 tained life. 
 
 However, for all practical purposes, reciprocal 
 breathing, under manometrically controlled posi- 
 tive, negative, or differental pressure, has proven 
 the only safe method of compensating pneumothorax 
 during intrathoracic operations upon the human 
 subject. 
 
 81 
 
Any consideration of pneumothorax involves an 
 understanding of some elementary facts of the 
 respiratory mechanism. Respiration is made pos- 
 sible in the thorax of the human subjects by a 
 partial vacuum existing in the pleural space after 
 the contraction of the lungs during expiration. 
 This vacuum is represented by a varying negative 
 pressure of from 4 to 10 mm. of mercury. Conse- 
 quently thoracotomy requires either positive-pres- 
 sure insufflation, with or without respiratory move- 
 ments, or autorespiration in the negative or differen- 
 tial pressure cabinet, to prevent the collapse of the 
 lung resulting in dyspnea, displacement of the 
 thoracic viscera, shock, and death. 
 
 With the body of the patient within the cabinet 
 in which the air has been rarefied to approximately 
 the negative pressure in the pleural cavity (4 to 
 10 mm.) and the head of the patient is outside 
 the chamber, permitting the respiring of normal 
 pressure atmosphere, Sauerbruch, by varying the 
 negative pressure as required, has been able to 
 conduct intrathoracic operations with almost the 
 same confidence as in abdominal surgery. In the 
 Meyer cabinet differential pressure allows the sur- 
 geon to use positive, negative, or combinations of 
 both pressures as needed. The great distinction 
 between the cabinet control of pneumothorax and 
 intratracheal insufflation is that in the former 
 autorespiration is depended on to conserve life, 
 and already overtaxed and weakened nerve centers 
 are called upon to formulate respiratory impulses, 
 while during intratracheal insufflation these centers 
 can be made to remain passive, thereby adding a 
 determining factor between success and failure. 
 Moreover, in some operative procedures those 
 muscles which participate in respiration are ren- 
 dered inactive, thereby making the use of intra- 
 tracheal insufflation all the more imperative. This 
 demand is accentuated whenever during the course 
 of any intrathoracic procedure dislocation of the 
 posterior lobes of the lungs inhibits the usual respi- 
 ratory movements. 
 
 Respiratory movements are not only concerned 
 in the aeration of the lungs, but also contribute a 
 factor essential to the normal maintenance of the 
 pulmonary circulation and of considerable impor- 
 tance to that of the systemic. Thus the pulmonary 
 circulation may be regarded as of double function, 
 the ventricular, impelling the blood onward with 
 rapid pulsations of the cardiac rhythm, while the 
 
 82 
 
lungs contribute the slower but more voluminous 
 impulses of the respiratory cycle. (Davies.) 
 
 Hence it is that during intracheal insufflation 
 Meltzer has found it inadvisable to use a pressure 
 which altogether suspends respiratory movements, 
 resulting in apnea and C0 2 asphyxia, and suggests 
 that, in so far as it is possible or necessary, the 
 lungs be periodically deflated five or six times to 
 secure not only a more satisfactory diffusion of 
 the air and anesthetic in the smaller bronchi and 
 alveoli, but also to eliminate CO a accumulation, and 
 further to preserve the stimulus of respiratory 
 movements upon the pulmonary and systemic circu- 
 lations. In cases of open pneumothorax in which 
 the respiratory mechanism is not paralyzed, spon- 
 taneous respirations offer the required aid to con- 
 tinuous intratracheal insufflation. 
 
 However, it is always advisable to arrange for 
 occasional interruptions of the continuous insuffla- 
 tion, especially in operations in which the thorax 
 has to be laid wide open and the posterior and 
 inferior portions of the lungs have to be dislo- 
 cated, in which condition spontaneous respirations 
 are of no avail. The occasional deflation of the 
 lungs insures the continuance and efficiency of the 
 pulmonary ventilation under all circumstances. It 
 is essential, however, that this deflation be not 
 allowed to result in a complete collapse of the lung, 
 for reinflation under the circumstances may leave 
 portions of the lung atelectatio. 
 
 Moreover, such deflation is valuable as a diag- 
 nostic factor in differentiating healthy from patho- 
 logical lung tissue by the change of color and the 
 presence or absence of proper distention. Again 
 partial deflation is useful in left-sided pneumo- 
 thorax, particularly in suturing the wounds of the 
 heart, under which circumstances hemorrhage from 
 the heart wound, according to Friedrich, diminishes 
 in proportion as the lungs are allowed to collapse. 
 
 The partial pneumothorax thus becomes the regu- 
 lator of the hemorrhage and is allowed to persist 
 until suture of the heart wound has been com- 
 pleted, after which the pericardium and pleura are 
 closed with the lungs properly reinflated. 
 
 Extensive laboratory experiments, which have 
 been verified by post-operative results in the human 
 subject, prove conclusively that so far as respi- 
 ratory complications are concerned intratracheal 
 insufflation is an innocuous procedure even in the 
 presence of the lobar pneumonia. Also it has been 
 
 83 
 
found in practice that the recurrent air-stream 
 through the trachea precludes the possibility of 
 aspirating vomited material or hemorrhage from 
 the pharynx. 
 
