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diff --git a/old/52983-h/52983-h.htm b/old/52983-h/52983-h.htm deleted file mode 100644 index 04005be..0000000 --- a/old/52983-h/52983-h.htm +++ /dev/null @@ -1,2582 +0,0 @@ -<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" - "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> -<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en"> - <head> - <meta http-equiv="Content-Type" content="text/html;charset=iso-8859-1" /> - <meta http-equiv="Content-Style-Type" content="text/css" /> - <title> - The Cleveland Medical Gazette, Vol. I No. 4, Feb. 1886, by A. R. Baker, a Project Gutenberg eBook. - </title> - <style type="text/css"> - -body {margin-left: 10%; margin-right: 10%;} - -p {margin-top: .75em; text-align: justify; - margin-bottom: .75em; text-indent: 1.5em;} - -hr {width: 33%; margin-top: 1em; margin-bottom: 1em; - margin-left: auto; margin-right: auto; clear: both;} - -hr.chap {width: 65%; margin-top: 2em;} -hr.full {width: 95%; margin-top: 2em;} -hr.r20 {width: 20%; margin-top: 1em; margin-bottom: 1em;} - -table {margin-left: auto; margin-right: auto; border-collapse: collapse;} - -.pagenum {position: absolute; right: 3.5%; - font-size: small; text-align: right; color: #808080;} /* page numbers */ -.bdtd {border-style: double none none none;} -.bdb {border-bottom: solid #000 1px;} - -.smcap {font-variant: small-caps;} -.center {text-align: center; margin:0; text-indent: 0;} -.tdl {text-align: left;} -.tdr {text-align: right;} -.tdr2 {text-align: right; padding-right:2em;} -.caption2, .caption3, .caption4 {font-weight: bold; text-align: center; text-indent:0;} -.caption2 {font-size:1.50em; margin-top: 1.0em;} -.caption3 {font-size:1.25em; margin-top: 0.5em;} -.caption4 {font-size:1.15em; margin-top: 0.5em;} -.pmb4 {margin-bottom: 4em;} - -/* Images */ - -.fig_center {margin: auto; text-align: center;} - -.fig_left {float: left; clear: left; margin-left: 0; - margin-bottom: 1em; margin-top: 1em; - margin-right: 1em; padding: 0; text-align: center;} - -.fig_right {float: right; clear: right; margin-left: 1em; - margin-bottom: 1em; margin-top: 1em; - margin-right: 0; padding: 0; text-align: center;} -.trans_notes {padding: 2em; background-color: #f0e0e0;} - </style> - </head> -<body> - - -<pre> - -The Project Gutenberg EBook of The Cleveland Medical Gazette, Vol. 1, No. -4, February 1886, by Various - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: The Cleveland Medical Gazette, Vol. 1, No. 4, February 1886 - -Author: Various - -Editor: A. R. Baker - S. W. Kelley - -Release Date: September 4, 2016 [EBook #52983] - -Language: English - -Character set encoding: ISO-8859-1 - -*** START OF THIS PROJECT GUTENBERG EBOOK CLEVELAND MEDICAL GAZETTE, FEBRUARY 1886 *** - - - - -Produced by The Online Distributed Proofreading Team at -http://www.pgdp.net (This file was produced from images -generously made available by The Internet Archive) - - - - - - -</pre> - - -<div class="fig_center" style="width: 246px;"> -<img src="images/cover.jpg" width="246" height="324" alt="" /> -</div> - - -<p><span class="pagenum"><a name="Page_145" id="Page_145">« 145 »</a></span></p> - - - - -<div class="fig_center" style="width: 496px; margin-top: 4em;"> -<img src="images/title.png" width="496" height="91" alt="The Cleveland Medical Gazette" /> -</div> - -<table summary="table" style="width: 100%; border-top: solid #000 1px; border-bottom: solid #000 1px;"> -<tr> - <td class="tdl"><i>VOL. I.</i></td> - <td class="center"><i>FEBRUARY, 1886.</i></td> - <td class="tdr"><i>No. 4.</i></td> -</tr> -</table> - -<p class="caption2">ORIGINAL LECTURES.</p> - -<hr class="full" /> - - -<p class="caption3">ULCER OF THE STOMACH.</p> - -<p class="caption4">A LECTURE BY PROF. L. OSER OF VIENNA, AUSTRIA.</p> - -<p class="center">[Translated for the <span class="smcap">Cleveland Medical Gazette</span> by <span class="smcap">Dr. C. Rosenwasser</span>].</p> - - -<p>Gentlemen! The disease which we intend to study to-day is -one, the traces of which are found much oftener at post-mortems -than the disease itself in the clinic. A great many cases are -overlooked and improperly diagnosed for reasons which I shall -state hereafter.</p> - -<p>It has been called by various names. Round ulcer, perforating -ulcer, chronic ulcer, corroding ulcer and simple ulcer are -only different designations for one and the same condition. I -prefer to call it <i>peptic ulcer</i>, as it is always the result of self-digestion -of a part of the walls of the stomach, but is not always -round, nor perforating, nor chronic, nor corroded; nor is it always -simple, several ulcers having occasionally been found in one -and the same stomach.</p> - -<p>Pathologists have not yet come to a positive decision on the -<i>modus operandi</i> of its origin, but several conditions are mentioned -as necessary for its development.</p> - -<p><span class="pagenum"><a name="Page_146" id="Page_146">« 146 »</a></span></p> - -<p>1. The self-digestion of a part of the stomach by the gastric -juice.</p> - -<p>2. Disturbances of the circulation of the blood in the walls -of the stomach.</p> - -<p>3. The alkalinity of the blood circulating in the walls of the -stomach prevents the digestion of the mucous membrane. If -this action on the walls of the stomach is prevented in any way, -the development of an ulcer is aided. This clause has been -accepted until recently, when it has been rendered somewhat -doubtful by the results of certain experiments.</p> - -<p>The first clause is sustained by the fact that the peptic ulcer -is only found in those parts which are brought into direct contact -with the gastric juice. It is further proven by the softening -of the stomach so frequently found at post-mortem. But as -long as the circulation of the blood in the walls of the stomach -is normal, ulcers do not form. The formation of an ulcer in the -stomach presupposes a local disturbance of the circulation. It -is usual to find thrombi and diseases of the bloodvessels in cases -where ulcers of the stomach occur. For this reason the latter -is more common in anaemic persons where the circulation is -retarded and the bloodvessels frequently subject to fatty degeneration.</p> - -<p>Virchow regards embolism of a small vessel as the origin of -ulcer of the stomach. Cohnheim disproved this beyond doubt -by showing that there is an abundant circulation in the walls of -the stomach by which the parts affected are again quickly supplied -with blood. Klebs takes for granted a spasmodic contraction -of single bloodvessels as the cause of the retardation of -the circulation, while Rindfleich attributes it to the poor anastomotic -connection of the gastric veins. He calls attention to -the frequent coincidence of ulcer and hemorrhagic infarct in the -walls of the stomach. Cohnheim injected chromate of lead into -the gastric branch of the splenic artery in animals, and when -he succeeded in cutting off the arterial supply of the mucous -and submucous layers <i>only</i>, he found as a result large ulcers with -sharp, well-defined margins and a circular base. If the animals -were examined in the second week after the experiment, they -showed several small ulcers in place of the larger one. In the -<span class="pagenum"><a name="Page_147" id="Page_147">« 147 »</a></span> -third week the ulcers were found to have healed. From these -experiments you can see that the gastric ulcer has a natural tendency -to heal when not interfered with. By experiments such -as these it has been proven beyond doubt that disturbances of -circulation of a small part of the stomach may lead to ulcer. -But the causes of these disturbances, and the reasons why some -ulcers do not heal, are still disputed questions.</p> - -<p>Pavy claims that the alkalinity of the blood prevents the gastric -juice from acting on the walls of the stomach. When he -introduced acids into the stomach and allowed the circulation -of the blood to continue, no ulcers resulted; if he impeded the -circulation, the stomach was digested by its acid contents. -Samelson instituted experiments to test the statement of Pavy. -He introduced large quantities of various acids into the stomach -of his animals without observing ulceration as a result; he also -neutralized the blood by the injection of weakened acids into -the bloodvessels, but no ulceration followed. But he did not -impede the gastric circulation in his experiments, while Pavy -did, hence the difference in their results. Clinical experience, -however, favors Pavy's views. We can prevent the further progress -of the gastric ulcer by the use of alkalies, while acids only -favor its growth. These questions still need additional research -before they are definitely solved.</p> - -<p>Gastric ulcer may occur in any part of the digestive tract -which is exposed to the action of the gastric juice; hence it is -found in the lower part of the œsophagus, any part of the -stomach and the upper part of the duodenum. It is found most -frequently in the pyloric end of the stomach, because this part -is most frequently subjected to mechanical irritation and to the -action of the gastric juice.</p> - -<p>The shape of the ulcer is usually conical or terraced, its diameter -being largest in the mucous membrane and smallest at -its base, in the deeper structures.</p> - -<p>The gastric ulcer must be very common. In about five per -cent of all cadavers we find ulcers in the stomach or else scars -as traces of former ulceration. Ulcer of the stomach is frequently -passed over without recognition, because most physicians -do not decide upon this diagnosis, unless hæmatemesis -<span class="pagenum"><a name="Page_148" id="Page_148">« 148 »</a></span> -occurs. Gastric hemorrhage, however, is not necessarily a concomitant -feature of every gastric ulcer, and the hemorrhage -may occur without vomiting, the blood being either digested -and absorbed or passing on into the bowel and causing dark -stools. Thus occasionally the only symptom of hemorrhage of -the stomach is the appearance of darker stools, a symptom of -doubtful value when taken alone, but of some importance when -in connection with others.</p> - -<p>A few years ago an elderly lady was admitted into the hospital -on account of severe pain in the stomach and the appearance -of dark stools. While in the hospital vomiting of blood -set in, continuing three days, and then the patient died. At -the post-mortem we found that an ulcer of the stomach had -burrowed through the diaphragm and pericardium into the wall -of the left ventricle, perforating finally with a small opening into -the left ventricle. I can only explain the length of the time -between perforation and death (three days) by assuming that -part of the gastric fistula leading through the walls of the heart -was firmly closed during systole, and only allowed a small quantity -of blood to ooze through during each diastole.</p> - -<p><i>Symptomatology.</i> If you were to rely upon the occurrence of gastric -hemorrhage in making your diagnosis, a great many blunders -would necessarily occur, as this symptom is present in but one -quarter of all the cases. I can give you an exact picture of -the symptoms from experience on myself, having repeatedly been -a sufferer from gastric ulcer and having studied every phase of -the question carefully upon myself, frequently experimenting to -get at various truths.</p> - -<p>One of the most important and characteristic symptoms is the -<i>localized pain or soreness</i> which is felt in a small, well defined -area, and either originates or is increased by chemical or mechanical -irritation. This spot always was sensitive both to -warm and cold food. Salty food, alcoholic or sour articles -brought on pain. I could feel when the food passed the spot. -It was always more sensitive about an hour or two after a meal, -when the process of digestion was most active. My ulcer was -on the anterior wall of the stomach, so that I could greatly ease -the pain after meals by lying upon my back, while lying upon -<span class="pagenum"><a name="Page_149" id="Page_149">« 149 »</a></span> -the abdomen greatly aggravated it, as the food then came in contact -with the ulcer. I was a student yet when first suffering -from this trouble, and was treated by one of our prominent professors -for heart disease. He even gave me a certificate stating -that I was suffering from beginning hypertrophy of the left -ventricle. I was not improving under this treatment, and was -taken one day with violent pain in the stomach, followed by -vomiting of a large quantity of blood. Now the state of things -was cleared up, and under the proper treatment (for ulcer of -the stomach) I soon regained my health. I remained well for -a long time, but in the course of the last twenty years have -passed through several relapses. One of these, I distinctly remember, -occurred while I was making a tour through the Alps. -I had walked quite a distance that day and being very thirsty -drank three glasses of water in quick succession. I immediately -felt a pain in the stomach, and could distinctly feel how -one of the old scars was again rent asunder.</p> - -<p>During these repeated attacks I found that the painful sensation -was really divisible into three distinct periods, that of constant -increase, during which the ulcer is developing and extending, -that of remaining at one height, and that of gradual decrease -during the period of healing. I could distinctly tell from -these various changes how my ulcer was getting along.</p> - -<p>Two different kinds of pain are felt, the one constant and the -other occasional. The <i>constant pain</i> is usually present where -the ulcer has extended deeper into the tissues or when the surrounding -tissues are implicated. This pain is increased during -digestion or when pressure is made on the parts from without. -The <i>occasional pains</i> are either of a dyspeptic type, caused by the -catarrh which usually accompanies the ulcer, or of a cardialgic -(neuralgic) type, the result of irritation of the exposed nerve-endings -with the ulcer. These cardialgias are acute attacks of -very severe, excruciating pain, which occur during or between -the periods of digestion and are felt in the epigastrium and back -mostly, but sometimes radiate over the entire abdomen, into -the chest and even into the limbs. These attacks differ in no -respect from those occurring in some diseases of the gall bladder, -kidneys, peritoneum or uterus, and are consequently not -<span class="pagenum"><a name="Page_150" id="Page_150">« 150 »</a></span> -characteristic of gastric ulcer. The dyspeptic pain partakes -more of the character of feeling of fullness, a sense of oppression -in the epigastrium, heartburn, etc., such sensations as occur -in catarrh of the stomach and are felt during digestion.