ties were good for making these observations, we have been driven to the conclusion that alcohol has less deleterious influence in this respect than we had formerly thought, but that it fully justifies its bad name in another direction because of its pernacious effect upon the nervous system. So that while we are safe in interdicting alcohol, we must not assume that a bad condition of the renal and circulatory system exists in an alcoholic merely because he is an alcoholic.

On the other hand, experiments recently carried on in dietetics have borne data which have a tendency to condemn most severely over-eating in general, and especially the excessive indulgence of nitrogenous foods. In the light of these observations we are now called upon to pay more strict regard to diet than to the interdiction of alcohol in subjects regarded as possible candidates for apoplexy. For a long while I have, in the treatment of cases of high blood pressure and arterial disease, been utilizing the dietary principles usually pronounced in the literature on the subject, often with unsatisfactory results. Recently I have been enlightened on the subject by my friend, Dr. A. C. Eustis, of New Orleans, who has worked with Chittenden, of this country, and Von Noorden, of Vienna, and who has conducted extensive experiments of his own, with results that show that the diet list in such a case must be much more restricted than formerly thought, and that certain substances (milk and eggs) which we have heretofore regarded as comparatively innocent articles of diet, must be rejected. This is so because these substances contain too much tyrosin, derivatives of which are highly responsible for increased blood pressure. Dr. Eustis' results show that less dependence need be put in vasodilating drugs and purgation, though these must be used in conjunction.

I have adopted Dr. Eustis' principles with good results thus far. If these dietary principles enable us to reduce blood pressure in a satisfactory way, our means of treating cases of threatened cerebral hemorrhage and those in which the insult has already occurred, have certainly been greatly advanced; for no one who has had experience in this connection has failed to realize the great amount of comfort and benefit that is conferred upon a case of abnormally high blood pressure by taking away or minimizing the agent or agents which have acted as a chronic toxin, to the discomfort and danger of the subject. I do not include the dietary principles referred to in the text of this article, as Dr. Eustis intends to publish his observations soon, which I am sure will make important advance in the theory of dietetics.

The writer has often seen pronounced degeneration of the arteries with accidents, in men who have led monotonous lives of strict application to business, but withal abstemious habits in eating and drinking. They were usually temperamentally of the kind who feel every re sponsibility rather too much, and live under a sort of strained punctilousness. Similar observations have been made by many, but worry and strenuousness have been pointed to as the objectionable things. I cannot escape the observation. that monotony in the life of the individual has the same influence and should be avoided with equal care.

All these considerations are obviously important in the handling of a case of threatened or actual cerebral hemorrhage. not only as the ultimate influences leading to the stroke, but as factors still operating after the primary accident has occurred, therefore threatening secondary strokes, and keeping the subject in a state of discomfort.

When the actual apoplexy has occurred, under the usual circumstances the recumbent posture must be immediately and strictly enforced. The greatest caution. should be observed to not move the patient roughly or more than is necessary. Clothing or other things exerting pressure about the neck, throat or abdomen, should be removed, and the head slightly elevated. The side of the head upon which the hemorrhage has occurred should be covered with an ice-cap for several hours. If the state be a sthenic one, with pounding pulse, etc., venesection is immediately beneficial; likewise reduction in the volume of the body fluids by a quickly acting purge is helpful. The patient should be kept abed for at least three weeks, even in the milder strokes, and the usual measures of nursing and care adopted. Especially should the bowel movement be kept semi-fluid, to obviate straining, which would occasion a sudden and dangerous rise of the blood pressure.

The fundus of the eye should be watched immediately after the attack, and if the disc is observed to be choked or swollen, or if other signs of intracranial pressure seem to in any way menace the patient, a decompression operation is ujst as much indicated as in other conditions leading to intracranial pressure, as has been emphasized by Lund and Thomas, of Boston, and others.

Syphilis being one of the most frequent causes of arterial disease and hemorrhage of the brain, no time should be lost in determining the presence or absence of this agent, preferably by means of spinal puncture and cystological examination of the fluid, which seems more reliable than the Wassermann reaction under these circumstances. In specific cases potash and mercury often confer great benefit, and according to the writer's experience the only cases of cerebral hemorrhage that

reach a practical recovery are specific ones in which there has been a small hemorrhage and specific inflammatory deposit about it, which latter lesion has been chiefly responsible for the symptoms. Salvarsan is not indicated in these cases, because cerebral states have behaved badly with this agent, and for the reason that renal changes often exist.