 Physiologically, the intrinsic value of intra- 
 tracheal insufflation is exemplified not only in the 
 original work of Fell, but also in the laboratory 
 experiments of Shaklee and Githens on the treat- 
 ment of strychnine poisoning, in which, although 
 the very centers of respiration were paralyzed, in- 
 tratracheal insufflation reached the climax of its 
 usefulness as a measure of resuscitation and the 
 conservation of life. 
 
 Meltzer has also found that anesthesia by intra- 
 tracheal insufflation is far superior in many re- 
 spects to the usual methods of administering ether. 
 The anesthesia is much safer, far more readily con- 
 trolled ; less of the anesthetic agent is used, patients 
 go under and come out more rapidly, and an effi- 
 cient method of artificial respiration is immediately 
 at hand to take care of untoward complications. 
 
 In recent studies on the influence of intra- 
 tracheal insufflation on blood pressure and respi- 
 ration, Meltzer and Githens found that a mano- 
 metric pressure of from 30 to 40 mm. and a percent- 
 age of ether just sufficient to complete anesthesia, 
 from 50 to 75 per cent, were innocuous, but that 
 an increase of pressure and the percentage of ether 
 for any appreciable length of time would result in 
 an undulating fall of blood pressure, a slowly and 
 diminished excursion of respiratory movements, 
 with final cessation of breathing, although the 
 heart continued to beat. 
 
 Resuscitation was possible in animals within 20 
 minutes by the insufflation of pure air. From the 
 experiments it appeared that an overdose of ether 
 first paralyzed the functions of the medulla and 
 then much later the functions of the heart. Hence 
 the caution in administering intratracheal insuffla- 
 tion to reduce the ethery percentage in ratio to the 
 shallowness and diminished rate of respiration. 
 
 Untoward respiratory and associated cardiac 
 complications may also result from operative man- 
 ipulation of the vagi and their branches, and the 
 resulting false apnea may be controlled by the 
 hypodermic use of atropin. 
 
 An increase of pressure, accomplished either by 
 means of the air current or indirectly by momen- 
 tary pressure on the larynx, is valuable not only in 
 gauging the proper distention of the lung, but also 
 
 84 
 
in obviating cyanosis and in overcoming the re- 
 sistance of neurotic individuals to the anesthetic 
 effects of the ether. All investigators have found it 
 expedient to add a tank of oxygen to their arma- 
 mentarium for intratracheal insufflation. Under 
 certain circumstances a persistent cyanosis will 
 develop, which nothing short of oxygenation will 
 control. 
 
 While Brauer uses the Roth-Drager, and Davies 
 the Alcock regulating chloroform apparatus in con- 
 junction with mechanical respiration for purposes 
 of pulmonary anesthesia, ether seems to be a far 
 safer agent for routine narcosis by this method. 
 
 As early as 1827 Portal produced an artificial 
 pneumothorax without thoracotomy by the injection 
 of sulphuretted hydrogen gas into the thoracic cav- 
 ity to place the lung at rest when affected with tu- 
 berculosis. Holmgren pursued the same principle 
 of treatment for unilateral pulmonary tuberculosis 
 even in cases in which adhesions between the vis- 
 ceral and parietal pleurae contraindicated its use. 
 Hamman of Johns Hopkins is now utilizing a sim- 
 ilar technique with nitrogen gas. In the presence 
 of adhesions, the pieliminary injection of saline so- 
 lution to collapse the lung is advisable before in- 
 jecting the gas to produce the therapeutic pneumo- 
 thorax. 
 
 Perforation of the thoracic wall does not always 
 result in pneumothorax, unless the opening is larger 
 in diameter than that of the glottis, or is valve-like 
 in character as in oblique puncture of wounds. As 
 a rule, pneumothorax will disappear when the open- 
 ing in the chest wall has been closed by the adjacent 
 integumentary structures. These two facts have 
 enabled surgeons, by means of tubes under water 
 and the use of rubber tissue dressings, to allow for 
 post-operative drainage of the thorax without arti- 
 ficial control of pneumothorax. 
 
 Technique of Intratracheal Insufflation Anes- 
 thesia. — Apparatus for intratracheal insufflation 
 anesthesia has multiplied rapidly since the popu- 
 larization of the method by Elsberg. However, all 
 apparatus is similar in certain essentials. The 
 source of air current may be provided by foot bel- 
 lows, hand-driven or electrically-driven pumps, and 
 tanks of compressed air. The air-current may pass 
 directly into the ether container, or as is more ad- 
 visable, is stored in a low-pressure tank or gas- 
 ometer from which it passes into a Wolf bottle, to 
 be heated and moistened, and thence by regulating 
 
 85 
 
valve, either directly into, or only partially through 
 the ether container, thereby providing for aera- 
 tion pure and simple or insufflation with varying 
 percentages of ether. 
 
 Also a source of oxygenation is an expedient ad- 
 junct. The tube from the apparatus connects with 
 a mercury manometer and thence to the intubation 
 tube. 
 
