and none on the disease. The next day (12th), about noon, his condition became alarming. Respiration rapid; elevation of alae nasi; failing circulation, as shown by the cyanosis. This was probably the fifth day of the disease. Obtained oxygen and began inhalations. After the very first the patient expressed himself greatly relieved. The gas was frequently administered during the afternoon, and by late in the evening he began to show marked relief, objectively as well as subjectively. Although the urgent symptoms were controlled, the disease continued for about thirty-six hours, when resolution was established.

All the cases reported, with one exception, were males; ages ranged from fifteen to thirty-five years. The oxygen was given by inhalations, but it might be administered per rectum, for it has been proved that it is rapidly absorbed by the intestinal capillaries (Dr. Kelley, in "Therapeutic Gazette," 1887).

It is not the purpose of the paper to take up the subject of pneumonia, nor to dwell on the physiological action of oxygen, but simply to present a few results as they appeared clinically. The number of cases reported by any single observer may be too few to warrant conclusions, but when the general tenor is so uniform, we are certainly justified in giving oxygen our confidence. It is no panacea; it is not a remedy which is called for in a majority of cases, but it takes a place that cannot be supplied by any other means at our command.

DISCUSSION.

Dr. ECCLES.-There is one trouble with the paper; it does not state whether the oxygen was washed or not. Oxygen, if it is not washed, is likely to contain a considerable quantity of chlorine and possibly some hypochlorous acid, so that it would be difficult to say with certainty which did the work. If we had the assurance that it was well washed with water, we would know that the oxygen alone was the effective agent. The tendency of the temperature in many cases of pneumonia is at the proper time to suddenly descend without assistance, and in these instances it may have been the natural course of the disease.

Dr. WINFIELD. -The oxygen which was used is the regular oxygen sold in the market for inhalation purposes. I presume it was washed.

Dr. ECCLES.—It was probably not washed. One gentleman refers to oxygen as being toxic. The experiments of M. Paul Bert showed that, weight for weight and under heavy pressure, it is much more poisonous than prussic acid, but under ordinary conditions it has no toxic effects whatever. In cases of pneumonia where one lung is

almost useless and the other all right, the oxygen that could be consumed in the pure form would just about approach the same quantity as that taken from the air by a pair of sound lungs. Pure oxygen would, therefore, seem to be better than dilute in such cases. It would probably be wise to have the dilution inversely in proportion to the amount of lung tissue involved. The nitrogen of the air is inoperative therapeutically, the oxygen alone being active. In peroxide of hydrogen there might be some danger of toxic effects if used in large quantities, since nascent oxygen acts very much more rapidly than the ordinary free gas. The plan pursued by the gentleman to my right, of washing it with caustic soda and then distilled water, would give a practically pure article.

Dr. PAUL H. KRETZSCHMAR.-The paper of Dr. Winfield brought for the first time to my mind the fact that oxygen is not used a great deal in pneumonia; at least that is the impression I derived from his statement. I was under the impression until now that it was a common remedy in croupous pneumonia, and I have used it very frequently. I fully agree with Dr. Conkling and Dr. B. F. Westbrook as to the value of oxygen, and I wish to state that the oxygen which I have used has always been that prepared by Walton in Jersey somewhere, with an office at 280 Fourth Avenue, New York City, and it is a mixture of nitrogen and oxygen. I allow it to go from the cylinders into a rubber bag holding five gallons, and from there through the wash-bottle to the patient's mouth. In this way I can control the amount, and I use about two and a half gallons at one time, by about half emptying the bag at each sitting. I wash the oxygen every time before using. I have four cases of croupous pneumonia at present in my mind, in all of which oxygen has been used. The results are just exactly as stated by Dr. B. F. Westbrook. In one instance I have no doubt that the patient, a young woman about twenty-eight years old, was saved by the use of oxygen in liberal quantities. She was in the fifth or sixth day of pneumonia. It was a case where I was called in consultation with my brother, Dr. W. H. Kretzschmar.

We found the patient in a cyanosed condition, pulse feeble, temperature 103°, and panting for breath. Oxygen was at once suggested and applied, followed by the most satisfactory results, and I believe. that that patient would not have recovered without the use of oxygen. I saw all three of the other cases in consultation, one with Dr. Janeway, one with Dr. John T. Conkling, and one with Dr. John A. McCorkle. They all died with the oxygen, and they would have died without it. However, if it is only one in four where we can claim that oxygen has done good work, of course credit should be given to the remedy, and we should use it whenever we have an opportunity.

I would not have said anything about the use of oxygen in pneumonia, because I thought was generally used. Dr. Winfield claims that his cases are exceptional ones, but I think every practitioner is in the habit of using it in order to keep a patient above water long enough to give him a chance to pass over a crisis.

Dr. HENRY CONKLING.-Mention is made in the paper just read of heart-failure in pneumonia. There are certain objections to the statements that are made as to the frequent occurrence of death in pneumonia by heart-failure. It has been my work for some time past in the dead-house of St. Peter's Hospital to make a number of observations upon the formation of ante-mortem heart clot; while the observations are not yet sufficiently numerous to give statistics, yet valuable information has been obtained from them. Some of the examinations having been made upon cases of pneumonia, the results have, therefore, a direct bearing upon the present topic.

