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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..d7b82bc --- /dev/null +++ b/.gitattributes @@ -0,0 +1,4 @@ +*.txt text eol=lf +*.htm text eol=lf +*.html text eol=lf +*.md text eol=lf diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..82b1cf7 --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #60511 (https://www.gutenberg.org/ebooks/60511) diff --git a/old/60511-0.txt b/old/60511-0.txt deleted file mode 100644 index d8c0b68..0000000 --- a/old/60511-0.txt +++ /dev/null @@ -1,2266 +0,0 @@ -The Project Gutenberg EBook of The American Practitioner and News. Vol. -XXV. No. 3. Feb. 1, 1898, by H. A. Cottell - -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 American Practitioner and News. Vol. XXV. No. 3. Feb. 1, 1898 - A Semi-Monthly Journal of Medicine and Surgery - -Author: H. A. Cottell - -Release Date: October 17, 2019 [EBook #60511] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK AMERICAN PRACTITIONER, FEB 1, 1898 *** - - - - -Produced by Richard Tonsing and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - - - - - - - - - - THE - AMERICAN PRACTITIONER AND NEWS. - “_NEC TENUI PENNÂ._” - VOL. XXV. LOUISVILLE, KY., FEBRUARY 1, 1898. NO. 3 - - - Certainly it is excellent discipline for an author to feel that he - must say all he has to say in the fewest possible words, or his - reader is sure to skip them; and in the plainest possible words, or - his reader will certainly misunderstand them. Generally, also, a - downright fact may be told in a plain way; and we want downright - facts at present more than any thing else.—RUSKIN. - - - - - Original Articles. - - - SOMETHING ON THE DISUSE OF PHLEBOTOMY. - - BY RUFUS W. GRISWOLD, M. D. - -When I began looking into medical books preparatory to practice, fifty -years ago, the standard authors given us to read were not backward in -recommending blood-letting in the acute diseases; and a little later, -when an attendant at lectures at the College of Physicians and Surgeons -at New York, the professors were not lacking with the like advice. But -there has come a change, and so much of a change that, in this section -of country at least, the lancet has mostly gone out of use. That the -frequent use to which it was put seventy-five or a hundred years ago was -not at all times wise is likely; but the extent to which it has been -given up is also not wise. Rather more to notice some of the reasons why -it has so largely been abandoned than to argue for a reintroduction of -that ready and efficient instrument is the purpose of this paper. - -A prominent point in the consideration of this comparative abandonment -of the lancet is presented in the question: Has there been such a change -in the type of the acute inflammatory diseases from three or four -generations ago as to render the abstraction of blood less necessary and -less useful? There are plenty of sound, hard-headed old doctors who will -give a negative reply to this query; and occasionally we may notice some -of them putting themselves in print to that effect. A Baltimore -practitioner not so very long ago said: “The necessity for the use of -the lancet is as great at the present time as it ever was in the past; -the type of the disease has undergone no such changes as to render the -abstraction of blood unnecessary or improper in the successful -management of all cases attended with a full, tense, and quick pulse.” -Others speak the like; but the majority of opinion is not pronounced in -that direction, but rather adverse. Conversations during a forty-four -years’ practice with men who began their professional calling sixty -years ago, when the lancet was in often call, is to the import that -there _has been_ such a change in diseases as renders the frequent -resort to blood-letting less important than formerly; that there is less -of the sthenic type in even inflammatory fevers, a more general -disposition to take on what we call typhoid forms, and thus depletion, -either by the evacuation of blood or the exhibition of reducing drugs, -is not so beneficial in even the acute inflammatory diseases as -formerly. This is the view that has been entertained by a large part of -those who began practice half a century or more ago, and this view has -been sustained by a large amount of written authority; but it does not -go to the extent of justifying that degree of abandonment of bleeding -that has prevailed for the last forty years. The general opinion of -to-day is, that while positions like that taken in the quotation given -are too positive, on the other hand our _practice_ is quite too lax; for -while we still believe in blood-letting to some extent, we but seldom -make use of it. Now as to the _why_. - -Perhaps the first reason why the lancet is less used than formerly is -found in the fact, or rather in the belief, of the change indicated. It -is largely accepted as true by the older men in the profession that -patients do not bear blood-letting as well as three generations ago. -Accepting this as correct, it rationally follows that we should bleed -less. But this is only one of the factors in the account, and not the -largest one. The opinion that the physicians of the early part of this -century used the lancet too often is beyond doubt correct. The doctrine -of the purely symptomatic nature of fever put prominently forward by -Brousais, and earnestly championed by active and pushing minds a century -ago, and which was generally received in Europe and in this country, -gave such an unfortunate impetus to the use of the lancet as finally led -to its abuse. Patients were bled for almost every thing; not only for -the fevers of acknowledged inflammatory type, such as acute pleurisy and -the like, were bled for, but also cases of typhus, typhoid, etc., upon -the ground that the fever in the case was only a symptom of the -inflammatory action and was to be subdued or lessened by antiphlogistic -remedies, chief of which was the abstraction of blood. The theory of the -essentiality of fever became lost sight of, and the doctor treated for -an inflammation rather than for a fever. - -Without giving up the theory in which they had been educated, some -physicians began to see that in some epidemics of disease a larger -percentage of cases were lost among those where venesection had been -used than among those similarly sick who were not bled. The deduction -from this was that it would be better to bleed less. But a change was -not to be made without a struggle. Reference to the medical literature -of the first half of the century shows that there was a deal of warm -discussion between the blood-letters and the anti-blood-letters. Out of -the observations and discussions made there was cultivated a prejudice, -professional to a moderate extent but popular to a large one, against -bleeding _per se_, and without reference to the character of the disease -under treatment or to the differing conditions that might exist, which -helped to carry the usage from its former abuse at times to the opposite -extreme of general abandonment. It is a universal law in nature that the -farther the pendulum swings in one direction, the farther will it swing -in the opposite on its return. The pendulum of venesection had swung too -far forward for the best in the treatment of disease, and the return -carried it quite beyond the best in the backward reaction. - -Beyond the reasons noted for the present comparative non-use of the -lancet, there has been added a pressure of an erroneous and illegitimate -nature that has aided to put bleeding under a general ban more -unfortunate for the sick than was the former rather indiscriminate use. -Somewhat contemporaneously with the warm discussion upon bleeding -carried on in the profession, and perhaps partly out of that discussion, -there started up in various parts of the country an illegitimate class -of practitioners, mostly illiterate and destitute of preliminary -culture, interchangeably known as Botanics, Thompsonians, Eclectics, -etc., whose chief stock in trade for public acceptance was denunciation, -without regard to the conditions that might be met in a case, of -leeching, bleeding, blistering, scarification, and other agents for -cures. This denunciation found ready public credit. Not only from the -mouths of the class named, but in various other ways, the prejudice they -sought to create was widely diffused. Outside of the libraries of the -profession you seldom see a medical book; anywhere else they have been -rarities. But in many sections of the country for the last sixty years a -canvass of the families would show an abundance of books, published for -family reading, emanating from irregular practitioners, all of them -saturated with lying abuse of the methods of treatment of the regular -physicians. These books were loaned from one family to another, much as -the weekly papers or the cheap novel; and they were read and believed -in. The result was that many who read were indoctrinated with the belief -that bleeding, no matter what the disease or the conditions, was not -only not necessary, but pernicious, and often the cause of death; and -there was little printed contradiction offered to disabuse the public -mind of this false accusation. - -Co-ordinating with this means of false instruction has been and is the -public press. As respectable practitioners do not stoop to the quackery -of advertising, the pecuniary interest of the press, so far as means and -methods for the cure of diseases is concerned, is identical with the -pecuniary interests of advertising quacks. The public press sells itself -to the broad diffusion of the ways and means of medical quackery in all -its forms. The subsidies of impostors and patent medicine men fill up -one carotid artery for the support of the press; and the influence of -that press, however weak the intellect that bestrides its tripod, is -more potent than a hundred of the ablest men in the profession, for the -sufficient reason that the voice of the men in the profession seldom -strikes the public ear through the same broad and forceful channel. - -The result of the false teaching of the class of books alluded to and of -the medical advertising, and of the bleating of the tramping lecturers -was that a large part of many communities came to believe that -blood-letting was a crime against health, and a hindrance to recovery -from disease, no matter what might be the conditions. The average -intelligence of even well-educated communities goes no further than to -accept the plausible teaching that is every day thrust upon its -tympanum; it does not stop to criticise the motives nor to analyze the -arguments of the advertiser, nor is it cultured in this direction to the -capacity of justly weighing them according to their true significance. -The average intelligence of even well-educated communities is not up to -that grasp of the science of medicine necessary to determine between -false and fallacious teaching and that which is rational and correct; it -does not differentiate between clap-trap and honesty; it does not -separate humbug from truth, and as an ocean of humbug passes the public -gullet easier than an ounce of truth, it is not strange that the -condition obtaining about bleeding is not so much that the physician has -discarded it as improper, or has lost sight of its value in many cases, -as that the community will not tolerate him in the abstraction of blood. -Public prejudice overrides professional opinion, unless the opinion runs -current with the prejudice. To bleed your patient and then have him die -is to be damned; if he dies without being bled, no matter whatever else -you may do or leave undone, the chances of being cursed are largely -lessened. Besides this, very little or nothing is gained against the -prejudice by recovery after bleeding, since the popular opinion will be -that the patient would have gotten well quicker and better without it—an -opinion that can seldom be disproved. Exactly in the same way in any -case where venesection has been practiced and the patient does not get -well, the opponents of the operation will assert that the bleeding -caused the death, and that, in the absence of it, the patient would have -got well; which also is difficult to disprove. The average mind proceeds -from supposed causes to effects with most unreasonable logic. - -As a matter of fact, the whole art of the practice of medicine is -involved many times in many uncertainties as to the effects that are to -follow the administration of drugs or the institution of any procedure, -however simple, that it may puzzle the most sagacious to determine the -exact weight of any factor introduced, whether it be for good or for -ill. It should not therefore surprise us that to minds quite -unacquainted with the therapeutical effects of blood-letting in disease, -a death that follows a bleeding, however remote in point of time, should -be credited to the operation rather than to the disease for which the -operation was performed. An uncertain percentage of cases of many acute -inflammations will recover, whether bled or not; an uncertain percentage -of them will die, whether bled or not, and no matter how treated; and, -while it will sometimes happen that of two cases of the same disease the -one that is bled will get well and the one that is not bled will -succumb, it will the next week happen that of two other cases of the -same trouble the one that is bled will slip off and the one not bled -will hold on finely. And it is a notorious fact that in some -communities, if a patient is bled and then dies, nine out of every ten -persons in the neighborhood will say, and part of them will believe, -that the bleeding was an accessory if not the chief cause of the -untoward event; and it is usually quite impossible for the doctor to -show that the nine are not right in their view of the matter. - -Under these circumstances it can hardly surprise us that the use of the -lancet has gone out of fashion. It is not so much that we have less -faith in its beneficence, rationally employed, as that our patients are -opposed to it. Whether in spite of the opposition we should employ it -oftener than we do is a question that every one must settle for himself. -It might be possible for a bold and determined man to work up that road -to confidence with his patients in it, but the path is so beset with -difficulties that a hundred will fall by the way where one succeeds. A -single death after phlebotomy will do more to impede the success of a -young man in the profession than a dozen deaths without it; it is wise -therefore to be cautious in the use of so potent a remedy, and to sin -less in commission than in omission of opening a vein. It may be said -that whether he succeeds or fails it is the duty of the physician to do -in all cases what he thinks will be the best for his patient. This -position may have its merits but it is a better thing to teach than to -act upon. There is no law of right that demands of the practitioner that -he shall assume the responsibility of the stupidity and ignorance of all -his patients, and, worse still, of all the irrational prejudice they -have allowed themselves to imbibe, and which no amount of logical facts -will dispossess them of. - -The writer, in the nearly fifty years of his practice as student and -graduate, has had an average share, perhaps, of his patients die; but he -has never had one die of any sort of fever after he had been bled as an -aid in subduing that fever. On the other side, he has had patients die -of the acute inflammatory diseases when they have not been bled; and, -to-night, recalling those cases, he is of the opinion that some of them, -if they had been well tapped in the arm at the outset of the sickness, -they would have been saved. - - ROCKY HILL, CONN., December, 1897. - - - TAKA-DIASTASE IN THE TREATMENT OF AMYLACEOUS DYSPEPSIA. - - BY WALTER P. ELLIS, M. D. - -Pepsina porci, the pepsin of the hog, was one among the first of the -animal products to be used in medicine, and many physicians, not well -versed in organic chemistry, supposed that in it they possessed a -sovereign remedy for indigestion in all its forms and stages, and the -confirmed dyspeptic had only to apply the specific to have his digestive -apparatus restored to its youthful health and vigor. Unfortunately for -this view and for the sufferers, the fact was overlooked, or not duly -appreciated, that pepsin is only one of several substances which Nature -employs in the complete digestion of food, and that the products or -secretions of several different glands have a part in the process, each -of which is essential to the proper preparation of food for the -nourishment of the human body. - -It has been estimated by competent observers that as great a proportion -as seventy-five per cent of all the intractable cases of dyspepsia in -this country are caused primarily by faulty saccharification of the -starchy foods which constitute such a large portion of the diet of the -American people. This being the fact, is it any wonder that the -administration of pepsin alone should fail to give relief in many cases? -It fails because the fault lies, not in the stomach, but in the salivary -and other glands whose secretions possess the amylolytic property, and -the remedy is the administration of substances that will restore that -property to the secretions, or which possess it in and of themselves. - -Until quite recently the practitioner was compelled to rely for this -purpose upon the various malt extracts upon the market, the diastatic -power of which was so feeble that the service they rendered was but -slight. What was needed, and for which many of the most patient -investigators were searching, was a diastase which would do for the -starchy elements of the food what pepsin does for the proteids. The -digestion of food in man has been the subject of much patient and -methodical study and investigation during the last two decades, notably -by Ewald, Kellogg, Hayem, and Winter, and others, resulting in the -placing of the therapeutics of disordered digestion upon an exact -scientific basis. It is not, however, necessary for the purposes of this -paper to go very deeply into the minutæ; a superficial survey will -suffice. - -Digestion begins in the mouth with the act of mastication, the presence -of food in the mouth, or even the thought of it, acting upon the -salivary glands to produce a free flow of saliva, which, being -thoroughly incorporated with the food by the act of mastication, exerts -its peculiar influence upon the starchy constituents, converting them -into dextrose, maltose, etc. This amylolytic action lasts but a short -while, the ptyalin of the saliva being active only in neutral or -slightly alkaline media; consequently when the food reaches the stomach -and peptic digestion begins, its effect ceases. - -The saccharification of the starchy elements of the food before reaching -the stomach serves to separate or disentangle them, as it were, from the -proteids, and deliver the latter to the stomach in the condition most -favorable to the action of the gastric ferment or pepsin. - -The stomach, after a variable length of time, during which the peptic -ferments accomplish their allotted task more or less thoroughly and -completely, delivers the resultant mass over to the small intestine, -where the secretions from the pancreas, liver, and intestinal glands, by -finishing the transformation of the starch begun before the stomach was -reached, emulsifying the fatty constituents, etc., complete the complex -work of digestion. - -It will be seen from the foregoing that the derangements of digestion -may, for ordinary clinical purposes, be divided into three classes, each -of which is distinct from either or both of the others, although they -shade into each other by imperceptible gradations, so that there are no -well-defined boundary lines separating them. The first class includes -all those cases which are characterized by a deficiency, in quality or -quantity, of the salivary secretion, and a consequent failure of or -interference with the digestion of the starchy elements of the -food—amylaceous dyspepsia. The second includes those in which there is -difficulty in the digestion of the proteids, due to a variety of -causes—gastric dyspepsia. In the third is placed those cases in which -the trouble is located below the stomach, and are caused by inability of -the pancreas and other glands to normally perform their -function—intestinal indigestion. - -One constantly meets with cases belonging to each of these varieties, -and he must correctly diagnose each case if he would apply the treatment -necessary to produce the best results. For the present, however, we have -only to do with the first variety, as my object in the preparation of -this paper is to direct the attention of the profession to a new -diastatic ferment which acts with as much or even greater energy upon -the amylaceous foodstuffs as does pepsin upon the proteids. - -Such a substance has long been a desideratum with those who treat many -dyspeptics, and who have been compelled to content themselves with malt -extracts with which the market is supplied. The substance referred to -was discovered by a Japanese chemist, Jokichi Takamine, not as the -result of accident but while working scientifically with that exact end -in view, and is now supplied to the profession by Parke, Davis & Co. -under the name of Taka-Diastase. The writer has had frequent occasion to -use it since it was first brought to his notice about a year and a half -ago, and in that time has not had a single case in which its -administration was not attended by the very best results. Notes of -several cases were kept, three of which will be presented here as the -most appropriate conclusion. - -CASE 1. L. A., white male, age thirty-eight, a barber by occupation, -consulted me first in the fall of 1894. He was at that time, as he had -been for several years, the victim of a most obstinate and intractable -form of dyspepsia. He had been a coal miner until forced by ill health -to quit that for some lighter occupation. He, however, continued to grow -worse until, when coming under my care, he was very much emaciated, -weak, nervous, and irritable, his stomach unable to retain any thing -save the blandest articles of diet, and those only in small quantities. -Treatment was begun by regulating his habits, diet, etc., and putting -him on an emulsion of bismuth subnit. and pepsin pur. immediately after -eating, and tr. nux vom., hydrochloric acid, and tr. colomba before -eating. His condition improved somewhat under this treatment, but only -to a limited extent, and it became evident that more efficient measures -must be resorted to if we hoped to accomplish permanent good. It had -been noted that a meal, however scant, composed mainly of starchy -substances was always productive of an acute attack, and acting upon -this suggestion extract of malt was added to the remedies he was using, -and, to a certain degree, with good effect. He, however, did not go on -to complete recovery, but the improvement ceased at a certain point, and -in spite of continued treatment with the remedies mentioned his -condition remained about stationary. Unable to work, morose, cross, and -irritable, existence was a burden to himself as well as family and -friends. At this juncture my attention was attracted to Taka-Diastase -and a supply was at once procured. The patient was given a number of -capsules containing five grains each, with instructions to take one -capsule at the beginning of each meal, continuing the bismuth and pepsin -mixture as before, immediately after eating. In a very short time -improvement was discernable, and from that time was rapid and -continuous. The treatment was kept up, with the addition later on of -ferruginous and bitter tonics, until there could be no doubt of his -complete and permanent restoration to health. He has now been at regular -work in the shop for several months, and says that he “never felt better -in his life.” - -CASE 2. Mrs. J. H., a white woman, aged forty-six, wife of a well-to-do -farmer. Until within the last year or two had enjoyed the best of -health, and was inclined to stoutness in consequence. Dyspeptic symptoms -had troubled her more or less during the time mentioned, and of late had -increased in severity so much that she asserted, at the time she -consulted me, that if she dared to eat any thing at all she suffered the -greatest agony in consequence. A neighboring physician had treated her -for some weeks previous to her visit to my office, and, as I afterward -learned, had given her the regulation treatment with pepsin, bismuth, -hydrochloric acid, etc., with results so discouraging that she had lost -all hope of receiving any benefit from “doctor’s medicine,” as she -called it, and it was only at the urgent solicitation of husband and -friends that she came to me for treatment, being careful to inform me -that she had no idea I could help her in the least. - -Her case was diagnosed “amylaceous dyspepsia,” and she was given -Taka-Diastase in eight-grain doses, half of which was to be taken before -eating and the remainder during or after, with tr. nux vom. and -hydrochloric acid, in moderate doses, _ter in die_. - -Despite her determination not to be benefited by “doctor’s medicine,” -the improvement was prompt and continuous, and so manifestly due to the -treatment that she soon forgot or overcame her antipathy, and with -characteristic inconsistency now asserts that it is impossible to get -along without it. She eats three meals regularly every day, and suffers -no inconvenience whatever in consequence. - -CASE 3. W., a white male, aged forty, had never had any serious illness, -and digestion had been especially good until about four weeks before -consulting me. At that time he, in company with some friends, ate quite -heartily of watermelon. He had always eaten watermelon freely and with -impunity prior to that occasion. It did not agree with him so well that -time, and in a few hours he was seized with an acute gastralgia of the -most severe character, and from that time to the present he has had more -or less trouble of that kind, even a very small quantity of food, -especially if it be of a starchy nature, giving rise to the most -distressing symptoms. - -The diagnosis of amylaceous dyspepsia was also made in this case, and he -was at once put upon the Taka-Diastase in doses of five grains given -with the meals, and temporarily excluding starchy foods from his diet as -much as possible without too great inconvenience. There was also great -torpidity of the liver, and for that he was given sod. phosphate in -teaspoonful doses every morning before breakfast, taken in a gobletful -of hot water. Under this treatment improvement was satisfactory and -rapid, and with the addition of bitter tonics later on he was ultimately -restored to complete health. - -_Remarks._ Case 1 was an example of that class with which, prior to the -introduction of Taka-Diastase, the general practitioner was too often -compelled to acknowledge his inability to cope successfully. In them -there is difficulty in the digestion of both amylaceous and proteid -substances, and the remedies usually recommended were efficacious only -so far as digestion of the latter was concerned, and did not reach the -former at all. The cure was incomplete, and must have remained so until -the substance we have been considering, or something analogous to it, -was furnished the physician with which to complete it. - -Cases 2 and 3 were examples of the first class mentioned above, viz., -amylaceous dyspepsia, and while under treatment with pepsin, etc., they -were considered the most intractable of all; under Taka-Diastase they -yield rapidly, and are cured in a surprisingly short time. - - LIVERMORE, KY. - - - - - Reports of Societies. - - - LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.