 Davies, adopting Kuhn's idea of a double intuba- 
 tion tube, uses a manometer to gauge the inlet and 
 outlet air pressures. 
 
 All experimenters have concluded that for the 
 Meltzer-Auer technique a silk-woven catheter 30 
 cm. long and of a diameter one-half that of the glot- 
 tis, usually from 22 to 26 of the French scale, serves 
 as the best intubation tube. It should have an 
 opening similar to the rectal tube at the tracheal 
 end, should be absolutely smooth and semi-rigid to 
 prevent it from being expelled by coughing or from 
 being compressed while in position. 
 
 Its introduction is best accomplished after the 
 preliminary introduction of narcosis by ethyl 
 chloride-ether or nitrous oxide-oxygen-ether anes- 
 thesia. 
 
 Intubation is greatly facilitated by means of 
 either the Jackson direct laryngoscope, Fischer's 
 modification of Hayes's instrument, or the intro- 
 ducer devised by Cotton. After the patient has 
 been deeply narcotized the mouth is opened wide 
 and so held by a gag. The head is well brought 
 forward and the tongue pulled forward by an as- 
 sistant until the opening of the larynx is brought 
 into view. The metal guide is introduced into the 
 opening and the intubation tube is gently pushed 
 onward until it is seen to pass over the epiglottis 
 into the larynx, after which the metal guide is 
 withdrawn and the tube is pushed further into the 
 trachea until it meets an obstruction, which is 
 either the wall of the right bronchus or the bifurca- 
 tion of the trachea. It is then withdrawn an inch 
 and is anchored in position to special mouth gags 
 provided for the purpose. 
 
 The distance from the incisors to the bifurcation 
 of the trachea is from 9 to 10 inches in the infant, 
 12 in a child, and about 17 inches in the adult. The 
 glottis in the adult is one-half the distance between 
 the incisors and the bifurcation of the trachea, and 
 Elsberg suggests making the intubation catheter 
 accordingly to insure greater accuracy in adjusting 
 its location. 
 
 86 
 
One-eighth to % gr. of morphine hypodermically 
 ten minutes before the administration of ether to 
 reduce the irritability of the larynx; or from twenty 
 minutes to half an hour previously when prelim- 
 inary anesthesia by ether is not resorted to. The 
 induction of narcosis by intratracheal insufflation 
 produces spasmodic coughing while the patient re- 
 mains conscious. 
 
 With the intubation tube introduced to the cor- 
 rect position, air may be heard rushing through the 
 catheter. Spasm of the larynx may now occur for 
 a few moments, but is of no consequence. At this 
 juncture the tube from the apparatus is connected 
 to the catheter with the pressure gauge of the 
 manometer controlling the air supply at 20 mm. 
 and the ether percentage at 50. If the lungs are 
 not kept properly distended by a pressure of from 
 10 to 20 mm. Hg, the intratracheal tube is either 
 out of position in the right bronchus or is too 
 small and is allowing too much air to escape by 
 way of the trachea. In the first instance the tube 
 must be retracted and in the second either a larger 
 sized tube must be introduced or else slight com- 
 pression of the trachea around the tube at the jugu- 
 lum must be intermittently utilized. Too large a 
 tube causes CO, accumulation and cyanosis. 
 
 Complete muscular relaxation is usually obtained 
 with from 50 to 75 per cent, of ether, and during 
 the course of narcosis the breathing is quiet, res- 
 pirations are reduced by one-third, the face re- 
 mains pink, while the veins of the forehead become 
 prominent; the pulse usually remains full, bound- 
 ing, and regular, the pupils do not dilate, and fre- 
 quently the corneal reflex is active, so much so that 
 the condition of the patient is rather one of anal- 
 gesia than anesthesia. Reaction from the anes- 
 thesia is so rapid that care must be exercised to 
 keep up etherization throughout the entire opera- 
 tion. The depth of narcosis is controlled by in- 
 creasing the air pressure and the percentage of 
 ether while at the same time avoiding a condition 
 of apnea, which supervenens at pressures of from 
 30 to 40 mm. Cyanosis and the accumulation of 
 CO, during the operative procedure are controlled 
 by periodic deflation and occasional oxygenation 
 with air. Pure oxygen is dangerous on account of 
 its toxicity when its tension becomes too great, and 
 it is too freely absorbed by the circulation. 
 
 At the close of anesthesia, ether is turned off, and 
 pure air, or a combination of air and oxygen, is in- 
 
 87 
 
sufflated under slightly increased pressure to blow 
 out the ether from the trachea and alveoli. Pa- 
 tients come out from under the influence of pul- 
 monary anesthesia by this method almost as soon 
 as the insufflation is discontinued and the tracheal 
 tube removed. Apnea is present for a few moments 
 after the removal of the intubation tube, but regu- 
 lar breathing is then rapidly re-established. Post- 
 anesthetic vomiting, headache, dyspnea, and cardiac 
 complications are of rare occurence. Postoperative 
 pneumonia, interstitial emphysema and pleural ef- 
 fusions have followed intrathoracic operations done 
 under both cabinet and intratracheal insufflation 
 methods and the determining etiological factor in 
 the complication has not been readily determined. 
 However, caution must be directed to a technical 
 mishap which may occur, and that is an accidental 
 injection of fluid ether into the lungs. Fischer 
 quotes a case in his own experience in which death 
 resulted from this contretemps and the mishap has 
 occurred in laboratory experiments. Only appara- 
 tus should be used which mechanically precludes 
 the possibility of such an occurrence. 
 