</p> - -<p><i>The characteristic pain in ulcer of the stomach is a localized feeling -of soreness.</i> It is not always prominent. Chemical or mechanical -irritation of the ulcer brings it on, or if already present, -aggravates it. Especially acids, both mineral and vegetable, have -this effect, while alkalies allay it. This pain only occurs during -the process of digestion, when the food or gastric juice comes in -contact with the ulcer, or when the stomach is distended with -gas, and tension exerted on the tender spot. During the periods -when the stomach is at rest it does not occur.</p> - -<p><i>Vomiting</i> occurs in about three-fourths of all cases of gastric -ulcer; vomiting of blood, however, only in about a quarter of -all the cases. The latter occurs oftener where the ulcer is -deep. In cases where the stomach is dilated, the amount vomited -may be enormous, and contain food which has been retained -in the dilated portion for several days.</p> - -<p>As a result, also, of the accompanying catarrh of the stomach -and the consequent diminished absorption of fluids, we find -<i>constipation</i> and <i>diminished secretion of urine</i> in cases of ulcer of -the stomach.</p> - -<p>Perforation of the stomach is most frequently caused by -gastric ulcer, and may be said to be a characteristic symptom; -but it usually occurs too late to be made use of in the treatment -of the ulcer. It is occasionally the first symptom which -calls the patient's attention to the fact that his stomach is and -has been seriously diseased. By the agglutinations of the base -of the ulcer with neighboring organs, through inflammatory -processes, perforation can take place into these organs. The -most frequent forms of perforation under such conditions are -those into the liver, spleen or pancreas, but cases have occurred -where perforation into the colon or pleural cavity has taken -place, or even into the pericardium, the heart or lungs. Some -time ago I saw a case of gangrene of the lung, the result of the -perforation of a gastric ulcer into this organ.</p> - -<p>A few days ago I saw an interesting case, where an acute -<span class="pagenum"><a name="Page_151" id="Page_151">« 151 »</a></span> -gastritis culminated in the vomiting of a large quantity of pus. -The patient had been having high fever for a few days, with -incessant vomiting and great tenderness in the epigastrium. -Evidently an abscess had formed in the neighborhood of the -stomach, and finally opened into this organ, with the given -result.</p> - -<p><i>Diagnosis.</i> There are two classes of characteristic symptoms—those -originating from the exposure of nerve-endings, and -those caused by ulceration into bloodvessels. The first class -includes the painful sensations, the characteristic soreness, which -occurs in about four-fifths of all the cases; the second class, the -hemorrhages, occurring in only one-fourth of all the cases. -You can readily see why pain occurs more often than hemorrhage. -Even a very superficial abrasion may expose nerve-endings -to the irritation of the food, while it takes a deeper -ulceration to lay open a larger bloodvessel. In order to make -a positive diagnosis, these two symptoms should be present.</p> - -<p>Vomiting of blood alone need not necessarily be caused by -a gastric ulcer. There are a great many other conditions which -may cause it. It should, however, put you on the guard, and -can, in a great many cases, justify a diagnosis of probable ulcer -of the stomach.</p> - -<p>The localized pain occurs, according to my experience, only -in cases of ulceration of the stomach; that is, in gastric or -peptic ulcer and in cancer of this organ. In order to differentiate -between these conditions, it becomes necessary to observe -whether the patient is cachectic or emaciated or not, and -whether a tumor can be felt in the region of the stomach. But -even these symptoms can be deceptive, as an abnormal hardness -or resistance—the result of perigastritic infiltration—may -occur in cases of simple ulcer, making the diagnosis almost -impossible. This is true especially in cases of ulcer of the -pyloric regions, while ulcers of the anterior wall of the stomach -are rarely accompanied by such infiltrations.</p> - -<p>The pylorus is the most sensitive part of the stomach, and -frequently the seat of pain, when no lesion can be detected -post-mortem. The other parts of the stomach only become -painful when attacked by ulcerative or other pathological processes. -<span class="pagenum"><a name="Page_152" id="Page_152">« 152 »</a></span> -Another point worthy of consideration is that all forms -of pain in the stomach are usually referred to the pyloric region -by the patient, even if they originate in other parts.</p> - -<p>From all this you can see that no positive diagnosis can be -made where any one of these symptoms is presented unaccompanied -by the others. A careful consideration of the symptoms -present will frequently, however, be of aid in making a -diagnosis. Intelligent patients will tell you that they have a -feeling of oppression, a feeling of distress in dyspepsia, but -will describe their feeling as that of distinct pain in ulcer. Pure -neuralgic pain is not always localized, but radiates into distant -parts, is not constant, but sets in all at once and disappears -with equal celerity, sometimes intermitting for days and weeks, -and then again setting in on the slightest nervous excitement. -Such pain is not aggravated by local pressure, shows no relation -to the digestive functions, does not depend upon the quality -or quantity of food taken, and may as well occur during a -fast as during a feast. Often such patients will tell you that -their pain does not cease until they have taken a hearty meal.</p> - -<p>In cases of peptic ulcer, you will find that the pain is in -direct relation to the amount and quality of food taken; that -the patient has little or no pain when the stomach is at rest; -that coarse foods as well as acids cause or aggravate the pain, -and that indifferent foods, such as milk, do not bring it about, -though they may sometimes cause a sense of fullness or oppression. -Some patients with ulcer will tell you that the position -of their body has an influence on their pain. If they are so -placed that the food, by its gravity, lies on the ulcer, the pain -is brought on or increased, while if the patient under such circumstances -then changes his position, he is relieved of his pain -partially, or even entirely. Yes, some such patients must -assume abnormal positions while their stomach is active, in -order to avoid this suffering. Some patients with gastric ulcer -cannot digest <i>any</i> food without great pain, and frequently live -on a very scanty diet, rather than risk taking more food and -enduring these excruciating pains again.</p> - -<p><i>Anomalous Cases.</i> Occasionally cases will occur in which the -symptoms presented do not justify the diagnosis of ulcer of -<span class="pagenum"><a name="Page_153" id="Page_153">« 153 »</a></span> -the stomach, only those of dyspepsia or else of gastric catarrh -being present, while we are still compelled to assume the diagnosis -of ulcer from the result of the treatment. Such cases -resist all kinds of treatment based upon the diagnosis of dyspepsia -or catarrh, and can only be cured by a strict "ulcer -cure."</p> - -<p>Another class of cases only presents gastralgic pain without -any other symptom. Such are frequently patients who have -had gastric ulcer before. Others will come to you with intercostal -neuralgia on the left side. They have, perhaps, tried all -the usual anti-neuralgic remedies, have gone through a course -of treatment by electricity, and spent a large amount of time -and money, without obtaining permanent relief, until some -physician puts them on a strict milk diet and cures them in -this way in a short time.</p> - -<p>Some cases of ulcer of the stomach present the queerest -symptoms. For instance: they complain of pain after drinking -milk, or even after taking a morphine powder, while they can -eat the coarsest food without any harm. Others run along -without presenting any symptoms at all, until they, as well as -their physicians, are surprised by the perforation of a gastric -ulcer.</p> - -<p>All these abnormal cases, which form about one-fifth of all -the cases occurring, are so indistinct that they frequently -remain unrecognized throughout their entire course, and baffle -the skill of the best diagnosticians.</p> - -<p>In order to be able to make a sure diagnosis, there must be -a localized pain, together with tenderness on pressure from -without on the painful spot. A great many persons in good -health are tender in the epigastrium, so that you have to be on -your guard in this direction, too. From the occurrence of -hæmatemesis in an otherwise healthy person you can, with -great probability, diagnose ulcer of the stomach.</p> - -<p><i>Differential Diagnosis.</i> In order to differentiate <i>between catarrh -and ulcer</i>, it is simply necessary to keep in mind the difference -in the character of the pain, the fact that local pressure is more -liable to aggravate the pain in ulcer than in catarrh, and the -<span class="pagenum"><a name="Page_154" id="Page_154">« 154 »</a></span> -occurrence of hemorrhage in the former. The two conditions, -however, frequently occur in the same patient.</p> - -<p>The differentiation between <i>ulcer and neurosis</i> has already been -discussed. The direct connection of the attacks of pain with -the introduction of food, and the character of the pain will soon -clear up the matter. Should you still be in doubt, a course of -treatment, such as an ulcer would demand, will soon clear up -the matter. If the case is one of ulcer, it will have been cured -or materially benefited, if it was a pure neurosis the patient -will if anything feel worse than before.</p> - -<p>By far the most difficult question to decide in making a diagnosis -is whether the case is one of <i>ulcer or cancer</i> of the -stomach. Here close attention to several points will usually -clear up the diagnosis. Cancer sufferers always have a sallow -complexion, a worn, emaciated, cachectic appearance, no matter -what or how much they eat. Ulcer patients frequently have -a robust, healthy appearance, and are emaciated or run down -only after repeated hemorrhages, or when other grave diseases, -such as heart disease, chlorosis, tuberculosis, etc., are also -present.</p> - -<p>The <i>presence or absence of a tumor</i> is a very important aid to -the diagnosis, though as I have already stated, not always reliable. -Sometimes an ulcer may be covered with granulations, -and its surroundings so infiltrated and hardened, that even post-mortem -the naked eye can not tell whether it is cancer or -simple ulcer, and the question has to be decided by microscope. -Such are likely the cases which form the bases of cancer cures -which are reported from time to time to have been effected by -the use of various remedies.</p> - -<p><i>Vomiting of blood</i> is a symptom common to both cancer and -ulcer of the stomach, but is usually more copious in the latter. -If the absence of acid in the gastric juice of cancerous stomachs -proves to be as reliable a symptom as has been recently asserted, -this will be an important feature in the differentiation -from ulcer.</p> - -<p>You will frequently be astonished by the success of your -treatment if you think of ulcer in doubtful cases of stomach -trouble, such as occurs in young girls with chlorosis and institute -<span class="pagenum"><a name="Page_155" id="Page_155">« 155 »</a></span> -a strict milk diet with the measures adopted for the cure of -ulcer.</p> - -<p><i>Prognosis.</i> From what has been said you can see that in -general the prognosis of ulcer of the stomach is good, that with -proper avoidance of all irritation, the ulcer has a tendency to -heal of itself. This tendency has been observed even in large -ulcers, where death was perhaps the result of some intercurrent -disease.</p> - -<p>Ulcers of the anterior wall of the stomach are more dangerous -than such as occur on the posterior wall, for the reason that in -the latter case adhesion with the neighboring structures are -more easily formed, and thus fatal perforation prevented. The -anterior wall takes a much more active part in the peristaltic -movement of the stomach, and as a result does not enter so -easily into adhesion with its surroundings. Even after an ulcer -has healed it always remains a weak point, and cases of rupture -of the stomach in old cicatrices are described by Chiari.</p> - -<p><i>Treatment.</i> The pain is the most important criterion as a -guide during the treatment. It is the signal by which I judge -of the present condition of the ulcer. According to the variation -of its character and intensity, I can judge whether the ulcer -is healing, is remaining stationary, or is spreading and increasing -in size or depth in spite of the treatment. If the pain has been -removed permanently the ulcer has been healed. From the relation -of this symptom to different kinds of food you can also -judge of a progress or improvement of the ulcer.</p> - -<p>Theoretically considered, that form of treatment would seem -the best which gives the stomach absolute rest, entire abstinence -from food, a fast of several weeks. But this can not be carried -out in practice. The patient could be nourished per rectum, -you might say, by means of nutrient enemata. In my opinion -this method of nourishment does not amount to much. I believe -that very little water is absorbed by the rectum, the patient -would suffer from thirst and you would then be compelled to -allow him to drink water at least.