to relieve the system of retained urinary excreta by acting on the skin and bowels, and to quiet nervous excitability. Croton oil, jaborandi, or the hydrochlorate of pilocarpine, or elaterium, even blood-letting, and the hot-air bath or pack, and chloral to calm the nerves, represent the chief remedial agents under this head. On the other hand, opium or morphine are regarded as the remedies to be chiefly relied upon. The infusion of digitalis is to be given at the same time in 2-ounce doses every three hours until its specific effects are produced. It seems to me that all of these remedies may have their use in certain cases, but there is a feeling among many physicians that opium and pilocarpine should be employed with care. Dry cups to the chest are one of the best remedies in pulmonary oedema, and when the chest is covered with them prompt relief generally follows. For obstinate anasarca incisions into the cellular tissue are sometimes practised with much benefit, relieving swelling and promoting diuresis. It is advisable to bathe the incisions with an antiseptic lotion.

It is difficult to classify the principal remedies in use in Bright's diseases, since many fulfil several functions, but the following is an attempted approximation to indicate their chief effects:

Indirect Diuretics.- Digitalis, dry cups, cannabis indica (when hæmaturia is present), caffeine.

Direct Diuretics.-Potassæ bitart., scoparius, water and the alkaline spring-waters, tannate of sodium (gr. xx to xxx), apocynum cannabinum.

Diaphoretics.-Hot-air bath, the pack, warm baths, jaborandi, pilocarpine.

with complications, and many cases require most careful watching. The treatment of them is partly that of the basic disease itself, and besides, the general remedies indicated for the various intercurrent maladies. Headache, nausea, gastritis, cardiac hypertrophy, serous inflammations, pneumonia, may all interfere with the comfort or partial health of the patient, and aggravate his sufferings or shorten his disease. They are more or less susceptible of alleviation.

In conclusion, the treatment of Bright's diseases, as of all others, is based upon our knowledge of their nature, and we are struck with the apparent deception connected with renal semeiology. It is not severe pain in the organ itself, but a blurred vision, an œdematous membranum tympani, hemicrania, a puffy eyelid, slight syncope, apparent dyspepsia, nervousness, slight enuresis, which are the signals of a distant morbid process. Often such symptoms are treated in vain, because the real disease is overlooked. It is well in making our diagnosis of any disease to bear these renal peculiarities always in mind. Then our treatment of diseases which seem to have no connection with renal disturbances will, more often than we would suppose, be directed to improving the functions of a diseased kidney.

ON LIGATION OF THE POPLITEAL
ARTERY IN ELEPHANTIASIS
OF THE LEG.

BY EMMANUEL DAGNINO, A.M., M.D., CARACAS, VENEZUELA.*

nine.

Medicines which diminish Albumen.-Gallic acid, hydrastis, iron, chloride of gold, fuchsin, and rosanilin.

Promoters of Tissue Metamorphosis (Metabelists).-Hyd. bichlorid., chloride of gold and sodium, potassii iodid., liq. potassæ (largely diluted).

Antispasmodics.-Chloral hydrate, opium, potassii bromid., hyd. c. creta (to prevent nausea).

Cathartics.-Elaterium and croton oil (hydragogue), euonymus (cholagogue), podophyllin (cholagogue), pulvis purgans, hyd. c. creta (laxative, Satterthwaite), 3 to 5 grs. daily in cirrhotic kidney.

The course of Bright's diseases is beset

I.

'S there any etiological difference between the elephantiasis of the Greeks and that of the Arabians? Though in the actual state of science the general and constitutional causes of the one and of the other disease cannot be ascertained in a precise manner, perhaps it may be assumed that though both classes of elephantiasis, presenting the hypergenesis and proliferation of certain anatomical elements, cause the hypertrophy of some tissues, still they are not the same disease, the same nosological entity. Tuberculous leprosy (in all its varieties) is undoubtedly

united to certain alterations of the spinal

marrow.