 Again, post-operatively, it may become necessary 
 to resume insufflation without anesthesia to control 
 shock, to aid flagging respiration and circulation, 
 and to prevent serious effusions. Under such cir- 
 cumstances the success of Fell in saving life under 
 the most disheartening conditions must be remem- 
 bered, and the method pursued to its limits. 
 
 Aside from its value purely as a resuscitative 
 measure in asphyxia, drowning, poisoning from 
 drugs and anesthetics, the convulsive stage of 
 rabies and tetanus, impaired respiratory function 
 in certain diseases, it must also be remembered that 
 intratracheal insufflation as a method of anesthesia 
 is a very desirable adjunct to the surgery of the 
 head and neck, and especially for operations on the 
 spine when the patient must be placed flat on the 
 stomach during the course of operative procedure. 
 
 While etherization in association with intracheal 
 insufflation appears to be the safest form of anes- 
 thesia for intrathoracic operations, Boothby, after 
 using the nitrous oxide-oxygen-ether technique, 
 has been favorably impressed with the latter 
 method, and Willy Meyer also suggests that the 
 innocuousness of nitrous oxide may play an impor- 
 tant role in conserving patients under thoracotomy 
 the additional shock of a poisonous anesthetic 
 agent. 
 
 88 
 
FOUR CLINICAL LECTURES. 
 (Brief Abstracts) 
 
 HELD AT THE NEW YORK POLYCLINIC MEDICAL SCHOOL 
 AND HOSPITAL DURING THE WEEK OF THE MEET- 
 ING OF THE INTERNATIONAL SURGICAL 
 
 CONGRESS. 
 
 I— FRACTURES AND BURNS. 
 
 By JOHN A. WYETH, M.D. 
 
 Dr. Wyeth, as President of the Faculty and Senior 
 burgeon of the New York Polyclinic Medical School 
 and Hospital, after welcoming the visiting physi- 
 cians and surgeons, spoke briefly on "Fractures and 
 Burns," presenting illustrative cases of each. Dr. 
 Wyeth said in part: 
 
 I shall speak this morning of factures of a single 
 bone, the patella. As you know, fractures of the 
 patella are caused, as a rule, by violent contrac- 
 tions of the quadriceps extensor muscle while the 
 leg is in extreme flexion. The bone may be broken 
 by a direct blow or by a fall on the knee. A blow 
 and muscular action may combine to break it. 
 
 The line of fracture is usually transverse, or 
 nearly so, just below the middle of the bone. The 
 break may occur, however, above or below this 
 plane. Occasionally the bone is split longitudinally 
 by direct violence, or it may be comminuted. Frac- 
 ture of the patella is rarely incomplete, the sepa- 
 ration of the fragments varying from the smallest 
 fraction of an inch to as much as two or more 
 inches, and being wider at the inner than the outer 
 border. This lesion occurs, in the majority of in- 
 stances, between the ages of twenty and forty, and 
 is more common in males than in females. 
 
 Because of the superficial location of the lesion 
 the diagnosis is easily made, the depression between 
 the separated fragments serving as a guide. Should 
 the separation be very slight, lateral motion of one 
 fragment upon the other will elicit crepitus. 
 
 In the treatment of this condition I have lately 
 used a very simple, satisfactory, and painless 
 method of holding the fragments in continuous 
 apposition. After the transverse incision, which 
 exposes both broken surfaces, the clot is washed 
 out with hot sterile salt solution, and the frazzled 
 
 Copyright, William Wood & Company. 
 
 89 
 
periosteal edges are sutured together with fine linen, 
 thus approximating the fragments. The skin in- 
 cision is then sutured with chromicized catgut. 
 
 On a two and a half inch, half-curved Hagedorn 
 needle, a very strong linen thread, twelve inches 
 long (No. 4) is carried from side to side, deep into 
 the substance of the ligamentum patella?, just at its 
 insertion into the lower rim of this bone. A like 
 thread is inserted well into the substance of the 
 quadriceps extensor tendon at the upper margin of 
 the upper fragment. A light gauze dressing is 
 placed over the line of incision, and over this the 
 apposing ends of the two linen loops on each side, 
 above and below, are tied tight enough to hold the 
 fragments in close and continuous apposition, and 
 without the possibility of overriding. 
 
 A dry gauze dressing covers the field of oper- 
 ation, and a plaster-of-Paris cast is applied, hold- 
 ing the knee immobilized for eight weeks. At the 
 expiration of this time the holding sutures are re- 
 moved and the fragments are held securely in appo- 
 sition, while the knee is bent to not more than 
 20 degrees. The cast is reapplied and worn for four 
 weeks longer. 
 
 The limb is now put to use, with the necessary 
 precaution to prevent severe strain in overflexion 
 for at least six months. 
 