[1] - - Stated Meeting, December 3, 1897, the President, F. C. Wilson, M. D., in - the chair. - -Footnote 1: - - Stenographically reported for this journal by C. C. Mapes, Louisville, - Ky. - -_Uterine Fibroma._ Dr. L. S. McMurtry: I present this specimen of -uterine fibroma on account of two very interesting features of this -class of tumors which it illustrates. The first relates to the -morphology of these growths. The tumor is a very large one, and occupied -the entire pelvis and the abdomen to the superior limits of the -umbilical and lumbar regions. It is a multi-nodular tumor, and its -disposition in relation to the fundus of the uterus is unlike any -specimen that I have ever encountered. It will be observed that the -neoplasm springs from the lower segments of the uterus, and the fundus -is not involved in the growth at all. - -The second feature of interest, and this is especially interesting from -a surgical point of view, is the relation of the bladder to the tumor. -It is very common for the bladder to be carried upward with the growth, -thus rendering it very liable to injury in operation. This feature is -exceptionally conspicuous in this tumor on account of the nodular -condition where the bladder was attached, forming a sulcus. In releasing -the bladder, after splitting the capsule, the uneven surface of the -tumor caused me to inflict an injury upon the coats of that viscus. -After dissecting off the bladder I found that I had made an opening in -it at this point. It was immediately closed with a double row of catgut -sutures. The operation was done six days ago, and the convalescence of -the patient has been most satisfactory indeed. The bladder injury has -not complicated the patient’s convalescence at all, its function being -carried on just the same as if it had not been involved. The -convalescence has been afebrile from the beginning, and recovery is -assured. - -The method I observed in treating the pedicle was to amputate the cervix -very low down, leaving a very small rim of the cervix, and suturing the -peritoneum over it all the way across the pelvis, making the pedicle -extraperitoneal. The conformation of the growth and its relation to the -cervix uteri made this method of dealing with the pedicle especially -applicable in this particular instance. The patient is thirty-four years -of age, and the operation was urgent on account of persistent hemorrhage -and marked pressure symptoms. - - -_Discussion._ Dr. J. A. Larrabee: I would like to ask the reporter for -what length of time this tumor had been developing? - -Dr. L. S. McMurtry: The woman was thirty-four years of age, and -according to the history obtained the tumor was first noticed three -years ago. The patient has made a beautiful convalescence. I present the -specimen on account of its morphology, and because of the difficulties -that might be encountered in performing an operation in such cases by -the bladder being impacted in the sulcus. - - -_Tubercular Testis._ Dr. W. O. Roberts: This patient is twenty-four -years of age; his father and mother are living; father sixty-four, -mother fifty-four; his grandfather on his father’s side died at the age -of sixty-four of what was supposed to be consumption; his father’s twin -brother died at the age of twenty, after an illness of eight months, of -consumption; his mother’s family history is good. - -This young man had gonorrhea seven years ago, with orchitis of both -sides as a complication, the left testicle swelling first, then the -right; the swelling lasted in each for about two weeks. Had gonorrhea -again in November, 1896, and says again in December of the same year. At -this time he noticed that his left testicle was getting hard in places -and was swollen, but there was never any pain. The inflammatory process -has never been very acute. However, he noticed after taking a horseback -or bicycle ride the testicle would be somewhat tender. Had another -attack of gonorrhea during the month of September of the present year, -which he says lasted only two weeks, and during this attack the testicle -was also affected. - -He now has a swelling of the left testicle, and a hardness about it and -in the epididymis, which I would like for the members to examine, -expressing an opinion as to the nature of the trouble. - - -_Discussion._ Dr. J. M. Ray: I do not know that the ocular symptoms will -throw any light upon the case. I remember that this young man came to me -some time ago to have his eyes examined. He stated that he had been -under the care of a prominent oculist in the South, and had been fitted -with glasses. When I saw him he had some trouble in the use of his -glasses, and also complained of defective sight of one eye. Upon -examination I found a spot of atrophy of the choroid, showing the -location of a former acute choroidal disease, and there was considerable -diminution in acuteness of vision in that eye, with a defect in -refraction in the other eye. Under mydriatics I fitted him with glasses, -since which time he has been perfectly comfortable so far as his eyes -are concerned. - -He states that he remembers I said something to him at that time about -tubercular disease, after looking into his eyes, but I have forgotten -the circumstance; I only remember that I found choroidal disease. - -Dr. J. A. Larrabee: Of course we are all led somewhat by the diathetic -history of our cases. Chronic inflammations tend to take on the part of -the diathesis. I did not understand the reporter to say that any test -had been made, by withdrawal of some of the fluid or otherwise, to -determine the exact nature of the condition. I desire to say, however, -that if this were my testicle I would have it removed. I believe that -would be the safest plan. An absolutely positive diagnosis would be -difficult to make without a microscopical examination for the tubercle -bacillus, but I can not help feeling prejudiced in that direction. - -Dr. J. L. Howard: I agree with Dr. Larrabee as to what should be done -with this testicle; it should come out. I, too, think it tubercular, -although in all probability the gonorrhea is a factor in the case in -stimulating the growth of the testicle. I do not know that a -microscopical examination would give us much light upon the subject; in -fact I would not wait for that, I would simply remove the testicle at -once. - -Dr. Wm. Bailey: The question is not by any means settled as to the exact -nature of the disease in the case before us, whether the patient, having -had repeated attacks of gonorrhea, has not also been so unfortunate as -to have syphilis. With a tuberculous history of course a tuberculous -condition of the testicle seems plausible; but inasmuch as tuberculous -disease of the testicle may remain for a long time possibly without -great danger in affecting the patient otherwise, and knowing the changes -that take place in the testicle from repeated attacks of gonorrhea, -orchitis, etc., I believe if it were mine I would be disposed to keep it -for a while, particularly as the other testicle seems to be somewhat -atrophied, with this one of pretty good size. I think I would keep the -larger one. - -Dr. T. S. Bullock: I am inclined very much to agree in the opinion -expressed by Dr. Bailey. I have frequently seen, after repeated attacks -of gonorrhea, a testicle that had become enlarged, without any pain. The -testicle in this case appears to be perfectly smooth, and in view of the -fact that tubercular disease of this organ may exist for a long time -without affecting the general system, I should certainly keep the -testicle until my general health began to show some evidence of -declination. - -Dr. F. C. Wilson: The question is a very difficult one to decide. There -is one feature of the case that has not been sufficiently emphasized, -and that is the probable damage to the testicle itself by the repeated -attacks of gonorrhea. We know that the use of the testicle, so far as -any procreative uses may be concerned, has probably been abrogated by -these repeated attacks of gonorrhea, and with this view of the case the -question of removal of the testicle by surgical means would be -simplified; and it seems to me with the tuberculous history, if the -question could be decided even approximately, or even probably, that it -is tubercular, then it had better be removed. But it seems to me I would -first make every effort to solve the question, even aspirating or -removing a small part of the tissue so as to be able to make a -microscopical examination, and in that way possibly throw some light on -the subject. - -Dr. W. O. Roberts: It strikes me that this is tubercular, although it -may have been, as Dr. Howard says, excited by gonorrhea. The condition -feels to me nodulated and not smooth, and the disease appears to be -located chiefly if not entirely in the epididymis, and I think the -testicle should be removed. Whether it is tuberculous or not the -usefulness of the organ is destroyed, and I think it ought to come out -if it is tuberculous, especially because the other testicle will become -involved. So far as the cosmetic appearance is concerned, if that is a -feature in the case, we could insert a celluloid testicle. I believe if -the affected testicle is not removed, granting the diagnosis of -tuberculosis to be correct, that the other testicle will surely become -involved. - - -Dr. Turner Anderson: It is seldom that we have obstetric matters -presented to this society. I have thought perhaps a case I recently -attended might be of some interest. We are aware that the umbilical cord -is frequently found encircling the neck of the child. I delivered a -child four days ago in which the cord was wrapped around the neck twice, -then branched off under the arm, encircling the arm again at its dorsal -surface, then across again, branching over the back. You may better -understand the condition when I say that the cord came up from its -attachment at the umbilicus, encircling the neck twice, branching over -and under the axilla, around the arm, thence to its attachment to the -placenta. The woman was a primipara. As soon as the head was delivered I -detected that the cord was wrapped around the neck. I made an effort to -find the part that led to the placenta. The cord was found pulseless, -and I was in some doubt as to whether it had been so long encircling the -neck as to have produced death of the child. Just as the body of the -child was being extruded the cord snapped, tearing off fortunately from -its placental attachment. The child was delivered and after a little -effort was easily resuscitated. The pressure was so great, the traction -upon the cord was so decided, as to leave a white line across the back -of the child. There was a white mark around the neck, across the -clavicle, around the arm and over the back of the child which did not -disappear for some time afterward. - -The proper line of practice, I take it, in those cases where the cord is -around the neck of the child, is to first determine whether the cord is -still pulsating. If pulsating, we are justified in being a little more -tardy in our efforts to deliver the shoulders and release the child. If -possible we would of course draw down the cord and release it from the -neck of the child in this way; but in those cases where we are -confronted with the cord wrapped tightly around the neck of the child, -especially in the primipara, where the length of time which will be -consumed in delivery is uncertain, the line of practice I believe in -should be prompt delivery or division of the cord. As a rule when we are -confronted with a condition of this kind we can meet it satisfactorily -by a little delay and by holding the head of the child well up against -the vulva while the shoulders are being extruded. As the releasing pain -occurs and the shoulders and body are extruded, you can usually by -pressing the head well up prevent undue traction on the placenta and any -accident which might follow rapid delivery and undue traction upon the -cord. This was a case in which there was spontaneous rupture of the -cord; it tore away entirely by the uterine effort. This accident had no -influence upon delivery of the placenta; it came away promptly. It was -evidently not torn loose from its attachment, and there was no -hemorrhage. - -_Discussion._ Dr. J. A. Larrabee: The case is not only interesting, but -also somewhat unique as far as I am aware. We are all familiar with the -double wrapped cord, but in this case the acrobatic movements of the -child must have been considerable, in utero, to have produced the -condition described by Dr. Anderson; the child had evidently been -engaged in jumping the rope for some time. When the cord is wrapped -around the neck of the child as described, I think the best plan is to -expedite delivery. Of course in the primipara we must not be in too -great a hurry, we must utilize melting or crowning pressure to prevent -injury, but the management of these cases I think is entirely that of -dystocia, and powerful external pressure upon the fundus of the uterus, -bringing it down as low as possible, is the proper plan of expedition. -In the case reported, however, no amount of external pressure would have -accomplished any thing; fortunately the snapping of the cord enabled the -doctor to deliver and resuscitate the child, which is about the only -thing that could have been done. In this case it would have been almost -impossible to have divided the cord. Aside from the anomaly of the case, -which is worthy of especial mention, I do not know of any proceeding -which would have been equal to that which was followed. It is a little -strange that the placental attachment did not give way; if this had been -true, if there had been a separation of the uterine attachment of the -placenta, then we would have expected the placenta to have been expelled -with the child instead of a rupture of the umbilical cord. - -Dr. J. L. Howard: I would like to ask Dr. Anderson if usually, when the -cord is wrapped around the neck of the child, the cord is not an -abnormally long one? I have had this accident happen twice in my -experience, but no trouble resulted because of the abnormal length of -the cord in each instance. - -Dr. J. G. Cecil: This is an accident which as we know happens -frequently, as well as many other anomalous things in connection with -the umbilical cord. I would have been disposed, if the labor had been -delayed in this case, that is, the final delivery of the child, more -than four or five minutes, to have severed the cord, fearing that it -might have had something to do with the delay. If there was no pulsation -in the cord, there would have been little risk in cutting and not tying -it; then there would have been no further delay to the delivery; there -would have been no danger from hemorrhage, from premature separation of -the placenta, or danger from inversion of the uterus. However, as the -case turned out so well under the management that was adopted, it does -not become us to criticise that management, because the successful issue -proves the wisdom of the plan followed. - -I have once or twice encountered some delay in expulsion of the child by -reason of a short cord wound around the neck. I have never seen one so -displayed around the shoulder as in the case reported by Dr. Anderson. I -remember to have seen one case, however, in which there was a knot tied -in the cord, and tied so tightly that it shut off the circulation and -resulted in death of the child, and also complete atrophy of the cord -between the knot and the navel end. This was a very interesting case, -and was reported to the Louisville Clinical Society three or four years -ago by Dr. Peter Guntermann; it was one of the most interesting cases of -accidents to the cord that I have ever seen. How the knot was tied so -tightly in the cord can not well be explained; knots in the umbilical -cord are not very unusual, but it is unusual to see one tied so tightly -that the circulation is shut off thereby. It was thought, I believe, by -the reporter on that occasion that the accident was due to a fall which -the mother sustained just before the delivery, which was premature. - -Dr. Wm. Bailey: Nothing in the management of the case reported by Dr. -Anderson can be criticised by me. I am inclined to think that under no -circumstances was pressure made on the cord sufficient to interrupt the -circulation until after the head of the child was delivered. Then it -became a question as to the proper management. I believe it would have -been better to have cut the cord, as it might have lessened the -difficulty of delivery, and that there would have been no harm done to -the child in this case, because there was no pulsation in the cord. The -doctor had all the time for this delivery that would have been allowed -him if he had a breech presentation with the head making pressure upon -the cord, and ordinarily he would deliver such a case in from five to -seven minutes, and that would give a chance for resuscitation of the -child just as in the case of drowning. The child can be deprived of -circulation through the cord, in an accident like this, as long a time -as a person can be submitted to water, or drowned, and be resuscitated. -I have seen but one case in which there was a rupture of the cord during -delivery. I saw one exceedingly short cord, in which delivery of the -child ruptured the cord; it was not around the neck, it was simply too -short for the child to be delivered without detaching the placenta; just -as the child was delivered the cord was spontaneously severed at the -umbilicus, simply allowing me a sufficient amount to be caught with the -fingers and held until a ligature could be applied. I do not remember -the exact length of the cord, but it was so short that it was not -possible to deliver the child without either breaking the cord or -detaching the placenta. The cord ruptured spontaneously, and there was -no further accident or trouble. - -I believe if Dr. Anderson had to attend another case under exactly the -same circumstances he would prefer to cut the cord rather than to break -it off at the placental attachment. Inasmuch as he did not cut the cord -and the child was successfully delivered, and also as there was no -trouble in delivering the placenta, of course it makes no difference; -but I always like to have the cord attached to the placenta so that if -it becomes necessary to go after the placenta, in case of retention for -instance, I can have the cord as a guide. In Dr. Anderson’s case there -was no possible advantage in having the cord intact; as it was -pulseless, no injury could have been done the child by cutting the cord -before completing the delivery, and by cutting the cord as soon as it -was found that it encircled the neck, all possible difficulties as far -as the cord preventing delivery was concerned would have been removed. - -Dr. T. S. Bullock: I am very much interested in this case; I have never -seen one exactly like it. The greatest danger in this particular -instance was that alluded to by Dr. Cecil, viz., producing inversion of -the uterus. I think Dr. Anderson managed the case in the proper manner, -and by his method of expression the only possible danger was inversion -of the uterus. - -I have only seen one instance of dystocia from short cord; that was a -case in which the cord was the shortest I ever saw, and was wrapped -around the neck, where it was necessary in order to deliver the child to -cut the cord after tying it and then employ instruments, the cord being -so short that with each uterine action you could feel the cupping of the -uterus from tension on the cord. - -I think there would be less danger from premature separation of the -placenta than from inversion of the uterus. In the case Dr. Anderson has -reported the danger to the child from compression of the cord was -obviated by prompt delivery. - -Dr. J. A. Larrabee: Will not Dr. Bullock tell us whether the case he -refers to, where he could feel a descending or cupping of the uterus by -the expulsive efforts, was a primipara? - -Dr. T. S. Bullock: The woman was a primipara; the cord was very short, -it was tied and severed, then the delivery completed with forceps. I -would like to ask the gentleman whether, in those cases where they have -employed Crede’s method of delivering the placenta, they have noted a -cupping of the uterus from efforts to extrude the afterbirth? - -Dr. J. A. Larrabee: I have occasionally noticed cupping of the uterus -under those circumstances. - -Dr. F. C. Simpson: I remember a certain practitioner in this city -several years ago made the statement that he seldom tied the cord after -cutting it; that he did not see any necessity of tying the cord. If this -is true, then there would certainly be no danger in severing the cord in -cases such as Dr. Anderson has reported, and it would not even be -necessary to tie it until after the delivery had been completed. - -Dr. Wm. Bailey: I want Dr. Anderson to speak to one point in particular -in closing the discussion, viz., would there not be great danger if the -placenta was separated at a time when the child was still partly in the -uterus? - -Dr. F. C. Wilson: The only point I wish to bring out in connection with -the case is the possibility of detecting the fact that the cord is -around the neck of the child before delivery, and being on our guard for -it. Encircling of the cord around the neck of the child ought to give -rise to a funic bruit. You can hear very plainly a funic bruit, a bruit -which is synchronous with the fetal heart sounds. Where this can be -detected at a point where we know the neck of the child lies, it -indicates to us that the chord is around the neck. - -There are certain other circumstances under which we may also detect a -bruit: For instance, the one mentioned by Dr. Cecil, where the cord was -tied into a hard knot. I have met with several such cases in my -practice, and a bruit can be produced in this way, but at a different -place from the location of the neck, and it is a permanent bruit; a -bruit that is heard all the time. Where that is the case, of course it -indicates that there is some permanent obstruction of the cord, and the -likelihood is that it is due to a knot tied in the cord. We know that -sometimes the cord slips over the neck, and then the child’s body slips -through the cord, thus making a perfect knot; it then may be drawn -tighter and tighter, finally producing considerable obstruction. If the -bruit that is heard is evanescent, heard sometimes when you are -listening and