* Professor of Pathology in the University of Venezuela, Corresponding Editor of the Annual of the Universal Medical Sciences, etc.

The experiments of Vulpian on the spinal cord, producing affections of the skin somewhat similar to the cutaneous manifestations of general elephantiasis, command reserve in regard to the diagnosis of some cases, and bring to the mind the conviction that general elephantiasis is undoubtedly allied to spinal alterations. The anesthesia and hyperæsthesia, the atrophy and hypertrophy of a few tissues, that form the anatomical and pathological symptomatology of patients suffering from elephantiasis, are signs linked to the alterations of the nerves that animate and nourish those parts. This view, based on physiology and experimental physiology, that attributes to the spinal marrow and to the great sympathetic nerve so important and essential a part in that terrible illness, not thoroughly studied until now, would satisfactorily explain the influence of syphilis in producing tuberculous leprosy; for though it is true that in many cases, as I have been able to ascertain, the evident cause of that disease is the sudden cooling of the body when sweating, also it is true that in others, and very commonly, syphilis is the only cause to which I have been able to ascribe elephantiasis, without doubting in the least that, respecting others, contagion and hereditary disposition ought to be taken into consideration.

And now, is not visceral syphilis clearly demonstrated? It has also been proved that there are various syphilitic manifestations (sclerosis, sclerosis with patches and alterations of the gray and white nerve substances in different parts), bringing, as a consequence, functional and organic disorders, to be seen in the groups of symptoms characteristic of elephantiasis. In the history of many patients syphilis plays an important part. My opinion is that syphilis can bring about elephantiasis, just as suppression of sweat by water is a very frequent cause of it; in fact, probably the most common in warm climates. Among many cases I shall relate a very recent

one:

N. N., a native of San Rafael, applied for treatment in the Hospital of the Casa de Beneficencia. The physician, Dr. Francisco Suarez, desired me to examine this patient, whose only sickness was blindness. He was a man in good health, of about 45 years, married, with several children, all healthy. For about two years the patient could not apply himself to work; he was a laborer. He had two capsulo-lenticular cataracts, and his eyes were in a satisfactory state. There being neither

pains, nor synechia, nor anything that might point out an unfavorable prognosis, I advised the operation of lineal extraction. Both eyes were equally capable of being operated on. I performed both operations, with the interval of ten days, in the presence of Dr. Suarez, the physician of the hospital, Dr. C. L. Sanchez, Dr. Giro, a Cuban, and the assistants of the same hospital. Both operations had the most brilliant success, and the patient left the place with his sight in an excellent state, and not one of the physicians could observe in him the least morbid appearance. A year and a half ago a man, considered to be suffering from elephantiasis, went to my clinic of the Hospital of Chiquinquira. Trying to form a complete anamnesis by a methodical inquiry, I found that he had never suffered from syphilis, and that the only serious thing he had experienced during his life was an operation that I had performed. Then I knew that the unfortunate man I had before me was the same one whose cataracts I had extracted, and who was then enjoying perfect sight. Far better would it have been for him never to have recovered his sight; for as soon as he left the hospital he had gone to his native village, and applied himself to mining to earn his family's livelihood; and being once busily occupied in his labor, all in a sweat and shirtless, received the rain that fell on his bare back. From that very day he felt unwell, and, little by little, supervened the symptoms and signs of this dis

ease.

After about three years and a half he was affected with elephantiasis, and being denounced as such to the authorities of the place, the board of health commissioned me to examine him. The unfortunate man was declared by the municipal physicians and myself to be affected with elephantiasis, and was consequently sent to the celebrated Lazaret of the island of Martires, in the lake.

I might mention similar cases. The same thing would happen with syphilis and contagion. Inheritance has a great influence in many cases of tubercular diathesis, for some members of families have been seen to be affected with pulmonary tubercles, others with elephantiasis, which in many of those affected with this complaint, above all in the atrophic form, often ends with pulmonary tubercular phthisis.