 I have employed this method in the cases pre- 
 sented, with satisfactory results. 
 
 I wish also to present a case of an extensive burn 
 of the face, neck, chest, and right arm. This 
 patient was brought to the hospital in the ambu- 
 lance last night, in a state of shock, after having 
 been rescued from a burning building. 
 
 In connection with this case it may not be amiss 
 to recall to your minds a few points concerning 
 burns and scalds, which, as you know, may vary in 
 degree from the mildest form which produces a 
 simple inflammation of the epidermis, to the most 
 severe form, which destroys all the tissues or organs 
 or a part, and which may result in the death of the 
 individual. The gravity of the prognosis is usually 
 proportionate to the extent of the surface of the 
 integument destroyed, rather than to the depth of 
 the destructive process. 
 
 Burns of the head and face, such as the patient 
 presented, are the most dangerous; those of the 
 extremities the least grave. Recovery rarely fol- 
 lows destruction of one-third of the cutaneous sur- 
 face. Death may result from shock, from ulcer of 
 
 90 
 
the duodenum, or from exhaustion following pro- 
 longed suppuration and septic absorption. 
 
 When a severe burn or scald is encountered the 
 immediate indication is relief of pain by the hypo- 
 dermatic administration of morphia, or by some 
 form of opium given by rectum or stomach. The 
 most convenient local remedy is a saturated solu- 
 tion of baking soda in water, with submersion of 
 the burned surface, if possible, or a mixture of 
 bicarbonate of soda and cornstarch, one teaspoonf ul 
 of each to a quart of water. The dressing should 
 be kept wet with the solution, which is applied 
 freely to the burned area. After five or six hours 
 the free application of the following mixture, made 
 into an emulsion, will be found beneficial: 
 
 Ichthyol 3ss 
 
 Cotton-seed or olive oil O.ss 
 
 Limewater O.ss 
 
 This should be continuously applied for the first 
 three to five days during the stage of acute in- 
 flammation. 
 
 In order to bring about rapid repair of the skin 
 the following ingredients, mixed thoroughly, may 
 be used: 
 
 Ichthyol 3j 
 
 Diachylon ointment, 
 
 White vaseline aa §ii j 
 
 If these remedies are not convenient, the follow- 
 ing may be substituted with equal benefit: 
 
 Lead plaster, 
 
 Liquid albolene, 
 
 Lanolin, 
 
 Vaseline aa §j 
 
 These are melted together, and, when cooling, 40 
 minims of ichthyol added. 
 
 Either of these ointments should be applied 
 thickly on the soft, linty side of canton flannel, on 
 surgeon's lint, or on several layers of sterile gauze. 
 The application should be repeated daily at first, 
 after opening all blebs. In opening the blebs care 
 should be taken not to remove the epidermis of the 
 bleb, as this may become revitalized, thus greatly 
 accelerating the healing process. In changing the 
 dressing it is important not to disturb new granu- 
 lations, but simply to wipe over them. When heal- 
 ing is well under way the dressing need be changed 
 only every second or third day. 
 
 In the treatment of the depression or shock which 
 often follows severe burns, stimulation with whiskey 
 
 91 
 
or brandy, by enema or by mouth, is indicated, 
 as well as the hypodermic injection of morphine. 
 Physiological salt solution, introduced by the colon, 
 or injected into the areolar tissue, is of great value 
 when the burn is extensive and the shock profound. 
 It should always be remembered that opium and 
 alcohol should be given sufficiently cautiously to 
 avoid too profound narcosis with the former, and 
 with the latter increase in the fever reaction which 
 follows when the patient rallies from the shock. 
 
 In an emergency, when the remedies mentioned 
 may not be obtained, a coating of ordinary white 
 lead, as mixed for use in painting dwellings, is an 
 efficient protection when poured over the burn. 
 Flour sprinkled over until all the excoriated surface 
 is well hidden is a method of treatment which is 
 applicable in almost any emergency. Rubber tis- 
 sue, or oil-silk, sterilized and laid over the raw 
 surface, with cotton batting applied over it, but 
 never directly on the burned surface, is equally 
 efficient. Lint, or a soft cloth, dipped in a 2 per 
 cent, carbolized oil, may be employed directly on 
 the burn. 
 
 No pressure should be exercised in holding the 
 dressings in place. When the back and posterior 
 aspects of the extremities are chiefly involved, the 
 prone position is of necessity maintained. 
 
 92 
 
FOUR CLINICAL LECTURES. 
 
 II— OPERATIONS FOR INGUINAL HERNIA 
 
 UNDER LOCAL ANESTHESIA. 
 
 By JOHN A. BODINE, M.D. 
 
 Dr. Bodine presented a case of ordinary right- 
 sided inguinal hernia, upon which he operated 
 under local anesthesia, employing a solution of 
 novocain, 1-500. Dr. Bodine said in part: 
 
 In operating under local anesthesia the nervous 
 apprehension of the patient may be quieted to a 
 great degree by a calmative demeanor upon the 
 part of the surgeon and his assistants. This is 
 also influenced by the patient's position upon the 
 table. A position of comfort and relaxation should 
 be maintained. If the arms are crossed above the 
 head the patient will be "fidgety" throughout the 
 operation. 
 