not at others, that indicates simply a temporary pressure -upon the cord which may produce a bruit that is fetal in its rhythm, at -the same time it is heard occasionally only. Where the cord encircles -the neck and is drawn tightly it is apt to give rise to a bruit that is -more or less permanent, and always heard at a point where we know from -other methods of examination that the neck of the child is located. -Where this occurs we ought to be on the lookout and prepared to find the -cord encircling the child’s neck, and ought to endeavor to release it in -the first place, and where we are unable to do that, then the question -of severing the cord will come up. The cord being pulseless in the case -reported by Dr. Anderson would have simplified that question very -materially. The cutting of a cord that is not pulsating is an easy thing -and not at all dangerous. Even where the cord is pulsating I have cut it -repeatedly without even attempting to tie it, simply holding one end—of -course you have to make a guess as to which end is attached to the -child. You can not always tell that, but you can easily see from the -continued bleeding or pulsating whether you have the proper end or not, -and by simply holding that between the fingers the delivery can be -expedited, and then the cord can be tied immediately afterward. Where -the cord is pulseless there would be no danger in severing it and -leaving it untied and even unheld. I have time and again, after delivery -of the child, cut the cord and not tied it, but always waiting till -pulsation had ceased. I think there is no danger in doing this. If a -cord is cut after it ceases to pulsate and does not bleed by the time -the child is washed and ready to be dressed, there will be no hemorrhage -from it afterward. - -Dr. Turner Anderson: Referring to the point made by Dr. Howard, I -believe, whenever the umbilical cord presents anomalies as illustrated -by the case reported, that it is as a rule abnormally long. The cord in -this case was abnormally long. - -Dr. Larrabee made a point to which considerable importance should be -attached, viz., that it would not have been an easy matter to have -divided the cord in this case. I think practically he presents the case -exactly right. When a cord encircles the child’s neck twice, then -branches off and goes under the arm, then branches off over the back, it -presses the neck so tightly and the conditions are such that it would be -a very difficult matter to get one’s finger beneath the cord at the neck -and divide it. It is not such an easy matter to sever a cord under these -circumstances as one might suppose. I believe the majority of -obstetricians content themselves, when they find the cord is encircling -the neck, by simply making an effort to stimulate uterine contraction, -and to deliver the child as rapidly as is consistent with safety to the -mother, and while so doing take the precaution to support the head, to -hold it up well against the vulva and prevent undue traction on the -placenta. - -It is seldom that we fail to resuscitate a child born under these -circumstances. The cord as a rule is not encircling the child so tightly -so as to prevent our ability to resuscitate it. - -Dr. Bailey has correctly stated that arrest of pulsation in the cord -does not occur until after delivery of the head, and we have a limited -time then to stimulate uterine action and to disengage the body of the -child and release the cord from the neck. Contraction and arrest of -pulsation of the cord do not occur prior to that time as a rule. I can -conceive it possible that it might do so, but as soon as the head is -delivered, contraction then is so great that unless the cord is very -long there is an arrest of pulsation and the danger commences. -Fortunately we have recourse to stimulating uterine action, and have a -chance to deliver the child in the manner I have suggested with -sufficient promptness. - -I am satisfied Drs. Bailey and Bullock recognize all the dangers of -premature separation of the placenta in an uncontracting uterus. In the -primipara I can not believe that a slight cupping of the uterus, or the -premature separation of the afterbirth, would be a matter of any very -great moment. We are all agreed as to the dangers which may occur from -separation of the normally attached afterbirth prematurely in the -absence of uterine action. - -In the primipara we know how very closely the perineum, unless it is -lacerated, hugs the neck of the child, and to isolate and cut the cord -under such circumstances is a very difficult matter. I do not attach -much importance to not cutting the cord, although if I could feel it -around the neck of the child and could sever it I would not hesitate to -do so. - - -_Protrusion of the Rectum._ Dr. W. O. Roberts: To-day at my clinic at -the University of Louisville a man presented himself complaining of -hemorrhoids. I put him on the table on his back, drew his legs up to -make an examination, and he strained slightly, had an action from the -bowel, and passed out about four inches of his rectum. After examining -it carefully to see whether or not there were any hemorrhoidal masses -about it, or a tumor of any kind, I started to get some vaseline to -assist in replacing his rectum, when he drew it back himself as though -he had a string fastened to it. He did not touch it, but simply drew it -back. I turned the table about so the class could see the prolapsed -rectum, and he shot the rectum out and drew it back four or five times. -It is a very peculiar and unique condition to me, and I would like to -inquire if the members have ever encountered a condition of the kind in -their practice. - -_Discussion._ Dr. J. M. Williams: This is undoubtedly a case of prolapse -of the rectum with a lax condition of the connective tissue. It may be -from continually coming down, and I have no doubt that the bowel comes -down after each defecation; there is some kind of an action by which the -patient controls the rectum. It may be that contraction of the sphincter -muscle starts the rectum upward, and then it simply follows its course. -I can offer no other explanation of the condition. Certainly if the -bowel comes out four inches there would be considerable tension upon the -mesenteric attachment. It seems entirely possible that this phenomenon -could be influenced and controlled by the diaphragm and abdominal -muscles, and this may be the solution of this unique case. I have never -seen a case of this kind. - -_Epileptiform Seizures in an Infant Aged Ten Months._ Dr. J. A. -Larrabee: I have been considerably interested and I may say annoyed by a -case that has been under my care recently. It is in a family which is -decidedly neurotic, and in which there is possibly, without history or -committal, a taint of specific disease. It is not very unusual to have -epileptic manifestations in children at an early age, but the case I -desire to report is, I think, somewhat anomalous. There have been, for a -period of fourteen days, eleven petit mal seizures in every twenty-four -hours in an infant ten months old. These seizures have not apparently -concerned or involved the integrity of the child in any respect. The -intellectual functions, so far as intelligence is written upon the face -of an infant, do not seem to have been affected. The infant is just as -well apparently as if it did not have every hour or so an epileptic -convulsion. The attacks present the usual phenomena of true epilepsy. -The duration of these attacks is from one to two minutes, accompanied by -the usual phenomena, flushing, unconsciousness which is perfect, the -attack then passes off and the infant is well again. - -This condition of affairs having been going on for a period of fourteen -days in this case without any impairment in the general health of the -infant, or in its nutrition, certainly points, I think, to a specific -cause. I have often had cases, not quite so remarkable as this, where -the tendency has been neurotic or specific in character, which improved -under appropriate treatment; but this case has resisted all treatment, -even specific treatment by the inunction of mercurials and the -administration of the iodides. - -The condition is still in progress, the infant having eleven seizures in -every twenty-four hours, not exceeding this number and not falling -short. I have witnessed several of them, and they are perfectly -characteristic of epilepsy. An older child in the family passed through -an ordeal of paroxysms, was unable to walk for three years, and this -child has been restored under treatment, and that treatment has been -antisyphilitic. One child in the family has been lost, and the history -is that it died from scorbutus. The family is decidedly neurotic, and I -suspect a specific taint. - -The case has been exceedingly interesting and even annoying to me -because I have been unable to make the slightest impression upon it by -treatment in lessening the number or severity of the paroxysms. I am -pursuing the same line of treatment that I did in the case of the older -child which recovered, and believe I have sufficient ground for specific -treatment, but so far it has not been productive of relief. - -The peculiarity about the case is that the occurrence of these paroxysms -has not so far interfered with the nutrition or the general health of -the infant. In this respect I think the case is somewhat remarkable. - - -_Discussion._ Dr. T. S. Bullock: I would like to ask if Dr. Larrabee -gave the bromides in the case he has reported. - -Dr. T. H. Stucky: Have you tried the bromide of gold and arsenic? - -Dr. J. M. Ray: In connection with Dr. Larrabee’s case I recall one that -I saw several months ago in a child a little older than his which gave a -peculiar history. The mother brought the child to me, the history being -that the child complained of having something the matter with its ear. I -examined the ear carefully. No inflammatory or other disease was present -about the structures of the ear; hearing was perfect, and the drum -membrane was intact. The child at this time was three years of age. The -history that the mother gave me was about as follows: The child had -never complained of earache; she had never noticed any defect in -hearing, but sometimes two or three times a day the child would -apparently be interested in her toys or in something about the room, and -all at once she would scream and run to her mother and say that the -house was turning over, that there was a bug in her ear, etc. This would -happen several times a day, and on several occasions the child had -fallen over apparently unconscious, or in a state of partial -unconsciousness. - -After looking into the ear carefully and not finding any evidence of -disease, I referred the case to the family physician, and in talking the -matter over with him he suggested that these attacks were probably petit -mal. He put the child upon bromide of gold and arsenic, and a prompt -recovery resulted. The last I heard from the case the attacks were few -in number, occurring at long intervals and slight in character, although -at one time they occurred two or three times a day. - -Dr. T. H. Stucky: I have seen several cases of epilepsy in children, but -never saw one in a child so young as that reported by Dr. Larrabee. I -have followed out the usual routine, giving bromides and other remedies -with varying results; and later, following the suggestion of Dr. -Buchman, of Fort Wayne, have tried combination mentioned by Dr. Ray, -viz., the bromide of gold and arsenic. I believe the latter to be -especially indicated and exceedingly serviceable where we have reason to -suspect a taint, as mentioned by Dr. Larrabee, getting as we do the -sedative influence of the bromide, the alterative influence of the gold, -and also the well-known effects of the mercury contained in the -combination. - -I believe where anemia is very marked in these cases, and there is a -feeble heart action, and we are fearful of the depressing effects of the -bromides alone, that in the use of the bromide of strontium and gold we -gain a decided advantage, getting as we do the sedative as well as the -cardiac influence of the strontium salts. Dr. Marvin demonstrated this -conclusively before this society in a statement made by him in regard to -the action of strontium salts in digestive disturbances, especially -those conditions characterized by marked flatulency. If this be true, -and we have reason to believe it is, it appears to me that the bromide -of strontium and gold would be even better than the bromide of gold and -arsenic in cases such as Dr. Larrabee has reported. - -Dr. J. A. Larrabee: The case is reported not to demonstrate any unusual -manifestation of epilepsy, but on account of the exact regularity and -periodicity of the seizures, and the age of the patient, coupled with -the fact that the treatment which seems to be indicated has not been -followed by relief. In looking up the literature of the subject I find -that cases of this character are usually attributed to a specific cause. - -In answer to Dr. Bullock’s inquiry: I have used the bromides in this -case without any effect whatever. Of course epilepsy in the child is -nothing new, but this case presents some peculiarities. There is a -decided neurotic tendency in the family, which may have some bearing -upon the case. The child is going along having the number of seizures -stated each day without any evidence of disturbance of nutrition or -impairment of general health, which is rather remarkable. Some of the -attacks are almost grand mal, most of them petit mal, and I am convinced -that the trouble is due to specific taint. - -The next move I make will be to put the child upon the bromide of gold -and arsenic. - - JOHN MASON WILLIAMS, M. D., _Secretary_. - - - - - Abstracts and Selections. - - -THE INFLUENCE OF THE ORGANISM UPON TOXINS.—Metchnikoff (_Ann. de -l’Instit. Pasteur_, November 25, 1897,) has applied the method of -comparative pathology to the question of the mechanism by which the -animal organism prepares antitoxins, and the laws which regulate their -production. By growing bacteria and lowly fungi upon culture media -containing toxines he was enabled to show that the virulence of the -latter was in most cases diminished and sometimes destroyed. In any case -these microbes have no influence in the production of antitoxins, and -the idea of preparing them by this means must be abandoned. The animal -organism alone being capable of producing antitoxins, the next point was -to find out whether this was a property common to all animals, or -limited to the superior. Metchnikoff found that the injection of large -quantities of tetanus toxin into scorpions and the larvæ of other -arthropods produced no antitoxin. The toxin remained for months in the -blood or tissues without losing its properties; similar results were -obtained when it was taken into the alimentary canal of the leech. It -was hence shown that even those invertebrates in which antimicrobic -phagocytosis is most marked are utterly incapable of producing -antitoxins. Coming next to vertebrates, no power of producing antitoxin -is possessed by fish or amphibia; it first appears in reptiles, but not -in all kinds. Thus tortoises, like invertebrates, can retain tetanus -toxin in the blood for a lengthened period without forming antitoxins; -it is in reptiles that the production of the latter is first observed, -but in them only when they are kept at a temperature higher than 30° C. -If the temperature is 20° C. the results are just the same as in -tortoises and invertebrates. The establishment of the antitoxic property -in these cold-blooded animals is not attended with any rise of -temperature, and the same is true in warm-blooded animals such as fowls. -With regard to the last-named animals, whose power of producing tetanus -antitoxin was first demonstrated by Vaillard, Metchnikoff has some new -and important observations. He finds that practically all the toxin -injected into the peritoneum passes into and remains in the blood, none -of the organs being toxic after their blood has been washed out. To this -an exception is found in the case of the genital organs, ovaries, and -testicles, which possess the power of fixing some of the circulating -toxin. This they share with the leucocytes, to the toxicity of which -that of the blood is due. After a while the toxic power of the blood -diminishes, and after passing through a neutral period it becomes -antitoxic. It is now found that with the exception of the generative -organs, none of the organs when freed from blood possess any antitoxic -power. The genital glands are found to be markedly antitoxic, but the -author brings evidence to show that the antitoxin is not manufactured by -them, but is absorbed from the blood, so that in the fowl the antitoxic -property resides solely in the blood. Metchnikoff concludes that it is -not possible to accept the idea that natural immunity depends on -antitoxic power, and he further points out that the latter is evolved in -the history of the animal kingdom at a much later date than the -phenomena of phagocytosis.—_British Medical Journal._ - - -THE TREATMENT OF TUBERCULOSIS WITH TUBERCULIN R.—Dauriac (_Progrès -Médical_, December 4 and 11, 1897,) reports the results of the -employment of Koch’s tuberculin R. in various cases of tuberculosis; -fourteen of these presented local affections, such as suppuration over -the sternum, enlarged cervical glands, ulceration of the skin, etc. All -of the patients were satisfactorily cured. In a second paper he -describes the results in fifteen cases of pulmonary tuberculosis in -various stages of the disease; all were greatly improved, and many are -described as cured. One of the cases was insufficiently nourished and -clad, had no fixed residence, and, when the treatment was commenced, -large cavities were found at the apices of both lungs. A case is also -described in which, in addition to pulmonary tuberculosis, lesions were -present in the kidneys and the bladder. This patient also made a -complete recovery. The treatment, in spite of these brilliant results, -is supposed to be most applicable to the earliest stages of the disease, -and it is suggested that it would be advisable to detect the presence of -tuberculosis by injections of minute doses of the original form of -tuberculin. The treatment is usually commenced with a dose of 1/500 mg. -This should be increased daily until a dose of 10/500 mg. is reached; -this then should be increased 1/50 mg. daily until ⅕ mg. is reached, and -this increased ⅕ mg. daily until 1 mg. is given. This can then be -further increased if considered desirable, the maximum dose being about -20 mg. The immediate effects of the injections are usually _nil_. With -doses in excess of ⅗ mg. a slight elevation of temperature is -occasionally observed. Local reaction is extremely rare. The subsequent -effects consist in reduction of fever, cessation of sweats, increase in -appetite, and disappearance of tuberculous lesions. As none of the -patients reported in this paper was admitted to the hospital, but simply -came three times or less frequently a week to the dispensary for -injections, improvement could not possibly have been due to any -alteration in their hygienic surroundings.—_The Philadelphia Medical -Journal._ - - -CESAREAN SECTION BY TRANSVERSE INCISION OF FUNDUS.—Braun (_Centralbl. f. -Gynak._, No. 45,) has had experience of Fritsch’s cesarean section, the -operation being the second of its kind ever recorded. Fritsch bases his -practice on the course of the secondary branches of the uterine arteries -which run horizontally, so that a longitudinal incision down the front -of the gravid uterus can not fail to cause free hemorrhage. He is -accustomed to extirpate diseased fallopian tubes completely, snipping a -wedge-shaped piece out of the uterine cornu. Bleeding is always free, -but the tying of a suture passed antero-posteriorly under the bleeding -vessel stops it at once. The ligature lies at right angles to the -vessel, the most favorable position. Hence Fritsch conceived the idea of -making an incision straight along the fundus from cornu to cornu, in -order to extract the fetus in a cesarean section. Braun publishes full -notes of his own case. The patient was a rachitic primipara with a -universally and irregularly contracted pelvis. The conjugata vera was -two and three-quarter inches. Labor pains had set in. Care was taken to -antevert the gravid uterus sufficiently, the upper part of the wound -being held together with forceps during delivery of the child. Then the -transverse incision was made. Braun found that it bled as much as the -longitudinal incision in cesarean sections where he had operated during -labor at term or in relatively early pregnancy. The placental site did -not lie near the fundus. The delivery of the fetus, which was living and -weighed six pounds, was neither harder nor easier than through a -vertical incision. The wound in the fundus was under four inches long -after the fetus had been extracted. The sutures had to be placed close -together, fifteen deep and eight superficial being applied. Ergot was -given after the abdominal wound was closed, as there was hemorrhage. The -patient made a good recovery.—_British Medical Journal._ - - -LABOR IN MATURE PRIMIPARÆ.—De Koninck (_Revue Medicale_, Louvain, -October 30, 1897,) has compiled an instructive memoir on labor in -primiparæ married for some years and relatively mature (twenty-eight -years Bidd and Pourtad, thirty-two Ahlfeld). De Koninck gives thirty as -the earliest year coming under “maturity,” the “_primipares agees_” of -French authorities. He sets aside as curiosities certain cases of -primiparæ almost “aged” in the English sense of the term, such as -Cohnstein’s two women aged fifty and Steinmann’s woman aged fifty-two. -It appears that in a genuine uncomplicated case of delayed impregnation -the advent of the catamenia is always found to have occurred late in -youth. Out of 401 such cases menstruation was retarded till twenty in -39, till twenty-four in 4, and till twenty-six in 1. As to the retarded -first pregnancy, abortion, ectopic gestation, twins, and special renal -mischief are relatively frequent. Above all, lingering labor is -specially common, statistics even exceeding guesses and _a priori_ -reasoning in this respect. In 12 out of 17 noted by De Koninck labor -lasted from forty to fifty hours, the remaining labors being yet longer; -1 exceeded ninety hours. Feebleness of uterine contraction is absolute -from first to last, and independent of any obstetrical combination. They -also cause far more physical and mental exhaustion than the vigorous -contractions of a young uterus, and at the same time are more painful. -There are discrepancies in the “pains” seen in mature primiparæ of the -same age, probably homologous with the great variations in the age of -menopause observed in otherwise normal women. The uterus may be older in -one woman aged thirty-five than in another of the same age. The forceps -and other obstetrical operations are often required in the mature. Most -of the above facts are easily explained. The excess of male infants -borne by mature primiparæ (thirty per cent) is a less explicable -phenomenon. Hecker considers the predominance of male infants as a -speciality of all primiparæ, but Rumpe turns attention to the fact that -in a family of children the predominance of males is commoner the -further the mother is from her first menstrual period.—_Ibid._ - - -KINESITHERAPY IN HEART DISEASE.—Colombo (_Gazz. Med. di Torino_, 48, N. -39, 40, 1897,) pleads for a more general use of kinetic treatment in -heart disease. Even in advanced cases he seems to think such treatment -is very advantageous. Milder forms of treatment, for example, the -Swedish method of gymnastic exercise, should be started at first, and -afterwards more active methods, for example Oertel’s, can be tried. The -action of the Swedish method is most marked upon the peripheral vessels, -while Oertel’s system acts more directly upon the heart itself, so that -dividing heart disease into disease of central or cardiac, and that of -peripheral or vascular origin, the different methods could be applied -accordingly. The Swedish method, moreover, has this advantage, that it -can be applied in severe cases which can not leave their beds. Barie -(_Sem. Med._, November 12, 1897,) advocates the treatment of heart -disease by Swedish gymnastics. The aim of the exercises is to facilitate -the work of the heart by increasing its contractile power and by -lessening the peripheral resistance. The exercises are a series of -regulated, combined, or alternating movements of resistance or -opposition. The movements employed fall under the main groups: (1) -Kneading, rubbing, or stroking of the muscular masses in the limbs and -abdomen; (2) movements of circumduction which facilitate the circulation -in the main venous trunks; (3) movements which favor respiration. The -exercises are very varied, and accomplished by means of passive and -active movements, numerous different manipulations, and by special -apparatus. The average duration of the treatment ought not to be less -than an hour a day during three months of each year. The treatment is -suitable for cases of dilatation, hypertrophy, fatty degeneration, -chronic myocarditis, and various neuroses and functional affections of -the heart. Such symptoms as shortness of breath, palpitation, insomnia, -cephalalgia, giddiness, gastric phenomena, edema, ecchymosis, cyanosis, -improve or disappear under treatment. The pulse-rate is lowered, but -rises again as soon as treatment is interrupted. Rational application of -the treatment does not exclude internal treatment by ordinary medical -means, and the two methods may often be employed simultaneously with the -best results.