</p> - -<p>Luckily we do not need to resort to such extreme measures -in the majority of cases. With the exclusive use of the proper -bland, liquid food, we usually attain the same results. In the -<span class="pagenum"><a name="Page_156" id="Page_156">« 156 »</a></span> -treatment of gastric ulcer I lay the main stress on the restriction -and regulation of the diet, and put the patient on an exclusive -milk diet. Milk contains all the constituents necessary for the -nourishment of the human body.</p> - -<p>I begin by giving every half hour to one hour a small quantity -of skimmed, boiled milk, which has been cooled on ice. -The patient must rest in bed or on a lounge, as he is weakened -by the treatment, and can not follow his usual avocation. I -forbid all other articles of food. With this diet a patient with -ulcer should have no pain and usually has none. Should there -be pain it is necessary to find out whether the feeling described -as such be not simple oppression, or a feeling of weight in the -stomach. Some patients do not seem to digest milk well. It -ferments, forms gases and then they have this feeling of oppression. -Some drink the milk too fast and take too much at a -time, swallowing a lot of air with the milk, thus distending their -stomachs unnecessarily. The patient must be instructed to -drink the milk slowly, and only take a small quantity at a -time (about one or two ounces). Some patients can not stand -iced milk but bear luke warm milk much better. Others seem -to prefer milk which has slightly soured.</p> - -<p>The patients should adhere to this strict diet as long as possible, -regulating the length of time according to the duration -and intensity of the disease. They have to observe the above -rules one or two weeks at least, several weeks if possible.</p> - -<p>Often you will meet with the reply: "I have already tried -this diet, I was put on milk diet once before by Dr. —— and it -did not help me any, I even felt worse afterwards." If you inquire -more closely, however, you will find that they drank milk several -times a day, but ate bread with it, soaking this in the milk. -This is what is understood to be a milk cure. Gentlemen! I -am sorry to say that this misunderstanding is not confined to -the general public, but that some physicians even do not know -better, and consider such a course of diet a milk diet. I cannot -impress it upon your minds any too strongly not to allow yourselves -to be diverted from your purpose by any such assertions, -but to order another course of milk diet, wherever you find it -indicated, and see to it that it is carried out properly this time. -<span class="pagenum"><a name="Page_157" id="Page_157">« 157 »</a></span> -You will thereby occasionally meet with excellent success where -a previous wrong attempt in the same direction failed.</p> - -<p>After the patient has been free from pain from eight to ten -days, I then add to his diet soft boiled eggs with a slight addition -of salt, beginning on the first day with one half of an -egg. If this is well borne I gradually allow more day by day, -until he is able to digest four or five a day without difficulty. -Eggs do not agree with some patients. In such cases I pass on -the use of meat. I have beefsteak chopped fine, roasted in little -meat cakes of the size of a silver half dollar. One of these -is given to begin with, and if well borne repeated every two or -three hours as long as there is no pain. When eggs agree I -prefer to give them for a few days before beginning with the -meat, waiting until such patients can digest four or five eggs a -day. After the meat has been borne well in small quantities -for a while, I gradually increase the quantity taken per day until -it reach a pound or two.</p> - -<p>You cannot be too careful and should instruct the patient to -return to the strict milk diet as soon as any pain is felt, no matter -how nicely he may have been getting along up to the time. -Not until the patient has been entirely free from pain for several -weeks is it advisable to allow the use of cereals boiled in -milk, such as rice or tapioca. Then he can also be allowed to -take a quarter of a biscuit (well baked) at each meal. A full -meal, however, in the sense in which it is ordinarily understood, -a large quantity of food taken at one time, is still to be avoided. -It is better to give small quantities of food oftener, in order not -to distend the stomach, and thus run the danger of too great a -strain upon the newly healed ulcer.</p> - -<p>These meat cakes made of beef can be taken for a week or -so, and then if well borne other kinds of meat may be occasionally -substituted.</p> - -<p><i>Wine and alcoholic liquors in general</i> are to be avoided for several -months.</p> - -<p><i>Beer</i> should never be taken by one who has suffered from -gastric ulcer. In fact it is well for all who have stomach trouble -to avoid the use of beer, especially such as have had ulcer. -Such patients have to be on their guard in matters of diet -<span class="pagenum"><a name="Page_158" id="Page_158">« 158 »</a></span> -through the remainder of their lives, and must avoid excesses -both in eating and drinking. You will occasionally come across -persons who can not stand a milk diet in any form whatever. -They frequently do not bear eggs well. In such cases I proceed -at once, but with great care, to the use of meat in very -small quantities, finally chopped and roasted, and have it taken -several times a day. You will frequently have to try one -article of food and then another, and experiment for awhile -before you reach that form of diet which suits the case best.</p> - -<p>There are a number of <i>substitutes</i>, some of which are really -good, while others are worthless. Of them all I prefer the -fresh meat juice <i>ext. carnis recent. pressum</i>, and have it prepared -in the following manner: The meat (beef should be used) is -cut into thin slices, placed between pieces of tissue paper, and -pressed in a hydraulic press. The juice thus obtained is given -in teaspoon doses every half hour or so, just as though it were -medicine. In the majority of cases I have the meat juice made -by the druggist, so that a large number of the patients think it -is medicine. It has a rather pleasant taste and is well borne by -the stomach. There are a great many <i>peptones</i> in the market, -a large number of which ought not to be used, as they are not -fresh and more likely to do harm than good. Of them all the -English make is the best, as it is usually well preserved, being -packed dry.</p> - -<p>Patients who can only take a small quantity of nourishment -by the stomach can be materially aided by the use of nutritious -enemata given luke warm once or twice a day. When the -rectum is very irritable a suppository containing one-half to -one grain of ext. opii given a half hour before the enema is -very serviceable. There are a great many <i>other remedies</i> recommended -in the text books, but I would advise you not to rely -too much on them. Lay your main stress on the dietetic part -of the treatment, and use remedies only where they are absolutely -necessary to support this. Among the remedies used -the alkalies are the most valuable. Bicarbonate of soda alone, -or in combination with ext. belladonna when the stomach is -very irritable.</p> - -<p><span class="pagenum"><a name="Page_159" id="Page_159">« 159 »</a></span></p> - -<p> -<span style="margin-left: 1em;">℞ Sod. Bicarb., ʒiss.</span><br /> -<span style="margin-left: 2.5em;">Ext. Belladon., gr ii. Misce et div. in pulv. XVI.</span><br /> -<span style="margin-left: 2.5em;">Sig. One in the morning and one in the evening.</span><br /> -</p> - -<p>Or I sometimes substitute atropia sulph. (1/120 gr. pro dosi) -for the belladonna. At any rate the use of alkalies is the most -plausible treatment. But the permanent alkalization of the -contents of the stomach by the frequent use of large doses -of alkalies, as has been recommended in Paris by Debove is not -plausible, as by this the process of digestion would be checked -entirely.</p> - -<p>It is also good to give a dose of Carlsbad salts in the morning -every two or three days, in order to correct the constipation -usually attendant upon such a course of diet. These salts also -aid in rendering the contents of the stomach more alkaline, and -in this way aid the plan spoken of before.</p> - -<p>I do not think it advisable to send patients with gastric ulcers -to <i>health resorts</i> or watering places. They can only regain their -health by a strict enforcement of dietetic measures, and these -can be carried out just as well at the patient's home as at the -health resort. For the treatment of such cases <i>after the ulcer</i> -has healed, these health resorts can be of great benefit, but the -patient must be cautioned not to commit excesses in eating or -drinking, especially to the latter must their attention be called, -as it is customary in most resorts adapted to such cases, to drink -large quantities of the medicated waters in the morning. It is -also well to caution the patients with regard to their diet before -sending them away. This should be unirritating, bland and -easily digestible. Among the European health resorts, Carlsbad -is the most suitable for such cases.</p> - -<p>There are unfortunately some patients who are not benefited -by any method of treatment hitherto thought of, but luckily they -are few, and if you will follow the rules I have laid down you -will in a great many cases meet with splendid results.</p> - -<p>One important question still remains to be answered, namely: -"What should be done in case of hemorrhage of the stomach?" -Here the patient must be left quiet just where he happens to -be—placed in a horizontal position on his back if possible. Ice -bags should be applied to the region of the stomach, small -<span class="pagenum"><a name="Page_160" id="Page_160">« 160 »</a></span> -pieces of ice swallowed, and hypodermic injections of ergotin -given. This is all that can be done with benefit in such cases. -The patient should not be transported for several hours. -Monsel's solution can be of no service, as it cannot be introduced -into the stomach in a sufficient concentration to be of -benefit.</p> - -<p>In cases of perforation of an ulcer all that can be done is to -give anodynes to ease the pain and make the patient's condition -as comfortable as possible. Schlipp recommends that when perforation -is threatened on account of gaseous distention of the -stomach, the stomach tube should be used to evacuate the -organ.</p> - -<p>The mechanical treatment, washing out the stomach with the -stomach tube or stomach pump is contraindicated in cases -of ulcer, as more damage can be done by such procedure than -good.</p> - - -<div class="bdtd bdb"> - -<p class="caption2">ORIGINAL ARTICLES</p> - -</div> - -<p class="caption3">THE RECOGNITION OF MORTIFIED BOWEL IN<br /> - OPERATIONS FOR THE RELIEF OF<br /> - STRANGULATED HERNIA.</p> - -<p class="caption4"><span class="smcap">By REUBEN A. VANCE, M. D., CLEVELAND, OHIO.</span></p> - -<p>The medical practitioner who has been hastily summoned to -operate upon a patient with strangulated hernia finds himself -confronted with problems, the gravity of which can alone be -appreciated by those who have frequently met them. The -medical treatment to be adopted, the extent to which taxis -should be employed, and the time it is prudent to delay operative -interference when other measures have proved fruitless, -are grave questions upon the solution of which the life of the -patient depends. The operation decided upon, the particular -method to be employed and the manner of dealing with the -stricture—with or without opening the sac—are matters of -<span class="pagenum"><a name="Page_161" id="Page_161">« 161 »</a></span> -minor consequence, and affairs that should be settled in the -mind of every practitioner by a reference to sound surgical -principles and the teachings of experience. There are questions -connected with the condition of the parts strangulated -that must be solved by the surgeon during the progress of the -operation, about which much less is said in works on surgery -than their importance warrants. These pertain to the vitality -of the part that has been strangulated, and the duty of the surgeon -in the premises. If the part is still living, it matters not -how much damaged by compression, it should be returned at -once into the abdomen; upon this step the patient's life depends. -If the part is mortified and dead, to return it within -the cavity of the belly is to insure the patient's destruction; if -he is to have a chance for life, other measures must be -adopted.</p> - -<p>Again, the decision of the operator can but rarely be guided -or aided by aught but the conditions revealed by his knife during -the operation. The state of the patient and the history of -the case may indicate the imminence of mortification of the -bowel; in the end the appeal is to the senses of the surgeon, -and upon the conclusion at which he then arrives will depend -the fate of the patient.</p> - -<p>Under these circumstances it behooves every man who may -be placed in position to make such a momentous decision to at -least go to the task, sustained by every aid that can be derived -from the experience of those who themselves have been placed -in this dilemma and compelled to act with such lights as they -then possessed—whose records, next to personal experience, -become the best guide for those forced to follow in their footsteps.