 In the effort to avoid bleeding points it is of 
 great importance that the lower end of the incision 
 should not extend beyond the lateral end of the 
 suprapubic skin fold. It may be started as high 
 as one desires. This incision may be deepened to 
 the operative field without encountering a vessel 
 large enough to demand a ligature, whereas, if the 
 incision be extended an inch lower, a large number 
 of ligatures will be required. Not only does the 
 catgut thus employed, when softened by the tissues, 
 invite sepsis, but, in cocaine work, it means a num- 
 ber of acute stabbing pains whenever a blood vessel 
 is cut or tied. The incision so placed gives ample 
 room by downward traction of the mobile skin, and 
 nearly always permits the completion of the oper- 
 ation without the use of a ligature. 
 
 The line of incision is infiltrated with the novo- 
 cain or other anesthetic solution throughout its 
 extent. This is accomplished by introducing the 
 needle just under the superficial epithelium. The 
 anesthesia thus induced will permit the incision to 
 be painlessly deepened to the aponeurosis of the 
 external oblique. Upon splitting and reflecting the 
 aponeurosis, the iliohypogastric nerve is anesthet- 
 ized by injecting a little of the solution into the 
 sheath of the nerve as high up as possible. 
 
 The ilio-inguinal nerve is also sought, but if it is 
 not found the hernial coverings should be infiltrated 
 in a straight line over the neck of the sac, and the 
 
 93 
 
incision deepened until this structure is reached. 
 If omentum is excised it is generally gently with- 
 drawn, ligated and amputated without additonal in- 
 jection, and, in my experience, without pain. If, 
 however, only the iliohypogastric nerve has been 
 found some infiltration will be needed into the con- 
 joined tendon. The cord is lifted from its position 
 and the operation concluded according to the Bassini 
 method. 
 
 Two suggestions are offered which have proved 
 of worth to me: First, if a strip of gauze is used 
 to hold up the cord it may, during the necessary 
 manipulation, roll the cord on its long axis, and 
 exposure to air may cause agglutination in this 
 position of torsion. A wetted strand of catgut as a 
 retractor will obviate this danger. Second, the deep 
 suture should include but one-half the thickness of 
 the conjoined tendon, thus avoiding strangulation. 
 
 1)4 
 
FOUR CLINICAL LECTURES. 
 Ill— FRACTURES. 
 
 By ALEXANDER LYLB, M.D. 
 
 Dr. Lyle presented three patients whose histories 
 were briefly detailed, in part, as follows : 
 
 Case I. — This patient, a man forty-nine years of age, 
 while working in the well of an elevator was crushed 
 by the descending car, sustaining injuries to the pelvis. 
 Upon being released from his confined position he com' 
 plained of scarcely any pain, and it was not until he 
 made an attempt to stand that the pain became notice- 
 able. 
 
 Careful examination revealed a fracture of the 
 pelvis, the exact extent of which could not be de- 
 termined by palpation. Examination by rectum elicited 
 no evidence of injury to this organ, and catheteriza- 
 tion of the bladder showed no blood in the urine. Shock 
 was not marked. The patient was placed in bed and a 
 very tight wide muslin binder put about the pelvis. 
 The following day an x-ray examination was made, 
 which revealed a very marked bilateral fracture of the 
 pelvis. In the skiagraph an irregular line of the frac- 
 ture could be seen, starting from the crest of the ilium 
 and extending down, terminating in the greater sciatic 
 notch. There were no wounds in the skin. 
 
 The patient was observed very closely after being 
 put to bed, in order to determine the presence of any 
 internal injuries, but the abdominal viscera proved to 
 be uninjured. 
 
 The treatment of this case, like that of all fractures 
 of the pelvis, has been very simple. Straps of ad- 
 hesive plaster were brought around the pelvis, in order 
 to immobilize it, and this was reinforced by a firm mus- 
 lin bandage. The patient's convalescence has been un- 
 eventful. He will be kept quiet in bed for eight weeks 
 before he is allowed to stand. 
 
 In all cases of this kind it is well to bear in 
 mind the great danger of rupture of the urethra, 
 of the bladder, and of the pelvic vessels. As soon 
 as internal injury can be determined operation 
 should be resorted to. 
 
 Case II. — The next patient, a woman of thirty-five 
 years of age, sustained a transverse fracture of the 
 surgical neck of the humerus, as shown in Fig. 1. The 
 head of the humerus may be seen in the glenoid fossa, 
 while the broken end of the shaft has pierced the 
 pectoral muscles and lies immediately beneath the 
 clavicle. 
 
 After several attempts to reduce this fracture and to 
 hold it in position by mechanical means had failed, it 
 was determined to open through the deltoid and replace 
 the fragments. With complete ether anesthesia, the 
 bone was exposed. Upon bringing the fragments to- 
 
 95 
 
Fig. 1. — Fracture of the neck of the humerus. 
 
 gether it was found that they could be dove-tailed into 
 each other so firmly that plating or wiring was unneces- 
 sary. The tissues were then sutured, a small pad of 
 cotton placed in the axilla, and a firm plaster-of-Paris 
 spica applied. 
 
