I then prepared to plug the naris posteriorly, and had the patient sit up in a chair preparatory to this operation. While sitting there he complained of a gone sensation, and fainted. I immediately gave him a hypodermic of strychnin sulphate, one-fortieth of a grain, and on the patient's coming out of this attack of syncope, supported him to the bed and put him in a recumbent posture. The hemorrhage ceased with the fainting spell. I then gave him a hypodermic of five drops of a 1 to 1000 solution of adrenalin chloride, and packed the naris anteriorly with gauze soaked in adrenalin solution of the same strength, having decided not to introduce the posterior nasal tampon at this time. Returning home, I had hardly entered the house before I was called to the 'phone and informed that Mr. G.'s nose had again begun to bleed. Catching a car at once I was at the patient's bedside in a half hour, and found that the blood had oozed through the gauze packing and again had commenced to drip. Removing the gauze from his naris, I passed a catheter through the naris into the naso-pharynx, attached to it a piece of silk thread, and drew a gauze plug tightly into the posterior naris, at the same time packing gauze into the anterior naris. A nurse was then summoned to take charge of the patient, who had some little rise of temperature and was very weak. There was no further hemorrhage in this case, the anterior and posterior plugs being removed from the naris the following afternoon, and merely a light gauze plug being placed anteriorly. The patient's temperature subsided under quinin and free purgation. In eight years' practice this is the second bleeder that I have encountered, and while I realized that in this case I was taking a chance of having an obstinate hemorrhage to contend with, I am quite sure that had I anticipated any such trying experience as fell to my lot, I would not willingly have undergone it even to give the patient the benefit that I hoped would result from the trivial operation performed in his case. Usually in bleeders we can glean a history of a hemorrhagic diathesis which will serve to warn us as to the probability that a patient such as this is a hemophiliac, but most surgeons are inclined to take chances where they see that an operation offers the prospect of bettering a patient's condition. One or two experiences with bleeders will tend to cause them to think considerably more of their own mental and physical comfort, and to have less regard for the possible ben efits of an operation to the patient. The elder Mr. Weller constantly enjoined upon his hopeful son Samuel to "bevare of the vidders," and every surgeon who has had experience with a hemophiliac will likewise conjure his less experienced confrères to "beware of the bleeders." Lyceum Building. NEURASTHENIA-DIAGNOSIS AND TREATMENT.* G. W. PENN, M.D. HUMBOLDT, TENN. THE subject upon which I am asked to write something for this meeting was not of my own choosing, and since the committee could not have known that I possess a decided skepticism regarding the existence of a disease entity per se of a sufficiently established independence to warrant it a place in our nosology, I hope I will be pardoned for confining my remarks chiefly to the diagnosis, or from my viewpoint, the differentiation of the symptom complex or complexes, called too loosely, neurasthenia (nerve-weakness). It is a good name to tell the patient, and also useful on busy days, when one lacks time or inclination, or possibly ability to make a careful, systematic search for the causus morbi in the given case. I do not mean to say that there are not, as Osler says, people born with a small capital of vitality which is soon exhausted by too frequent and severe drafts, with physical bankruptcy as a result; but may there not be even in these cases a pathology that would be better classified by a less mysterious, if high-sounding title, than neurasthenia? Nerve weakness is present in many and varied conditions, with of course, as varied pathology, and I believe that a careful hunt will in most instances locate the trouble. Even admitting that a distinct, and always the same condition, of departure from the normal exists, that we might regard as a disease entity, I am sure you will sustain with me the charge of inaccuracy in a great many instances, because of the chaotic status of the disease in question. Acting on this assumption I am going to attempt a description of what neurasthenia is * Read before Gibson County Medical Society, Trenton, Tenn., Oct. 18, 1904. not. It is not the nerve weakness in many women with ruptured perineum or uterus, entailing as they do prolapsus, endometritis and general bad health. Nor is it much the same train of symptoms seen in delicate girls who have more ambition than brains, to use a paraphrase that my friend Dr. Frank Jones, of Memphis, applied to himself (with apologies to Dr. Jones.) Nor is it the same symptom complex seen in old alcoholics, incipient melancholics, overworked business men, who simply need rest, mental and physical. Nor is it the nerve-worn sufferers from rectal disease; nor yet is it the condition, though even the recent text-books claim it, consequent upon an enfeebled digestion, the so-called neurasthenia gastrica, which is just plain chronic subacute gastritis, with a predominance of nervous