Reports of Societies.

Stated Meeting, December 3, 1897, the President, F. C. Wilson, M. D., in the chair.

1. Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.

Uterine Fibroma.Dr. L. S. McMurtry: I present this specimen of uterine fibroma on account of two very interesting features of this class of tumors which it illustrates. The first relates to the morphology of these growths. The tumor is a very large one, and occupied the entire pelvis and the abdomen to the superior limits of the umbilical and lumbar regions. It is a multi-nodular tumor, and its disposition in relation to the fundus of the uterus is unlike any specimen that I have ever encountered. It will be observed that the neoplasm springs from the lower segments of the uterus, and the fundus is not involved in the growth at all.

The second feature of interest, and this is especially interesting from a surgical point of view, is the relation of the bladder to the tumor. It is very common for the bladder to be carried upward with the growth, thus rendering it very liable to injury in operation. This feature is exceptionally conspicuous in this tumor on account of the nodular condition where the bladder was attached, forming a sulcus. In releasing the bladder, after splitting the capsule, the uneven surface of the tumor caused me to inflict an injury upon the coats of that viscus. After dissecting off the bladder I found that I had made an opening in it at this point. It was immediately closed with a double row of catgut sutures. The operation was done six days ago, and the convalescence of the patient has been most satisfactory indeed. The bladder injury has not complicated the patient’s convalescence at all, its function being carried on just the same as if it had not been involved. The convalescence has been afebrile from the beginning, and recovery is assured.

The method I observed in treating the pedicle was to amputate the cervix very low down, leaving a very small rim of the cervix, and suturing the peritoneum over it all the way across the pelvis, making the pedicle extraperitoneal. The conformation of the growth and itsrelation to the cervix uteri made this method of dealing with the pedicle especially applicable in this particular instance. The patient is thirty-four years of age, and the operation was urgent on account of persistent hemorrhage and marked pressure symptoms.

Discussion.Dr. J. A. Larrabee: I would like to ask the reporter for what length of time this tumor had been developing?

Dr. L. S. McMurtry: The woman was thirty-four years of age, and according to the history obtained the tumor was first noticed three years ago. The patient has made a beautiful convalescence. I present the specimen on account of its morphology, and because of the difficulties that might be encountered in performing an operation in such cases by the bladder being impacted in the sulcus.

Tubercular Testis.Dr. W. O. Roberts: This patient is twenty-four years of age; his father and mother are living; father sixty-four, mother fifty-four; his grandfather on his father’s side died at the age of sixty-four of what was supposed to be consumption; his father’s twin brother died at the age of twenty, after an illness of eight months, of consumption; his mother’s family history is good.

This young man had gonorrhea seven years ago, with orchitis of both sides as a complication, the left testicle swelling first, then the right; the swelling lasted in each for about two weeks. Had gonorrhea again in November, 1896, and says again in December of the same year. At this time he noticed that his left testicle was getting hard in places and was swollen, but there was never any pain. The inflammatory process has never been very acute. However, he noticed after taking a horseback or bicycle ride the testicle would be somewhat tender. Had another attack of gonorrhea during the month of September of the present year, which he says lasted only two weeks, and during this attack the testicle was also affected.

He now has a swelling of the left testicle, and a hardness about it and in the epididymis, which I would like for the members to examine, expressing an opinion as to the nature of the trouble.

Discussion.Dr. J. M. Ray: I do not know that the ocular symptoms will throw any light upon the case. I remember that this young man came to me some time ago to have his eyes examined. He stated that he had been under the care of a prominent oculist in the South, and had been fitted with glasses. When I saw him he had sometrouble in the use of his glasses, and also complained of defective sight of one eye. Upon examination I found a spot of atrophy of the choroid, showing the location of a former acute choroidal disease, and there was considerable diminution in acuteness of vision in that eye, with a defect in refraction in the other eye. Under mydriatics I fitted him with glasses, since which time he has been perfectly comfortable so far as his eyes are concerned.