</p> - -<p>The history of the case may throw some light upon the state -of the intestine. This is especially so in those cases in which -the severity of the symptoms suddenly subsides without the -rupture having been reduced. The pain is violent, the abdomen -distended and singultus and stercoracious vomiting present; -suddenly the patient's suffering cease, and were it not for the -cold extremities, flickering pulse and persistent tumor—but -above all, the teachings of experience—the surgeon could not -<span class="pagenum"><a name="Page_162" id="Page_162">« 162 »</a></span> -but acknowledge that all tangible appearances portended a -change for the better. Yet, almost invariably gangrene of the -gut has taken place, and the fallacious evidences of improvement -above noted are in reality its best clinical exponent. -Certain almost as these signs are, when present, yet it comparatively -seldom happens that the surgeon has their aid in guiding -him in the measures he must adopt; they form, but infrequently, -a part of the history of cases submitted to operation. -If present, the surgeon is reasonably sure of what he will find -when he operates; they may be absent and mortification yet -exist. The patient's chance of life depends upon the surgeon's -ability to recognize mortification of the bowel when he sees it, -and his promptitude and skill in dealing with it when present.</p> - -<p>It scarcely need be said that mere darkening in color of the -bowel, effusion of fluid into the sac, or exudation of lymph -about the stricture are of no special significance in this connection, -and bear in no way upon the presence or absence of mortification. -It has been again and again repeated in manuals -treating of hernia operations that a deep, purplish discoloration -of the bowel and absence of circulation indicate mortification; -that when these physical signs are present the surgeon should -press upon the strictured part, and if the color remains unchanged -when the finger is removed, the bowel is dead. It -requires but little practical experience in dealing with these -cases to appreciate the fallacious character of these signs; the -gut may be fairly black from congestion and yet alive; the -color may remain unchanged under pressure and still that fact -have no bearing on the question of mortification, for a band of -stricture, as yet unappreciated, may be the sole cause of the -persistent hyperæmia.</p> - -<p>It is quite different as regards certain other signs, especially -when two or more of them are seen in conjunction. <i>If the -bowel be dark and mottled with grayish spots, of contracted and -shrivelled aspect, with a slight amount of discolored fluid surrounding -the gut, and a cadaveric odor apparent when the sac is opened</i>, -mortification is certainly present, and the return of the strictured -part within the abdominal cavity dooms the patient to -certain death. The surgeon's duty is to open the sphacelated -<span class="pagenum"><a name="Page_163" id="Page_163">« 163 »</a></span> -gut, apply a poultice and favor the relief of the obstructed -bowel by a free discharge of the intestinal contents through the -outlet thus formed. An artificial anus is thus established, and -the patient, for a time, must be content with this deformity; -fortunately it is a condition susceptible of relief, and the surgeon -may ultimately free his patient of even this defect.</p> - - -<hr class="chap" /> - -<p class="caption2">JABORANDI AS A GALACTAGOGUE.</p> - -<p class="caption3">JOHN H. LOWMAN, M. D.</p> - -<p class="caption4">Professor of Materia Medica in the Medical Department of the Western Reserve - University.</p> - -<p>There is a decided difference of opinion among therapeutics -as to the effect of jaborandi on the mammary gland. Some -claim that it has no effect upon the gland. Some claim that it -assists in increasing the secretion of milk.</p> - -<p>This note is made to show the action of jaborandi as a galactagogue -in the recent puerperal state. The preparation used -was the fluid extract obtained from Squibb & Co.</p> - -<p>M. S., age thirty-five years, a multipara, of fair health, -not well nourished. The babe was two weeks old at the time -of this observation, and in good condition. The secretion of -milk by the mother began gradually to fail until not one-third -the average quantity was produced. The child was then nourished -artificially. The fluid extract of jaborandi was given -to the mother. The dose was eight minims every three hours. -About fifty minims were taken in twenty-four hours. On -the second day of the administration of the drug the milk -increased in quantity. By the third day it had increased still -more, so that the child had nourishment from the mother sufficient -to satisfy it. Increased salivary and cutaneous secretions -led to a discontinuance of the drug. The milk flowed in good -quantities for eight days, and then rapidly diminished. Jaborandi -was again used. The plan of administration was the same. -Increase of the milk was again noted. The renewed activity of -the mammary glands continued for five or six days only. For -<span class="pagenum"><a name="Page_164" id="Page_164">« 164 »</a></span> -a third time the drug was used, and its use followed by good -effects. In the meantime the nourishment of the mother had -been pushed. Iron, quinine and mineral acids were also given. -The general health of the patient improved. After the last -increased activity the secretion of the gland remained normal -for three weeks, after which the patient passed from observation. -During the last two weeks no jaborandi was used.</p> - -<p>Whereas in this case the improved condition of the individual -was responsible for the permanent increase in the supply of -milk, the use of the jaborandi and the temporary increase were -apparently more than coincidental. During the first two -stimulations the quality of the milk deteriorated; the quantity -of cream diminished; the specific gravity fell; no microscopic -examination of the milk was made. After the last increase in -the activity of the glands the quality of the milk was good.</p> - -<p>Two similar cases were noted. B., aged nineteen years, -primipara, had a tedious labor. She recovered slowly. She -was well nourished and has previously been well. At the end -of the second week of convalescence the milk began to fail. -Jaborandi was used as in the case just cited. Marked improvement -in the milk was noticed the second day the drug was -given. On the fourth day the medicine was omitted. The -milk continued to flow in sufficient quantities for ten days. -The quantity then gradually and rapidly diminished. The -medicine was again given for four days with the desired effect, -which remained for the following ten days that the patient was -under observation.</p> - -<p>D., age twenty-five years, a multipara, was a poorly nourished -person, the mother of two children. The confinement -was normal. The milk failed soon after its appearance. Following -the use of jaborandi the milk increased rapidly in quantity, -but diminished in three days on withdrawing the drug. -The milk continued to respond to the jaborandi for the four -weeks that the patient was under observation, but no permanent -result was obtained.</p> - -<p>On three other cases the jaborandi was used with scarcely -perceptible effect or no effect at all. From a few cases it is impossible -to generalize with expectation of a truthful conclusion. -<span class="pagenum"><a name="Page_165" id="Page_165">« 165 »</a></span> -We can, however, know that the jaborandi has an effect on the -mammary gland, and causes an increase of the milk in puerperal -women. This effect is by no means a constant sequel to -the administration of the drug. As far as my observation is -concerned the effect of jaborandi is temporary, and can be useful -only where there is a tendency in the gland to assume its -normal function. This tendency may at times be subordinated -to general influences and even entirely subdued. In such conditions -a timely stimulation of the gland may tide over the -threatening arrest of function. Variation in the activity of the -mammary gland, especially in the early puerperal state, is not -unusual. The close relation of the increase of milk and the -use of jaborandi justifies, however, the assumption of effect and -cause.</p> - -<p>No effect was observed on the children. Jaborandi is excreted -by the mammary glands, and it was consequently withheld -as soon as practicable, lest the child should feel its -presence.</p> - - -<hr class="chap" /> - -<p class="caption2">INDICATIONS FOR OPENING THE MASTOID PROCESS.</p> - -<p class="caption3">BY A. R. BAKER, M. D., CLEVELAND, OHIO.</p> - -<p>The operation of opening the mastoid process is said by -some to have been first performed by Riolan in 1649; according -to others, by Petit in 1750, and later by Jasser, in 1776. -During the latter part of the eighteenth century the operation -was performed frequently without definite pathological indications. -But after the unfortunate death of the Danish physician -Berger (1791) the operation was very seldom or never performed -until 1864, by Mayer, following the suggestions made by -Tröltsch some years previous. Berger, for chronic deafness without -suppuration of the middle ear, had the operation performed -upon himself, and died on the twelfth day from meningitis. -During the past twenty years the operation has taken its place -as one of the recognized surgical proceedings owing to the -<span class="pagenum"><a name="Page_166" id="Page_166">« 166 »</a></span> -work of the German physicians Moos, Jacobi, Hartman, Bezold, -Schwartz and others, who have laid down the real indications -for the operation from their extensive clinical observations and -pathological researches. The American otologists, Roosa, -Agnew, Buck and others were among the very first to perform -the operation, and have done much to establish its claim to -recognition. And yet it is somewhat remarkable that some of -our text books barely mention the operation; and as short a -time ago as 1883, Strawbridge, at the meeting of the American -Otological Society, said that he had seen over four thousand -cases of purulent middle ear disease within twelve years, and -yet had not trephined in a single case; and several other authorities -looked upon the operation as a questionable one. Knapp -took decided grounds in favor of the operation, and cited three -fatal cases in which he believed an operation would have saved -life. Kipp had seen quite a number of fatal cases in which -the post-mortem had shown the mastoid cells filled with pus, -which had given rise to cerebral abscess. Dr. C. H. Burnett -reported a fatal case which died from pyemia, and he thought -if his patient had been operated a year before his life would -have been saved.</p> - -<p>Gruening said surgery has established that wherever there -is a focus of purulent discharge it should be removed. This, -(removal of the focus) is a life-saving operation and should be -done under all circumstances. Dr. Roosa said that he believed -the revival of this operation of opening the mastoid process has -saved many lives. Since his first operation not a year has passed -that he has not found it necessary to repeat it several times. -He says further that "it is true that we shall seldom need to -open the mastoid if an experienced practitioner sees a case of -acute aural disease early in its course. It is an operation for -neglected cases, where suppuration has been allowed to advance -from the tympanic cavity in consequence of not having a free -outlet through the drum-head. But purulent inflammation of -the mastoid may occur in acute cases that have been thoroughly -treated by leeching, poultices, rest, etc., from the start."</p> - -<p>The most recently stated indications for opening the mastoid -process are:</p> - -<p><span class="pagenum"><a name="Page_167" id="Page_167">« 167 »</a></span></p> - -<p>1. Purulent inflammation in the mastoid process appearing in -the course of suppuration of the middle ear when persistent -severe pain in the bone cannot be subdued by the application -of the ice-bag, leeches, or by Wilds' incision. (Schwartz).</p> - -<p>2. Painful inflammation in the mastoid process occurring in -acute and chronic suppuration of the middle ear, in consequence -of growths filling up the external meatus or the tympanic -cavity. When attempts to remove the obstacle to the free -escape of pus have failed, the operation is imperative. (Grüning). -The operation is indicated even though the soft parts over the -mastoid are not swollen or infiltrated. (Politzer).</p> - -<p>3. When the posterior superior wall of the meatus is bulging, -and when after incision the abscess is not emptied and the -symptoms of retention of pus continue. (Toynbee, Duplay).</p> - -<p>4. Persistent pain and tenderness in the mastoid process -lasting for days or weeks, in which there is probably an osseous -abscess not communicating with the tympanic cavity. (Politzer).</p> - -<p>5. In every suppuration of the middle ear combined with -inflammation of the mastoid process in which fever, vertigo and -headache are developed during the course of the affection, -which may indicate a dangerous complication. In such cases -the indication for the operation is vital. (Politzer, Roosa, Buck.)</p> - -<p>As to the time when the operation should be performed, -writers do not agree. While one proposes that the operation -should be done as soon as there are symptoms of inflammation -of the mastoid process, another defers it till the dangerous -symptoms (fever, headache, vertigo, etc.,) set in. The latter -proposal must not be followed, as in many cases it would be too -late; on the other hand, many cases will recover without an -operation. As far as it can be formulated, I would say that in -a given case of acute purulent inflammation of the mastoid process -I would first apply leeches, poultices, cathartics, antiflogistics. -If the inflammation is not promptly subdued, I would -make a Wilds' incision, including the periosteum, if the bone is -found softened; or if a fistulous opening is found, this should be -enlarged at once. If the bone is found healthy and not roughened, -if there is no fever, vertigo, headache, etc., I would wait -<span class="pagenum"><a name="Page_168" id="Page_168">« 168 »</a></span> -a few days; if the symptoms, pain, tenderness, etc., do not -subside, I would then perforate the mastoid process.