bronchial catarrh. This is also confirmed by the studies of M. Chentemesse, of the Hôpital St. Antoine, who affirms distinctly that there is no lessening of the bacilli, and that very marked relief has been afforded to asthmatic patients. Moreover, no evidence is forthcoming to show that sulphuretted hydrogen is poisonous to the tubercular bacillus. It is, so to speak, the natural gas of putrefaction, and without definite proof cannot be considered to be even probably inimical to low organic forms. Dr. James Henry Bemett has published in the British Medical Journal, December, 1886, a paper upon Bergeon's method of treatment, in which, however, he adds nothing to our knowledge of the subject, merely stating his own experience in a single case of asthma. In this city the method of treatment has been used in the Philadelphia Hospital in a large number of cases, especially in the wards of Dr. Bruen. A personal inspection of the result shows that the statements made by the French observers are correct, and there seems to be no doubt that under the treatment there is rapid alteration of some cases of phthisis for the better. In the Philadelphia Hospital the solution at first used contained five grains of the chloride of sodium and five grains of the sulphide of sodium, but at present the strength has been doubled, so that in the Wolffe's bottle, through which the carbonic acid passes, ten grains of each of the chemicals is put. Once charging of the Wolffe's bottle is made to suffice for a number of patients, each of whom receives at each treatment from three to five pints of carbonic acid. It will be seen at once that in this method the amount of sulphuretted hydrogen received by the patient is unknown and variable, and is very small. A personal inspection of the carbonic acid used showed that it is very impure, the odor indicating that it contains sulphurous acid. Chemical testing has shown that the gas coming from the Wolffe's bottle contains sulphuretted hydrogen, the odor of which is also distinctly present. The chloride of sodium in the solution would appear to be superfluous, the carbonic acid reacting directly with the sulphide of sodium. The following formula represents the probable change: NaS+CO2+H2O — NaCO, + H„S. Such is the evidence which I have been able to gather from the experience of others in regard to Bergeon's treatment, and it is sufficient to indicate that we are in the presence of a very important improvement of, or rather a very important addition to, medical therapeu = ease. tics. It is of vital importance to decide the mode in which the treatment acts. The experiments of Dujardin-Beaumetz show that the carbonic acid is not the active agent, and that the good achieved is produced by the sulphuretted hydrogen. Reasons already assigned are sufficient to make it improbable that the good achieved is the result of any parasiticidal influence. All clinical experience indicates that heredity is in the production of consumption a vastly more important factor than is any poison introduced into the body from without. Only a portion of the medical profession believes in the active contagiousness of phthisis, whilst the experience of any life insurance company affords a firm foundation for the belief in the heredity of the disIf the bacilli really are the exciting cause of phthisis, the susceptibility to their action must be a more important factor in the production of phthisis than are the bacilli themselves. There is at present, then, no proof that the sulphuretted hydrogen, when it does good in phthisis, acts by killing the bacilli, and there is still less proof that it in any way increases the direct resistive powers of the individual to the action of the bacilli. In some acute and chronic diseases of the skin, local applications of sulphur act with the most astonishing rapidity and effectiveness, and the thought naturally suggests itself that in Bergeon's treatment of consumption good is achieved by the action of the sulphuretted hydrogen upon the inflamed lung-tissue, or in other words, that the plan of treatment is simply a means of making an application of sulphur to the pulmonic mucous membrane and tissue. This thought is not merely of speculative interest, but also of practical importance, for it suggests that the method of treatment will prove of value not only in consumption but in various forms of chronic or subacute affections of the lungs. This is confirmed by what experience we have. Cases of asthma and pulmonic catarrhs have already been quoted in this article as having been published in the French journals, in which the remedy has proven of the greatest service. I saw in the Philadelphia Hospital one case of asthma with chronic catarrh and emphysema in which the administration of the rectal injections had been followed by the most pronounced relief. In another case, of catarrhal pneumonia with an enormous amount of purulent expectoration, and