He states that he remembers I said something to him at that time about tubercular disease, after looking into his eyes, but I have forgotten the circumstance; I only remember that I found choroidal disease.

Dr. J. A. Larrabee: Of course we are all led somewhat by the diathetic history of our cases. Chronic inflammations tend to take on the part of the diathesis. I did not understand the reporter to say that any test had been made, by withdrawal of some of the fluid or otherwise, to determine the exact nature of the condition. I desire to say, however, that if this were my testicle I would have it removed. I believe that would be the safest plan. An absolutely positive diagnosis would be difficult to make without a microscopical examination for the tubercle bacillus, but I can not help feeling prejudiced in that direction.

Dr. J. L. Howard: I agree with Dr. Larrabee as to what should be done with this testicle; it should come out. I, too, think it tubercular, although in all probability the gonorrhea is a factor in the case in stimulating the growth of the testicle. I do not know that a microscopical examination would give us much light upon the subject; in fact I would not wait for that, I would simply remove the testicle at once.

Dr. Wm. Bailey: The question is not by any means settled as to the exact nature of the disease in the case before us, whether the patient, having had repeated attacks of gonorrhea, has not also been so unfortunate as to have syphilis. With a tuberculous history of course a tuberculous condition of the testicle seems plausible; but inasmuch as tuberculous disease of the testicle may remain for a long time possibly without great danger in affecting the patient otherwise, and knowing the changes that take place in the testicle from repeated attacks of gonorrhea, orchitis, etc., I believe if it were mine I would be disposed to keep it for a while, particularly as the other testicle seems to be somewhat atrophied, with this one of pretty good size. I think I would keep the larger one.

Dr. T. S. Bullock: I am inclined very much to agree in the opinion expressed by Dr. Bailey. I have frequently seen, after repeated attacks of gonorrhea, a testicle that had become enlarged, without any pain. The testicle in this case appears to be perfectly smooth, and in view of the fact that tubercular disease of this organ may exist for a long time without affecting the general system, I should certainly keep the testicle until my general health began to show some evidence of declination.

Dr. F. C. Wilson: The question is a very difficult one to decide. There is one feature of the case that has not been sufficiently emphasized, and that is the probable damage to the testicle itself by the repeated attacks of gonorrhea. We know that the use of the testicle, so far as any procreative uses may be concerned, has probably been abrogated by these repeated attacks of gonorrhea, and with this view of the case the question of removal of the testicle by surgical means would be simplified; and it seems to me with the tuberculous history, if the question could be decided even approximately, or even probably, that it is tubercular, then it had better be removed. But it seems to me I would first make every effort to solve the question, even aspirating or removing a small part of the tissue so as to be able to make a microscopical examination, and in that way possibly throw some light on the subject.

Dr. W. O. Roberts: It strikes me that this is tubercular, although it may have been, as Dr. Howard says, excited by gonorrhea. The condition feels to me nodulated and not smooth, and the disease appears to be located chiefly if not entirely in the epididymis, and I think the testicle should be removed. Whether it is tuberculous or not the usefulness of the organ is destroyed, and I think it ought to come out if it is tuberculous, especially because the other testicle will become involved. So far as the cosmetic appearance is concerned, if that is a feature in the case, we could insert a celluloid testicle. I believe if the affected testicle is not removed, granting the diagnosis of tuberculosis to be correct, that the other testicle will surely become involved.

Dr. Turner Anderson: It is seldom that we have obstetric matters presented to this society. I have thought perhaps a case I recently attended might be of some interest. We are aware that the umbilical cord is frequently found encircling the neck of the child. I delivereda child four days ago in which the cord was wrapped around the neck twice, then branched off under the arm, encircling the arm again at its dorsal surface, then across again, branching over the back. You may better understand the condition when I say that the cord came up from its attachment at the umbilicus, encircling the neck twice, branching over and under the axilla, around the arm, thence to its attachment to the placenta. The woman was a primipara. As soon as the head was delivered I detected that the cord was wrapped around the neck. I made an effort to find the part that led to the placenta. The cord was found pulseless, and I was in some doubt as to whether it had been so long encircling the neck as to have produced death of the child. Just as the body of the child was being extruded the cord snapped, tearing off fortunately from its placental attachment. The child was delivered and after a little effort was easily resuscitated. The pressure was so great, the traction upon the cord was so decided, as to leave a white line across the back of the child. There was a white mark around the neck, across the clavicle, around the arm and over the back of the child which did not disappear for some time afterward.