phenomena, such as we may and do have in any severe indigestion of chronic nature. Neither is it the wonderful train of symptoms so graphically described in almanacs and the average lay papers as lost manhood, though in these cases the fear that they may be unable to leave another edition of an undesirable social unit to receive their falling mantle and heir their expected fortune often makes this class of patients give the doctor that "tired feeling"; and I firmly believe in the existence of neurasthenia only when one of these deluded fellows haunts my office for about six months. The reason that these conditions are not neurasthenia, that is, as a distinct disease, is because they are simply symptoms of pathology indicated in each case, and when the underlying cause is removed, will generally get well. Now your genuine neurasthenic never gets well, only by spells, and short ones at that; my experience is that the reason is purely that the patients of this type have procrastinated too long, or refused absolutely, the treatment needful in the case. It is hard to make some women believe in a uterine headache or that constipation or rectal disease is responsible for her indisposition. Seriously, confining the term neurasthenia to the cases in which an organic basis for morbidity cannot be found after a careful search, and which have at the same time a hereditary neurotic temperament, we will weed out most of them, and even here, some word designating an etiology that is of a hereditary, or at least congenital, origin would, it seems to me, relieve us of confusion, and tend to greater accuracy in diagnosis. Neurasthenia, hysteria and melancholia are probably gradations, in the order named, of a condition of lowered nervous energy of the cranial and spinal nerves, the sympathetic system, or the encephalon, respectively, that can in most instances be attributed to something other than "just nervous," though I know that it is occasionally difficult or impossible to determine what. Future research will doubtless throw great light on this subject. In the meantime, let us be very sure we have not overlooked some condition amenable to treatment, before we give our patients that almost incurable malady, neurasthenia. SUCCESSFUL REDUCTION Of Dislocation of the Shoulder Joint of Three Months Duration.* ALFRED MOORE, M.D. MEMPHIS. DISLOCATIONS of one joint or another of the various articulations of the osseous structure are so common, and especially that of the shoulder, that few physicians would be interested in a report of a case unless there was something new to offer in the method of treatment or some other interesting feature of the case. The only feature of this case worthy of note was the apparent ease with which the dislocation was reduced after so long a time. The case was as follows: R. H., white, 59 years of age, was riding horseback and leading a horse, when the horse that was being led suddenly made a lunge, jerking the gentleman from the saddle and dragging him some distance, his right hand being caught in the rein of the horse he was leading. The right shoulder and arm were very painful, and it was thought by the attendants that there was a fracture and the arm was treated accordingly, but after several weeks of torture the patient went to another physician who diagnosed dislocation with the X-ray, but did not attempt replacement. * Read before Memphis and Shelby County Medical Society, Oct. 18, 1904. Three months after having received injury the arm was painful and of practically no use. There was evidence of injury to the ulnar nerve, as the little and ring fingers were numb and useless. This arm could be abducted but little. and the elbow could not lie against the chest when the right hand was placed upon the left shoulder. The head of the right humerus was very prominent and there was a marked depression beneath the acromion. The diagnosis of subcoracoid dislocation was made, and reduction by manipulation was attempted under anesthesia, the head of the humerus slipping into the genoid cavity after a few minutes manipulation. Dr. Charles A. Powers, in his discussion of Dr. Willard's excellent paper on "Old Unreduced Dislocations" which appeared in the Journal of the American Medical Association, mentioned a case of four months duration which was easily reduced after from eight to ten minutes manipulation, but unfortunately there are many complications and obstructions which render this replacement impossible except by the use of undue force which is often harmful. When intelligent manipulative methods fail it would be much safer to undertake an open operation rather than the use of extreme force where replacement is demanded. Randolph Building. PROGRESS OF MEDICINE. MEDICINE. An Analysis of Forty-two Cases of Venous Thrombosis W. S. Thayer (Med. News, vol. 85, no. 14) says: 1. In 42 cases of typhoid thrombosis the onset occurred almost invariably in the third week or later. 2. Local pain and fever were usually the first symptoms. The fever sometimes preceded the localizing symptoms. 3. In 28.2 per cent. of our venous thromboses occurring in connection with typhoid fever there were chills. In several instances the chill preceded the appearance of localizing symptoms. In the past two years I have seen in consultation three further cases in which otherwise unaccountable chills during |