general symptoms so bad that a fatal prognosis had been given, the administration of the remedy was at once followed by rapid lessening and even cessation in the purulent secretion, and in a short time by convalescence. As an important illustrative case, I cite one from my own recent experience. Mrs. L., over 70 years of age, received a severe contusion of the side in a railway accident, which was followed by pleurisy, in turn followed by bronchial pneumonia, with an enormous expectoration. She has been under my care for nearly three months, and though often temporarily benefited by various remedies, had failed to properly respond to the most careful treatment that I could give her. The expectoration remained exceedingly profuse, amounting sometimes to a pint in the course of twenty-four hours, although very irregular. The general symptoms were very bad: sinking spells were frequent and alarming. I finally told the family that she would die, unless the gaseous injections would do something for her. Within forty-eight hours after the use of the gas, the expectoration notably decreased; the expression of the patient's face changed entirely, and at present writing, fifteen days after the use of the sulphuretted hydrogen, she is expectorating not one-sixth the quantity she did formerly, has regained the natural expression of her face and color of her skin, as well as her appetite, and a fair amount of strength, and seems to be convalescent. A notable A priori, there is no evident reason why this solution, if injected into the rectum in proper doses, should not exert all the influence upon the pulmonic tissue obtained by Bergeon's treatment. I have tried the solution thrown into the rectum, and found it free from any irritant action. The habitual use of injections two or three times a day is, however, very disagreeable to most patients, and the questions naturally arise, Is there any necessity of administering the drug by the bowels, and will not sulphuretted hydrogen water be taken without too much repugnance by the mouth and without nauseating? At the various sulphur springs large quantities of such water are habitually drunk by the patients. Led by such considerations, I have tried the sulphuretted hydrogen water in as many cases as I have been able to get, and so far, when properly given, it has been usually taken readily, and has not disagreed with the stomach. Some persons, however, will not tolerate it at all. The effects upon the disease have seemed to be entirely similar to those produced by the injections. At first a half-ounce, afterwards an ounce, of the saturated solution of the sulphuretted hydrogen should be placed in a tumbler, and two or three ounces of carbonic acid water be run into it from a highly-charged siphon, the whole being drunk while effervescing. This may be given three to five times a day, so that the patient will receive daily between a halfpint and a pint of the sulphuretted hydrogen gas. Injections of gas into the rectum produce in some persons more or less violent attacks of colic, especially if given at a time. when the food is well down in the intestinal tract. Thus, in the case of Mrs. L. the night According to Gay-Lussac and Thénard, injection caused so much pain that it could water at 52° Fahrenheit will absorb three not be borne, although the injection in the times its volume of sulphuretted hydrogen. morning was actually pleasant. The two To prepare this solution, the gas, previously methods of administration were then comwashed with water, is passed alternately bined, the gas injection being given in the through each of two bottles half filled with morning and the sulphuretted hydrogen water water; while it is being passed through one, in the afternoon and evening. Within the last the other is closed with the stopper and forty-eight hours, at Mrs. L.'s earnest request, shaken, to insure complete absorption; and the gas injections have been entirely abanthus the process is continued till the water is doned in favor of the exhibition by the mouth. completely saturated. One of the bottles is Of course the two methods are simply differthen completely filled with the liquid, and re-ent ways of accomplishing the same result, and fact in this case is that the injections of gas relieve in a few minutes the sense of suffocation and sinking the patient formerly felt in the mornings. The secretion of urine was sensibly increased. As tested on three occasions, the subnormal temperature rose 0.4° F. within the half-hour after the exhibition of the gas either by the mouth or rectum. One difficulty with Bergeon's method of treatment in private practice is the cumbersomeness of the apparatus and the skilled labor required for the preparation of the carbonic acid. A plan which would avoid this and reach the same result in regard to the lung-disease is certainly a desideratum. may be variously combined or substituted for one or another according to the