The proper line of practice, I take it, in those cases where the cord is around the neck of the child, is to first determine whether the cord is still pulsating. If pulsating, we are justified in being a little more tardy in our efforts to deliver the shoulders and release the child. If possible we would of course draw down the cord and release it from the neck of the child in this way; but in those cases where we are confronted with the cord wrapped tightly around the neck of the child, especially in the primipara, where the length of time which will be consumed in delivery is uncertain, the line of practice I believe in should be prompt delivery or division of the cord. As a rule when we are confronted with a condition of this kind we can meet it satisfactorily by a little delay and by holding the head of the child well up against the vulva while the shoulders are being extruded. As the releasing pain occurs and the shoulders and body are extruded, you can usually by pressing the head well up prevent undue traction on the placenta and any accident which might follow rapid delivery and undue traction upon the cord. This was a case in which there was spontaneous rupture of the cord; it tore away entirely by the uterine effort. This accident had no influence upon delivery of the placenta; it came away promptly. It was evidently not torn loose from its attachment, and there was no hemorrhage.

Discussion.Dr. J. A. Larrabee: The case is not only interesting, but also somewhat unique as far as I am aware. We are all familiar with the double wrapped cord, but in this case the acrobatic movements of the child must have been considerable, in utero, to have produced the condition described by Dr. Anderson; the child had evidently been engaged in jumping the rope for some time. When the cord is wrapped around the neck of the child as described, I think the best plan is to expedite delivery. Of course in the primipara we must not be in too great a hurry, we must utilize melting or crowning pressure to prevent injury, but the management of these cases I think is entirely that of dystocia, and powerful external pressure upon the fundus of the uterus, bringing it down as low as possible, is the proper plan of expedition. In the case reported, however, no amount of external pressure would have accomplished any thing; fortunately the snapping of the cord enabled the doctor to deliver and resuscitate the child, which is about the only thing that could have been done. In this case it would have been almost impossible to have divided the cord. Aside from the anomaly of the case, which is worthy of especial mention, I do not know of any proceeding which would have been equal to that which was followed. It is a little strange that the placental attachment did not give way; if this had been true, if there had been a separation of the uterine attachment of the placenta, then we would have expected the placenta to have been expelled with the child instead of a rupture of the umbilical cord.

Dr. J. L. Howard: I would like to ask Dr. Anderson if usually, when the cord is wrapped around the neck of the child, the cord is not an abnormally long one? I have had this accident happen twice in my experience, but no trouble resulted because of the abnormal length of the cord in each instance.

Dr. J. G. Cecil: This is an accident which as we know happens frequently, as well as many other anomalous things in connection with the umbilical cord. I would have been disposed, if the labor had been delayed in this case, that is, the final delivery of the child, more than four or five minutes, to have severed the cord, fearing that it might have had something to do with the delay. If there was no pulsation in the cord, there would have been little risk in cutting and not tying it; then there would have been no further delay to the delivery; there would have been no danger from hemorrhage, from premature separation of the placenta, or danger from inversion of the uterus. However,as the case turned out so well under the management that was adopted, it does not become us to criticise that management, because the successful issue proves the wisdom of the plan followed.

I have once or twice encountered some delay in expulsion of the child by reason of a short cord wound around the neck. I have never seen one so displayed around the shoulder as in the case reported by Dr. Anderson. I remember to have seen one case, however, in which there was a knot tied in the cord, and tied so tightly that it shut off the circulation and resulted in death of the child, and also complete atrophy of the cord between the knot and the navel end. This was a very interesting case, and was reported to the Louisville Clinical Society three or four years ago by Dr. Peter Guntermann; it was one of the most interesting cases of accidents to the cord that I have ever seen. How the knot was tied so tightly in the cord can not well be explained; knots in the umbilical cord are not very unusual, but it is unusual to see one tied so tightly that the circulation is shut off thereby. It was thought, I believe, by the reporter on that occasion that the accident was due to a fall which the mother sustained just before the delivery, which was premature.