—_Ibid._ - - -LIVE FROGS AS AN ANTITHERMIC.—An English practitioner of Constanta, -Roumania, writes: On the evening of October 19th I was called to visit a -Roumanian boy, six years old, suffering from typhoid fever. I found him -_in extremis_, almost pulseless. The child’s head was completely wrapped -over with a large white sheet, and as I looked at it this enormous white -envelope seemed to be on the move, and while I was surveying this -covering there crept from under it a small frog, which quietly sat over -the child’s left arm. It seemed quite content. I immediately called the -mother’s attention to it and requested her to take the animal away, -thinking it had crept there as an intruder. “Oh, no!” said the old lady, -“a doctor recommended that a lot of them should be kept to the head to -keep it cool.” Seeing the head covering still on the move, I raised it -for curiosity, and in a second out jumped about twenty other frogs and -hopped away in all directions. I have often heard the expression “as -cold as a frog,” but this was the first time I had seen a frog applied -as a head-cooler.—_London Lancet._ - - -TREATMENT OF ENDOMETRITIS IN BROMINE VAPOR.—Nitot (_La Gynecologie_, -October 15, 1897,) maintains that the correct prophylactic treatment of -parenchymatous metritis and chronic salpingitis consists in rapid cure -of recent endometritis, which is the starting point of those troublesome -diseases. To insure cure a remedy is needed which can penetrate to the -deepest recesses of the muscosa, and even the tubes, without dangerous -effects. Caustics and fluid preparations do not possess such properties. -A gas is required, and it must be freely diffusible, antiseptic, and -capable of acting on the epithelium so as to modify without destroying -them (“anticatarrhal action”). Bromine emits gas with the necessary -qualities; a saturated aqueous solution should therefore be placed in a -bottle with double tubing like an ether spray or the chloroform bottle -in a Junker’s inhaler. A hollow sound, connected with one tube, is -passed into the uterus, while the solution is made to bubble by pressure -on a ball connected with the second tube. Thus vapor is propelled into -the uterus. Nitot claims the best results, and notes that the advantages -of gaseous diffusion over intra-uterine injections or other medication -are self-evident.—_British Medical Journal._ - - - - - THE AMERICAN PRACTITIONER AND NEWS. - - - “_NEC TENUI PENNÂ._” - - ══════════════════════════════════════════════════════════════════════ - Vol. 25. FEBRUARY 1, 1898. No. 3. - ══════════════════════════════════════════════════════════════════════ - - H. A. COTTELL, M. D., Editor. - - * * * * * - - A Journal of Medicine and Surgery, published on the first and fifteenth - of each month. Price, $2 per year, postage paid. - - * * * * * - - This journal is devoted solely to the advancement of medical science - and the promotion of the interests of the whole profession. Essays, - reports of cases, and correspondence upon subjects of professional - interest are solicited. The editor is not responsible for the views - of contributors. - - * * * * * - - Books for review, and all communications relating to the columns of - the journal, should be addressed to the Editor of THE AMERICAN - PRACTITIONER AND NEWS, Louisville, Ky. - - * * * * * - - Subscriptions and advertisements received, specimen copies and bound - volumes for sale by the undersigned, to whom remittances may be sent - by postal money order, bank check, or registered letter. Address - - JOHN P. MORTON & COMPANY, Louisville, Ky. - - * * * * * - - - - - THE ART OF NEGLECTING WOUNDS. - - -The New York Post-Graduate Clinical Society[2] was recently treated to a -moving discourse on the novel subject of “The Art of Neglecting Wounds,” -by Dr. Robert T. Morris, one of the instructors in surgery in the -Post-Graduate School. - -Footnote 2: - - The Post-Graduate, Vol. XIII, No. 13, January, 1898. - -The author confined his remarks to wounds made by the surgeon when -operating, and hints pretty strongly, though he does not say so, that -their subsequent treatment even by the surgeon himself might not -inappropriately be called “meddlesome surgery.” - -For instance: In incised wounds (the margins of which have not been -quite approximated) the capillaries begin to develop granulation tissue -in the coagulated lymph deposited upon the surface in a few hours if the -trophic nerves have not been much injured. This granulation tissue is -extremely delicate and will not bear handling. When such a wound is -suppurating freely the strong temptation to wipe away the pus with -sponge or gauze should be resisted for two reasons, first, “Granulation -tissue suffers traumatism whenever it is touched, no matter how lightly, -and, as a result of such traumatism, there will be developed exuberant -granulation tissue, which will be poorly supplied with blood-vessels. We -have in weak granulations, so to speak, what might be called ‘watered -stock.’ It is a very common result of our well-intentioned but -ill-directed efforts at keeping the wound clean.” - -Gauze upon the granulations will injure the tissue still more, since its -filaments entangle the granulations, which on removal of the dressing -are broken off in small fragments. The device which prevents this injury -is a covering of very soft gutta-percha tissue or Lister’s protective -silk. But the surgeon who practices this let-alone method, though backed -by sound pathological knowledge and therapeutic principles, will not -escape the censure of the family or the nurse, and too often allows his -sense of neatness to take precedence of his more sober sense founded -upon pathological knowledge. - -This “neglect” is particularly desirable when epithelium is shooting -across the wound. These hyaline cells are so extremely delicate that the -slightest touch will damage or remove them to the detriment of the -healing process. The dressing on a suppurating wound should be allowed -to remain five or six days. Though the ignorant may find fault with the -surgeon for such temporizing, he must insist upon it for the patient’s -well-being. - -Another illustration is drawn from the operation for appendicitis, in -which we have adhesions, pus, and wide infection. Here new pathological -factors are met with. The peritoneum throngs with polynuclear leucocytes -which are engaged in destroying the bacteria. If time be given these -faithful guards to mass themselves in the peritoneal lymph channels, -they will prevent the extension of the peritonitis from this point. The -surgeon, having evacuated the pus, removed the appendix, and inserted -the drainage apparatus, is tempted, because of its bad smell, to wash -out the wound. Such a measure would not only give the patient -detrimental annoyance, but would inflict a new traumatism upon the -tissues. “This traumatism calls out an unnecessary number of leucocytes, -and an unnecessary degree of reactive inflammation ensues. If, on the -other hand, the colon bacilli are allowed to increase, they will at -first produce a very foul odor to the discharge, but in three or four -days we will usually find streptococci abundant, and perhaps displacing -all other bacteria.” In such cases, leave the drainage apparatus in -place and “neglect” the wound. “Repair and destruction of bacteria will -go on much better if we leave the wound alone, after having removed the -principal mass—the contents of the abscess cavity.” - -Another illustration is found in burns of the second degree. Here large -blisters have formed and broken, and much skin is denuded of its -cuticle. In such a case the author administers an anesthetic, opens the -blebs, removes the detached skin, scrubs the parts with an antiseptic -solution, covers the denuded surface with strips of gutta-percha tissue, -and leaves the case to nature. When a change is made, it should be of -the outer dressings only. And the reasons for this treatment are that in -such burns “the serum which is thrown out is germicidal, and is -destroying all the bacteria upon the skin very rapidly. This germicidal -action will go on so long as the serous exudation is free, but when the -coagulation of lymph begins on the surface, this action becomes very -much diminished, and the bacteria are then liable to liquefy the lymph -and grow very rapidly, as new portions of serum are thrown out. This -leads to sepsis and sometimes to the formation of thrombi, with necrosis -of the duodenum and perforating ulcer. The patient’s friends complain if -the dressings are left long in place, and yet I know of no wounds which -do so well when ‘neglected’ as burns.” - -In the discussion that followed, the author, being asked what he would -do with suppurating sinuses, said “he knew of sinuses that had been kept -open week after week and month after month, and had proved veritable -gold lodes to the surgeons. If the surgeon had been compelled to go away -for a time, these sinuses would have healed long before they did. This -might seem like a joke, but it was a fact with which he was brought face -to face all the time. His rule was to leave sinuses alone, in the belief -that the poorly fed granulations lining them would in time cause -approximation of the walls, and healing would occur. It was true that -exceptions would have to be made for some sinuses, but that did not -affect the rule as given.” - -Such considerations give accentuation to the dictum of Velpeau, that -“nature is a good physician but a bad surgeon,” and dignify the _bon -mot_ of Holmes, who, seeing the smoothly healed and finely cushioned -stump which resulted in time after an amputation, exclaimed: - - “There’s a divinity that shapes our ends, - Rough hew them how we will!” - -For the surgeon’s far more than the physician’s successes depend upon -the _vis medicatrix naturæ_, and he who is best versed in physiological -and pathological processes, and administers the surgical art -accordingly, will secure the best results. - -They who neglect their surgical cases from ignorance, carelessness, or a -wanton disregard of the great pathological dicta of the day, can find no -justification in these teachings, for the truth, as embodied in the -author’s closing words, puts all such to shame and confusion: “A good -deal of skill is required in order to neglect wounds well. This -‘neglect’ of course implies a proper understanding of the processes with -which one is dealing.” - - - - - Obituary. - - - DR. J. Q. A. STEWART. - -On the 25th ultimo this accomplished physician and estimable gentleman -died at his home in Farmdale, Ky. He had been in failing health for -something more than a year. His ailment was Bright’s disease, and the -end was precipitated by uremia. - -Dr. Stewart was born near Louisville, Ky., in 1829. In 1849, having -secured a good common school education, and graduating in law, he went -to the gold fields of California, where he sojourned for seven or eight -years. Returning to his native State, he entered upon the study of -medicine, and graduated from the Kentucky School of Medicine in 1859. He -began practice in Daviess County, Ky., but after a few years moved to -Owensboro, where a larger field of usefulness and fuller success awaited -him. - -In 1878 Dr. Stewart was called by Governor John B. McCreary to the -position of Medical Superintendent of the Kentucky Institution for the -Training of Feeble-Minded Children. It was here that the chief work of -his life was done. And it was here that he served humanity and the State -with honor, with ability, with fidelity, and with an earnest, -self-sacrificing devotion to the welfare of these rejected waifs of -humanity which entitles him to place and rank among the higher -philanthropists of our philanthropic profession. - -In the care of the feeble-minded Dr. Stewart added to his executive work -the habits of a careful student, and became one of the best known -alienists of the land. His address as retiring President of the Kentucky -State Medical Society in 1894 was an able and scholarly treatise upon -the management of the feeble-minded. It was received with great favor by -the Fellows, and has since been the subject of high encomiums from -doctors, lawyers, and political economists. - -After sixteen years of State service Dr. Stewart purchased the old -Kentucky Military Institute near Frankfort, where he established the -“Stewart Home for the Feeble-Minded.” The venture was successful beyond -expectation, and here in the bosom of his family he passed serenely and -blissfully the closing years of his gentle, useful, and beautiful life. - -[Illustration: DR. J. Q. A. STEWART.] - - - - - Notes and Queries. - - -THE SURGERY OF THE THYROID FROM A NEUROLOGIC STANDPOINT.—In a -suggestively written paper in the January number of the American Journal -of the Medical Sciences, Dr. J. J. Putnam uses the following words: “We -are rather in the habit of assuming that the removal of large portions -of the thyroid does no harm, provided it does not cause myxedema. But -the probability is that we shall learn to recognize affections which lie -between myxedema and health, as well as peculiarities of development and -disorders of nutrition for which the thyroid is more or less -responsible.” ... That this is a statement of fact will hardly be -disputed by any neurologist, but that it expresses a truth that has as -yet been insufficiently impressed on the profession generally is another -fact the importance of which is not likely to be overestimated. It is -only within a comparatively brief period that we have learned that the -thyroid had any definite function and our knowledge of its physiology is -still very far from being exhaustive. The dangers also of interference -with it are as yet also only partially known, but it is certain that -they are not confined to the operation itself. The cases of sudden fatal -dyspnea occurring hours after an apparently prosperous operation in -Graves’ disease, recently reported by Debove and others, are in evidence -of this, and Dr. Putnam adduces other important facts and arguments -against any too venturesome surgery of the thyroid gland. Among these -are the experiments of Halsted, showing that excision of the gland in -dogs had a serious and very evident disturbing effect upon their -offspring, and that even very slight operative interference produced -hypertrophic changes and apparent increase of secretion in the gland -itself; and the observations of Kocher of goiter and cretinism inherited -from parents with no disease other than impaired thyroid function are -also cases in point. Still another fact brought forward by Putnam is the -one that removal or atrophy of the thyroid in infancy checks the growth -and function of the reproductive organs, and gives rise to the various -disturbances of development that follow the suppression of this very -important function. The close relations of the various internally -secreting glands, the thyroid, the testicles and ovaries, the suprarenal -glands, and the pituitary body, for this it seems probable must be -included in this category, are revealed in many pathologic conditions, -and the thyroid as the largest, and presumably the most important, has -apparently a larger part in the disturbances than any of the others. It -seems to be involved to some extent in many cases of acromegaly; its -relations with the genital development have already been mentioned, and -its implication in many pathologic conditions of organs is probable and -is strongly suggested by the clinical history in certain cases of -Graves’ disease. Seeligmann has indeed recently reported a case of this -affection apparently closely associated with genital disorder in which -he obtained decided benefit from the administration of ovarian extract, -thus adding another suggestion to the therapeutics of the disorder. - -When any organ is removed, as Putnam says, two factors are set in -operation which may have more or less important effects upon the system -generally. One of these is the action of toxins, the other is the effort -of the organism to adapt itself to the new and changed conditions. The -first of these is important enough in the case of removal of the thyroid -gland, but the other, from what we are beginning to know of its -physiology, must be even more important. Because the function of the -organ is already deranged, it does not necessarily follow that matters -will be remedied by its removal. The operation may only make a bad -matter worse. The mortality of thyroidectomy, according to Poncet, is -from fifteen to thirty per cent, which is alone enough to induce -caution. When the facts brought forward by Dr. Putnam are also -considered, the known and the possible and hinted though yet unknown -effects of thyroid ablation, there is still more reason for prudence and -hesitancy in this operation. - -Of course when a goiter has become a dangerous mechanical -embarrassment to important functions, or when a tumor exists in the -thyroid that by its growth and situation has become a threatening -danger, the case is clear, and operation may not only be justifiable -but necessary. It is in such affections as Graves’ disease, in which -thyroid operations are still somewhat popular, that we are likely to -have not only useless but dangerous surgery, and the time seems to -have come to emphasize the cautions implied in Dr. Putnam’s paper. The -theory of hyperthyroidization in this disease, though it has -apparently much in its favor, is not yet sufficiently demonstrated, -and even were it so, would not form a justification for any -indiscriminate or frequent practice of operative interference. Graves’ -disease is not by any means a hopeless disorder under medical -treatment, even in its advanced stages; it is therefore impossible to -say when surgery is indicated as a last resort. When the facts of its -absolute inefficiency in perhaps the larger proportion of instances in -which it has been tried, the immediate dangers of the operation which -are not slight, and the remote ones pointed out by Dr. Putnam, are all -taken into consideration, it would seem that it ought to be relegated -to innocuous desuetude.—_Journal of the American Medical Association._ - - -THE TREATMENT AND PROGNOSIS IN GRAVES’ DISEASE.—This short article is -prepared solely with the view of eliciting from medical men who have met -with cases of exophthalmic goiter in their practice, the results of -their observations regarding many points of interest in connection with -this curious disease. I do not intend to give a systematic description -of the affection in question. This can be found in any good modern -text-book. Described many years ago by Parry, Basedow, and by others -more recently, it is much better understood and more widely known than -formerly. - -Opinions differ radically as to its real nature. The best modern -authorities regard it as a pure neurosis, and functional only in -character, although organic changes often develop during its course in -the heart, thyroid gland, and elsewhere. Some still speak of it as due -to changes in the medulla oblongata; others again look upon functional -and structural changes in the thyroid gland as the real cause of the -malady. My own experience inclines me to view it as a neurosis pure and -simple, although marked and characteristic structural changes supervene -during its course, and may become permanent. Probably in the near future -we shall learn more as to its exact nature. Already it is satisfactory -to note that cases are far earlier and more frequently recognized, and -that their treatment is more successful. - -From their first appearance its special features attract attention. -These are few in number, and easily borne in mind: 1. An unusual and -more or less constant rapidity of the heart’s action; 2. The early -presence of more or less protrusion of the eyeballs; 3. A marked -enlargement of the thyroid gland; a tendency to tremors or tremblings -under very little, and sometimes no excitement, although this always -increases it. It is not surprising that these indications of -exophthalmic goiter which develop more or less rapidly and become often -most distressingly marked, should cause much anxiety to the patients and -their friends, as well as to their medical attendants. - -With regard to the duration of ordinary chronic cases (for acute ones -are seldom met with), what has been the experience of those who may read -this article? I have never met with an acute case, but have seen months -and one or two years pass before there was more than a partial -improvement. - -One case, a very bad one, in which the patient’s circumstances were so -poor that she worked on during her illness, when she should have had -care and rest, recovered completely. But so serious was this case, that -the sight of both eyes was entirely lost from the excessive protrusion -of the eyeballs during the disease. When I first saw her, which was -years after her recovery, the story of her case was intensely -interesting, but most sad. - -Then as to the frequency with which relapses occur in this disease, it -would be interesting to get the experience of good men. Many speak of -relapses being frequent, even after apparently complete recovery has -taken place. Others think them not of so common occurrence. - -There are also many points of great interest in connection with the -prognosis. One of these is the probability of the recovery being -perfect. My own experience has been that the lighter or milder the case -the greater the probability of a perfect cure. - -Another matter of interest is in connection with cases in which the -symptoms greatly abate, the health indeed appearing to be perfectly -restored, but in which the exophthalmos and thyroid enlargement continue -noticeable; whether in such patients very slight causes may not lead to -a return of the disease. From what I have seen, the conclusion appears -correct, that provided the heart’s action is normal as to frequency, and -not too easily disturbed, these cases are not specially likely to have a -second attack, which is tantamount to saying that, provided the heart’s -action has become normal, any other relic of the illness is -comparatively unimportant. - -I have observed, too, more or less scleroderma present when the attack -has not been by any means of a serious character, and when afterward the -general health became all but perfectly restored. This is an interesting -concomitant. It would be desirable to have others give their experience -as to its occurrence in cases they may have attended. - -Then as to the effects of pregnancy during the course of the disease; -some high authorities speak very strongly as to its great danger. Others -remark that the affection has improved during gestation. This is another -matter on which fuller information would be most useful. - -As to the percentage of fatal cases, this is hardly as yet to be -determined so as to be useful to the practitioner. My own cases have led -me to the conclusion that every particular case has to be regarded _per -se_, that is, if the symptoms are light and comparatively trifling, and -show signs of abating, the prognosis is favorable, while under an -opposite state of things it is the reverse. - -As to treatment, what has succeeded best in my hands has been enjoining -upon patients the necessity of a great deal of physical rest, at least -ten or twelve hours a day if possible, and the avoidance of all mental -worry. On this, great stress should be laid. These patients require -abundant nourishment. Galvanism in my hands has been found most useful; -employed twice a day and so applying the poles that the current may go -from the back of the neck through the thyroid gland, and the heart, and -even (the current being made very weak) through the eyeballs. This -current has been continued for months, and in some cases for a year and -a half, with good effects. Sometimes tincture of digitalis has been -useful in moderate doses, ten or twelve minims three times in -twenty-four hours, in some cases, and useless in others. Iron has been -found of great value and persisted in for a long time. As a nerve-tonic, -strychnine in small doses has been exceedingly beneficial. Quinine, if -used, should, unless malaria complicates the case, be used in small -doses only, such as 1½ grains three times a day, with the iron and -strychnine. - -I know that many of the matters I have mooted in this paper have been -quite recently discussed by Drs. Ord and McKenzie, of London, in an -excellent article on exophthalmic goiter in the fourth volume of the new -System of Medicine edited by Allbutt, but a still wider discussion on -the matters alluded to, and on many others, by practitioners who have -met with and treated such cases, will do much good, and tend to make the -care of such cases more pleasant and the results of treatment more -satisfactory. _Walter B. Geikie, M. D., C. M., D. C. L., in Philadelphia -Medical Journal._ - - -DANGERS OF THE NASAL DOUCHE.