</p> - -<p>For the performance of the operation trepans were formerly -used, which were replaced by drills which are still used by -Buck, Jacobi, Lucae and others, but by most operators they -have been set aside, owing to their uncertain and dangerous -advance in the deep parts, and on account of their soiling the -wound with splinters. The most rational and safe method is -by means of the chisel, as recommended by Schwartz, and is -performed as follows: The patient being anæsthetized, a -perpendicular incision beginning a little above the linea temporalis, -extending an inch and a half in length immediately behind -the attachment of the auricle. Formerly I employed a -straight incision, but recently have followed the suggestion of -Politzer, and from the superior end of the perpendicular incision -a second one is made backward at right angles, thus forming -a flap, which I have found to simplify the operation very -much, as it affords a better view of the locality and extent of -any pathological changes which may have taken place, and -gives more room for operative procedures, and the periosteum -can readily be removed to any desired extent. The linea -temporalis and the more or less strongly developed protuberance -on the posterior superior orifice of the osseous meatus, so -strongly urged by authors, are very nice guides theoretically or -to point out on an exceptional skull in the class room, but -practically are seldom well enough developed to be of any -use to the operator. The best guide to go by is to take -the superior wall of the meatus as the upper boundary, and -the angle formed by the plane of the mastoid with the posterior -wall of the external meatus for the anterior boundary when opening -the mastoid. This is best determined by pressing the -finger into the meatus. Often in children, and when the bone is -diseased in adults, the cortical plate of bone can be removed -with the hand chisel, and we come at once upon the pus cavity, -or diplœ, or cholesteatomatous epidermic masses, or a sequestrum -of dead bone, or bleeding granulation tissue, or whatever the case -may present. Sometimes the external plate is very thick and -we have to chisel our way carefully for almost half an inch -<span class="pagenum"><a name="Page_169" id="Page_169">« 169 »</a></span> -before reaching the diplœ, or may find the entire mastoid process -sclerossed. No absolute rule can be given as to the depth -it is safe to penetrate. Schwartz says "never to go deeper -than 25 mm." Buck says "it is better to place the extreme -limit at 20 mm," about three-fourths of an inch.</p> - -<p>Although I do not consider the operation a particularly -dangerous one, especially with the chisel where we can watch -each step of the operation; and even though we opened into the -lateral sinus or the duramater, the injury would not be necessarily -fatal. Yet I would not advise any one to attempt it (unless the indications -are imperative) who has not performed the operation -on the dead subject. Politzer says "no one should operate -on the living before having performed the operation at least -forty or fifty times on the dead." I cannot close this article -better than in the words of Dr. St. John Roosa, to whose admirable -work I am indebted for a large portion of this article.</p> - -<p>"Yet, hesitation, when the way is plain, or when the chances -are largely on the side of the necessity of the removal of pus, -cannot be too sternly condemned. No drug has yet been discovered -which can be substituted for the scalpel or trephine -when pus has actually formed in the mastoid cells. I wish, -however, to repeat what I have said before on the subject of -surgical operations. I am in full accord with the great English -surgeon, Sir James Paget, who, in his admirable lectures, -expresses many times his hesitation to perform any surgical -operation, however trivial, that is not absolutely required. We -have no right, I think, to perform operations to clear up doubtful -diagnosis. If in case the operation proves to have been -unnecessary, the patient will be decidedly the worse for it. If -we put ourselves in the place of our patients, what we may -regard as a trifling thing—"a mere cut"—will not be so -esteemed. A mere cut, when unnecessary, may have the most -serious consequences, and all the history and symptoms should -be carefully weighed before even that is undertaken. Such -care will never prevent prompt, rapid and thorough surgical -interference when demanded.</p> - -<p>In teaching medical students, I have always found them, -when fully awakened to the dangers of neglecting certain diseases, -<span class="pagenum"><a name="Page_170" id="Page_170">« 170 »</a></span> -to be more apt to do too much than too little, especially -with the knife and active drugs. It is possible, also, that the -crying ignorance and neglect of the previous decades in regard -to the treatment of aural disease has had a tendency to cause -us, who see many of the afflictions of the ear, to lean toward -the side of surgical operations upon the drum, head and mastoid. -This is a leaning no less dangerous to the cure of some -cases than was the steering toward Scylla or Charybdis to the -safe navigation of ancient mariners."</p> - - -<hr class="chap" /> - -<p class="caption2">A CASE OF ANOMALOUS DEVELOPMENT OF THE<br /> - ANTERIOR PILLARS OF THE SOFT PALATE.</p> - -<p class="caption3">BY B. L. MILLIKIN, M. D.,</p> - -<p class="caption4">Oculist and Aurist to Charity Hospital, Cleveland, O.</p> - -<p>Some time since, Mrs. G. D., age about 23, applied to me -on account of deafness and tinnitus of both ears. In pursuing -my examination I found the following unusual anatomical relations -of the anterior pillars of the soft palate, which I deem -not unworthy of record.</p> - -<p>The uvula and posterior border of the soft palate are normal -in appearance and formation; but, beginning about the middle -of the anterior pillars, these gradually widen out into thick, -heavy, broad, muscular folds, which attach themselves firmly -to the sides and dorsum of the tongue, extending two or three -lines upon the dorsum. They seem to be intimately connected -with the muscle of the tongue itself, making them very firm. -The posterior pillars are much less well developed than the anterior, -and do not control or prevent the drawing forward of -the soft palate when the tongue is protruded. The tonsils are -small in size but normally located.</p> - -<p>The attachments of these bands give a peculiar appearance -to the throat. When the tongue is in a state of rest, in the -bottom of the mouth, or, better still, when the tongue is depressed, -these bands hang like two large curtains, narrowing -<span class="pagenum"><a name="Page_171" id="Page_171">« 171 »</a></span> -very much the faucial opening. When the tongue is protruded -they are put upon the stretch, and narrow very greatly the -faucial opening by drawing forward and downward the whole of -the soft palate, so that the posterior border of the soft palate -and uvula rest firmly upon the dorsum of the tongue. When -the tongue is thus protruded the attachments of these membranes -are brought forward almost to the teeth.</p> - -<p>In a state of relaxation there is formed back of these folds, -on either side, quite a deep cavity, which often collects quantities -of solid food, to the great annoyance of the patient. She -even sometimes is obliged to remove these obstructions with -the fingers, or, by gulping or swallowing frequently, is able to -dislodge them. She has no difficulty in swallowing liquids.</p> - -<p>There is some impediment in her speech, a peculiar lisping -as if she did not have good control of her tongue, which she -has always attributed to the fact that she is of German parentage. -Her English is, however, very good, other than as above -indicated.</p> - -<p>In looking up what anatomical literature is at my command, -I find no reference to any anomalies of this kind, although I -have been able to consult the standard French, German and -English works on general anatomy. I myself have never seen -a case with an anatomical construction approaching this, so I, -therefore, present it for record.</p> - - -<hr class="chap" /> - -<p class="caption2">HINTS ON VOCAL TRAINING—THE BREATH.</p> - -<p class="caption3"><span class="smcap">By BERNARD W. FISHER, A. M.</span></p> - -<p>The prevalence of throat troubles is so marked in America, -and by no means least so in this city, that if one hundred individuals, -collected at random, had their throats examined, it is -probable that four out of every five would be found to have -these delicate organs more or less affected. Whatever cause -may be assigned by the medical expert in each particular case, -the importance of a thorough mastery of the art of correct -<span class="pagenum"><a name="Page_172" id="Page_172">« 172 »</a></span> -breathing can hardly be insisted upon too strongly. If it be -urged that the widely distributed works of Behnke and others -must have put an end to any general ignorance of the importance -of this branch of vocal training, I can only reply that a -defective style of breathing is by no means uncommon even in -public singers, while among amateurs it is so rare that a perfect -management of the breath excites in a critical observer a feeling -of gratified surprise. The name and works of Behnke -have, of course, been known in this country for a considerable -time, but some of his statements are too striking to be omitted -in an article on this subject. When lecturing at the Tonic -Sol-fa College, London, he took ten students and measured -their lung capacity in cubic inches, by means of the spirometer, -with wrong or "collar-bone" breathing. He then showed -them how to breathe correctly, that is, midriff and rib breathing. -The average increase among the ten was twenty-five cubic -inches of air; the least increase twelve inches, and the greatest -forty-five. He adds: "I imagine that these figures are more -eloquent than any words, and I think it superfluous to make -any further comment on them."—('Mechanism of the Human -Voice,' page 20.) Now, putting aside the extreme increase of -forty-five inches, let anyone consider what an increase in lung -capacity of twenty-five cubic inches of air must mean to the -vocalist in the execution of difficult passages, to the speaker -using his voice by the hour, and, lastly, to the running athlete. -It will surprise a young man commencing vocal training to -inform him that, at the same time, he will become a better man -in the gymnasium and the race; but unless good lungs are an -advantage to the athlete in name only, the above figures tell -their own tale. I may add that, in teaching young men and -boys, I always put this view of the subject before them, knowing -that it will be an incentive to their acquiring a thorough -mastery over the interesting art of "taking breath."</p> - -<p>Correct breathing cannot <i>cure</i> disease. The medical expert -must do that. But it will <i>prevent</i> disease; and when the throat, -under proper treatment, has been brought to a healthy state, it -will assuredly be the chief means of keeping it in that condition. -The following is a striking instance to the same effect:</p> - -<p><span class="pagenum"><a name="Page_173" id="Page_173">« 173 »</a></span></p> - -<p>Some years since, an English clergyman had to give up all -ministerial duty from "Clerical Sore Throat." Acting under -the absurd advice of a London teacher of elocution, he resided -in Spain for five years without the slightest benefit. He then -returned, and at the house of the elocutionist who had made -him an exile saw a copy of Behnke's celebrated work. Coming -to the conclusion that the author must be rather clever, he at -once consulted him. Following his advice he had his throat -made medically sound by Lennox Browne, and then took the -usual course in breathing and voice production under Behnke. -A short time after I was with Herr Behnke, when a post card -arrived from the clergyman: "I preached yesterday in Chichester -cathedral, and was congratulated on the strength of my -voice and the ease with which I filled the building."</p> - -<p>A few weeks since I heard a sermon in a Cleveland church. -The preacher took short "collar-bone" breathings, using -twice the power necessary for the building, and towards the -conclusion was in evident distress (which naturally communicated -itself to his hearers), a failing voice and perspiring face. -If before entering the ministry he had learned to breathe and -use his voice properly, such troubles could never have -existed.</p> - -<p>There is yet another unpleasant affliction which correct -breathing will rarely fail to cure, a high-pitched and effeminate -voice in a man. I quote again a case from the same work:</p> - -<p>Mr. M——, a tall, thin young man, engaged in evangelistic -work, suffered from "weakness of voice." He spoke chiefly -in a "child voice," over which he had very little control. His -breathing power increased by sixty cubic inches in two lessons. -"In one week more," adds Herr Behnke, "I could dismiss -him with a full, sonorous man's voice in place of the uncertain -child's squeak with which he had come to me."</p> - -<p>I must lastly point out that the cure of stammering often -entirely depends on the management of the breath, and in all -cases it must be an important agent.</p> - -<p>The limits of this paper allow but a brief notice of the best -course for a breathing instructor to follow. Let the pupil lie -down on his back, place the hand lightly on the lower part of -<span class="pagenum"><a name="Page_174" id="Page_174">« 174 »</a></span> -the lungs, and tell him to inhale easily through the nostrils, -allowing the air to fill the lower part of the lungs, avoiding all -motion of the shoulders and heaving up of the chest. When -the lungs are fully inflated count four with deliberation, and let -the pupil inhale all the air as suddenly as possible. Gradually -increase the counting week by week up to twelve, which marks -a real control over the unused muscles. The next course is for -the pupil to inhale suddenly and exhale slowly. The instruction -given is of necessity meagre, but it need hardly be pointed -out, no written directions can take the place of personal teaching. -From four to six weeks is usually sufficient for the young -and vigorous to gain command over the breathing apparatus; -older pupils have sometimes great difficulty in mastering the -muscles, unruly through disuse.