When we make a post-mortem examination in a man well advanced in life, who has met with an accidental death, with heart normal, microscopically and macroscopically, we are bound to come to the conclusion that we are dealing with an organ which is one of the strongest in the body, and the very nature of the formation of the heart, with layer after layer of muscular fibres, seven in number, gives to it the force for long-continued work, such as it has to do during a long-continued life, so that when a person in perfect health is attacked by the sudden or severe chill of pneumonia, it is hardly rational to imagine that that person will die of heart-failure at the end of seven or eight days, for the reason that the heart muscle cannot degenerate in so short a time unless there be some septic condition. In those cases where the post mortem examination was made there has been found an ante-mortem clot firmly adherent, well formed both in the right and left heart, and in those cases in which the clot was formed in the left heart it has been found firmly adherent to the mitral valve as a rule; usually the posterior valve, binding the valve down to the posterior wall of the left heart, producing in some instances typical mitral regurgitation, with damming back of the blood. In other cases the clot has been so formed that when the valve was opened up there has been no regurgitation present, for the reason that the clot has taken the place of the valve which is bound down and has produced a perfect closure of both orifices.

In the wards of St. Peter's Hospital I made, during the last few months, a number of tracings with the sphygmograph for the purpose. of finding out the condition of the heart of a dying person. Some have been cases of pneumonia, some have been pulmonary tuberculosis well advanced, and one a man dying from relapsed typhoid

fever. Sphygmograph tracing of a patient with pneumonia on the fifth or sixth day, where there may be complete consolidation of one lung and partial consolidation at the base of the other lung, does not in any way whatever show a weak heart even at the end of the sixth day; it shows merely a heart which cannot work on account of cramped position. If the left lung be solid from apex to base the heart cannot have its normal rotary movement upon contraction. The needle of the sphygmograph does not show that the heart is weak from muscular degeneration, so I have thought that heart-failure is not so much to be looked out for as death from conditions in the respiratory and vascular tract, and those are the formation of fibrinous clots partly in the blood and partly in the lung itself. When the blood comes up passes through the lungs,

to the right heart imperfectly oxidized and it does not become sufficiently oxidized by the air breathed by the patient, partly because the vessels in the lung are crowded upon and diminished, and that is why the heart has so much hard work to do.

I have used oxygen in a number of cases, especially those of primary anæmia, using it as a specific pure and simple to get rid of the leucomaines and ptomaines in the body. When the blood comes up imperfectly oxidized to the right heart the extra amount of oxygen placed around in the air in the room acts as a tonic on the blood, and lessens the tendency to the formation of these clots, and lessens the tendency to sudden death from the passage of air into the lung caused by the transmission of clots in the tract. So it seems to me that this oxygen which has been washed four times, acts simply to lessen fibrination of the blood, and in that way as a tonic to the heart. I think if it was used in all cases of pneumonia in the early stages it would heighten the prognosis and render cases of sudden death far fewer than at the present time.

In regard to the making of oxygen, I always make my own oxygen from chlorate of potash and black oxide of manganese. As it comes from the retort it is passed through two wash-bottles filled with caustic soda, then through a third wash-bottle of distilled water, and then collected in a bag, then through a fourth wash-bottle. This gives it four washings, two with a solution and two with pure water. In all of these pamphlets written and papers published, where other gases have been used with the oxygen, it is quite impossible to say whether the good results have been obtained from the oxygen or from the combination, or from the other gas, but I have always used the pure gas.

Now I do not think oxygen is a remedy to be used when the patient is in extremis. I think it must be used from the very start. To get the good effects the patient must breathe it himself, and the muscles

be in a sufficiently strong condition to bring the gas into the lungs. If a patient is in a collapsed condition he cannot do this, but if it is used in the early stage of the disease and the patient takes it from the bottle by the mouth it has its full effect, and also aids in preventing the complications which may arise later on.

CASE OF SYPHILITIC BONE-DISEASE OF THE ANKLE

JOINT.

BY GEORGE WACKERHAGEN, M.D.

Presented to the Brooklyn Surgical Society, November 21, 1889.

H. C., aged twelve years, complained of pain in both lower extremities, in February, 1889, and was treated by his physician for rheumatism. In a few weeks the pain generally subsided, excepting at the inner side of the left ankle, where a slight swelling was noticed. This gradually increased in size until May, when it was freely incised, and discharged considerable pus. The discharge continued, but the swelling remained about the same until July 24th, when the patient first came under my care for operation. He was weak and pallid; the swelling extended about three inches above and around the inner malleolus; the sinuses were traced, both, in an upward and backward direction, for about an inch and a half.

An incision was made through the tumor down to the bone and prolonged half an inch below the tip of the inner malleolus, and the periosteum raised as far as was necessary to thoroughly expose the bone, which was found diseased to such an extent that, after using the chisel, only a thin shell of the lower end of the tibia remained. Nearly all of the inner malleolus was removed, which made it necessary to open and explore the ankle-joint. You will notice that there remains. very good motion at the ankle, and he can walk without pain.

About the 1st of October an abscess formed, involving the upper, outer, and anterior third of the right thigh. This was freely laid open, and the internal surface thoroughly curetted and treated antiseptically.

The patient's general health has greatly improved since the operation.