—Lichtwitz (_Sem. Med._, November 26, 1897,) -deprecates the routine prescription of the nasal douche in all cases of -hypersecretion of the nasal mucous membrane. Irrigation is called for -only when the nasal fossæ require clearing of pus and crusts, for -instance in idiopathic ozena. This affection is mainly limited to the -nasal fossæ properly so called, and irrigation is in such a case the -most fitting form of procedure. An ordinary syringe or enema syringe -with suitable nozzle should be used. In all other nasal affections -irrigation is inadequate or useless; it is even dangerous. Repeated -flooding of the mucous membrane may give rise to olfactory lesions. -Antiseptics are highly injurious and pure water is badly borne; the -physiological solutions of sodium chloride, sod. bicarb. or sod. sulph. -are the only harmless liquids. In numerous cases irrigation has caused -the sense of smell to be temporarily or permanently diminished or lost. -Distressing frontal or occipital headache may result owing to the liquid -passing into the sinuses. The injection of irritating liquids may even -set up inflammation of these cavities. The most skilful and careful -irrigation is insufficient in many cases to prevent the resulting -headache. A very grave complication is the penetration of the liquid -into the middle ear, suppurating otitis media occasionally supervening. -In acute coryza, especially in children, douching should never be -practiced. In one such case known to the author mastoiditis followed -irrigation of the nasal cavities. The predisposition to otitis is -increased after retro-nasal operations, in particular after ablation of -adenoid vegetations. For eight years the author has given up all -irrigation after pharyngo-tonsillotomy, and during that period has met -with no case of post-operative complication.—_British Medical Journal._ - - -ANTIPYRIN.—In July of this year the antipyrin patent, held by the Hochst -color-works, will expire by limitation, it having run its course of -fifteen years—the span of life allowed to a German patent. During these -fifteen years the monopolists have sold the drug at about $12.50 a -pound, but it will, of course, fall considerably in price the moment the -manufacture and sale are permitted competitors. It is anticipated that -it will shortly fall to at least half its present price, when the usual -convention of the principal competitors will be called and the -inevitable trust formed, leading to a consequent rise in price. It is -rumored that a number of chemical works are busy with the manufacture of -antipyrin, so as to be prepared with it immediately upon the expiration -of the patent.—_Philadelphia Medical Journal._ - - -PROFESSOR ROBERT KOCH has been invited by the Indian Government to make -another stay in India for the purpose of studying the epidemic and -endemic diseases of man and beast so prevalent there. Koch is now -engaged on work that will keep him in German East Africa for some time, -probably about a year, and does not think of leaving until he has -concluded it. - - - - - Special Notices. - - -RHEUMATOID ARTHRITIS.—Rheumatoid arthritis is a chronic progressive -disease with an almost hopeless prognosis as regards a complete cure. -The most that can be hoped for is to arrest its progress for a longer or -shorter time, and to render the patient’s life more tolerable by -improving his health and relieving the pains in the affected -articulations. Galvanism, massage, baths, and an invigorating diet have -been found of more or less value, as well as the administration of -cod-liver oil, ferruginous preparations, and the iodides. A -comparatively new remedy that seems to have a promising future before it -in the treatment of this disease is Lycetol. Judging from the -observations thus far published its use in rheumatoid arthritis is -capable of effecting considerable improvement. One of its distinct -advantages is that, owing to its pleasant taste and freedom from -irritating effects, its administration can be kept up for a long time, a -point of great importance in the treatment of chronic affections, in -which remedies must be given for a prolonged period before beneficial -results can be expected. In two cases recently reported by Dr. Paul -Norwood (Times and Register, November 6, 1897), one being a very bad one -of chronic rheumatoid arthritis, the results were very encouraging. A -slow but steady improvement occurred in the second case, while in the -first the patient provoked a recurrence by discontinuing the treatment. -In view of the obstinate character of the affection and its resistance -to the remedies heretofore in use, Lycetol should be certainly -considered an eligible remedy in these cases. - - -MEETING OF AMERICAN MEDICAL PUBLISHERS’ ASSOCIATION.—The Fifth Annual -Meeting of the American Medical Publishers’ Association will be held in -Denver, on Monday, June 6, 1898 (the day preceding the meeting of the -American Medical Association). - -Editors and publishers, as well as every one interested in Medical -Journalism, cordially invited to attend and participate in the -deliberations. Several very excellent papers are already assured, but -more are desired. In order to secure a place on the program, -contributors should send titles of their papers at once to the -Secretary. - - CHAS. WOOD FASSETT, St. Joseph, Mo. - - -OBSTINATE CONSTIPATION.—I used Chionia, a teaspoonful three times a day -and at bed times, in a case of long standing obstinate constipation. The -first three nights I directed a hot water enema to be given every night. -This treatment brought about regular and spontaneous evacuations, and -resulted in a complete cure. - - E. T. BAINBRIDGE, M. D. - - Lickton, Tenn. - - -THE phosphates of iron, soda, lime, and potash, dissolved in an excess -of phosphoric acid, is a valuable combination to prescribe in nervous -exhaustion, general debility, etc. Robinson’s Phosphoric Elixir is an -elegant solution of these chemicals. (See advertisement.) - - -=LABOR SAVING=: The American Medical Publishers’ Association is prepared -to furnish carefully revised lists, set by the Mergenthaler Linotype -Machine, as follows: - -=List No. 1= contains the name and address of all reputable advertisers -in the United States who use medical and pharmaceutical publications, -including many new customers just entering the field. In book form, 50 -cents. - -=List No. 2= contains the address of all publications devoted to -Medicine, Surgery, Pharmacy, Microscopy, and allied sciences, throughout -the United States and Canada, revised and corrected to date. Price, -$1.25 per dozen gummed sheets. - -List No. 2 is furnished in gummed sheets, for use on your mailer, and -will be found a great convenience in sending out reprints and exchanges. -If you do not use a mailing machine, these lists can readily be cut -apart and applied as quickly as postage stamps, insuring accuracy in -delivery and saving your office help valuable time. - -These lists are furnished free of charge to members of the Association. -Address CHARLES WOOD FASSETT, Secretary, cor. Sixth and Charles streets, -St. Joseph, Mo. - ------------------------------------------------------------------------- - - - - - TRANSCRIBER’S NOTES - - - 1. Silently corrected typographical errors and variations in spelling. - 2. Anachronistic, non-standard, and uncertain spellings retained as - printed. - 3. Footnotes have been re-indexed using numbers. - 4. Enclosed italics font in _underscores_. - 5. Enclosed bold font in =equals=. - - - - - -End of the Project Gutenberg EBook of The American Practitioner and News. -Vol. XXV. No. 3. Feb. 1, 1898, by H. A. Cottell - -*** END OF THIS PROJECT GUTENBERG EBOOK AMERICAN PRACTITIONER, FEB 1, 1898 *** - -***** This file should be named 60511-0.txt or 60511-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/0/5/1/60511/ - -Produced by Richard Tonsing and 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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Vol. -XXV. No. 3. Feb. 1, 1898, by H. A. Cottell - -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 American Practitioner and News. Vol. XXV. No. 3. Feb. 1, 1898 - A Semi-Monthly Journal of Medicine and Surgery - -Author: H. A. Cottell - -Release Date: October 17, 2019 [EBook #60511] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK AMERICAN PRACTITIONER, FEB 1, 1898 *** - - - - -Produced by Richard Tonsing and 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='tnotes covernote'> - -<p class='c000'><b>Transcriber’s Note:</b></p> - -<p class='c000'>The cover image was created by the transcriber and is placed in the public domain.</p> - -</div> - -<div class='titlepage'> - -<div> - <span class='pageno' id='Page_85'>85</span> - <h1 class='c001'><span class='c002'>THE</span><br /> <span class='sc'>American Practitioner and News</span>.<br /> <span class='small'>“<i><span lang="la" xml:lang="la">NEC TENUI PENNÂ.</span></i>”</span><br /> <span class='large'><span class='sc'>Vol. XXV.</span>       <span class='sc'>Louisville, Ky., February 1, 1898.</span>       <span class='sc'>No. 3</span></span></h1> -</div> - -</div> -<div class='c003'></div> -<blockquote> -<p class='c004'>Certainly it is excellent discipline for an author to feel that he must say all he has to say in the -fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his -reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain -way; and we want downright facts at present more than any thing else.—<span class='sc'>Ruskin.</span></p> -</blockquote> - -<div class='chapter'> - <h2 class='c005'>Original Articles.</h2> -</div> - -<h3 class='c006'>SOMETHING ON THE DISUSE OF PHLEBOTOMY.</h3> - -<div class='nf-center-c0'> -<div class='nf-center c007'> - <div><span class='small'>BY RUFUS W. GRISWOLD, M. D.</span></div> - </div> -</div> - -<p class='c004'>When I began looking into medical books preparatory to practice, -fifty years ago, the standard authors given us to read were not backward -in recommending blood-letting in the acute diseases; and a little -later, when an attendant at lectures at the College of Physicians and -Surgeons at New York, the professors were not lacking with the like -advice. But there has come a change, and so much of a change that, -in this section of country at least, the lancet has mostly gone out of use. -That the frequent use to which it was put seventy-five or a hundred -years ago was not at all times wise is likely; but the extent to which it -has been given up is also not wise. Rather more to notice some of the -reasons why it has so largely been abandoned than to argue for a reintroduction -of that ready and efficient instrument is the purpose of -this paper.</p> - -<p class='c004'>A prominent point in the consideration of this comparative abandonment -of the lancet is presented in the question: Has there been -such a change in the type of the acute inflammatory diseases from -three or four generations ago as to render the abstraction of blood less -necessary and less useful? There are plenty of sound, hard-headed old -doctors who will give a negative reply to this query; and occasionally -we may notice some of them putting themselves in print to that effect. -A Baltimore practitioner not so very long ago said: “The necessity for -the use of the lancet is as great at the present time as it ever was in the -<span class='pageno' id='Page_86'>86</span>past; the type of the disease has undergone no such changes as to -render the abstraction of blood unnecessary or improper in the successful -management of all cases attended with a full, tense, and quick -pulse.” Others speak the like; but the majority of opinion is not pronounced -in that direction, but rather adverse. Conversations during -a forty-four years’ practice with men who began their professional calling -sixty years ago, when the lancet was in often call, is to the import -that there <em>has been</em> such a change in diseases as renders the frequent -resort to blood-letting less important than formerly; that there is less -of the sthenic type in even inflammatory fevers, a more general disposition -to take on what we call typhoid forms, and thus depletion, either -by the evacuation of blood or the exhibition of reducing drugs, is not -so beneficial in even the acute inflammatory diseases as formerly. This is -the view that has been entertained by a large part of those who began -practice half a century or more ago, and this view has been sustained -by a large amount of written authority; but it does not go to the -extent of justifying that degree of abandonment of bleeding that has -prevailed for the last forty years. The general opinion of to-day is, -that while positions like that taken in the quotation given are too positive, -on the other hand our <em>practice</em> is quite too lax; for while we still -believe in blood-letting to some extent, we but seldom make use of it. -Now as to the <em>why</em>.</p> - -<p class='c004'>Perhaps the first reason why the lancet is less used than formerly is -found in the fact, or rather in the belief, of the change indicated. It is -largely accepted as true by the older men in the profession that patients -do not bear blood-letting as well as three generations ago. Accepting -this as correct, it rationally follows that we should bleed less. But this -is only one of the factors in the account, and not the largest one. The -opinion that the physicians of the early part of this century used the -lancet too often is beyond doubt correct. The doctrine of the purely -symptomatic nature of fever put prominently forward by Brousais, and -earnestly championed by active and pushing minds a century ago, and -which was generally received in Europe and in this country, gave such -an unfortunate impetus to the use of the lancet as finally led to its -abuse. Patients were bled for almost every thing; not only for the -fevers of acknowledged inflammatory type, such as acute pleurisy and -the like, were bled for, but also cases of typhus, typhoid, etc., upon -the ground that the fever in the case was only a symptom of the -inflammatory action and was to be subdued or lessened by antiphlogistic -<span class='pageno' id='Page_87'>87</span>remedies, chief of which was the abstraction of blood. The theory of -the essentiality of fever became lost sight of, and the doctor treated for -an inflammation rather than for a fever.</p> - -<p class='c004'>Without giving up the theory in which they had been educated, -some physicians began to see that in some epidemics of disease a larger -percentage of cases were lost among those where venesection had been -used than among those similarly sick who were not bled. The deduction -from this was that it would be better to bleed less. But a change -was not to be made without a struggle. Reference to the medical -literature of the first half of the century shows that there was a deal of -warm discussion between the blood-letters and the anti-blood-letters. -Out of the observations and discussions made there was cultivated a -prejudice, professional to a moderate extent but popular to a large one, -against bleeding <i><span lang="la" xml:lang="la">per se</span></i>, and without reference to the character of the -disease under treatment or to the differing conditions that might exist, -which helped to carry the usage from its former abuse at times to the -opposite extreme of general abandonment. It is a universal law in -nature that the farther the pendulum swings in one direction, the -farther will it swing in the opposite on its return. The pendulum of -venesection had swung too far forward for the best in the treatment of -disease, and the return carried it quite beyond the best in the backward -reaction.</p> - -<p class='c004'>Beyond the reasons noted for the present comparative non-use of -the lancet, there has been added a pressure of an erroneous and illegitimate -nature that has aided to put bleeding under a general ban -more unfortunate for the sick than was the former rather indiscriminate -use. Somewhat contemporaneously with the warm discussion upon -bleeding carried on in the profession, and perhaps partly out of that -discussion, there started up in various parts of the country an illegitimate -class of practitioners, mostly illiterate and destitute of preliminary -culture, interchangeably known as Botanics, Thompsonians, -Eclectics, etc., whose chief stock in trade for public acceptance was -denunciation, without regard to the conditions that might be met in a -case, of leeching, bleeding, blistering, scarification, and other agents for -cures. This denunciation found ready public credit. Not only from -the mouths of the class named, but in various other ways, the prejudice -they sought to create was widely diffused. Outside of the libraries of -the profession you seldom see a medical book; anywhere else they -have been rarities. But in many sections of the country for the last -<span class='pageno' id='Page_88'>88</span>sixty years a canvass of the families would show an abundance of -books, published for family reading, emanating from irregular practitioners, -all of them saturated with lying abuse of the methods of treatment -of the regular physicians. These books were loaned from one -family to another, much as the weekly papers or the cheap novel; and -they were read and believed in. The result was that many who read -were indoctrinated with the belief that bleeding, no matter what the -disease or the conditions, was not only not necessary, but pernicious, -and often the cause of death; and there was little printed contradiction -offered to disabuse the public mind of this false accusation.</p> - -<p class='c004'>Co-ordinating with this means of false instruction has been and is -the public press. As respectable practitioners do not stoop to the -quackery of advertising, the pecuniary interest of the press, so far as -means and methods for the cure of diseases is concerned, is identical -with the pecuniary interests of advertising quacks. The public press -sells itself to the broad diffusion of the ways and means of medical -quackery in all its forms. The subsidies of impostors and patent medicine -men fill up one carotid artery for the support of the press; and -the influence of that press, however weak the intellect that bestrides -its tripod, is more potent than a hundred of the ablest men in the profession, -for the sufficient reason that the voice of the men in the -profession seldom strikes the public ear through the same broad and -forceful channel.</p> - -<p class='c004'>The result of the false teaching of the class of books alluded to -and of the medical advertising, and of the bleating of the tramping lecturers -was that a large part of many communities came to believe that -blood-letting was a crime against health, and a hindrance to recovery -from disease, no matter what might be the conditions. The average -intelligence of even well-educated communities goes no further than -to accept the plausible teaching that is every day thrust upon its tympanum; -it does not stop to criticise the motives nor to analyze the -arguments of the advertiser, nor is it cultured in this direction to the -capacity of justly weighing them according to their true significance. -The average intelligence of even well-educated communities is not -up to that grasp of the science of medicine necessary to determine -between false and fallacious teaching and that which is rational and -correct; it does not differentiate between clap-trap and honesty; it does -not separate humbug from truth, and as an ocean of humbug passes -the public gullet easier than an ounce of truth, it is not strange that -<span class='pageno' id='Page_89'>89</span>the condition obtaining about bleeding is not so much that the physician -has discarded it as improper, or has lost sight of its value in many -cases, as that the community will not tolerate him in the abstraction of -blood. Public prejudice overrides professional opinion, unless the opinion -runs current with the prejudice. To bleed your patient and then -have him die is to be damned; if he dies without being bled, no -matter whatever else you may do or leave undone, the chances of being -cursed are largely lessened. Besides this, very little or nothing is -gained against the prejudice by recovery after bleeding, since the popular -opinion will be that the patient would have gotten well quicker -and better without it—an opinion that can seldom be disproved. Exactly -in the same way in any case where venesection has been practiced -and the patient does not get well, the opponents of the operation will -assert that the bleeding caused the death, and that, in the absence of -it, the patient would have got well; which also is difficult to disprove. -The average mind proceeds from supposed causes to effects with most -unreasonable logic.</p> - -<p class='c004'>As a matter of fact, the whole art of the practice of medicine is -involved many times in many uncertainties as to the effects that are to -follow the administration of drugs or the institution of any procedure, -however simple, that it may puzzle the most sagacious to determine -the exact weight of any factor introduced, whether it be for good or for -ill. It should not therefore surprise us that to minds quite unacquainted -with the therapeutical effects of blood-letting in disease, a death that -follows a bleeding, however remote in point of time, should be credited -to the operation rather than to the disease for which the operation was -performed. An uncertain percentage of cases of many acute inflammations -will recover, whether bled or not; an uncertain percentage of them -will die, whether bled or not, and no matter how treated; and, while -it will sometimes happen that of two cases of the same disease the one -that is bled will get well and the one that is not bled will succumb, it -will the next week happen that of two other cases of the same trouble -the one that is bled will slip off and the one not bled will hold on -finely. And it is a notorious fact that in some communities, if a patient -is bled and then dies, nine out of every ten persons in the neighborhood -will say, and part of them will believe, that the bleeding was an -accessory if not the chief cause of the untoward event; and it is usually -quite impossible for the doctor to show that the nine are not right in -their view of the matter.</p> - -<p class='c004'><span class='pageno' id='Page_90'>90</span>Under these circumstances it can hardly surprise us that the use of -the lancet has gone out of fashion. It is not so much that we have -less faith in its beneficence, rationally employed, as that our patients -are opposed to it. Whether in spite of the opposition we should -employ it oftener than we do is a question that every one must settle -for himself. It might be possible for a bold and determined man to -work up that road to confidence with his patients in it, but the path is -so beset with difficulties that a hundred will fall by the way where one -succeeds. A single death after phlebotomy will do more to impede the -success of a young man in the profession than a dozen deaths without -it; it is wise therefore to be cautious in the use of so potent a remedy, -and to sin less in commission than in omission of opening a vein. It -may be said that whether he succeeds or fails it is the duty of the physician -to do in all cases what he thinks will be the best for his patient. -This position may have its merits but it is a better thing to teach -than to act upon. There is no law of right that demands of the -practitioner that he shall assume the responsibility of the stupidity and -ignorance of all his patients, and, worse still, of all the irrational prejudice -they have allowed themselves to imbibe, and which no amount of -logical facts will dispossess them of.</p> - -<p class='c004'>The writer, in the nearly fifty years of his practice as student and -graduate, has had an average share, perhaps, of his patients die; but -he has never had one die of any sort of fever after he had been bled as -an aid in subduing that fever. On the other side, he has had patients -die of the acute inflammatory diseases when they have not been bled; -and, to-night, recalling those cases, he is of the opinion that some of -them, if they had been well tapped in the arm at the outset of the -sickness, they would have been saved.</p> - -<div class='lg-container-l'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='small'><span class='sc'>Rocky Hill, Conn.</span>, December, 1897.</span></div> - </div> - </div> -</div> - -<div> - <span class='pageno' id='Page_91'>91</span> - <h3 class='c006'>TAKA-DIASTASE IN THE TREATMENT OF AMYLACEOUS DYSPEPSIA.</h3> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c007'> - <div><span class='small'>BY WALTER P. ELLIS, M. D.