</p> - -<p>Herr Behnke allows no use of the voice beyond ordinary -speaking while the breathing exercises are going on. I have -followed this rule much modified, and do not find the results -unsatisfactory.</p> - -<p class="pmb4">The total neglect of this important subject in both American -and English schools is to me perfectly astounding. Half an -hour a week for three months would be ample for the purpose. -These few hours would confer a benefit of the highest value, -and lasting a lifetime.</p> - -<p><span class="pagenum"><a name="Page_175" id="Page_175">« 175 »</a></span></p> - - - - -<div class="fig_center" style="width: 376px;"> -<img src="images/title2.png" width="376" height="50" alt="The Cleveland Medical Gazette." /> -</div> - -<p class="caption2"><i>A MONTHLY JOURNAL OF MEDICINE AND SURGERY.</i></p> - -<hr class="r20" /> - -<p class="caption4"><span class="smcap">One Dollar per Annum in Advance.</span></p> - -<hr class="r20" /> - -<p class="caption4">All letters and communications should be addressed to the<br /> -<span class="smcap">Cleveland Medical Gazette</span>, No. 5 Euclid Avenue, <span class="smcap">Cleveland, Ohio</span>.</p> - -<div class="fig_left">A. R. BAKER, M. D., <i>Editor</i>.</div> -<div class="fig_right">S. W. KELLEY, M. D., <i>Associate Editor</i>.</div> - -<div class="bdtd bdb" style="clear: both;"> - -<p class="caption2">EDITORIAL.</p> - -</div> - -<p>We have mailed the <span class="smcap">Gazette</span> regularly to a number of our -friends who have not remitted their dollar. We hope they will -do so soon.</p> - - -<hr class="chap" /> - -<p class="caption3">MEDICAL DEFENSE ASSOCIATION.</p> - -<p>Last month we urged the necessity of the profession organizing -a medical defense association. We publish this month -the proceedings of the Chicago Medical Society, in which the -same question is discussed very fully.</p> - - -<hr class="chap" /> - -<p class="caption3">STATE SOCIETY REORGANIZATION.</p> - -<p>The editor of the Cincinnati Medical Journal asks the secretaries -of local societies to bring the matter before their respective -organizations, and suggests that they invite expression -upon the following propositions:</p> - -<p><span class="pagenum"><a name="Page_176" id="Page_176">« 176 »</a></span></p> - -<p>1. To so change the constitution of the State Society as to -make the members of county societies members of the State -Society simply by virtue of their local membership.</p> - -<p>2. Present members of the State Society to remain members -without reference to membership in local societies.</p> - -<p>3. All members to stand upon an equal footing, thus doing -away with the delegate system.</p> - -<p>4. All papers to be presented to the State Society must -first be presented to the local society, by which it may be -referred to the State Society.</p> - - -<hr class="chap" /> - -<p class="caption3">MEDICAL PRACTICE BILL.</p> - -<p>A bill to establish a medical board of examiners and licenses, -and to regulate the practice of medicine and surgery in the -State of Ohio, and to define the duties and powers of such -board, will be presented to the Legislature of Ohio. It provides -for:</p> - -<p>1. A mixed board so far as schools are concerned.</p> - -<p>2. No attache of a medical college is eligible to a place on -the board.</p> - -<p>3. All candidates for the practice of medicine in Ohio shall -submit to an examination by this board.</p> - -<p>4. None but graduates in medicine and surgery shall be eligible -to examination.</p> - -<p>5. Licenses may be refused or revoked for criminal or dishonorable -conduct.</p> - -<p>6. Graduates at present practicing in the State may continue -without submitting to an examination, but must register in the -office of the probate judge.</p> - -<p>These are the essential features of the bill, and on the whole -good. It does not interfere with physicians already in practice, -which has caused the failure of nearly every bill presented to -the Ohio Legislature becoming a law. Excluding college professors -from becoming members of the board is fair to the profession, -and saves the bill from being the tool of the medical -colleges, unlike the Pennsylvania law, and yet it does not -<span class="pagenum"><a name="Page_177" id="Page_177">« 177 »</a></span> -ignore the medical schools entirely as educational and graduating -bodies, like the Illinois and West Virginia laws. It is -impracticable, even if desirable, to ignore denominational lines -in medical legislation.</p> - -<hr class="chap" /> - -<p class="caption3">PHYSICAL EXAMINATION OF YOUNG GIRLS.</p> - -<p>The following remarks were made by the president of the -Royal College of Physicians, December 28, and were the result -of an inquiry into the conduct of Dr. Haywood Smith, by the -college, for having physically examined the girl, Eliza Armstrong, -without the consent of parent or guardian:</p> - -<p>"It is, in the opinion of this college, a grave professional -and moral offence for any physician to examine physically a -young girl, <i>even</i> at the request of a parent, without having first -satisfied himself that some decided medical good is likely to -accrue to the patient from the examination, and, also, without -having first explained to the parent or legal guardian of the -girl the advisability of such examination in general and the -special objections that exist to their being made. Moreover, -the college feels that a young girl should on no consideration -be examined, excepting in the presence of a matron of mature -age, and, so far as the physician knows, of good moral character...." -The rest of the remarks were put direct to -Dr. Smith, and are of no general interest.</p> - -<p>The decision of the college was favorable to Dr. Smith; his -name was <i>not</i> erased from the roll.</p> - - -<hr class="chap" /> - -<p class="caption3">SUET BANDAGES.</p> - -<p>"These are admirable for dressing. You can make them -by melting mutton tallow over a slow fire. Have your -bandages of close cloth, ready cut the proper length -and breadth, dip them into the suet; when saturated, hold them -so as to let them drip off, or the grease may be spread upon -the cloth. Hang them over a line where they may be protected -from dust; let them cool, fold them, put away for use. -<span class="pagenum"><a name="Page_178" id="Page_178">« 178 »</a></span> -These bandages are especially adapted to dress old ulcers and -wounds. They are smooth and adapt themselves perfectly to -the surface; are agreeable to the patient, and can be medicated -with any therapeutical agent you wish."—<i>American Medical -Digest</i>, quoting Dr. Edwin Brock in <i>New England Medical -Monthly</i>.</p> - -<p>A disadvantage of the tallow bandage is its becoming rancid. -Vaseline, not becoming rancid, has been tried, but melts too -easily. For most purposes the wax bandage is as good as the -tallow, perfectly smooth and does not become rancid, but -cannot very well be medicated. A useful material for a bandage -of this kind is the paraffine, as recommended by Tait.</p> - -<p>The tallow bandage can be put to another use by those who -do not live convenient to an instrument dealer. When made -wide the tallow bandage can be rolled into a very good rectal -bougie, large or smaller as you wish by a few more or less -thicknesses of the cloth. By the same means a very good -vaginal dilator can be extemporized for cases of stricture or -vaginismus. But where it is to remain long <i>in situ</i> for these -cases beeswax or a mixture of beeswax and tallow, which are -generally available in the country, make a better substitute. -"Cere cloth" was formerly much used by gynecologists.</p> - -<hr class="chap" /> - -<p>We observe that Dr. Piffard has retired from his editorial -connection with the Journal of Cutaneous and Venereal Diseases. -The Journal will be continued under the sole editorial -charge of Dr. P. A. Morrow. We may remind our readers -that this is the only publication in the English language devoted -to Skin and Venereal Diseases, and during the three years of -its existence it has won for itself a high reputation for scientific -excellence as well as practical utility. In addition to presenting -all that is new and valuable in these special departments, -the colored lithographs and wood engravings with which the -original articles are illustrated are worth more than the price of -subscriptions. Judging from the handsome appearance of the -January number, which is enriched by an admirable chromo-lithograph -and a number of well-executed woodcuts, and the -eminently practical character of its contents, this high standard -will be maintained in the future.</p> - -<p><span class="pagenum"><a name="Page_179" id="Page_179">« 179 »</a></span></p> - - - - - -<p class="caption2">SOCIETY PROCEEDINGS.</p> - -<hr class="chap" /> - -<p class="caption3">CHICAGO MEDICAL SOCIETY.</p> - -<p class="caption4">OFFICIAL REPORT.<br /> - -<i>Stated Meeting, January 18th, 1886.</i><br /> - -<span class="smcap">President pro. tem., D. W. Graham, M. D., in the chair.</span></p> - -<p>Dr. E. J. Doering read a paper entitled</p> - -<p class="caption3">MUTUAL PROTECTION AGAINST BLACKMAIL.</p> - -<p>The author stated that among the many trials which physicians -have to encounter in the practice of their profession is -the ever-existing liability of being blackmailed. This may -either assume the more frequent form of a so-called malpractice -suit, or the relatively less frequent charge of a criminal assault, -according to the viciousness of the complainant. Such suits -against physicians are increasing. One reason quoted was the -fact that every city is overrun with petty lawyers, who have -little or nothing to do, and are always willing to encourage any -suit whatever, if there be the least prospect of getting something -out of the defendant. The author stated that since investigating -the matter he became convinced that many of these blackmail -schemes were settled before being made public. Many a physician -preferred being robbed of one or two hundred dollars, rather -than incur the publicity, the loss of time and the endless expense -of a lawsuit. Again, the average jury, composed of the ignorant -and illiterate, will always have a strong leaning toward the complainant -and against the defendant in a malpractice suit, as -physicians are popularly supposed to be capitalists. The author -stated that personally he had never been sued or even threatened -with a suit, and it was therefore from no motive of selfish -interest, but from a sincere regard for the welfare of the profession, -that he advocated the formation of an association for the -mutual protection of physicians against blackmailing suits of all -<span class="pagenum"><a name="Page_180" id="Page_180">« 180 »</a></span> -kinds. His plan is to organize a society composed of two or -three hundred members of the regular profession, all of whom -shall be of acknowledged ability, possessing a good moral character -and standing in the community. Said association to employ -the best legal talent attainable, by the year, to furnish the -members such legal advice as they may desire at any time and -defend any suit against the members arising in the discharge -of their professional duties. It was stated that the expense to -each member of an association composed of about two hundred -would not exceed five dollars per annum, and that an initiation -fee of five dollars would create a sufficient fund for court expenses. -Such an association would be a power in preventing -suits. Let it be known that the individual physician is backed -by the financial and moral support of a few hundred of the best -physicians, and aided by the best legal talent obtainable, and he -will be let severely alone by the offscouring and dregs of society -who constitute, almost without exception, the blackmailing element -in our professional life. The author stated that he was -not aware of the existence of such an association as the one proposed -in any other city, but the principle at least has been -carried out recently by the New York County Medical Society, -in voting $500 to assist in the defense of the Drs. Purdy, members -of the Society, in the case of Brown <i>vs.</i> Purdy. After -reading a number of letters from prominent physicians in favor -of forming a protective association, and presenting several legal -opinions sustaining the advisability, practicability and legal status -of such a society, the author concluded by stating his firm belief -that such an association for mutual protection was needed, -that it would be a power for good, that it would draw the profession -closer together, that, in short, it would be based on the -principles of a common brotherhood, viz.: equality, harmony, -justice and unity.</p> - -<p><span class="smcap">Dr. F. C. Hotz</span> said that the extract of his letter to Dr. -Doering, which was incorporated in the paper, indicated that at -the time it was written he did not think favorably of the project. -And, after listening with much interest to the doctor's -arguments, he saw no reason for changing his opinion. Professional -reputation and honor is the most personal of all personal -<span class="pagenum"><a name="Page_181" id="Page_181">« 181 »</a></span> -property; if he lost it, it does not hurt anybody but -himself, and therefore if any attack be made on it he should -certainly wish to employ among the able lawyers the one in -whose ability he had the greatest confidence. But he was not -sure whether the lawyer retained by this protective union would -be the one to whom he should like to trust the defense of his -reputation. The attorney might be able, or abler, than the -lawyer of his own choice; but should the case go against him, -he should never feel satisfied that the lawyer had done all that -could be done for him unless he had full confidence in him. It -is with the lawyer as with the physician, a question of confidence, -and his patrons find no fault with his treatment as long -as they have implicit faith in his ability.