II.

The same causes cannot be assigned to partial or local elephantiasis, for it seems that the disease is only to be found in determined

localities, which would tend to prove that the causes are limited. It is impossible to extend one's self in a simple note, wishing only to record a few facts and observations that are not to be overlooked, as nothing ought to be despised that regards the sciences of observation and experimentation. In the locality of Maracaibo (the city, its environs, and adjacent villages) elephantiasis is very common; a proof of it being that the greatest part of those that are in the Lazaret come thence; and there are more than one hundred, besides those that pass unnoticed. Why does the same thing not happen with partial elephantiasis in the arms and legs? I have seen and treated several cases, but none from Maricaibo nor its adjacent villages, but from the Cordillera, the Distrito Sucre (Seccion Zuelia), inhabited by colored people, and a case, if I mistake not, from Coro. I have seen partial elephantiasis of other organs in natives of Maracaibo (one single case), but none of the upper or lower limbs. The first and only case I saw was in the Hospital of Santa Ana, I being an externe, and one of my beloved teachers, Dr. Vicente Linarez, being physician of said hospital. The patient being a tall, lusty metis, having his left lower limb hypertrophied to such an extent that it resembled a big stump (pilon), an elephant leg. No treatment was successful, and the poor man left the hospital without my knowing whither he went, but of course feeling himself always as if he were bound to the earth by that enormous leg, that weighed perhaps as much as the rest of his body.

In 1867 a colored man from Sucre (then Gibraltar) made his appearance in the hospital under my charge, having his left upper limb affected with elephantiasis up to the third part of the arm. He could not support it, as he expressed himself, and begged for amputation as soon as possible, to get rid of that torment. I employed the iodides, intus et extra, arsenical preparations, compressive bandages, till I was able to prevail upon him to abandon the idea of having his limb amputated. He was a planter, always in the wet, but never had been affected with syphilis. I did not comply with the patient's wish, fearing that the operation would prove fatal. He then asked for his dismissal, which I granted. Several days after, I was invited by Dr. Francisco Suarez to go to the hospital under his direction to perform the amputation of an arm. At one o'clock P.M. I presented myself, with my assistants, internes of the hospital under my charge, Maniero and

Ramirez, and we three were surprised to meet with the same individual that had come to another hospital to demand the amputation I had refused. I frankly manifested my opinion to my friend and colleague; but he considered himself authorized to perform the operation, inasmuch as no remedy could free the desperate man from that burdensome arm. Declining for my part all responsibility, I performed the operation in the upper third, expecting to find there the tissues uninjured. I must say that the vessels were in perfectly good state, the ligatures were easily applied, the dressing according to the ordinary method employed at that time, and, though we all feared that the process of cicatrization would be unsuccessful, the healing was rapid and complete. The patient left the hospital and I lost sight of him.

About six or eight months after, the same person applied to the Hospital of Chiquinquira, where he was admitted. In the visit I met again with that unfortunate man, whose hopes had so soon vanished away, having then his left lower limb affected with elephantiasis. What had produced that terrible repullulation of the fatal disease? I do not know, but I noted down that fact, which I did not consider extraneous to the annals of science. I believe I have read something similar in an article of the Medical Dictionary in fifteen volumes, published from 1830 to 1835, and perhaps owing to that reminiscence I refused to accept the amputation. The general condition of the individual was bad: pallid, worn out, strengthless, destitute of digestive powers, in a diathesic state, having a lower limb enormously hypertrophied, with the characteristic aspect of elephantiasis; and lingering with a vespertine fever, died a few days after, not in the hospital, but in a village.