</span></div> - </div> -</div> - -<p class='c004'><span lang="la" xml:lang="la">Pepsina porci</span>, the pepsin of the hog, was one among the first of -the animal products to be used in medicine, and many physicians, not -well versed in organic chemistry, supposed that in it they possessed a -sovereign remedy for indigestion in all its forms and stages, and the -confirmed dyspeptic had only to apply the specific to have his digestive -apparatus restored to its youthful health and vigor. Unfortunately for -this view and for the sufferers, the fact was overlooked, or not duly -appreciated, that pepsin is only one of several substances which -Nature employs in the complete digestion of food, and that the products -or secretions of several different glands have a part in the -process, each of which is essential to the proper preparation of food -for the nourishment of the human body.</p> - -<p class='c004'>It has been estimated by competent observers that as great a proportion -as seventy-five per cent of all the intractable cases of dyspepsia -in this country are caused primarily by faulty saccharification of the -starchy foods which constitute such a large portion of the diet of the -American people. This being the fact, is it any wonder that the -administration of pepsin alone should fail to give relief in many -cases? It fails because the fault lies, not in the stomach, but in the -salivary and other glands whose secretions possess the amylolytic -property, and the remedy is the administration of substances that will -restore that property to the secretions, or which possess it in and of -themselves.</p> - -<p class='c004'>Until quite recently the practitioner was compelled to rely for this -purpose upon the various malt extracts upon the market, the diastatic -power of which was so feeble that the service they rendered was but -slight. What was needed, and for which many of the most patient -investigators were searching, was a diastase which would do for the -starchy elements of the food what pepsin does for the proteids. The -digestion of food in man has been the subject of much patient and -methodical study and investigation during the last two decades, notably -by Ewald, Kellogg, Hayem, and Winter, and others, resulting in the -placing of the therapeutics of disordered digestion upon an exact -scientific basis. It is not, however, necessary for the purposes of this -<span class='pageno' id='Page_92'>92</span>paper to go very deeply into the <span lang="la" xml:lang="la">minutæ</span>; a superficial survey will -suffice.</p> - -<p class='c004'>Digestion begins in the mouth with the act of mastication, the -presence of food in the mouth, or even the thought of it, acting upon -the salivary glands to produce a free flow of saliva, which, being thoroughly -incorporated with the food by the act of mastication, exerts its -peculiar influence upon the starchy constituents, converting them into -dextrose, maltose, etc. This amylolytic action lasts but a short while, -the ptyalin of the saliva being active only in neutral or slightly -alkaline media; consequently when the food reaches the stomach and -peptic digestion begins, its effect ceases.</p> - -<p class='c004'>The saccharification of the starchy elements of the food before -reaching the stomach serves to separate or disentangle them, as it -were, from the proteids, and deliver the latter to the stomach in the condition -most favorable to the action of the gastric ferment or pepsin.</p> - -<p class='c004'>The stomach, after a variable length of time, during which the -peptic ferments accomplish their allotted task more or less thoroughly -and completely, delivers the resultant mass over to the small intestine, -where the secretions from the pancreas, liver, and intestinal glands, by -finishing the transformation of the starch begun before the stomach -was reached, emulsifying the fatty constituents, etc., complete the complex -work of digestion.</p> - -<p class='c004'>It will be seen from the foregoing that the derangements of digestion -may, for ordinary clinical purposes, be divided into three classes, -each of which is distinct from either or both of the others, although -they shade into each other by imperceptible gradations, so that there -are no well-defined boundary lines separating them. The first class -includes all those cases which are characterized by a deficiency, in -quality or quantity, of the salivary secretion, and a consequent failure -of or interference with the digestion of the starchy elements of the -food—amylaceous dyspepsia. The second includes those in which -there is difficulty in the digestion of the proteids, due to a variety of -causes—gastric dyspepsia. In the third is placed those cases in which -the trouble is located below the stomach, and are caused by inability of -the pancreas and other glands to normally perform their function—intestinal -indigestion.</p> - -<p class='c004'>One constantly meets with cases belonging to each of these varieties, -and he must correctly diagnose each case if he would apply the -treatment necessary to produce the best results. For the present, however, -<span class='pageno' id='Page_93'>93</span>we have only to do with the first variety, as my object in the -preparation of this paper is to direct the attention of the profession to -a new diastatic ferment which acts with as much or even greater -energy upon the amylaceous foodstuffs as does pepsin upon the -proteids.</p> - -<p class='c004'>Such a substance has long been a desideratum with those who treat -many dyspeptics, and who have been compelled to content themselves -with malt extracts with which the market is supplied. The substance -referred to was discovered by a Japanese chemist, Jokichi -Takamine, not as the result of accident but while working scientifically -with that exact end in view, and is now supplied to the profession -by Parke, Davis & Co. under the name of Taka-Diastase. -The writer has had frequent occasion to use it since it was first -brought to his notice about a year and a half ago, and in that time -has not had a single case in which its administration was not attended -by the very best results. Notes of several cases were kept, three of -which will be presented here as the most appropriate conclusion.</p> - -<p class='c004'><span class='sc'>Case 1.</span> L. A., white male, age thirty-eight, a barber by occupation, -consulted me first in the fall of 1894. He was at that time, as he had -been for several years, the victim of a most obstinate and intractable -form of dyspepsia. He had been a coal miner until forced by ill health -to quit that for some lighter occupation. He, however, continued to -grow worse until, when coming under my care, he was very much -emaciated, weak, nervous, and irritable, his stomach unable to retain -any thing save the blandest articles of diet, and those only in small -quantities. Treatment was begun by regulating his habits, diet, etc., -and putting him on an emulsion of bismuth subnit. and pepsin pur. -immediately after eating, and tr. nux vom., hydrochloric acid, and tr. -colomba before eating. His condition improved somewhat under this -treatment, but only to a limited extent, and it became evident that -more efficient measures must be resorted to if we hoped to accomplish -permanent good. It had been noted that a meal, however scant, composed -mainly of starchy substances was always productive of an acute -attack, and acting upon this suggestion extract of malt was added to -the remedies he was using, and, to a certain degree, with good effect. -He, however, did not go on to complete recovery, but the improvement -ceased at a certain point, and in spite of continued treatment with the -remedies mentioned his condition remained about stationary. Unable -to work, morose, cross, and irritable, existence was a burden to himself -<span class='pageno' id='Page_94'>94</span>as well as family and friends. At this juncture my attention was -attracted to Taka-Diastase and a supply was at once procured. The -patient was given a number of capsules containing five grains each, -with instructions to take one capsule at the beginning of each meal, -continuing the bismuth and pepsin mixture as before, immediately -after eating. In a very short time improvement was discernable, and -from that time was rapid and continuous. The treatment was kept -up, with the addition later on of ferruginous and bitter tonics, until -there could be no doubt of his complete and permanent restoration to -health. He has now been at regular work in the shop for several -months, and says that he “never felt better in his life.”</p> - -<p class='c004'><span class='sc'>Case 2.</span> Mrs. J. H., a white woman, aged forty-six, wife of a well-to-do -farmer. Until within the last year or two had enjoyed the best -of health, and was inclined to stoutness in consequence. Dyspeptic -symptoms had troubled her more or less during the time mentioned, -and of late had increased in severity so much that she asserted, at -the time she consulted me, that if she dared to eat any thing at all she -suffered the greatest agony in consequence. A neighboring physician -had treated her for some weeks previous to her visit to my office, and, -as I afterward learned, had given her the regulation treatment with -pepsin, bismuth, hydrochloric acid, etc., with results so discouraging -that she had lost all hope of receiving any benefit from “doctor’s medicine,” -as she called it, and it was only at the urgent solicitation of -husband and friends that she came to me for treatment, being careful -to inform me that she had no idea I could help her in the least.</p> - -<p class='c004'>Her case was diagnosed “amylaceous dyspepsia,” and she was -given Taka-Diastase in eight-grain doses, half of which was to be -taken before eating and the remainder during or after, with tr. nux -vom. and hydrochloric acid, in moderate doses, <i><span lang="la" xml:lang="la">ter in die</span></i>.</p> - -<p class='c004'>Despite her determination not to be benefited by “doctor’s medicine,” -the improvement was prompt and continuous, and so manifestly -due to the treatment that she soon forgot or overcame her antipathy, -and with characteristic inconsistency now asserts that it is impossible -to get along without it. She eats three meals regularly every day, and -suffers no inconvenience whatever in consequence.</p> - -<p class='c004'><span class='sc'>Case 3.</span> W., a white male, aged forty, had never had any serious -illness, and digestion had been especially good until about four weeks -before consulting me. At that time he, in company with some friends, -ate quite heartily of watermelon. He had always eaten watermelon -<span class='pageno' id='Page_95'>95</span>freely and with impunity prior to that occasion. It did not agree -with him so well that time, and in a few hours he was seized with an -acute gastralgia of the most severe character, and from that time to the -present he has had more or less trouble of that kind, even a very -small quantity of food, especially if it be of a starchy nature, giving -rise to the most distressing symptoms.</p> - -<p class='c004'>The diagnosis of amylaceous dyspepsia was also made in this case, -and he was at once put upon the Taka-Diastase in doses of five grains -given with the meals, and temporarily excluding starchy foods from -his diet as much as possible without too great inconvenience. There -was also great torpidity of the liver, and for that he was given sod. -phosphate in teaspoonful doses every morning before breakfast, taken -in a gobletful of hot water. Under this treatment improvement was -satisfactory and rapid, and with the addition of bitter tonics later on he -was ultimately restored to complete health.</p> - -<p class='c004'><em>Remarks.</em> Case 1 was an example of that class with which, prior -to the introduction of Taka-Diastase, the general practitioner was too -often compelled to acknowledge his inability to cope successfully. In -them there is difficulty in the digestion of both amylaceous and proteid -substances, and the remedies usually recommended were efficacious only -so far as digestion of the latter was concerned, and did not reach the -former at all. The cure was incomplete, and must have remained so -until the substance we have been considering, or something analogous -to it, was furnished the physician with which to complete it.</p> - -<p class='c004'>Cases 2 and 3 were examples of the first class mentioned above, -viz., amylaceous dyspepsia, and while under treatment with pepsin, -etc., they were considered the most intractable of all; under Taka-Diastase -they yield rapidly, and are cured in a surprisingly short time.</p> - -<div class='lg-container-l'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='small'><span class='sc'>Livermore, Ky.</span></span></div> - </div> - </div> -</div> - -<div class='chapter'> - <span class='pageno' id='Page_96'>96</span> - <h2 class='c005'>Reports of Societies.</h2> -</div> - -<h3 class='c006'>LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.<a id='r1' /><a href='#f1' class='c008'><sup>[1]</sup></a></h3> - -<div class='nf-center-c0'> -<div class='nf-center c007'> - <div>Stated Meeting, December 3, 1897, the President, F. C. Wilson, M. D., in the chair.</div> - </div> -</div> - -<div class='footnote' id='f1'> -<p class='c004'><a href='#r1'>1</a>. Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.</p> -</div> - -<p class='c004'><em>Uterine Fibroma.</em> Dr. L. S. McMurtry: I present this specimen of -uterine fibroma on account of two very interesting features of this -class of tumors which it illustrates. The first relates to the morphology -of these growths. The tumor is a very large one, and occupied -the entire pelvis and the abdomen to the superior limits of the umbilical -and lumbar regions. It is a multi-nodular tumor, and its disposition -in relation to the fundus of the uterus is unlike any specimen that I -have ever encountered. It will be observed that the neoplasm springs -from the lower segments of the uterus, and the fundus is not involved -in the growth at all.</p> - -<p class='c004'>The second feature of interest, and this is especially interesting -from a surgical point of view, is the relation of the bladder to the -tumor. It is very common for the bladder to be carried upward with -the growth, thus rendering it very liable to injury in operation. -This feature is exceptionally conspicuous in this tumor on account of -the nodular condition where the bladder was attached, forming a sulcus. -In releasing the bladder, after splitting the capsule, the uneven -surface of the tumor caused me to inflict an injury upon the coats of -that viscus. After dissecting off the bladder I found that I had made -an opening in it at this point. It was immediately closed with a -double row of catgut sutures. The operation was done six days -ago, and the convalescence of the patient has been most satisfactory indeed. -The bladder injury has not complicated the patient’s convalescence -at all, its function being carried on just the same as if it had -not been involved. The convalescence has been afebrile from the -beginning, and recovery is assured.</p> - -<p class='c004'>The method I observed in treating the pedicle was to amputate -the cervix very low down, leaving a very small rim of the cervix, and -suturing the peritoneum over it all the way across the pelvis, making -the pedicle extraperitoneal. The conformation of the growth and its -<span class='pageno' id='Page_97'>97</span>relation to the cervix uteri made this method of dealing with the pedicle -especially applicable in this particular instance. The patient is -thirty-four years of age, and the operation was urgent on account of -persistent hemorrhage and marked pressure symptoms.</p> - -<p class='c009'><em>Discussion.</em> Dr. J. A. Larrabee: I would like to ask the reporter -for what length of time this tumor had been developing?</p> - -<p class='c004'>Dr. L. S. McMurtry: The woman was thirty-four years of age, and -according to the history obtained the tumor was first noticed three years -ago. The patient has made a beautiful convalescence. I present the -specimen on account of its morphology, and because of the difficulties -that might be encountered in performing an operation in such cases -by the bladder being impacted in the sulcus.</p> - -<p class='c009'><em>Tubercular Testis.</em> Dr. W. O. Roberts: This patient is twenty-four -years of age; his father and mother are living; father sixty-four, -mother fifty-four; his grandfather on his father’s side died at the age -of sixty-four of what was supposed to be consumption; his father’s -twin brother died at the age of twenty, after an illness of eight months, -of consumption; his mother’s family history is good.</p> - -<p class='c004'>This young man had gonorrhea seven years ago, with orchitis of -both sides as a complication, the left testicle swelling first, then the -right; the swelling lasted in each for about two weeks. Had gonorrhea -again in November, 1896, and says again in December of the same year. -At this time he noticed that his left testicle was getting hard in places -and was swollen, but there was never any pain. The inflammatory -process has never been very acute. However, he noticed after taking -a horseback or bicycle ride the testicle would be somewhat tender. -Had another attack of gonorrhea during the month of September of -the present year, which he says lasted only two weeks, and during -this attack the testicle was also affected.</p> - -<p class='c004'>He now has a swelling of the left testicle, and a hardness about it -and in the epididymis, which I would like for the members to examine, -expressing an opinion as to the nature of the trouble.</p> - -<p class='c009'><em>Discussion.</em> Dr. J. M. Ray: I do not know that the ocular symptoms -will throw any light upon the case. I remember that this young -man came to me some time ago to have his eyes examined. He stated -that he had been under the care of a prominent oculist in the South, -and had been fitted with glasses. When I saw him he had some -<span class='pageno' id='Page_98'>98</span>trouble in the use of his glasses, and also complained of defective -sight of one eye. Upon examination I found a spot of atrophy of the -choroid, showing the location of a former acute choroidal disease, and -there was considerable diminution in acuteness of vision in that eye, -with a defect in refraction in the other eye. Under mydriatics I fitted -him with glasses, since which time he has been perfectly comfortable -so far as his eyes are concerned.</p> - -<p class='c004'>He states that he remembers I said something to him at that time -about tubercular disease, after looking into his eyes, but I have forgotten -the circumstance; I only remember that I found choroidal disease.</p> - -<p class='c004'>Dr. J. A. Larrabee: Of course we are all led somewhat by the -diathetic history of our cases. Chronic inflammations tend to take on -the part of the diathesis. I did not understand the reporter to say -that any test had been made, by withdrawal of some of the fluid or -otherwise, to determine the exact nature of the condition. I desire to -say, however, that if this were my testicle I would have it removed. I -believe that would be the safest plan. An absolutely positive diagnosis -would be difficult to make without a microscopical examination for the -tubercle bacillus, but I can not help feeling prejudiced in that direction.</p> - -<p class='c004'>Dr. J. L. Howard: I agree with Dr. Larrabee as to what should be -done with this testicle; it should come out. I, too, think it tubercular, -although in all probability the gonorrhea is a factor in the case in -stimulating the growth of the testicle. I do not know that a microscopical -examination would give us much light upon the subject; in -fact I would not wait for that, I would simply remove the testicle at -once.</p> - -<p class='c004'>Dr. Wm. Bailey: The question is not by any means settled as to -the exact nature of the disease in the case before us, whether the -patient, having had repeated attacks of gonorrhea, has not also been so -unfortunate as to have syphilis. With a tuberculous history of course -a tuberculous condition of the testicle seems plausible; but inasmuch -as tuberculous disease of the testicle may remain for a long time possibly -without great danger in affecting the patient otherwise, and knowing -the changes that take place in the testicle from repeated attacks of -gonorrhea, orchitis, etc., I believe if it were mine I would be disposed -to keep it for a while, particularly as the other testicle seems to -be somewhat atrophied, with this one of pretty good size. I think I -would keep the larger one.</p> - -<p class='c004'><span class='pageno' id='Page_99'>99</span>Dr. T. S. Bullock: I am inclined very much to agree in the opinion -expressed by Dr. Bailey. I have frequently seen, after repeated attacks -of gonorrhea, a testicle that had become enlarged, without any pain. -The testicle in this case appears to be perfectly smooth, and in view of -the fact that tubercular disease of this organ may exist for a long time -without affecting the general system, I should certainly keep the testicle -until my general health began to show some evidence of declination.</p> - -<p class='c004'>Dr. F. C. Wilson: The question is a very difficult one to decide. -There is one feature of the case that has not been sufficiently emphasized, -and that is the probable damage to the testicle itself by the -repeated attacks of gonorrhea. We know that the use of the testicle, -so far as any procreative uses may be concerned, has probably been -abrogated by these repeated attacks of gonorrhea, and with this view -of the case the question of removal of the testicle by surgical means -would be simplified; and it seems to me with the tuberculous history, -if the question could be decided even approximately, or even probably, -that it is tubercular, then it had better be removed. But it seems to -me I would first make every effort to solve the question, even aspirating -or removing a small part of the tissue so as to be able to make a microscopical -examination, and in that way possibly throw some light on the -subject.</p> - -<p class='c004'>Dr. W. O. Roberts: It strikes me that this is tubercular, although -it may have been, as Dr. Howard says, excited by gonorrhea. The -condition feels to me nodulated and not smooth, and the disease -appears to be located chiefly if not entirely in the epididymis, and I -think the testicle should be removed. Whether it is tuberculous or -not the usefulness of the organ is destroyed, and I think it ought to -come out if it is tuberculous, especially because the other testicle will -become involved. So far as the cosmetic appearance is concerned, if -that is a feature in the case, we could insert a celluloid testicle. I -believe if the affected testicle is not removed, granting the diagnosis -of tuberculosis to be correct, that the other testicle will surely become -involved.</p> - -<p class='c009'>Dr. Turner Anderson: It is seldom that we have obstetric matters -presented to this society. I have thought perhaps a case I recently -attended might be of some interest. We are aware that the umbilical -cord is frequently found encircling the neck of the child. I delivered -<span class='pageno' id='Page_100'>100</span>a child four days ago in which the cord was wrapped around the neck -twice, then branched off under the arm, encircling the arm again at its -dorsal surface, then across again, branching over the back. You may -better understand the condition when I say that the cord came up from -its attachment at the umbilicus, encircling the neck twice, branching -over and under the axilla, around the arm, thence to its attachment to -the placenta. The woman was a primipara. As soon as the head was -delivered I detected that the cord was wrapped around the neck. I -made an effort to find the part that led to the placenta. The cord was -found pulseless, and I was in some doubt as to whether it had -been so long encircling the neck as to have produced death of the -child. Just as the body of the child was being extruded the cord -snapped, tearing off fortunately from its placental attachment. The -child was delivered and after a little effort was easily resuscitated. The -pressure was so great, the traction upon the cord was so decided, as to -leave a white line across the back of the child. There was a white -mark around the neck, across the clavicle, around the arm and over -the back of the child which did not disappear for some time afterward.</p> - -<p class='c004'>The proper line of practice, I take it, in those cases where the cord -is around the neck of the child, is to first determine whether the cord -is still pulsating. If pulsating, we are justified in being a little more -tardy in our efforts to deliver the shoulders and release the child. If -possible we would of course draw down the cord and release it from -the neck of the child in this way; but in those cases where we are -confronted with the cord wrapped tightly around the neck of the child, -especially in the primipara, where the length of time which will be -consumed in delivery is uncertain, the line of practice I believe in should -be prompt delivery or division of the cord. As a rule when we are confronted -with a condition of this kind we can meet it satisfactorily by a -little delay and by holding the head of the child well up against the -vulva while the shoulders are being extruded. As the releasing pain -occurs and the shoulders and body are extruded, you can usually by -pressing the head well up prevent undue traction on the placenta and -any accident which might follow rapid delivery and undue traction -upon the cord. This was a case in which there was spontaneous rupture -of the cord; it tore away entirely by the uterine effort. This -accident had no influence upon delivery of the placenta; it came away -promptly. It was evidently not torn loose from its attachment, and -there was no hemorrhage.