</p> - -<p>An objection of greater weight, however, has been urged by -several of the doctor's correspondents in asking what possible -effect it might have if the fact was brought out in court that the -defendant belonged to such a union? The lawyers whose opinions -were obtained and read by the doctor, say it cannot legally affect -the case. There is no doubt but what this is true. But the -verdict of a jury in malpractice suits is not determined by the -legal aspect of the case; and circumstances which cannot have -any legal effect upon the case have often made a deep impression -upon a jury and decided the case against the physician. -To illustrate: In Dr. Bettman's first trial, the experts of the -prosecution testified so unreservedly in the doctor's favor that -had the case been submitted to the jury without arguments, the -doctor would have been acquitted at once. To fortify his cause -Dr. Bettman's lawyer called a number of experts, whose testimony -was of course only cumulative. Now what did the prosecuting -lawyer do? Did he make an effort to break down the -expert evidence by scientific arguments? No, sir; but he -wiped out its effect upon the jury by the mere waving of his -hand, speaking thus: "The defense has piled up a mountain -of expert evidence. But, gentlemen of the jury, what does it -all amount to? These doctors are working together in the -same hospital. Don't you see they have a common interest to -sustain each other, because every one of them may be in the -same fix some day? Don't you know they are clannish?<span class="pagenum"><a name="Page_182" id="Page_182">« 182 »</a></span> -They wont admit that one of them can make a mistake. O, -no!" One could fairly see the impression this harangue made -upon the jury, and they rendered a verdict against the doctor, -though it is certain the lawyers will say the fact of his being -associated with the experts in the same hospital should and -could legally not prejudice the jury. But it evidently did, all -the same. And after such experience, can you for one -moment believe it would not damage the physician's cause if he -and his experts belonged to a society formed for the express -purpose of mutual assistance in malpractice suits. A mighty -poor lawyer he would be who could not make a great deal out -of it before a jury.</p> - -<p>Very interesting was that part of the paper in which the doctor -evolved his idea how his new society could prevent, ward -off, malpractice suits. He believes the shysters would not be -so eager to engage in this business if they knew they had to -fight a corporation with plenty of means to employ the best -legal talent. Why this should discourage those fellows it is -hard to understand. They do not sue poverty-stricken doctors. -Whom they select for their victims they suppose to be rich, and -consequently able to employ a good lawyer. They do not -expect to have all easy game, but why should they not try it? -They don't risk anything by it. The blackmailer's stake is only -two dollars and a half for filing his application, and his lawyer's -stake is his time, which is not worth much anyhow. So you -see they have nothing to lose, but much to gain. What difference -should it make to them whether the opposing counsel is -engaged by one physician or by one hundred? If you wish to -devise means by which this blackmailing nuisance can be -stopped, or at least reduced to a minimum, you must try to get -to the roots of the evil; that is, you must find the causes which -usually bring it forth. And you will not go far to find them, -for you find them right at your door, in your own profession, -in the shape of <i>indiscriminate dispensation of gratuitous services -and of unkind remarks of one physician about another</i>. Physicians -are altogether too quick to give their services gratis to almost any -body at any time. But you know very well people do not -value very much what they can get for the mere asking; they -<span class="pagenum"><a name="Page_183" id="Page_183">« 183 »</a></span> -do not think much of what they get for nothing. And it is also -a widespread notion (especially among the lower educated -people) that the quality of service is regulated by the amount -of money they pay for it; that the treatment at a free dispensary, -because gratuitous, is not the same, not as good as at a -physician's office where they have to pay for it. These people -cannot persuade themselves that a physician will take the same -interest in a case whether or not he is paid for his services. The -poor, therefore, are always suspicious that they do not get -their full share of attention. They are quickly ready to charge -their physician with carelessness if the case goes wrong. And -with a patient in this frame of mind, it takes but very little -encouragement to begin a suit for damages. And in nine out -of ten cases, doubtless, this encouragement is furnished by the -members of our own profession. He did not mean to charge -physicians with purposely, wilfully, instigating a lawsuit against -a brother. Though this has been done, such extraordinary -baseness is a rare exception.</p> - -<p>What Dr. Hotz had reference to is the inconsiderate careless, -thoughtless habit of expressing an opinion about a case, or a -colleague. To illustrate: A physician at a dispensary shows -a bad case to professional friends, and without thinking of the -possible evil consequences, makes in the presence of the patient -some remark like this: "Well, perhaps I ought to have done -this or that." The patient, already laboring under the impression -that he was not fairly treated because he could not pay, -sees in the doctor's remark the strongest confirmation of his -suspicion, goes to a shyster and begins a suit for damages. -And doubtless, in a similar way the mind of a patient is often -poisoned and set against his physician by a careless or unkind -remark of another physician. So many physicians are always -ready to express their opinion about their colleagues in the -presence of anybody, or to criticise their professional acts upon -the information received from a patient or some old woman. -Now you all know how these people misconstrue the words of -a doctor; how they pervert the facts inadvertently. You must -admit you cannot rely on what patients tell you, and you cannot -form an opinion that is worth anything of a case you have -<span class="pagenum"><a name="Page_184" id="Page_184">« 184 »</a></span> -not seen or been informed about by the attending physician. -Why, then, don't you say so when somebody asks you what -you think about the case of Dr. H.? Or if you know the physician, -say he is competent to attend to his own business; if -you don't know him, change the subject. But at all events, -unless he be a notorious quack, refrain from uttering any words -which even only insinuate the possibility of a mistake or want -of skill of your colleague.</p> - -<p>Stop running each other down; stand by each other; sustain -each other, "stick together and be clannish;" let it be understood -in public that no reputable physician will prostitute himself -by going to court as expert for a blackmailer. If all the -reputable physicians of this city adopt and act on this principle, -blackmailing the medical profession would soon be a thing of -the past, and malpractice suits more effectually prevented than -by the organization of a protective union.</p> - -<p><span class="smcap">Dr. P. S. Hayes</span> said that, from his costly experience in a malpractice -suit, he felt that an association such as suggested by -Dr. Doering would be of great service. The lawyer employed -by such an association would speedily acquire such a fund of -medical knowledge that he would be considered an expert in -malpractice cases. He would not require an amount of coaching -necessary to prepare for any given case, as would be requisite -in the case of a lawyer who had no experience in such -cases. His opportunity for obtaining information in a given -case would be largely extended, for each member of the association -to whom he might apply would be interested in giving him -the desired knowledge. He would soon become acquainted -with medical witnesses and know which would give the best -testimony in any case.</p> - -<p>An association of the character suggested by the paper might -be a means of educating its members in regard to laws bearing -on the rights of physicians and their patients, now not generally -understood. For one he is heartily in favor of such an -association, and should give it his hearty support.</p> - -<p><span class="smcap">Dr. G. C. Paoli</span> said Dr. Doering's paper is not only a valuable -one, but contains such a high, noble, charitable feeling -that the Society ought to be grateful to him. He wondered -<span class="pagenum"><a name="Page_185" id="Page_185">« 185 »</a></span> -that such steps had not been taken before, because so many of -our professional brethren have not only suffered annoyance, but -pecuniary loss as well. How can we expect, from an ignorant -jury, a decision based on scientific knowledge and justice?</p> - -<p><span class="smcap">Dr. F. M. Weller</span> said that the subject of the paper was -worthy of consideration; that the discussion of the formation -of an association with an object so widely different from the -Medical Society seemed out of place; the one essentially scientific, -the other in the nature of an insurance. The right to -form such an organization was unquestioned; the policy should -be considered by each individual. That while any one might -be made the object of blackmail, he believed that charges of -malpractice more frequently arose from the ignorance of physicians -of the statutes affecting the practice of medicine, especially -those of the criminal code, and of the rulings of the courts -in cases.</p> - -<hr class="chap" /> - -<p class="caption2">PROCEEDINGS OF THE CUYAHOGA COUNTY MEDICAL<br /> - SOCIETY, NOVEMBER 5, 1885.</p> - -<p class="caption4">[Reported for the <span class="smcap">Gazette</span> by <span class="smcap">L. B. Tuckerman</span>, M. D., Cor. Sec.]</p> - -<p class="caption3">COMPULSORY VACCINATION.</p> - - -<p><span class="smcap">Dr. Himes</span> presiding.</p> - -<p><span class="smcap">Dr. Hart</span> said that thirty years ago, in a country region of -western Pennsylvania, he met an epidemic of smallpox. Over -thirty years earlier, under a State law, the whole community -had been vaccinated. Out of about fifty persons exposed to -the disease the most were adults who had been vaccinated at -the time referred to, or earlier. Referring to an article on the -epidemic prepared at the time, he finds that fully half had the -disease in some form, from the mildest varioloid to confluent -smallpox, one case of secondary smallpox occurring. While -he believed that fifty per cent. of those vaccinated in infancy -are protected for a lifetime, still he regards the presence of the -most distinct cicatrix as no criterion by which to determine -who are thus secure. From twelve to twenty years of age, -probably, fully one-half will have a more or less perfect result -<span class="pagenum"><a name="Page_186" id="Page_186">« 186 »</a></span> -from revaccination, and will in most cases be thenceforth protected -from all ordinary exposure to smallpox. But in the -presence of the varilous atmosphere of an epidemic of the -disease, revaccination is the only absolute safety. He has -always revaccinated himself as often as exposed, and advised -the same course for others. While smallpox prevailed here, -say from 1865 to 1873, where patients were not removed to a -pest house, and the only precaution enforced was the notice on -the house, he attended a considerable number of cases. He -always insisted on vaccinating every exposed person, and -although there were often unvaccinated children and adults -who had a thorough effect from revaccination, he never had a -second crop of calls in the same house.</p> - -<p>He referred to the complete revaccination of the Forty-first -Regiment, O. V. I., before going South. Many of the men -with a fair cicatrix had a perfect revaccination, while two hundred -or three hundred had more or less result. Humanized -virus was used. During their term of service, while repeatedly -exposed to smallpox, and where other regiments about them -suffered severely from the disease, they entirely escaped. -This immunity could only be referred to their revaccination, -and certainly affords the strongest proof of its prophylactic -power.</p> - -<p>While frequent renewals of the humanized virus is desirable, -he regarded it, when selected with the care which ought to be -observed, as milder in its effects and much more certain than -cowpox. In vaccinating with cowpox he has had severe effects -follow much more frequently than when he made use of the -humanized virus.</p> - -<p><span class="smcap">Dr. Dutton</span> did not believe that the profession should insist -on compulsory revaccination, at least until it was proven that -revaccination was absolutely necessary. A second vaccination -often produces a serious inflammatory sore, quite unlike the true -vaccine pustule, and an ulcer sometimes follows.</p> - -<p><span class="smcap">Dr. Preston</span> stated that, as he had observed, a large percentage -of those who were not revaccinated were liable to have -varioloid.</p> - -<p><span class="smcap">Dr. Scott</span> stated that we must either vaccinate or inoculate. -<span class="pagenum"><a name="Page_187" id="Page_187">« 187 »</a></span> -He was vaccinated by his mother fifty years ago, and was protected -yet. He had been revaccinated many times without -effect. He regarded the humanized scab the best. He believed -that the proportion that take again is less than Dr. Hart -is inclined to suppose. Every community has a right to compel -vaccination, and the question here is not of revaccination. -Bovine virus removes the danger of the communication of -syphilis, but the cultivation of the virus should be under State -control. Much of the trouble had come from scabs or points -from pustules where the lymph had been drawn off and the -pustules allowed to refill. A refilled pustule can communicate -almost anything.</p> - -<p><span class="smcap">Dr. Smith</span> said he had seen some of the worst arms he ever -saw from revaccination. He would rather have a mild case of -varioloid than such a case. It is not certain that a second sore -is evidence that the patient will not have varioloid.