 The patient's condition being excellent, the dressing 
 was not removed for four weeks. It was then taken 
 down and a light one applied, which remained for two 
 weeks longer. Following removal of this, massage and 
 passive motion were used, the patient now having al- 
 most complete use of her arm. Fig. 2 shows the condi- 
 tion after operation. 
 
 Case III. — The third patient is a young man twenty- 
 four years of age, who sustained a fracture of the 
 lower third of the right femur, as shown in Fig. 3. He 
 is a truck driver by occupation, and is consequently 
 very muscular. It will be noticed in the plate that the 
 muscles have contracted to such an extent that the 
 fragments have overlapped fully an inch. 
 
 Formerly our treatment in such cases consisted 
 
 96 
 
Fig. 2. — Fracture of the neck of the humerus after reduction. 
 
 in the application of Buck's extension, with suffi- 
 cient weights attached to counteract the muscular 
 force. Much of this traction was exerted upon or 
 below the knee, and consequently knee-joint com- 
 plications often became more severe than the frac- 
 ture. We now have a very decided improvement in 
 the line of traction in the Steinmann nail. This con- 
 sists of a long spike of steel which is put through 
 the lower end of the femur, just above the condyles, 
 and by the use of tongs traction is exerted upon 
 this, the knee-joint being left perfectly free. 
 
 Fig. 4 shows the femur after the Steinmann ap- 
 paratus has been in service and twelve pounds of 
 weight applied over the pulley. It will be observed 
 that not only has the muscular force been overcome, 
 but that the fragments have been pulled over an 
 inch apart. At this point the weights were reduced 
 to six pounds, and a plaster-of-Paris roll bandage 
 applied over the lower two-thirds of the femur, in 
 order thoroughly to immobilize the fragments that 
 are now in perfect alignment. 
 
 97 
 
A B 
 
 Pig. 3. — Fracture of the femur ; A, front view ; B, side view. 
 
 Fig. 
 
 4. — Fracture of the femur, shown in Fig. 3, after treat- 
 ment with the Steinmann apparatus. 
 
 98 
 
The patient's convalesence was normal in every 
 respect and he was able to walk out of the hospital, 
 without the assistance of even a cane, at the end 
 of eight weeks. 
 
 99 
 
FOUR CLINICAL LECTURES. 
 IV— CANCER. 
 
 By WILLIAM SEAMAN BAINBRIDGE, M.D. 
 
 Dr. Bainbridge presented a number of patients. 
 In some instances the patients had been operated 
 upon for cancer at a previous time, in others 
 operations were performed on this occasion. One 
 particular case belonging to the first category, sug- 
 gested certain practical points with reference to the 
 diagnosis and treatment of malignant disease, a 
 partial report of which is here given : 
 
 The patient, a woman, seventy-one years of age, pre- 
 sented herself at the hospital in March, 1914, complain- 
 ing of "throat trouble." In January, according to the 
 history, another physician opened the left tonsil for 
 "quinsy," the tonsil at that time being enlarged and 
 painful. The diagnosis of syphilis had been made by 
 one physician consulted, but the Wassermann reaction 
 was negative, as was likewise the history. Before I saw 
 her for the first time, in March, a small piece of the 
 tonsil had been removed for pathological examination, 
 and the pathologist had reported "inflammatory tissue." 
 
 When the patient came under my observation the ton- 
 sil was very much enlarged, indurated, and the sur- 
 face ulcerated. The surrounding tissue was edematous 
 and reddened. The patient complained of great pain, 
 and of difficulty in swallowing. Three sections were re- 
 moved from the ulcerated portion, and these were given 
 to three independent pathologists for examination. One 
 sent in the report, "inflammatory tissue"; the other two 
 reported "sarcoma." The latter coincided with the 
 clinical diagnosis, and, inasmuch as the mass was 
 growing very rapidly, with danger of death from 
 hemorrhage, immediate operation was advised. 
 
 On April 3, at the Polvclinic Hospital, the patient was 
 operated upon under general ether anesthesia. The 
 external carotid artery, including the ascending pharyn- 
 geal branch, was ligated, and the mass removed, with as 
 thorough dissection as circumstances allowed. 
 
 The patient recovered from the operation, and ex- 
 perienced great relief from the dysphagia and general 
 suffering caused by this enormous mass, which had filled 
 almost the entire mouth. To have left this mass, involv- 
 ing the soft palate, and interfering with respiration 
 and deglutition, would have meant early death, either 
 from hemorrhage or from pressure upon the trachea 
 and consequent interference with breathing. By tying 
 off the large vessels it was possible to remove the tumor, 
 to relieve suffering and to prolong life. 
 
 After the operation pieces of the tonsil were again 
 sent to different pathologists for a verification, if pos- 
 sible, of the clinical diagnosis of malignancy. Of the 
 four pathologists who examined these independently, 
 
 100 
 
three reported round-celled sarcoma, and one, inflam- 
 matory tissue. 
 
 A case of this kind is fraught with a number of 
 valuable lessons. 
 