Dr. Wm. Bailey: Nothing in the management of the case reported by Dr. Anderson can be criticised by me. I am inclined to think that under no circumstances was pressure made on the cord sufficient to interrupt the circulation until after the head of the child was delivered. Then it became a question as to the proper management. I believe it would have been better to have cut the cord, as it might have lessened the difficulty of delivery, and that there would have been no harm done to the child in this case, because there was no pulsation in the cord. The doctor had all the time for this delivery that would have been allowed him if he had a breech presentation with the head making pressure upon the cord, and ordinarily he would deliver such a case in from five to seven minutes, and that would give a chance for resuscitation of the child just as in the case of drowning. The child can be deprived of circulation through the cord, in an accident like this, as long a time as a person can be submitted to water, or drowned, and be resuscitated. I have seen but one case in which there was a rupture of the cord during delivery. I saw one exceedingly short cord, in which delivery of the child ruptured the cord; it was not around the neck, it was simply too short for the child to be delivered without detaching the placenta; just as the child was delivered the cord wasspontaneously severed at the umbilicus, simply allowing me a sufficient amount to be caught with the fingers and held until a ligature could be applied. I do not remember the exact length of the cord, but it was so short that it was not possible to deliver the child without either breaking the cord or detaching the placenta. The cord ruptured spontaneously, and there was no further accident or trouble.

I believe if Dr. Anderson had to attend another case under exactly the same circumstances he would prefer to cut the cord rather than to break it off at the placental attachment. Inasmuch as he did not cut the cord and the child was successfully delivered, and also as there was no trouble in delivering the placenta, of course it makes no difference; but I always like to have the cord attached to the placenta so that if it becomes necessary to go after the placenta, in case of retention for instance, I can have the cord as a guide. In Dr. Anderson’s case there was no possible advantage in having the cord intact; as it was pulseless, no injury could have been done the child by cutting the cord before completing the delivery, and by cutting the cord as soon as it was found that it encircled the neck, all possible difficulties as far as the cord preventing delivery was concerned would have been removed.

Dr. T. S. Bullock: I am very much interested in this case; I have never seen one exactly like it. The greatest danger in this particular instance was that alluded to by Dr. Cecil, viz., producing inversion of the uterus. I think Dr. Anderson managed the case in the proper manner, and by his method of expression the only possible danger was inversion of the uterus.

I have only seen one instance of dystocia from short cord; that was a case in which the cord was the shortest I ever saw, and was wrapped around the neck, where it was necessary in order to deliver the child to cut the cord after tying it and then employ instruments, the cord being so short that with each uterine action you could feel the cupping of the uterus from tension on the cord.

I think there would be less danger from premature separation of the placenta than from inversion of the uterus. In the case Dr. Anderson has reported the danger to the child from compression of the cord was obviated by prompt delivery.

Dr. J. A. Larrabee: Will not Dr. Bullock tell us whether the case he refers to, where he could feel a descending or cupping of the uterus by the expulsive efforts, was a primipara?

Dr. T. S. Bullock: The woman was a primipara; the cord was very short, it was tied and severed, then the delivery completed with forceps. I would like to ask the gentleman whether, in those cases where they have employed Crede’s method of delivering the placenta, they have noted a cupping of the uterus from efforts to extrude the afterbirth?

Dr. J. A. Larrabee: I have occasionally noticed cupping of the uterus under those circumstances.

Dr. F. C. Simpson: I remember a certain practitioner in this city several years ago made the statement that he seldom tied the cord after cutting it; that he did not see any necessity of tying the cord. If this is true, then there would certainly be no danger in severing the cord in cases such as Dr. Anderson has reported, and it would not even be necessary to tie it until after the delivery had been completed.