After I performed the amputation of the arm, and being convinced that the tissues of the stump were uninjured, excepting some connective tissue about the sheath that was hypertrophied, we proceeded to the dressing of the wound, and afterwards applied ourselves to the methodical inspection of the mutilated limb. In the first place we dissected the sheath, and found the artery and veins uninjured as far as we could follow them ; but the lymphatic vessels were hypertrophied, soft to the touch and the scalpel, in all the length of the diseased limb, having a yellowish color, and in some parts rather pale gray. After the inspection, we concluded that the hypertrophied state called partial or local elephantiasis had its seat in the white vascular or lym

phatic tissue. Is this hypertrophic disease a chronic lymphangitis? Is there any foreign element to the organism related to the places where this complaint is frequent (the Antilles)? Is it a parasitic disease that baffles all the therapeutical agents? I cannot say, and only wish to express my suspicions and doubts to scientific men; but whatever may be the extraneous cause, the anatomical tissue on which it acts is the tissue of the lymphatics.

How should we explain the metastasis of which I have spoken in this particular case? It is not probable that when the arm was amputated a germ of the disease should exist in the left lower limb; for, in the scrupulous inspection made over the body of the patient, none of the physicians observed the least thing that might point out the reappearance of the complaint in the left lower limb. This is certainly one of so many organic phenomena that are not to be scientifically explained. The mumps that descend to the pubic region, the phlegmon that appears sometimes in the calf of the leg in consequence of internal urethrotomy, the reappearance of some eruptions, as daily seen in medical practice, are positive phenomena not satisfactorily explained; but that fact has so far impressed my mind as to make me suspect that local elephantiasis may be allied to a general alteration of the liquids of the organism. In the second appearance of the disease, that man was not the same physiological subject; for in the first he was a healthy-looking man, excepting his burdensome arm, but in the second he had a sickly aspect and a deep alteration of the functions of nutrition. He was in a cachectic state. What had caused that change? I cannot tell, but some morbid element acted on that organism, infecting it, besides inducing hypertrophy of the left lower limb. So much darkness is to be dispelled only by gathering many similar facts and thoroughly studying them.

I entertained the conviction that this sickness was incurable, as the trial of the principal therapeutical agents, and even the amputation, had been altogether unsuccessful; but in 1873 I read in the Bulletin de Thérapeutique statistical information in regard to partial elephantiasis, in which the eminent observer proved that the ligation of the main artery in the diseased limb produced absolute amelioration, even the complete cure, according to several cases he had gathered.

The said paper mentioned about thirty successful cases of operation, and, on reading

those observations, I determined on trying the ligature in the first case that might present itself. The Casa de Beneficencia afforded it me,-a white, middle-aged man, from the Cordillera, who applied to that asylum on account of an enormous swelling of his left foot and leg. The physician of the hospital, Dr. Francisco Suarez, diagnosticated partial elephantiasis, and was perfectly right in so doing, for the progress, the aspect, and all the circumstances of the case rendered this diagnosis evident, even to those destitute of experience. That patient was not only a subject of curiosity to the young students, internes and externes, but also a focus of infection to the hall where he had been placed, and a torment on account of the peculiar stench that came from him. The hypertrophy of the skin and of the subcutaneous tissue was such that the foot and leg were largely and deeply fissured, discharging a kind of yellowish serous pus, and diffusing an offensive and insupportable stench, that did not disappear even after applying the most powerful antiseptics. Dr. Suarez had submitted the case to the most energetic treatment, but without the slightest benefit. The physician had the kindness to put him under my care, and I proposed the ligation of the popliteal artery as the only resource, and both physician and patient accepted my opinion. Fixing the day for the operation, I performed it, assisted by several physicians and the internes and externes of the hospital, who now are all graduate and perhaps all remember well the case I describe, that must be registered in the annals of this asylum. The first case that was to be treated by ligation inspired natural curiosity. The disease had invaded all the leg and the popliteal region. The ligature could not be made according to the classical method, having to meet with abnormal difficulties, owing to the pathological state of the tissues. The skin was actually very thick, and a great portion of adipose tissue, hypertrophied and soft, formed a barrier before reaching the vessels that were imbedded in hypertrophied connective tissue, so that the incision had to be larger than ordinary, the artery being placed at a great depth. At last, having reached it, and isolating it, the needle was passed and the knot secured. The proper dressing was applied, the patient placed in the supine position, with the leg in a state of semiflexion.