As to the value of potash in arterial disease of other causation, its usefulness is of course much more limited. Ron.berg especially is of the opinion that potash is helpful in cases where focalized disease of the arterioles with the formation of miliary aneurism obtains. Rather would the alkaline treatment of Lauder Brunton (comb. of pot. bicarb., pot. nitrate and sod. nitrite) seem preferable usually. As to the treatment of the paralysis infl.cted by damage to the fiber tracts, the methods employed are secondary to those directed to the lesion proper, and are neurological commonplaces that need not be dwelt upon here. The special treatment of aphasic states occurring in this connection is interesting, but somewhat foreign to this paper.

Rather frequently the optic thalamus is invaded by the escaping blood. when a very troublesome train of sensory symptoms is provoked and a morbid emotional state excited. This is so because the thalamus is a relay station for the larger portion of the sensory tracts coursing to the cortex, and to some extent at least a center for the expression of emotion. The sensory symptoms provoked are variable. and sometimes intensely and peculiarly unpleasant, bringing about a psychic state of great unrest or depression. Both these and the emotional instability usually, however, disappear when the blood pressure is lowered and after the lapse of a little time.

In these remarks I have had in mind.

only cerebral hemorrhage occurring in the course of circulatory, arterial and renal disease-so-called apoplexy. I have purposely avoided a labored attempt to deal with every phase of the question, knowing very well that all this is too familiar to a body of physicians such as compose this Association.

Society Proceedings

MEDI O-CHIRURGICAL SOCIETY.

DISCUSSION OF PAPER BY DR. W. D. HANES.

(See February Issue.)

DR. W. F. BOGGESS: I wish to thank Dr. Hanes for the very excellent paper he has given us. The medical profession of the city of Louisville feels very proud of Dr. Hanes. He has done a great deal of original work, and has revolutionized our ideas of many things with which we come in contact in our daily work. I must confess that my own ideas concerning the sigmoid and colon have been very materially changed since hearing Dr. Hanes' papers. I can easily understand how we may have been mistaken in our conception of the length of the large gut. We have all heard nurses and patients say that they could readily put a gallon or a gallon and a half of water into the colon, and we have all believed it until to-night. I think it was stated, many years ago, that no enema was effective unless from a gallon to a gallon and a half of water was put into the patient's bowel.

I was prepared for Dr. Hanes' remarks with reference to the use of the colon tubes, because I talked with Dr. Bruce a year or two ago, when he and Dr. Hanes were engaged in these investigations, and I saw some of the skiagraphs they made. After seeing these I quit telling nurses to give colon douches, and instead told them

to use a 161⁄2 catheter and call it a sigmoid douche, believing that the sigmoid is about as far up as we can get. I seldom use a colon tube now.

I do not know when I have heard a paper from which I have obtained so much positive and helpful information as I have from this one. It is original work that Dr. Hanes has done, and I do not believe he has been given the credit he should receive. As I said in the beginning, the profession of Louisville is very proud of him.

DR. LOUIS FRANK: We have all been aware of the work that Dr. Hanes and others have been doing along this line, and there is no question that the statement he makes, that the profession needs these facts to be repeatedly told to them, is true. I think, also, that in our trainingschools a mistake is made in not impress

ing them upon nurses. We hear a great deal about high colon douches and high enemata, and the impression that these. terms convey vary materially in different. individuals. I have found that most doctors and nurses, when spoken to regarding the high enemata, receive the impression that an enema with the tube introduced eighteen or twenty inches up the bowel is meant, and I believe that this is the common understanding of the term. There is no question that such impressions should be corrected. There is no doubt that it is impossible to introduce a tube farther than the rectum itself, and if a greater length of tube is introduced, it will simply coil upon itself in the

rectum.

Another impression that has got abroad, and which Dr. Hanes referred to, is that the greater quantity of fluid that can be injected into the bowel, the greater the benefit will be derived. I think this is also incorrect. For the purpose of stimulating peristalsis in the bowel, just as

good effect will be obtained from four to six ounces of a stimulating fluid as from ten to twelve ounces; in fact, my own impression is that if large enemas are retained they may do more harm than good by over-distending a portion of the bowel, resulting in partial paralysis of its muscular fibers, and producing an effect directly contrary to that which we desire. Therefore, I think it should be repeatedly impressed upon nurses in particular, that when a stimulating enema is given, for the purpose of exciting peristalsis in the bowel, it need not be an enormous quantity; that it is the quality of the enema rather than the quantity that produces the effect.

I have been very much interested in this subject, and I believe that the study of it in this portion of the country, and certainly among the local profession, has been greatly stimulated by the work Dr. Hanes has done. I think more work should be done with the X-rays from a diagnostic standpoint, not only in connection with the large bowel, but other portions of the intestinal tract, including the stomach and duodenum.

DR. CHARLES G. LUCAS: I agree with both of the previous speakers in the good things that have been said about Dr. Hanes. Until the publication of his first paper I had been under the impression that I could get a colon tube quite a good distance up the bowel, but after hearing Dr. Hanes' paper and afterwards reading it carefully in the JOURNAL, I have not used a colon tube.