</p> - -<p><span class="smcap">Dr. Corlett</span> stated that in the London Smallpox Hospital -they had for twenty years made it a rule to vaccinate every -attendant, and for twenty years there had been no case of smallpox -among the attendants. There is more attention paid to -instruction in vaccination there than here. Each student must -go at least six times to one of the dozen government stations -and receive instruction. Vaccination is done from arm to arm. -As soon as the vesicle is formed, and before pustulation, a -capillary tube is inserted and a portion of the lymph withdrawn. -They do not believe that there is danger of scrofula or syphilis -if there be no admixture of blood cells, either white or red, -with the lymph. He believes that the cases of eczema and -scrofula so often attributed to vaccination are really due to a -dyscrasia of the patient.</p> - -<p><span class="smcap">Dr. Millikin</span> inquired how long the lymph retained its activity -after being withdrawn into the capillary tube. <span class="smcap">Dr. Corlett</span> -stated that it could be used for six weeks or two months.</p> - -<p><span class="smcap">Dr. Vance</span> stated that the Germans of Cincinnati, irrespective -of creed, preferred inoculation to vaccination. Hence -there was always smallpox in Cincinnati. In spite of the stringent -laws against it, inoculation was systematically carried on. -The parent would take the infant to a neighboring hillside and -<span class="pagenum"><a name="Page_188" id="Page_188">« 188 »</a></span> -leave it with a dollar-bill beside it, and go away. In a few -minutes he would return, the dollar-bill would be gone, and the -child was inoculated. The law against it cannot be enforced.</p> - - - - -<div class="bdtd bdb"> - -<p class="caption2">CORRESPONDENCE.</p> - -</div> - -<p class="caption3">NEW YORK LETTER.</p> - -<p class="caption4">THE USES OF COCAINE IN SURGERY.</p> - -<p>It is not the object of this communication to speak of the -discovery of this drug and the experiments which were necessary -to bring it before the profession as a reliable and trustworthy -agent. That cocaine is a valuable addition to the armamentarium -of the surgeon, I think no one will doubt, but how beneficial, I -think but few fully realize.</p> - -<p>Cocaine is constantly growing in favor with the surgeons -here in New York. New fields of usefulness are opening, and in -nearly all of the minor and many of the major operations it is -taking the place of ether and chloroform. These older anæsthetics, -although so useful, were accompanied by danger, and -many deaths are attributed to their use, while so far, I know of -no well authenticated case where death or serious symptoms -have resulted from the use of this new anæsthetic. Its first use -was restricted almost exclusively to the eye and mucous membrane, -but the hypodermic syringe has made it as useful to the -general surgeon as to the oculist.</p> - -<p>There is not a day passes but that we see operations of more -or less magnitude performed under its influence at some -of the clinics or hospitals of New York. Circumcision, hemmorrhoids, -fistula in ano, felon, ingrowing toe-nails, hydrocele, cutting -for foreign bodies, removal of small tumors, etc., are some -of the operations for which we very seldom see an anæsthetic -given.</p> - -<p>At St. Luke's hospital an operation for ventral hernia was -performed by the use of cocaine alone, where it was necessary -<span class="pagenum"><a name="Page_189" id="Page_189">« 189 »</a></span> -to open the abdominal cavity for three inches and reach into -the abdomen with the fingers to draw up the peritoneum, and -all done with perfect success. Amputations of the fingers and -toes are not uncommon, and amputation of the leg and fore-arm -have been successfully performed by its use.</p> - -<p>External and internal urethrotomy and cleft palate are usually -performed by its aid. I have seen large stones removed from -the urethra in this way without any expression of pain from the -patient, he talking with the surgeon about the case while it was -in progress.</p> - -<p>Dr. Corning, of New York, has devised a method by which -the local effect of the drug may be indefinitely prolonged. His -theory was that the drug was washed from the tissues of the -blood and its effects thus lost. To prevent this he applies -elastic ligatures around the part, between the injection and the -heart, about two or three minutes after the injection is made. -When the injection is on the body or face where the ligature -can not be used, he uses large rings to surround the part, so -arranged that firm pressure can be made upon them, and thus -cut off the active circulation. He claims for this that a weaker -solution can be used and the effects continued for a much longer -time.</p> - -<p>The mode of proceeding is usually to inject from ten to fifty -drops of a 4 per cent. solution around the part to be operated -upon, using an ordinary hypodermic syringe. From three to -five drops of this solution are injected at short intervals in a -zone surrounding the part to be operated; or a larger -quantity is injected near the body of the nerve supplying -the part. If this is reached the anæsthesis is complete. -In two or three minutes the knife can be freely used, -and the patient feels no pain, although they look at the knife as -it divides the tissues. In the throat clinic a solution of cocaine -is used with an atomizer to allay the irritability of sensitive -parts, that a more thorough examination may be made. At -the eye clinic cocaine is used as a mydriatic, atropia being seldom -used for the purpose of examinations.</p> - -<p>Patients usually dread the action of an anæsthetic; the -nausea, headache, and lassitude following its administration are -<span class="pagenum"><a name="Page_190" id="Page_190">« 190 »</a></span> -things not pleasant to contemplate, but with this new drug -none of these are encountered.</p> - -<p>The conclusions are, then, from our present experience, that -cocaine is a pleasant, safe and efficient local anæsthetic.</p> - -<p class="tdr2"><span class="smcap">O. T. Maynard.</span></p> - -<hr class="chap" /> - -<p class="caption3">BALTIMORE LETTER.</p> - -<p>At the last meeting of one of the city medical societies one -of the members reported a case of typhoid fever in which the -pulse had remained quite low for over a week. Several questions -were asked concerning the <i>normal</i> pulse of the man. The -doctor insisted that he knew the normal pulse was higher, as he -had examined it many times in health. This was strange and -so many members plied the doctor with questions that he finally -confessed that the young man was a member of the family when -he (the doctor) was courting his (the doctor's, not the patient's) -wife. Of course the entire society understood at once that -the doctor felt the pulse of the entire family during this love-sickness. -There are many ways of courting—Josh Billings had a very -good way. Some fellows buy the old gentleman a cane (very -appropriate and often <i>useful</i>); the small brother a box of candy, -so that he will vacate the parlor—and for the baby sister a wax -doll with long flaxen hair—which she invariably informs the -neighborhood was given to her "by Sallie's beau."</p> - -<p>We once knew a nice young man who had been told that the -best plan was to court the mother for a while. He heeded the -advice and was getting along very finely, when one day he received -an invitation to attend the marriage of his girl to the -fellow who had been courting <i>her</i> and not her <i>mother</i>.</p> - -<p>This little occurrence turned our minds to the humorous -things of our experiences, and after adjournment of the society -a number of "funny" things were related as we walked homeward.</p> - -<p>The following is interesting to the gynæcologists:</p> - -<p>A young married woman (without children, or she would -have other things to require her attention) had been for some -<span class="pagenum"><a name="Page_191" id="Page_191">« 191 »</a></span> -time afflicted with uterine trouble. She had been treated by -several physicians. Various pessaries had been worn. The -last attendant discovered that it mattered not what kind of -pessary was used, nor in what position it was placed in order -to afford satisfactory relief. Finally an abdominal supporter, -with cup and stem attachment was wanted and obtained. This -by far surpassed any other, until one day it "hurt a little." -The patient at once thought of an improvement. She removed -the cup and stem, detached the cup and reintroduced the stem. -It gave perfect satisfaction and has been worn with comfort for -about three months. We sincerely hope this simple instrument -will be able to permanently retain the displaced—mind—in -proper position. We offered it to the profession as the finest -instrument yet discovered for such cases. It is not patented, -no royalty is received by the discoverer, and no extra charge -is made for the thread on the internal end of the stem.</p> - -<p>The medical colleges have resumed their regular lectures, -the students having returned from their Christmas visit to their—mothers.</p> - -<p>One of the societies inaugurated the new year by a banquet, -which was a most delightful affair. It was given at the Eutaw -House, was well attended, substantial, and well served. The -toasts formed no small part of the enjoyment. Some of the -reminiscences of the older members afforded much merriment.</p> - -<p>A very interesting case of the heart displaced to the left side -was exhibited to the Clinical Society by Dr. McSherry at the -meeting of January 8. It is rare, and only a few cases are -reported. Displacement to right side is not of unfrequent -occurrence, and a number of cases are recorded. The apex -beat in this case is heard two inches to the left of a perpendicular -line through the left nipple. The first line of dullness is one -inch and a half to the left of the center of the sternum. Attachment -to a contracted lung due to phthisis is the probable -cause of the displacement. At the same meeting there were -reported two cases of laparotomy for intestinal obstruction. -Both terminated in recovery.</p> - -<p>A somewhat novel, but said to be successful, treatment for -cases of "wry neck" due to neuralgia or "cold" was mentioned -at the Medical and Surgical Society on the 14th. It is to sit -for one half hour or more near a very hot stove, placing the affected -side opposite an open door. A screen should be placed -beyond the patient so as to confine the heat as much as possible -to his immediate locality.</p> - -<p>It was suggested by the mention of a case, in a child eleven -years old, which had continued four weeks, in spite of treatment. -<span class="pagenum"><a name="Page_192" id="Page_192">« 192 »</a></span> -One physician thought the Faradic current a specific -in such cases.</p> - -<p>I have read with pleasure a little work which, if I mistake -not, will be most welcome to the profession. It is a book of -nearly seventy pages, entitled 'Practical Notes on the Treatment -of Skin Diseases.' I am glad to say also, that it is written -and published by a Baltimore physician, Professor Rohé, -whose 'Text Book of Hygiene' I took occasion to mention in -my last communication.</p> - -<p>I suppose all country practitioners, if not those of the city also, -who are busy from morning till night with hardly two hours a -day for reading, have felt as I have on many occasions, the need -of some concise practical text books not given to speculations -and generalizations! Especially is this needed in "Skin Diseases," -because of the meager knowledge that we common -practitioners have of the subject. There has seemed to me to be -a tendency to call most skin diseases "eczema," just as it undoubtedly -is to call all vague pains throughout the body "rheumatism."</p> - -<p>Dr. Rohé very truly remarks that "most text books on dermatology -have as their besetting sins complicated classifications -or 'systems,' an awkward nomenclature, great prolixity and a -lack of definiteness in the description of typical diseases, and an -undue multiplication of morbid processes." No one better understands -this than a practical physician who has spent half an -hour hunting through one or two large text books for light on -a case in hand and finally "falls back on" his 'Dunglison.' It -seems quite clear that without a fine atlas most of the large -works on dermatology are for the most part unintelligible.</p> - -<p>Dr. Rohé's book is one of a series, the others to follow -shortly if this is accorded a hearty reception. This first series -is devoted to the diseases of the perspiratory and sebaceous -glands. Their anatomy and physiology are briefly stated, then -follows the descriptions of the diseases commonly met with, as -well as the rarer forms, in terse, plain language. The last few -pages contain formulæ which experience has shown to be of -value. The subjects of "prickly heat" and "acne" are especially -well treated, and either of them is more than worth the -price of the book.</p> - -<p>I have dwelt at much length on this subject because I feel -that this little work ought to be in the hands of every busy -practitioner who is not well acquainted with diseases of the -skin. It can be had by sending twenty-five (25) cents to the -author, Dr. George H. Rohé, 139 North Calvert street, Baltimore, -Md.</p> - -<p class="tdr2">F.</p> - -<div class="trans_notes"> -<p class="caption2">Transcriber Note</p> - -<p>The cover was made from an image generously provided by The Internet -Archive and is placed in the Public Domain.</p> -</div> - - - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of The Cleveland Medical Gazette, Vol. 1, -No. 4, February 1886, by Various - -*** END OF THIS PROJECT GUTENBERG EBOOK CLEVELAND MEDICAL GAZETTE, FEBRUARY 1886 *** - -***** This file should be named 52983-h.htm or 52983-h.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/2/9/8/52983/ - -Produced by The Online Distributed Proofreading Team at -http://www.pgdp.net (This file was produced from images -generously made available by The Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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