peculiarities of the individual cases within the last day or two. It is a matter of the greatest importance to fix definitely the dose of sulphuretted hydrogen gas. With the method employed in the Philadelphia Hospital this cannot possibly be done. The solution employed in the Hôpital Cochin, whose formula is given in the first part of this article, seems to be superior to the solution of the chloride and the sulphide of sodium, in affording known quantities of sulphuretted hydrogen. Even with it, however, the chemical reactions are so slow that practically it is scarcely possible to decide how much of the gas is evolved in a brief time. The substitution of sulphuric for tartaric acid would largely obviate this. When the medicine is given by the mouth exact dosage is possible. In Mrs. L. five ounce-doses appeared to be too much. She is now taking three doses daily. In a recent number of the British Medical Journal it is stated that M. Morel affirmed before the Biological Society of Paris that the dose of the gas is twenty-five cubic centimetres. That it is not incapable of doing harm is shown by the experiments of M. Peyron, who injected into the rectum of a dog one hundred and fifty cubic centimetres of a saturated solution of sulphuretted hydrogen in two doses at intervals of three minutes. Symptoms of poisoning began to be manifested within two minutes, and death took place in ten minutes. Another dog died quickly after two injections of the same strength, given at intervals of twelve minutes, while two others, in whom only very small quantities of the gas, or large quantities very much diluted, had been injected, experienced only slight inconvenience, and rapidly recovered. Not long since, in the University Hospital in Philadelphia, about one quart of a mixture containing equal | quantities of carbonic acid and sulphuretted hydrogen were injected into the rectum of a patient; within three minutes the man was unconscious and apparently dying. The breathing-rate was one hundred per minute, and the respirations so shallow that they could scarcely be observed. The pulse at once became very rapid and feeble, and even imperceptible at the wrist, while a very marked odor of sulphuretted hydrogen appeared in the breath. Under treatment the symptoms all subsided in about fifteen minutes. The rapidity with which these symptoms developed and with which they subsided indicates that when the gas is thrown into the rectum its effect is very immediate and fugacious, and it is entirely possible that the more continuous influence of rectal injections of the aqueous solution of sulphuretted hydrogen may act better in pulmonic diseases than does the short influence of the gases now administered. Of course poisoning by overdoses of sulphuretted hydrogen is a no more valid objection to its proper use than is opium poisoning to the employment of opium. 1925 CHESTNUT ST., PHILADELPHIA, April 2, 1887. CUNEIFORM OSTEOTOMY FOR ANTERIOR I BY MILTON JOSIAH ROBERTS, M.D.† (Concluded from page 163.) CLINIC OF OCTOBER 26. THOUGHT it might be of interest to you to bring before you to-day the little colored boy upon whom we operated a week ago for the correction of anterior tibial and fibular curvatures. It is always well to know the history of a case subsequent to an operation in order to correctly judge of the value of the operation. An operation may at the time of its performance appear to be a very brilliant one, but in the light of subsequent events may take on an entirely different appearance. You will remember that we performed four cuneiform osteotomies upon this patient, requiring eight complete divisions of the bones of the leg. Fortunately for us, Dr. McNutt was able to provide a bed in the babies' ward for our patient, so that his subsequent condition could be carefully watched. Dr. Vinton, who has had charge of the patient since the operation, reports his condition as follows: October 19, after the operation, at 4.45 P.M., his temperature was 98, pulse 89, respiration 30. On October 20, at 4 P.M., his temperature reached 101°, but quickly began to fall. On the 22d inst., the third day after the operation, his temperature fell to normal, and has remained so ever since. There is no indication of any suppuration, the dressings re A Clinical Lecture delivered at the New York PostGraduate Medical School and Hospital, October 26 and December 18, 1886. † Professor of Orthopedic Surgery and Mechanical Therapeutics, Visiting Orthopedic Surgeon to the City Hospital on Randall's Island, Consulting Orthopedic Surgeon to the Woman's Hospital, Brooklyn, etc. Phonographically reported by J. J. Sullivan, M.D. maining perfectly dry and clean. He is now eating and sleeping well, and all his bodily functions seem to be normally performed. We will endeavor to keep this patient under observation, that you may note for yourselves the progress of the case. Now, with regard to the correction of anterior tibial