It is astonishing how many people use colon tubes upon themselves. One of the greatest troubles I find in connection with the use of enemas by my patients is that they not only use too much fluid, but they hang the syringe too high, thus making the hydrostatic pressure too great. I had the pleasure of working with Dr. Kuttner,

of Berlin, and he told me that he rarely instructed the patient to use more than a pint of fluid, directing them to use a fountain syringe, and to assume a recumbent position on the left side with the right leg drawn up. In cases where I am anxious to get an action, I generally make use of milk and molasses.

Dr. Hanes brought out a number of good points in his paper. He said he does not believe there is any case of mucous colitis which has not a pathological basis. Ewald, who has done a great deal of work along this line, states that in only two cases out of a large number of cases of mucous colitis, in which death had occurred from other causes, could any pathological cause for the condition be found at autopsy. I believe we can all recall patients who passed great quantities of mucus and subsequently got well. I remember one case in particular-a patient from Owensboro-which Dr. Hanes saw with me; she had a severe mucous colitis, produced by adhesions such as Dr. Hanes speaks of.

I do not believe that every one of these cases will be found to have a pathological basis; undoubtedly a great many of them are neurotic in origin.

DR. AP MORGAN VANCE: I have been very much interested in Dr. Hanes' work, and I agree with him that the ordinary colon tube might as well be eight inches long as eight feet long, so far as getting it up into the gut is concerned. However, from my experience, I am convinced that it is not impossible to get some sort of a tube up to the cecum. Dr. Cecil had a patient who went to New York and spent several months there under the care of Dr. Tuttle. She was supposed to have a chronic mucous colitis. When she came back here she desired to have the treatment practiced by Dr. Tuttle continued. This consisted in the introduction of a

tube, three and a half or four feet long, and half an inch in diameter. She said that Dr. Tuttle had made a practice of introducing this tube about twice a week, and when it got around to the cecum he would inject some sort of fluid. I was selected by Dr. Cecil and the woman's husband to follow Dr. Tuttle's directions, which I did, and I am convinced that this tube was entirely too stiff to have curled up in the rectum. It was a horse catheter, and I passed it into this woman's bowel its entire length a number of times. I do not know whether Dr. Cecil was ever present at these seances. This woman would get herself into position, lying on the left side with the trunk at an angle of about 45 degrees from the horizontal, and it would take just about an hour to get the full length of the tube into the bowel. It could be introduced from six to twelve inches without any trouble; then I would turn the stop-cock and let a little oil flow in and it would go up a little farther. Then I would push it up and pull it back, and after a while it would go on up.

Then the fluid was

injected, the tube pulled out, and the woman would remain in position for a while to let the fluid get in its work, and then get up and pass it.

Now, to go back to the time when we used to treat all obstructions of the bowel, locked bowel or what-not, by the introduction of a tube, most of the time using a horse catheter-a spiral wired affair, SO stiff that it is impossible to bend it at an angle. We used to introduce these tubes for almost every condition of the bowe!, but the only ones we ever relieved with them were cases of impaction. On one occasion, while on my way to a medical meeting at Shelbyville, I was called fron the train at a way-station to see an old gentleman, and I did not get away from there for three days. This man had an

impaction in the hepatic region. I did not have a colon tube with me and for a time I thought the patient would die. I asked some of the family if they could furnish me anything in the way of a rubber tube, and some one brought me one of these white rubber tubes, about threequarters of an inch in diameter, and so stiff that it could not be bent to any greater degree than an ordinary garden hose. I whittled a knob for it out of a spool, melted some lard for lubrication, and after some difficulty I managed to introduce it, and I am absolutely sure that it did not coil up in the rectum. I finally unloaded about a bucketful of "mortar" from this man, on the second day, and he got well.

About thirty years ago, Dr. Cummins called me to help him operate upon an old woman who had a strangulated left femoral hernia. During her convalescence I would go there every day and ask her if her bowels moved, and each time she told me they had. I did not know enough at that time to find out for myself. On the night of the sixteenth day I was called to come quick, and as I went in the door the woman said: "Doctor, did you bring your forceps? I am about to be delivered." I finally evacuated from her bowel about three-fourths of a water-bucket full of feces.

Another feature that I would like to speak of is bowel peristalsis. I do not know whether this is as great in the human as it is in the dog, but when we first began to operate on dogs we early found it easy to determine the efferent or afferent ends by putting the finger into the intestine, it pulled like everything, and when a piece of gauze was put into the distal end of the ileum, it would shoot into the gut with great force. This suggested to me a plan for getting rid of the Murphy button. I believe the difficulty