The limb, of course, became rather cold, and I retired after prescribing the means of checking the effects of the sudden interrup

tion of the circulation. On the following day I found nothing particular, only it seemed that the sero-purulent discharge produced by the fissures had diminished, as was also the case with the bad smell. After the lapse of about fifteen days the wound was healed without any inconvenience. By that time we were all convinced that the local complaint had evidently improved: the fissures disappeared, the skin looked thinner, and the color of the limb was more like the natural. The operation had favorably influenced that desperate case, therapeutically considered. Two months after the operation the patient walked freely about the hospital, and one day was dismissed, not by the physician, but by the director, his place being wanted for a patient that urgently required it. This was my first case of this class, and a very successful one indeed.

Some time afterwards I had in the hospital under my charge a case of elephantiasis of both legs, a white man from the Cordillera, 45 years of age, who was in a similar condition to the former patient, and, having proposed the operation, he submitted to it. I performed the ligation of the left popliteal artery in the presence of several physicians and students in service, not considering it prudent to proceed to both ligatures on the same day. This operation was perfectly well performed in the space of twenty minutes, having had the aid of Drs. Sanchez, Rincón, C. Oguendo, and others. The case was a very happy one in its results; and the patient seeing that in a short time his leg and foot tended to regain the normal form, asked for the second operation, which I ceded to Dr. Rincón, a skilful operator in the service of the hospital, who, having the aid of Dr. Oguendo, performed the ligation of the artery in the other limb, with the same successful result as the former. That man left the hospital nearly in perfect health, after having suffered a severe attack of yellow fever, which he recovered from.

These three cases of ligation of the popliteal to cure elephantiasis of the leg must be taken into consideration by those who practise in places where this disease is frequent or endemic. The ligature of the lingual has been recommended against the epithelioma of the tongue (its point). From the results I have obtained in the ligation of the popliteal, I am inclined to advise it before trying the amputation that nearly always brings but a transient cure, for soon after it the infected - submaxillary ganglions announce the reap

pearance of the terrible evil in another very important region.

CURE OF AN ANEURISM BY SUBCUTANEOUS INJECTIONS OF ALCOHOL. In a case of extensively branching aneurism of the vessels of the occipital region, which had endured seventeen years, resisting all treatment, PLESSING injected alcohol with good results. Beginning with a thirty per cent. solution every two days, he soon increased the strength of the solution to seventy-five per cent., allowing a longer time to elapse between the injections.

In commencing the treatment, a dose of 20 minims was injected in four or six points of the tumor at one-half an inch from its border.

Pain, moderately severe, followed, but ceased in half an hour.

As the tumor became smaller and harder, the injections were made more nearly in the

centre.

In two weeks' time a firm infiltration had formed about the tumor's margin, the skin was less tense, and the pulsations weaker.

In about a month, after the use of six ounces of fluid, the tumor was a firm mass, which showed pulsation in two points only: a necrosis of the skin occurred at these points, and erysipelas spread from these lesions. The infiltration of tissue partly disappeared; the pulsation did not return. In two months' time the patient was cured, and several months have elapsed without a recurrence. Pulsation and infiltration have alike disappeared.-Deutsche Medizinal Zeitung, November 25, 1886.

PEPTONE SUPPOSITORIES.

SAUTER prepares these suppositories with cacao butter, each containing twenty-five grains of peptone: they are mixed, and kept cold to prevent the fat from becoming rancid.

In cases where patients cannot be nourished in the normal manner, they serve an excellent purpose, fifteen grains of dried peptone equalling two and one-half drachms of meat in nutritive value.

Children may be given one suppository four times daily; grown persons, two three times daily. The suppository should be lubricated with olive oil, and the rectum previously cleansed by an enema.-Pharmaceutische Post, November 20, 1886.