Dr. Wm. Bailey: I want Dr. Anderson to speak to one point in particular in closing the discussion, viz., would there not be great danger if the placenta was separated at a time when the child was still partly in the uterus?

Dr. F. C. Wilson: The only point I wish to bring out in connection with the case is the possibility of detecting the fact that the cord is around the neck of the child before delivery, and being on our guard for it. Encircling of the cord around the neck of the child ought to give rise to a funic bruit. You can hear very plainly a funic bruit, a bruit which is synchronous with the fetal heart sounds. Where this can be detected at a point where we know the neck of the child lies, it indicates to us that the chord is around the neck.

There are certain other circumstances under which we may also detect a bruit: For instance, the one mentioned by Dr. Cecil, where the cord was tied into a hard knot. I have met with several such cases in my practice, and a bruit can be produced in this way, but at a different place from the location of the neck, and it is a permanent bruit; a bruit that is heard all the time. Where that is the case, of course it indicates that there is some permanent obstruction of the cord, and the likelihood is that it is due to a knot tied in the cord. We know that sometimes the cord slips over the neck, and then the child’s body slips through the cord, thus making a perfect knot; it then may be drawn tighter and tighter, finally producing considerable obstruction. If the bruit that is heard is evanescent, heard sometimes when you are listening and not at others, that indicates simply a temporarypressure upon the cord which may produce a bruit that is fetal in its rhythm, at the same time it is heard occasionally only. Where the cord encircles the neck and is drawn tightly it is apt to give rise to a bruit that is more or less permanent, and always heard at a point where we know from other methods of examination that the neck of the child is located. Where this occurs we ought to be on the lookout and prepared to find the cord encircling the child’s neck, and ought to endeavor to release it in the first place, and where we are unable to do that, then the question of severing the cord will come up. The cord being pulseless in the case reported by Dr. Anderson would have simplified that question very materially. The cutting of a cord that is not pulsating is an easy thing and not at all dangerous. Even where the cord is pulsating I have cut it repeatedly without even attempting to tie it, simply holding one end—of course you have to make a guess as to which end is attached to the child. You can not always tell that, but you can easily see from the continued bleeding or pulsating whether you have the proper end or not, and by simply holding that between the fingers the delivery can be expedited, and then the cord can be tied immediately afterward. Where the cord is pulseless there would be no danger in severing it and leaving it untied and even unheld. I have time and again, after delivery of the child, cut the cord and not tied it, but always waiting till pulsation had ceased. I think there is no danger in doing this. If a cord is cut after it ceases to pulsate and does not bleed by the time the child is washed and ready to be dressed, there will be no hemorrhage from it afterward.

Dr. Turner Anderson: Referring to the point made by Dr. Howard, I believe, whenever the umbilical cord presents anomalies as illustrated by the case reported, that it is as a rule abnormally long. The cord in this case was abnormally long.

Dr. Larrabee made a point to which considerable importance should be attached, viz., that it would not have been an easy matter to have divided the cord in this case. I think practically he presents the case exactly right. When a cord encircles the child’s neck twice, then branches off and goes under the arm, then branches off over the back, it presses the neck so tightly and the conditions are such that it would be a very difficult matter to get one’s finger beneath the cord at the neck and divide it. It is not such an easy matter to sever a cord under these circumstances as one might suppose. I believe the majority of obstetricians content themselves, when they find the cord isencircling the neck, by simply making an effort to stimulate uterine contraction, and to deliver the child as rapidly as is consistent with safety to the mother, and while so doing take the precaution to support the head, to hold it up well against the vulva and prevent undue traction on the placenta.

It is seldom that we fail to resuscitate a child born under these circumstances. The cord as a rule is not encircling the child so tightly so as to prevent our ability to resuscitate it.