curves. I know you will hear a great many physicians say it is a perfectly simple matter to overcome these deformities by means of operations performed with the chisel and mallet. I have yet to see, however, the report of any cases in which the the jars which are communicated to the bony framework by means of the repeated blows of the mallet upon the chisel are transmitted to. the central nervous system, and necessarily are the cause of more or less shock. I have known of more than one patient operated upon for tibial curvature with the chisel and mallet who has lost his life in consequence of the operation, and who, at the time of the operation, was in perfect health. Such disastrous results, however, are not as likely to find their way into medical literature as those of a more pleasing nature. deformity was so exaggerated as in this case where it has been completely rectified. You can readily appreciate this when you recall to mind the difficulties which the surgeon must necessarily encounter when he endeavors to remove a wedge-shaped piece from a bone by means of a chisel. At best it can only be accomplished in a bungling and unworkmanlike manner, for a chisel is not the tool with which to remove V-shaped pieces from any hard substance. In any of the mechanic arts a workman desiring to remove a V-shaped piece from any hard substance would never think of resorting to the use of a chisel. Then, again, CLINIC DECEMBER 18, 1886. I have again brought before you the little colored boy upon whom I operated about eight weeks ago, this time with the dressings removed. He has not had an untoward symptom since the operation, and union of the bones and soft parts has taken place without the formation of pus. As you see, when placed in the position in which he was originally photographed, the anterior deformity has been perfectly corrected. (See Fig. 1.) You will remember on the occasion of the operation I directed your attention to the fact that this child presented a double deformity, viz., anterior curvature of both tibiæ and both fibulæ, in conjunction with a slight degree of bowleg deformity. These deformities, the anterior and the lateral, it should be borne in mind, lie in two different planes. In the anterior deformity the right and left plane of the leg is distorted, while in the bow-leg deformity the mesial plane of the leg is distorted.* The anterior deformity of the leg-bones has been perfectly corrected. No attempt, however, was made to correct the bow-leg deformity at the time of the operation. When When placed upon his feet (see Fig. 2) you will FIG. 2. ways deterred me from the multiple cross division of long bones has been the fear of interfering with their nutrition. I am not at all satisfied, however, that it is not feasible to undertake such an operation, but until I have knowledge of its reliability from other sources, I shall not hazard such a procedure upon a living human being. It would be of great practical value to perform a series of experiments upon the lower animals in order to determine the limitations to multiple crosssections of the long bones. If it can be demonstrated, as a result of these experiments, that we can make a complete section of a long bone in two or more planes without interfering with its nutrition, nothing will be simpler than the straightening of long bones that are deformed in more than one plane. Experiments on living human beings should never be undertaken unless they are legitimate, and experiments only become legitimate when, by means of a rational line of thought, observation, or experimentation, the conclusion is reached that they are feasible. Thus reinforced, we feel confident of the justice of our undertaking, and experimentation then takes on the garb of legitimacy. What I propose to do in this case, however, Showing bow-leg deformity. readily appreciate the persistence of this deformity. And it is to a practical point connected with the correction of deformities lying in two planes to which I wish now to direct your attention. Had I deemed it perfectly safe to have divided the bones of the tibia and fibulæ just distal to their proximal epiphyses, on the occasion of the operation for the correction of the anterior deformity, I could have readily corrected the bow-leg deformity, and he would now have been presented to you with perfectly straight legs. It has not, however, been shown, so far as I am aware, that it is perfectly safe to endeavor to straighten at one sitting a bone which is deformed in more than one plane. The thought which has al * Anatomical Geometry and Toponomy, etc. Bruce's bow-leg apparatus. is not now to submit the patient to a second operation for the correction of his bow-leg deformity, but to correct this by mechanical means. For this purpose I shall make use of an extremely simple form of apparatus, the invention of Dr. Charles E. Bruce, one of the assistants to the orthopedic chair in this in |