</p> - -<p class='c004'><span class='pageno' id='Page_101'>101</span><em>Discussion.</em> Dr. J. A. Larrabee: The case is not only interesting, -but also somewhat unique as far as I am aware. We are all familiar -with the double wrapped cord, but in this case the acrobatic movements -of the child must have been considerable, in utero, to have -produced the condition described by Dr. Anderson; the child -had evidently been engaged in jumping the rope for some time. -When the cord is wrapped around the neck of the child as described, -I think the best plan is to expedite delivery. Of course in the primipara -we must not be in too great a hurry, we must utilize melting or -crowning pressure to prevent injury, but the management of these -cases I think is entirely that of dystocia, and powerful external pressure -upon the fundus of the uterus, bringing it down as low as possible, is -the proper plan of expedition. In the case reported, however, no -amount of external pressure would have accomplished any thing; -fortunately the snapping of the cord enabled the doctor to deliver and -resuscitate the child, which is about the only thing that could have -been done. In this case it would have been almost impossible to have -divided the cord. Aside from the anomaly of the case, which is -worthy of especial mention, I do not know of any proceeding which -would have been equal to that which was followed. It is a little -strange that the placental attachment did not give way; if this had -been true, if there had been a separation of the uterine attachment of -the placenta, then we would have expected the placenta to have been -expelled with the child instead of a rupture of the umbilical cord.</p> - -<p class='c004'>Dr. J. L. Howard: I would like to ask Dr. Anderson if usually, -when the cord is wrapped around the neck of the child, the cord is not -an abnormally long one? I have had this accident happen twice in -my experience, but no trouble resulted because of the abnormal -length of the cord in each instance.</p> - -<p class='c004'>Dr. J. G. Cecil: This is an accident which as we know happens frequently, -as well as many other anomalous things in connection with -the umbilical cord. I would have been disposed, if the labor had been -delayed in this case, that is, the final delivery of the child, more than -four or five minutes, to have severed the cord, fearing that it might -have had something to do with the delay. If there was no pulsation in -the cord, there would have been little risk in cutting and not tying it; -then there would have been no further delay to the delivery; there -would have been no danger from hemorrhage, from premature separation -of the placenta, or danger from inversion of the uterus. However, -<span class='pageno' id='Page_102'>102</span>as the case turned out so well under the management that was -adopted, it does not become us to criticise that management, because -the successful issue proves the wisdom of the plan followed.</p> - -<p class='c004'>I have once or twice encountered some delay in expulsion of the -child by reason of a short cord wound around the neck. I have never -seen one so displayed around the shoulder as in the case reported by -Dr. Anderson. I remember to have seen one case, however, in -which there was a knot tied in the cord, and tied so tightly that it shut -off the circulation and resulted in death of the child, and also complete -atrophy of the cord between the knot and the navel end. This was a -very interesting case, and was reported to the Louisville Clinical -Society three or four years ago by Dr. Peter Guntermann; it was one of -the most interesting cases of accidents to the cord that I have ever -seen. How the knot was tied so tightly in the cord can not well be -explained; knots in the umbilical cord are not very unusual, but it is -unusual to see one tied so tightly that the circulation is shut off -thereby. It was thought, I believe, by the reporter on that occasion -that the accident was due to a fall which the mother sustained just -before the delivery, which was premature.</p> - -<p class='c004'>Dr. Wm. Bailey: Nothing in the management of the case reported -by Dr. Anderson can be criticised by me. I am inclined to think that -under no circumstances was pressure made on the cord sufficient to -interrupt the circulation until after the head of the child was delivered. -Then it became a question as to the proper management. I believe it -would have been better to have cut the cord, as it might have lessened -the difficulty of delivery, and that there would have been no harm -done to the child in this case, because there was no pulsation in the -cord. The doctor had all the time for this delivery that would have -been allowed him if he had a breech presentation with the head making -pressure upon the cord, and ordinarily he would deliver such a case in -from five to seven minutes, and that would give a chance for resuscitation -of the child just as in the case of drowning. The child can be -deprived of circulation through the cord, in an accident like this, as -long a time as a person can be submitted to water, or drowned, and be -resuscitated. I have seen but one case in which there was a rupture -of the cord during delivery. I saw one exceedingly short cord, in -which delivery of the child ruptured the cord; it was not around the -neck, it was simply too short for the child to be delivered without -detaching the placenta; just as the child was delivered the cord was -<span class='pageno' id='Page_103'>103</span>spontaneously severed at the umbilicus, simply allowing me a sufficient -amount to be caught with the fingers and held until a ligature could -be applied. I do not remember the exact length of the cord, but it -was so short that it was not possible to deliver the child without -either breaking the cord or detaching the placenta. The cord ruptured -spontaneously, and there was no further accident or trouble.</p> - -<p class='c004'>I believe if Dr. Anderson had to attend another case under exactly -the same circumstances he would prefer to cut the cord rather than to -break it off at the placental attachment. Inasmuch as he did not cut -the cord and the child was successfully delivered, and also as there -was no trouble in delivering the placenta, of course it makes no difference; -but I always like to have the cord attached to the placenta so -that if it becomes necessary to go after the placenta, in case of retention -for instance, I can have the cord as a guide. In Dr. Anderson’s case -there was no possible advantage in having the cord intact; as it was -pulseless, no injury could have been done the child by cutting the -cord before completing the delivery, and by cutting the cord as soon -as it was found that it encircled the neck, all possible difficulties as -far as the cord preventing delivery was concerned would have been -removed.</p> - -<p class='c004'>Dr. T. S. Bullock: I am very much interested in this case; I have -never seen one exactly like it. The greatest danger in this particular -instance was that alluded to by Dr. Cecil, viz., producing inversion of -the uterus. I think Dr. Anderson managed the case in the proper -manner, and by his method of expression the only possible danger was -inversion of the uterus.</p> - -<p class='c004'>I have only seen one instance of dystocia from short cord; that -was a case in which the cord was the shortest I ever saw, and was -wrapped around the neck, where it was necessary in order to deliver -the child to cut the cord after tying it and then employ instruments, -the cord being so short that with each uterine action you could feel -the cupping of the uterus from tension on the cord.</p> - -<p class='c004'>I think there would be less danger from premature separation of -the placenta than from inversion of the uterus. In the case Dr. -Anderson has reported the danger to the child from compression of the -cord was obviated by prompt delivery.</p> - -<p class='c004'>Dr. J. A. Larrabee: Will not Dr. Bullock tell us whether the case -he refers to, where he could feel a descending or cupping of the uterus -by the expulsive efforts, was a primipara?</p> - -<p class='c004'><span class='pageno' id='Page_104'>104</span>Dr. T. S. Bullock: The woman was a primipara; the cord was -very short, it was tied and severed, then the delivery completed with -forceps. I would like to ask the gentleman whether, in those cases -where they have employed Crede’s method of delivering the placenta, -they have noted a cupping of the uterus from efforts to extrude the -afterbirth?</p> - -<p class='c004'>Dr. J. A. Larrabee: I have occasionally noticed cupping of the -uterus under those circumstances.</p> - -<p class='c004'>Dr. F. C. Simpson: I remember a certain practitioner in this city -several years ago made the statement that he seldom tied the cord -after cutting it; that he did not see any necessity of tying the cord. If -this is true, then there would certainly be no danger in severing the -cord in cases such as Dr. Anderson has reported, and it would not -even be necessary to tie it until after the delivery had been completed.</p> - -<p class='c004'>Dr. Wm. Bailey: I want Dr. Anderson to speak to one point in -particular in closing the discussion, viz., would there not be great -danger if the placenta was separated at a time when the child was still -partly in the uterus?</p> - -<p class='c004'>Dr. F. C. Wilson: The only point I wish to bring out in connection -with the case is the possibility of detecting the fact that the cord is -around the neck of the child before delivery, and being on our guard -for it. Encircling of the cord around the neck of the child ought to -give rise to a funic bruit. You can hear very plainly a funic bruit, a -bruit which is synchronous with the fetal heart sounds. Where this -can be detected at a point where we know the neck of the child lies, it -indicates to us that the chord is around the neck.</p> - -<p class='c004'>There are certain other circumstances under which we may also -detect a bruit: For instance, the one mentioned by Dr. Cecil, where -the cord was tied into a hard knot. I have met with several such -cases in my practice, and a bruit can be produced in this way, but at -a different place from the location of the neck, and it is a permanent -bruit; a bruit that is heard all the time. Where that is the case, of -course it indicates that there is some permanent obstruction of the -cord, and the likelihood is that it is due to a knot tied in the cord. We -know that sometimes the cord slips over the neck, and then the child’s -body slips through the cord, thus making a perfect knot; it then may -be drawn tighter and tighter, finally producing considerable obstruction. -If the bruit that is heard is evanescent, heard sometimes when -you are listening and not at others, that indicates simply a temporary -<span class='pageno' id='Page_105'>105</span>pressure upon the cord which may produce a bruit that is fetal in its -rhythm, at the same time it is heard occasionally only. Where the cord -encircles the neck and is drawn tightly it is apt to give rise to a bruit -that is more or less permanent, and always heard at a point where we -know from other methods of examination that the neck of the child is -located. Where this occurs we ought to be on the lookout and prepared -to find the cord encircling the child’s neck, and ought to endeavor -to release it in the first place, and where we are unable to do -that, then the question of severing the cord will come up. The cord -being pulseless in the case reported by Dr. Anderson would have simplified -that question very materially. The cutting of a cord that is -not pulsating is an easy thing and not at all dangerous. Even where -the cord is pulsating I have cut it repeatedly without even attempting -to tie it, simply holding one end—of course you have to make a guess -as to which end is attached to the child. You can not always tell that, -but you can easily see from the continued bleeding or pulsating -whether you have the proper end or not, and by simply holding that -between the fingers the delivery can be expedited, and then the cord -can be tied immediately afterward. Where the cord is pulseless there -would be no danger in severing it and leaving it untied and even -unheld. I have time and again, after delivery of the child, cut the -cord and not tied it, but always waiting till pulsation had ceased. I -think there is no danger in doing this. If a cord is cut after it -ceases to pulsate and does not bleed by the time the child is washed -and ready to be dressed, there will be no hemorrhage from it afterward.</p> - -<p class='c004'>Dr. Turner Anderson: Referring to the point made by Dr. Howard, -I believe, whenever the umbilical cord presents anomalies as illustrated -by the case reported, that it is as a rule abnormally long. The -cord in this case was abnormally long.</p> - -<p class='c004'>Dr. Larrabee made a point to which considerable importance -should be attached, viz., that it would not have been an easy matter to -have divided the cord in this case. I think practically he presents -the case exactly right. When a cord encircles the child’s neck twice, -then branches off and goes under the arm, then branches off over the -back, it presses the neck so tightly and the conditions are such that it -would be a very difficult matter to get one’s finger beneath the cord at -the neck and divide it. It is not such an easy matter to sever a cord -under these circumstances as one might suppose. I believe the -majority of obstetricians content themselves, when they find the cord is -<span class='pageno' id='Page_106'>106</span>encircling the neck, by simply making an effort to stimulate uterine -contraction, and to deliver the child as rapidly as is consistent with -safety to the mother, and while so doing take the precaution to support -the head, to hold it up well against the vulva and prevent undue -traction on the placenta.</p> - -<p class='c004'>It is seldom that we fail to resuscitate a child born under these circumstances. -The cord as a rule is not encircling the child so tightly -so as to prevent our ability to resuscitate it.</p> - -<p class='c004'>Dr. Bailey has correctly stated that arrest of pulsation in the -cord does not occur until after delivery of the head, and we have a -limited time then to stimulate uterine action and to disengage the body -of the child and release the cord from the neck. Contraction and -arrest of pulsation of the cord do not occur prior to that time as a -rule. I can conceive it possible that it might do so, but as soon as the -head is delivered, contraction then is so great that unless the cord is -very long there is an arrest of pulsation and the danger commences. -Fortunately we have recourse to stimulating uterine action, and have -a chance to deliver the child in the manner I have suggested with sufficient -promptness.</p> - -<p class='c004'>I am satisfied Drs. Bailey and Bullock recognize all the dangers -of premature separation of the placenta in an uncontracting uterus. -In the primipara I can not believe that a slight cupping of the uterus, -or the premature separation of the afterbirth, would be a matter of -any very great moment. We are all agreed as to the dangers which -may occur from separation of the normally attached afterbirth prematurely -in the absence of uterine action.</p> - -<p class='c004'>In the primipara we know how very closely the perineum, unless -it is lacerated, hugs the neck of the child, and to isolate and cut the -cord under such circumstances is a very difficult matter. I do not -attach much importance to not cutting the cord, although if I could feel -it around the neck of the child and could sever it I would not hesitate -to do so.</p> - -<p class='c009'><em>Protrusion of the Rectum.</em> Dr. W. O. Roberts: To-day at my clinic -at the University of Louisville a man presented himself complaining -of hemorrhoids. I put him on the table on his back, drew his legs up -to make an examination, and he strained slightly, had an action from -the bowel, and passed out about four inches of his rectum. After -examining it carefully to see whether or not there were any hemorrhoidal -<span class='pageno' id='Page_107'>107</span>masses about it, or a tumor of any kind, I started to get some -vaseline to assist in replacing his rectum, when he drew it back himself -as though he had a string fastened to it. He did not touch it, but -simply drew it back. I turned the table about so the class could see -the prolapsed rectum, and he shot the rectum out and drew it back -four or five times. It is a very peculiar and unique condition to me, -and I would like to inquire if the members have ever encountered a -condition of the kind in their practice.</p> - -<p class='c004'><em>Discussion.</em> Dr. J. M. Williams: This is undoubtedly a case of -prolapse of the rectum with a lax condition of the connective tissue. -It may be from continually coming down, and I have no doubt that the -bowel comes down after each defecation; there is some kind of an -action by which the patient controls the rectum. It may be that -contraction of the sphincter muscle starts the rectum upward, and then -it simply follows its course. I can offer no other explanation of the -condition. Certainly if the bowel comes out four inches there would -be considerable tension upon the mesenteric attachment. It seems -entirely possible that this phenomenon could be influenced and controlled -by the diaphragm and abdominal muscles, and this may be the -solution of this unique case. I have never seen a case of this kind.</p> - -<p class='c004'><em>Epileptiform Seizures in an Infant Aged Ten Months.</em> Dr. J. A. -Larrabee: I have been considerably interested and I may say annoyed -by a case that has been under my care recently. It is in a family -which is decidedly neurotic, and in which there is possibly, without -history or committal, a taint of specific disease. It is not very unusual -to have epileptic manifestations in children at an early age, but the -case I desire to report is, I think, somewhat anomalous. There have -been, for a period of fourteen days, eleven petit mal seizures in every -twenty-four hours in an infant ten months old. These seizures have -not apparently concerned or involved the integrity of the child in any -respect. The intellectual functions, so far as intelligence is written -upon the face of an infant, do not seem to have been affected. The -infant is just as well apparently as if it did not have every hour or so -an epileptic convulsion. The attacks present the usual phenomena of -true epilepsy. The duration of these attacks is from one to two -minutes, accompanied by the usual phenomena, flushing, unconsciousness -which is perfect, the attack then passes off and the infant is well -again.</p> - -<p class='c004'><span class='pageno' id='Page_108'>108</span>This condition of affairs having been going on for a period of fourteen -days in this case without any impairment in the general health of the -infant, or in its nutrition, certainly points, I think, to a specific cause. -I have often had cases, not quite so remarkable as this, where the -tendency has been neurotic or specific in character, which improved -under appropriate treatment; but this case has resisted all treatment, -even specific treatment by the inunction of mercurials and the administration -of the iodides.</p> - -<p class='c004'>The condition is still in progress, the infant having eleven seizures -in every twenty-four hours, not exceeding this number and not falling -short. I have witnessed several of them, and they are perfectly characteristic -of epilepsy. An older child in the family passed through an -ordeal of paroxysms, was unable to walk for three years, and this child -has been restored under treatment, and that treatment has been -antisyphilitic. One child in the family has been lost, and the history -is that it died from scorbutus. The family is decidedly neurotic, and -I suspect a specific taint.</p> - -<p class='c004'>The case has been exceedingly interesting and even annoying to -me because I have been unable to make the slightest impression upon -it by treatment in lessening the number or severity of the paroxysms. -I am pursuing the same line of treatment that I did in the case of the -older child which recovered, and believe I have sufficient ground for -specific treatment, but so far it has not been productive of relief.</p> - -<p class='c004'>The peculiarity about the case is that the occurrence of these -paroxysms has not so far interfered with the nutrition or the general -health of the infant. In this respect I think the case is somewhat -remarkable.</p> - -<p class='c009'><em>Discussion.</em> Dr. T. S. Bullock: I would like to ask if Dr. Larrabee -gave the bromides in the case he has reported.</p> - -<p class='c004'>Dr. T. H. Stucky: Have you tried the bromide of gold and arsenic?</p> - -<p class='c004'>Dr. J. M. Ray: In connection with Dr. Larrabee’s case I recall -one that I saw several months ago in a child a little older than his -which gave a peculiar history. The mother brought the child to me, -the history being that the child complained of having something the -matter with its ear. I examined the ear carefully. No inflammatory -or other disease was present about the structures of the ear; hearing -was perfect, and the drum membrane was intact. The child at this -time was three years of age. The history that the mother gave me -<span class='pageno' id='Page_109'>109</span>was about as follows: The child had never complained of earache; she -had never noticed any defect in hearing, but sometimes two or three -times a day the child would apparently be interested in her toys or in -something about the room, and all at once she would scream and run -to her mother and say that the house was turning over, that there was -a bug in her ear, etc. This would happen several times a day, and on -several occasions the child had fallen over apparently unconscious, or -in a state of partial unconsciousness.</p> - -<p class='c004'>After looking into the ear carefully and not finding any evidence of -disease, I referred the case to the family physician, and in talking the -matter over with him he suggested that these attacks were probably -petit mal. He put the child upon bromide of gold and arsenic, and a -prompt recovery resulted. The last I heard from the case the attacks -were few in number, occurring at long intervals and slight in character, -although at one time they occurred two or three times a day.</p> - -<p class='c004'>Dr. T. H. Stucky: I have seen several cases of epilepsy in children, -but never saw one in a child so young as that reported by Dr. Larrabee. -I have followed out the usual routine, giving bromides and other remedies -with varying results; and later, following the suggestion of Dr. -Buchman, of Fort Wayne, have tried combination mentioned by Dr. -Ray, viz., the bromide of gold and arsenic. I believe the latter to be -especially indicated and exceedingly serviceable where we have reason -to suspect a taint, as mentioned by Dr. Larrabee, getting as we do the -sedative influence of the bromide, the alterative influence of the gold, and -also the well-known effects of the mercury contained in the combination.</p> - -<p class='c004'>I believe where anemia is very marked in these cases, and there is a -feeble heart action, and we are fearful of the depressing effects of the -bromides alone, that in the use of the bromide of strontium and gold -we gain a decided advantage, getting as we do the sedative as well as -the cardiac influence of the strontium salts. Dr. Marvin demonstrated -this conclusively before this society in a statement made by him in -regard to the action of strontium salts in digestive disturbances, especially -those conditions characterized by marked flatulency. If this be -true, and we have reason to believe it is, it appears to me that the -bromide of strontium and gold would be even better than the bromide -of gold and arsenic in cases such as Dr. Larrabee has reported.</p> - -<p class='c004'>Dr. J. A. Larrabee: The case is reported not to demonstrate any -unusual manifestation of epilepsy, but on account of the exact regularity -and periodicity of the seizures, and the age of the patient, coupled -<span class='pageno' id='Page_110'>110</span>with the fact that the treatment which seems to be indicated has not -been followed by relief. In looking up the literature of the subject I -find that cases of this character are usually attributed to a specific cause.