 In the first place, it emphasizes the vital im- 
 portance of making a careful and thorough diag- 
 nosis, even in apparently simple affections such as 
 "sore throat" and "quinsy." Many times, in the daily 
 routine of the busy practitioner or of the hospital 
 or dispensary physician, it is difficult to accord to 
 each case the careful diagnostic consideration which 
 it should receive. For this reason the conscientious 
 and capable physician or surgeon may make errors 
 in diagnosis which a little more time, care, and 
 thought would obviate. 
 
 The same thing, it seems, applies to the patholo- 
 gist. If, armed with an adequate history of the 
 case and with the clinician's presumptive diagnosis 
 of malignancy, the pathologist is content to examine 
 one or two slides with negative results, and to 
 render a negative report, he is very apt to fall into 
 many pitfalls in diagnosis. Ordinarily, a few slides 
 will reveal the true diagnosis, but it must not be 
 forgotten that this may not be the case. Sometimes 
 malignancy is established only after the examina- 
 tion of a large number of sections. Numbers of in- 
 stances of this kind have been reported by myself 
 and others. For this reason a negative pathological 
 diagnosis should not be accepted in the light of 
 positive clinical evidence of malignancy. The case 
 under discussion illustrates this point. 
 
 In this connection it may be reiterated that 
 adequate clinical data in each case should be 
 given to the pathologist. It is fair neither to the 
 pathologist, to the patient, nor to the surgeon him- 
 self, that the laboratory worker be expected, from 
 the sections alone, to give reliable findings in all 
 cases. 
 
 In the second place, the case emphasizes the im- 
 portance of bearing in mind the question of the 
 auto-infectivity of cancer. It cannot be positively 
 stated, but, from the subsequent history, it is 
 quite probable that the first operation, that of 
 incising the tonsil for what was supposed to be 
 "quinsy," or acute suppurative tonsillitis, stimu- 
 lated malignant growth and accounted for the 
 rapid extension of the sarcoma. It is likewise 
 quite fair to assume that this operation very materi- 
 ally affected the ultimate outcome of the case, for, 
 while the patient, at the present time, is fairly com- 
 
 101 
 
fortable, can breathe and swallow with ease, and is 
 free from the danger of immediate death from 
 hemorrhage, suspicious induration in the neck sug- 
 gests early and rapid recurrence. 
 
 This patient's history recalls another case which 
 came under my observation in this institution in 
 1908. Each illustrates, in a telling manner, the 
 dangers of breaking down nature's barriers either 
 for the purpose of taking specimens for micro- 
 scopic study or through an error in diagnosis. In 
 the case which I have just presented to you the 
 growth was first cut into through a mistake in diag- 
 nosis, and afterward for the purpose of taking a 
 specimen. In the other case to which I refer the 
 second error was committed. In this instance a 
 little boy, three years of age, developed a small 
 tumor in front of the ear- after a fall which caused 
 a bruise in this region. The interne in the dis- 
 pensary of the hospital to which the mother carried 
 the child cut into this small lump and took out a 
 section for pathological examination, telling the 
 mother to return with the child in two weeks. The 
 result was that the tumor increased enormously in 
 size and with great rapidity, with involvement of 
 the lymphatics of the neck and with metastases in 
 the liver, spleen, and testes. Within about nine 
 months from the time the child received the fall 
 the condition had become inoperable, and the neo- 
 plasms, which proved to be sarcoma, irremovable. 
 This was the condition when I first saw the patient, 
 consequently no operation was performed. The 
 child died early in December, the fall having oc- 
 curred in February. 
 
 Such cases, one in a woman of seventy-one and 
 the other in a child of three, emphasize the im- 
 portance of keeping nature's barriers intact, in all 
 instances where there is a doubtful question of ma- 
 lignancy. Instead of incising the unbroken skin or 
 mucous membrane, the entire tumor should be re- 
 moved and the section taken afterward for purposes 
 of verification of diagnosis, and for determining 
 the advisability of more extensive removal of tissue. 
 If, perchance, nature's barriers have already been 
 broken down, as in the case of the woman, a sec- 
 tion may generally be removed without increasing 
 the danger of extension. Under all circumstances, 
 when the clinical diagnosis of maligancy is doubt- 
 ful and a section is removed for microscopic veri- 
 fication or reinforcement, a prompt report should 
 be insisted upon, in order that immediate operation 
 
 102 
 
may be resorted to if necessary. Inasmuch as neg- 
 ative pathological reports are not to be accepted in 
 the face of positive clinical diagnosis, it is often ad- 
 vantageous to resort to frozen sections at the time 
 of operation for the purpose of determining, in the 
 light of the pathological findings, the extent of 
 operative interference. 
 
 In closing I wish to reiterate once more the im- 
 perative duty of every surgeon who operates for 
 cancer to utilize all the diagnostic aids now at our 
 command before pronouncing a condition malignant 
 or non-malignant. Sins of commission may be just 
 as disastrous to the patient as sins of omission in 
 the matter of operative interference, and it is only 
 by refinements of diagnosis, plus the careful weigh- 
 ing of all the evidence that we may avoid both 
 pitfalls. 
 
 103 
 
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