Dr. Bailey has correctly stated that arrest of pulsation in the cord does not occur until after delivery of the head, and we have a limited time then to stimulate uterine action and to disengage the body of the child and release the cord from the neck. Contraction and arrest of pulsation of the cord do not occur prior to that time as a rule. I can conceive it possible that it might do so, but as soon as the head is delivered, contraction then is so great that unless the cord is very long there is an arrest of pulsation and the danger commences. Fortunately we have recourse to stimulating uterine action, and have a chance to deliver the child in the manner I have suggested with sufficient promptness.

I am satisfied Drs. Bailey and Bullock recognize all the dangers of premature separation of the placenta in an uncontracting uterus. In the primipara I can not believe that a slight cupping of the uterus, or the premature separation of the afterbirth, would be a matter of any very great moment. We are all agreed as to the dangers which may occur from separation of the normally attached afterbirth prematurely in the absence of uterine action.

In the primipara we know how very closely the perineum, unless it is lacerated, hugs the neck of the child, and to isolate and cut the cord under such circumstances is a very difficult matter. I do not attach much importance to not cutting the cord, although if I could feel it around the neck of the child and could sever it I would not hesitate to do so.

Protrusion of the Rectum.Dr. W. O. Roberts: To-day at my clinic at the University of Louisville a man presented himself complaining of hemorrhoids. I put him on the table on his back, drew his legs up to make an examination, and he strained slightly, had an action from the bowel, and passed out about four inches of his rectum. After examining it carefully to see whether or not there were any hemorrhoidalmasses about it, or a tumor of any kind, I started to get some vaseline to assist in replacing his rectum, when he drew it back himself as though he had a string fastened to it. He did not touch it, but simply drew it back. I turned the table about so the class could see the prolapsed rectum, and he shot the rectum out and drew it back four or five times. It is a very peculiar and unique condition to me, and I would like to inquire if the members have ever encountered a condition of the kind in their practice.

Discussion.Dr. J. M. Williams: This is undoubtedly a case of prolapse of the rectum with a lax condition of the connective tissue. It may be from continually coming down, and I have no doubt that the bowel comes down after each defecation; there is some kind of an action by which the patient controls the rectum. It may be that contraction of the sphincter muscle starts the rectum upward, and then it simply follows its course. I can offer no other explanation of the condition. Certainly if the bowel comes out four inches there would be considerable tension upon the mesenteric attachment. It seems entirely possible that this phenomenon could be influenced and controlled by the diaphragm and abdominal muscles, and this may be the solution of this unique case. I have never seen a case of this kind.

Epileptiform Seizures in an Infant Aged Ten Months.Dr. J. A. Larrabee: I have been considerably interested and I may say annoyed by a case that has been under my care recently. It is in a family which is decidedly neurotic, and in which there is possibly, without history or committal, a taint of specific disease. It is not very unusual to have epileptic manifestations in children at an early age, but the case I desire to report is, I think, somewhat anomalous. There have been, for a period of fourteen days, eleven petit mal seizures in every twenty-four hours in an infant ten months old. These seizures have not apparently concerned or involved the integrity of the child in any respect. The intellectual functions, so far as intelligence is written upon the face of an infant, do not seem to have been affected. The infant is just as well apparently as if it did not have every hour or so an epileptic convulsion. The attacks present the usual phenomena of true epilepsy. The duration of these attacks is from one to two minutes, accompanied by the usual phenomena, flushing, unconsciousness which is perfect, the attack then passes off and the infant is well again.

This condition of affairs having been going on for a period of fourteen days in this case without any impairment in the general health of the infant, or in its nutrition, certainly points, I think, to a specific cause. I have often had cases, not quite so remarkable as this, where the tendency has been neurotic or specific in character, which improved under appropriate treatment; but this case has resisted all treatment, even specific treatment by the inunction of mercurials and the administration of the iodides.

The condition is still in progress, the infant having eleven seizures in every twenty-four hours, not exceeding this number and not falling short. I have witnessed several of them, and they are perfectly characteristic of epilepsy. An older child in the family passed through an ordeal of paroxysms, was unable to walk for three years, and this child has been restored under treatment, and that treatment has been antisyphilitic. One child in the family has been lost, and the history is that it died from scorbutus. The family is decidedly neurotic, and I suspect a specific taint.

The case has been exceedingly interesting and even annoying to me because I have been unable to make the slightest impression upon it by treatment in lessening the number or severity of the paroxysms. I am pursuing the same line of treatment that I did in the case of the older child which recovered, and believe I have sufficient ground for specific treatment, but so far it has not been productive of relief.

The peculiarity about the case is that the occurrence of these paroxysms has not so far interfered with the nutrition or the general health of the infant. In this respect I think the case is somewhat remarkable.

Discussion.Dr. T. S. Bullock: I would like to ask if Dr. Larrabee gave the bromides in the case he has reported.

Dr. T. H. Stucky: Have you tried the bromide of gold and arsenic?

Dr. J. M. Ray: In connection with Dr. Larrabee’s case I recall one that I saw several months ago in a child a little older than his which gave a peculiar history. The mother brought the child to me, the history being that the child complained of having something the matter with its ear. I examined the ear carefully. No inflammatory or other disease was present about the structures of the ear; hearing was perfect, and the drum membrane was intact. The child at this time was three years of age. The history that the mother gave mewas about as follows: The child had never complained of earache; she had never noticed any defect in hearing, but sometimes two or three times a day the child would apparently be interested in her toys or in something about the room, and all at once she would scream and run to her mother and say that the house was turning over, that there was a bug in her ear, etc. This would happen several times a day, and on several occasions the child had fallen over apparently unconscious, or in a state of partial unconsciousness.

After looking into the ear carefully and not finding any evidence of disease, I referred the case to the family physician, and in talking the matter over with him he suggested that these attacks were probably petit mal. He put the child upon bromide of gold and arsenic, and a prompt recovery resulted. The last I heard from the case the attacks were few in number, occurring at long intervals and slight in character, although at one time they occurred two or three times a day.

Dr. T. H. Stucky: I have seen several cases of epilepsy in children, but never saw one in a child so young as that reported by Dr. Larrabee. I have followed out the usual routine, giving bromides and other remedies with varying results; and later, following the suggestion of Dr. Buchman, of Fort Wayne, have tried combination mentioned by Dr. Ray, viz., the bromide of gold and arsenic. I believe the latter to be especially indicated and exceedingly serviceable where we have reason to suspect a taint, as mentioned by Dr. Larrabee, getting as we do the sedative influence of the bromide, the alterative influence of the gold, and also the well-known effects of the mercury contained in the combination.

I believe where anemia is very marked in these cases, and there is a feeble heart action, and we are fearful of the depressing effects of the bromides alone, that in the use of the bromide of strontium and gold we gain a decided advantage, getting as we do the sedative as well as the cardiac influence of the strontium salts. Dr. Marvin demonstrated this conclusively before this society in a statement made by him in regard to the action of strontium salts in digestive disturbances, especially those conditions characterized by marked flatulency. If this be true, and we have reason to believe it is, it appears to me that the bromide of strontium and gold would be even better than the bromide of gold and arsenic in cases such as Dr. Larrabee has reported.

Dr. J. A. Larrabee: The case is reported not to demonstrate any unusual manifestation of epilepsy, but on account of the exact regularity and periodicity of the seizures, and the age of the patient, coupledwith the fact that the treatment which seems to be indicated has not been followed by relief. In looking up the literature of the subject I find that cases of this character are usually attributed to a specific cause.

In answer to Dr. Bullock’s inquiry: I have used the bromides in this case without any effect whatever. Of course epilepsy in the child is nothing new, but this case presents some peculiarities. There is a decided neurotic tendency in the family, which may have some bearing upon the case. The child is going along having the number of seizures stated each day without any evidence of disturbance of nutrition or impairment of general health, which is rather remarkable. Some of the attacks are almost grand mal, most of them petit mal, and I am convinced that the trouble is due to specific taint.

The next move I make will be to put the child upon the bromide of gold and arsenic.

JOHN MASON WILLIAMS, M. D.,Secretary.

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