</p> - -<p class='c004'>In answer to Dr. Bullock’s inquiry: I have used the bromides in -this case without any effect whatever. Of course epilepsy in the -child is nothing new, but this case presents some peculiarities. There -is a decided neurotic tendency in the family, which may have some -bearing upon the case. The child is going along having the number of -seizures stated each day without any evidence of disturbance of nutrition -or impairment of general health, which is rather remarkable. -Some of the attacks are almost grand mal, most of them petit mal, and -I am convinced that the trouble is due to specific taint.</p> - -<p class='c004'>The next move I make will be to put the child upon the bromide -of gold and arsenic.</p> - -<div class='lg-container-r'> - <div class='linegroup'> - <div class='group'> - <div class='line'>JOHN MASON WILLIAMS, M. D., <em>Secretary</em>.</div> - </div> - </div> -</div> - -<div class='chapter'> - <h2 class='c005'>Abstracts and Selections.</h2> -</div> - -<p class='c009'><span class='sc'>The Influence of the Organism upon Toxins.</span>—Metchnikoff (<cite><span lang="fr" xml:lang="fr">Ann. -de l’Instit. Pasteur</span></cite>, November 25, 1897,) has applied the method of comparative -pathology to the question of the mechanism by which the animal -organism prepares antitoxins, and the laws which regulate their production. -By growing bacteria and lowly fungi upon culture media containing toxines -he was enabled to show that the virulence of the latter was in most cases -diminished and sometimes destroyed. In any case these microbes have no -influence in the production of antitoxins, and the idea of preparing them -by this means must be abandoned. The animal organism alone being capable -of producing antitoxins, the next point was to find out whether this -was a property common to all animals, or limited to the superior. Metchnikoff -found that the injection of large quantities of tetanus toxin into scorpions -and the larvæ of other arthropods produced no antitoxin. The toxin -remained for months in the blood or tissues without losing its properties; -similar results were obtained when it was taken into the alimentary canal -of the leech. It was hence shown that even those invertebrates in which -antimicrobic phagocytosis is most marked are utterly incapable of producing -antitoxins. Coming next to vertebrates, no power of producing antitoxin -is possessed by fish or amphibia; it first appears in reptiles, but not in all -kinds. Thus tortoises, like invertebrates, can retain tetanus toxin in the -blood for a lengthened period without forming antitoxins; it is in reptiles -that the production of the latter is first observed, but in them only when they -<span class='pageno' id='Page_111'>111</span>are kept at a temperature higher than 30° C. If the temperature is 20° C. -the results are just the same as in tortoises and invertebrates. The establishment -of the antitoxic property in these cold-blooded animals is not -attended with any rise of temperature, and the same is true in warm-blooded -animals such as fowls. With regard to the last-named animals, whose power -of producing tetanus antitoxin was first demonstrated by Vaillard, Metchnikoff -has some new and important observations. He finds that practically -all the toxin injected into the peritoneum passes into and remains in the -blood, none of the organs being toxic after their blood has been washed out. -To this an exception is found in the case of the genital organs, ovaries, and -testicles, which possess the power of fixing some of the circulating toxin. -This they share with the leucocytes, to the toxicity of which that of the blood -is due. After a while the toxic power of the blood diminishes, and after -passing through a neutral period it becomes antitoxic. It is now found that -with the exception of the generative organs, none of the organs when freed -from blood possess any antitoxic power. The genital glands are found to -be markedly antitoxic, but the author brings evidence to show that the antitoxin -is not manufactured by them, but is absorbed from the blood, so that -in the fowl the antitoxic property resides solely in the blood. Metchnikoff -concludes that it is not possible to accept the idea that natural immunity -depends on antitoxic power, and he further points out that the latter is -evolved in the history of the animal kingdom at a much later date than the -phenomena of phagocytosis.—<cite>British Medical Journal.</cite></p> - -<p class='c009'><span class='sc'>The Treatment of Tuberculosis with Tuberculin R.</span>—Dauriac -(<cite><span lang="fr" xml:lang="fr">Progrès Médical</span></cite>, December 4 and 11, 1897,) reports the results of the employment -of Koch’s tuberculin R. in various cases of tuberculosis; fourteen -of these presented local affections, such as suppuration over the sternum, -enlarged cervical glands, ulceration of the skin, etc. All of the patients -were satisfactorily cured. In a second paper he describes the results in -fifteen cases of pulmonary tuberculosis in various stages of the disease; -all were greatly improved, and many are described as cured. One of the -cases was insufficiently nourished and clad, had no fixed residence, and, -when the treatment was commenced, large cavities were found at the apices -of both lungs. A case is also described in which, in addition to pulmonary -tuberculosis, lesions were present in the kidneys and the bladder. This -patient also made a complete recovery. The treatment, in spite of these -brilliant results, is supposed to be most applicable to the earliest stages of -the disease, and it is suggested that it would be advisable to detect the -presence of tuberculosis by injections of minute doses of the original form -of tuberculin. The treatment is usually commenced with a dose of <span class='fraction'>1<br /><span class='vincula'>500</span></span> mg. -This should be increased daily until a dose of <span class='fraction'>10<br /><span class='vincula'>500</span></span> mg. is reached; this then -should be increased <span class='fraction'>1<br /><span class='vincula'>50</span></span> mg. daily until ⅕ mg. is reached, and this increased -⅕ mg. daily until 1 mg. is given. This can then be further increased if -considered desirable, the maximum dose being about 20 mg. The immediate -<span class='pageno' id='Page_112'>112</span>effects of the injections are usually <i><span lang="la" xml:lang="la">nil</span></i>. With doses in excess of ⅗ -mg. a slight elevation of temperature is occasionally observed. Local -reaction is extremely rare. The subsequent effects consist in reduction of -fever, cessation of sweats, increase in appetite, and disappearance of tuberculous -lesions. As none of the patients reported in this paper was admitted -to the hospital, but simply came three times or less frequently a week to -the dispensary for injections, improvement could not possibly have been -due to any alteration in their hygienic surroundings.—<cite>The Philadelphia -Medical Journal.</cite></p> - -<p class='c009'><span class='sc'>Cesarean Section by Transverse Incision of Fundus.</span>—Braun -(<cite>Centralbl. f. Gynak.</cite>, No. 45,) has had experience of Fritsch’s cesarean section, -the operation being the second of its kind ever recorded. Fritsch -bases his practice on the course of the secondary branches of the uterine -arteries which run horizontally, so that a longitudinal incision down the -front of the gravid uterus can not fail to cause free hemorrhage. He is -accustomed to extirpate diseased fallopian tubes completely, snipping a -wedge-shaped piece out of the uterine cornu. Bleeding is always free, but -the tying of a suture passed antero-posteriorly under the bleeding vessel -stops it at once. The ligature lies at right angles to the vessel, the most -favorable position. Hence Fritsch conceived the idea of making an incision -straight along the fundus from cornu to cornu, in order to extract the fetus -in a cesarean section. Braun publishes full notes of his own case. The -patient was a rachitic primipara with a universally and irregularly contracted -pelvis. The conjugata vera was two and three-quarter inches. Labor pains -had set in. Care was taken to antevert the gravid uterus sufficiently, the -upper part of the wound being held together with forceps during delivery -of the child. Then the transverse incision was made. Braun found that -it bled as much as the longitudinal incision in cesarean sections where he -had operated during labor at term or in relatively early pregnancy. The -placental site did not lie near the fundus. The delivery of the fetus, which -was living and weighed six pounds, was neither harder nor easier than -through a vertical incision. The wound in the fundus was under four inches -long after the fetus had been extracted. The sutures had to be placed close -together, fifteen deep and eight superficial being applied. Ergot was given -after the abdominal wound was closed, as there was hemorrhage. The -patient made a good recovery.—<cite>British Medical Journal.</cite></p> - -<p class='c009'><span class='sc'>Labor in Mature Primiparæ.</span>—De Koninck (<cite><span lang="fr" xml:lang="fr">Revue Medicale</span></cite>, Louvain, -October 30, 1897,) has compiled an instructive memoir on labor in primiparæ -married for some years and relatively mature (twenty-eight years Bidd and -Pourtad, thirty-two Ahlfeld). De Koninck gives thirty as the earliest year -coming under “maturity,” the “<em>primipares agees</em>” of French authorities. He -sets aside as curiosities certain cases of primiparæ almost “aged” in the -English sense of the term, such as Cohnstein’s two women aged fifty and -<span class='pageno' id='Page_113'>113</span>Steinmann’s woman aged fifty-two. It appears that in a genuine uncomplicated -case of delayed impregnation the advent of the catamenia is always -found to have occurred late in youth. Out of 401 such cases menstruation -was retarded till twenty in 39, till twenty-four in 4, and till twenty-six in 1. -As to the retarded first pregnancy, abortion, ectopic gestation, twins, and -special renal mischief are relatively frequent. Above all, lingering labor is -specially common, statistics even exceeding guesses and <i><span lang="la" xml:lang="la">a priori</span></i> reasoning -in this respect. In 12 out of 17 noted by De Koninck labor lasted from -forty to fifty hours, the remaining labors being yet longer; 1 exceeded ninety -hours. Feebleness of uterine contraction is absolute from first to last, -and independent of any obstetrical combination. They also cause far more -physical and mental exhaustion than the vigorous contractions of a young -uterus, and at the same time are more painful. There are discrepancies in -the “pains” seen in mature primiparæ of the same age, probably homologous -with the great variations in the age of menopause observed in otherwise -normal women. The uterus may be older in one woman aged thirty-five -than in another of the same age. The forceps and other obstetrical operations -are often required in the mature. Most of the above facts are easily -explained. The excess of male infants borne by mature primiparæ (thirty -per cent) is a less explicable phenomenon. Hecker considers the predominance -of male infants as a speciality of all primiparæ, but Rumpe turns -attention to the fact that in a family of children the predominance of males is -commoner the further the mother is from her first menstrual period.—<i><span lang="la" xml:lang="la">Ibid.</span></i></p> - -<p class='c009'><span class='sc'>Kinesitherapy in Heart Disease.</span>—Colombo (<cite><span lang="it" xml:lang="it">Gazz. Med. di Torino</span></cite>, -48, N. 39, 40, 1897,) pleads for a more general use of kinetic treatment in -heart disease. Even in advanced cases he seems to think such treatment is -very advantageous. Milder forms of treatment, for example, the Swedish -method of gymnastic exercise, should be started at first, and afterwards -more active methods, for example Oertel’s, can be tried. The action of the -Swedish method is most marked upon the peripheral vessels, while Oertel’s -system acts more directly upon the heart itself, so that dividing heart disease -into disease of central or cardiac, and that of peripheral or vascular origin, -the different methods could be applied accordingly. The Swedish method, -moreover, has this advantage, that it can be applied in severe cases which -can not leave their beds. Barie (<cite>Sem. Med.</cite>, November 12, 1897,) advocates -the treatment of heart disease by Swedish gymnastics. The aim of the -exercises is to facilitate the work of the heart by increasing its contractile -power and by lessening the peripheral resistance. The exercises are a -series of regulated, combined, or alternating movements of resistance or -opposition. The movements employed fall under the main groups: (1) -Kneading, rubbing, or stroking of the muscular masses in the limbs and -abdomen; (2) movements of circumduction which facilitate the circulation -in the main venous trunks; (3) movements which favor respiration. The -exercises are very varied, and accomplished by means of passive and active -<span class='pageno' id='Page_114'>114</span>movements, numerous different manipulations, and by special apparatus. -The average duration of the treatment ought not to be less than an hour a -day during three months of each year. The treatment is suitable for cases -of dilatation, hypertrophy, fatty degeneration, chronic myocarditis, and various -neuroses and functional affections of the heart. Such symptoms as shortness -of breath, palpitation, insomnia, cephalalgia, giddiness, gastric phenomena, -edema, ecchymosis, cyanosis, improve or disappear under treatment. -The pulse-rate is lowered, but rises again as soon as treatment is interrupted. -Rational application of the treatment does not exclude internal treatment -by ordinary medical means, and the two methods may often be employed -simultaneously with the best results.—<i><span lang="la" xml:lang="la">Ibid.</span></i></p> - -<p class='c009'><span class='sc'>Live Frogs as an Antithermic.</span>—An English practitioner of Constanta, -Roumania, writes: On the evening of October 19th I was called -to visit a Roumanian boy, six years old, suffering from typhoid fever. I -found him <i><span lang="la" xml:lang="la">in extremis</span></i>, almost pulseless. The child’s head was completely -wrapped over with a large white sheet, and as I looked at it this enormous -white envelope seemed to be on the move, and while I was surveying this -covering there crept from under it a small frog, which quietly sat over the -child’s left arm. It seemed quite content. I immediately called the -mother’s attention to it and requested her to take the animal away, thinking -it had crept there as an intruder. “Oh, no!” said the old lady, “a -doctor recommended that a lot of them should be kept to the head to keep -it cool.” Seeing the head covering still on the move, I raised it for curiosity, -and in a second out jumped about twenty other frogs and hopped -away in all directions. I have often heard the expression “as cold as a -frog,” but this was the first time I had seen a frog applied as a head-cooler.—<cite>London -Lancet.</cite></p> - -<p class='c009'><span class='sc'>Treatment of Endometritis in Bromine Vapor.</span>—Nitot (<cite><span lang="fr" xml:lang="fr">La Gynecologie</span></cite>, -October 15, 1897,) maintains that the correct prophylactic treatment -of parenchymatous metritis and chronic salpingitis consists in rapid cure of -recent endometritis, which is the starting point of those troublesome diseases. -To insure cure a remedy is needed which can penetrate to the deepest recesses -of the muscosa, and even the tubes, without dangerous effects. Caustics -and fluid preparations do not possess such properties. A gas is required, -and it must be freely diffusible, antiseptic, and capable of acting on the -epithelium so as to modify without destroying them (“anticatarrhal action”). -Bromine emits gas with the necessary qualities; a saturated aqueous solution -should therefore be placed in a bottle with double tubing like an ether spray -or the chloroform bottle in a Junker’s inhaler. A hollow sound, connected -with one tube, is passed into the uterus, while the solution is made to bubble -by pressure on a ball connected with the second tube. Thus vapor is -propelled into the uterus. Nitot claims the best results, and notes that the -advantages of gaseous diffusion over intra-uterine injections or other medication -are self-evident.—<cite>British Medical Journal.</cite></p> - -<div><span class='pageno' id='Page_115'>115</span></div> -<div class='section ph2'> - -<div class='nf-center-c0'> -<div class='nf-center c010'> - <div><span class='sc'>The American Practitioner and News.</span></div> - </div> -</div> - -</div> - -<div class='nf-center-c0'> -<div class='nf-center c003'> - <div><span class='small'>“<i><span lang="la" xml:lang="la">NEC TENUI PENNÂ.</span></i>”</span></div> - </div> -</div> - -<table class='table0' summary=''> -<colgroup> -<col width='25%' /> -<col width='50%' /> -<col width='25%' /> -</colgroup> - <tr> - <td class='bttd bbtd c011'>Vol. 25.</td> - <td class='bttd bbtd c012'>FEBRUARY 1, 1898.</td> - <td class='bttd bbtd c013'>No. 3.</td> - </tr> -</table> - -<div class='nf-center-c0'> - <div class='nf-center'> - <div>H. A. COTTELL, M. D., Editor.</div> - </div> -</div> - -<hr class='c014' /> - -<div class='nf-center-c0'> - <div class='nf-center'> - <div>A Journal of Medicine and Surgery, published on the first and fifteenth of each month. Price, $2 per year, postage paid.</div> - </div> -</div> - -<hr class='c014' /> -<blockquote> -<p class='c004'>This journal is devoted solely to the advancement of medical science and the promotion of the -interests of the whole profession. Essays, reports of cases, and correspondence upon subjects of professional -interest are solicited. The editor is not responsible for the views of contributors.</p> - -<hr class='c014' /> - -<p class='c004'>Books for review, and all communications relating to the columns of the journal, should be -addressed to the Editor of <span class='sc'>The American Practitioner and News</span>, Louisville, Ky.</p> - -<hr class='c014' /> - -<p class='c004'>Subscriptions and advertisements received, specimen copies and bound volumes for sale by the -undersigned, to whom remittances may be sent by postal money order, bank check, or registered -letter. Address</p> - -<div class='lg-container-r'> - <div class='linegroup'> - <div class='group'> - <div class='line'>JOHN P. MORTON & COMPANY, Louisville, Ky.</div> - </div> - </div> -</div> - -<hr class='c014' /> -</blockquote> - -<div class='chapter'> - <h2 class='c005'>THE ART OF NEGLECTING WOUNDS.</h2> -</div> - -<p class='c009'>The New York Post-Graduate Clinical Society<a id='r2' /><a href='#f2' class='c008'><sup>[2]</sup></a> was recently treated -to a moving discourse on the novel subject of “The Art of Neglecting -Wounds,” by Dr. Robert T. Morris, one of the instructors in surgery in -the Post-Graduate School.</p> - -<div class='footnote' id='f2'> -<p class='c004'><a href='#r2'>2</a>. The Post-Graduate, Vol. <span class='fss'>XIII</span>, No. 13, January, 1898.</p> -</div> - -<p class='c004'>The author confined his remarks to wounds made by the surgeon -when operating, and hints pretty strongly, though he does not say so, -that their subsequent treatment even by the surgeon himself might -not inappropriately be called “meddlesome surgery.”</p> - -<p class='c004'>For instance: In incised wounds (the margins of which have not -been quite approximated) the capillaries begin to develop granulation -tissue in the coagulated lymph deposited upon the surface in a few -hours if the trophic nerves have not been much injured. This granulation -tissue is extremely delicate and will not bear handling. When -such a wound is suppurating freely the strong temptation to wipe away -the pus with sponge or gauze should be resisted for two reasons, -first, “Granulation tissue suffers traumatism whenever it is touched, -no matter how lightly, and, as a result of such traumatism, there will -be developed exuberant granulation tissue, which will be poorly supplied -with blood-vessels. We have in weak granulations, so to speak, -what might be called ‘watered stock.’ It is a very common result of -our well-intentioned but ill-directed efforts at keeping the wound clean.”</p> - -<p class='c004'>Gauze upon the granulations will injure the tissue still more, since -its filaments entangle the granulations, which on removal of the dressing -<span class='pageno' id='Page_116'>116</span>are broken off in small fragments. The device which prevents -this injury is a covering of very soft gutta-percha tissue or Lister’s -protective silk. But the surgeon who practices this let-alone method, -though backed by sound pathological knowledge and therapeutic -principles, will not escape the censure of the family or the nurse, and -too often allows his sense of neatness to take precedence of his more -sober sense founded upon pathological knowledge.</p> - -<p class='c004'>This “neglect” is particularly desirable when epithelium is shooting -across the wound. These hyaline cells are so extremely delicate -that the slightest touch will damage or remove them to the detriment -of the healing process. The dressing on a suppurating wound should be -allowed to remain five or six days. Though the ignorant may find -fault with the surgeon for such temporizing, he must insist upon it for -the patient’s well-being.</p> - -<p class='c004'>Another illustration is drawn from the operation for appendicitis, in -which we have adhesions, pus, and wide infection. Here new pathological -factors are met with. The peritoneum throngs with polynuclear -leucocytes which are engaged in destroying the bacteria. If time -be given these faithful guards to mass themselves in the peritoneal -lymph channels, they will prevent the extension of the peritonitis from -this point. The surgeon, having evacuated the pus, removed the -appendix, and inserted the drainage apparatus, is tempted, because of -its bad smell, to wash out the wound. Such a measure would not only -give the patient detrimental annoyance, but would inflict a new traumatism -upon the tissues. “This traumatism calls out an unnecessary -number of leucocytes, and an unnecessary degree of reactive -inflammation ensues. If, on the other hand, the colon bacilli are -allowed to increase, they will at first produce a very foul odor to the -discharge, but in three or four days we will usually find streptococci -abundant, and perhaps displacing all other bacteria.” In such cases, -leave the drainage apparatus in place and “neglect” the wound. -“Repair and destruction of bacteria will go on much better if we leave -the wound alone, after having removed the principal mass—the contents -of the abscess cavity.”</p> - -<p class='c004'>Another illustration is found in burns of the second degree. Here -large blisters have formed and broken, and much skin is denuded of its -cuticle. In such a case the author administers an anesthetic, opens -the blebs, removes the detached skin, scrubs the parts with an antiseptic -solution, covers the denuded surface with strips of gutta-percha -tissue, and leaves the case to nature. When a change is made, it -<span class='pageno' id='Page_117'>117</span>should be of the outer dressings only. And the reasons for this treatment -are that in such burns “the serum which is thrown out is germicidal, -and is destroying all the bacteria upon the skin very rapidly. -This germicidal action will go on so long as the serous exudation is -free, but when the coagulation of lymph begins on the surface, this -action becomes very much diminished, and the bacteria are then liable -to liquefy the lymph and grow very rapidly, as new portions of serum -are thrown out. This leads to sepsis and sometimes to the formation -of thrombi, with necrosis of the duodenum and perforating ulcer. The -patient’s friends complain if the dressings are left long in place, and yet -I know of no wounds which do so well when ‘neglected’ as burns.”</p> - -<p class='c004'>In the discussion that followed, the author, being asked what he -would do with suppurating sinuses, said “he knew of sinuses that -had been kept open week after week and month after month, and had -proved veritable gold lodes to the surgeons. If the surgeon had been -compelled to go away for a time, these sinuses would have healed long -before they did. This might seem like a joke, but it was a fact with -which he was brought face to face all the time. His rule was to leave -sinuses alone, in the belief that the poorly fed granulations lining them -would in time cause approximation of the walls, and healing would -occur. It was true that exceptions would have to be made for some -sinuses, but that did not affect the rule as given.”</p> - -<p class='c004'>Such considerations give accentuation to the dictum of Velpeau, -that “nature is a good physician but a bad surgeon,” and dignify the -<i><span lang="fr" xml:lang="fr">bon mot</span></i> of Holmes, who, seeing the smoothly healed and finely cushioned -stump which resulted in time after an amputation, exclaimed:</p> - -<div class='lg-container-b c015'> - <div class='linegroup'> - <div class='group'> - <div class='line'>“There’s a divinity that shapes our ends,</div> - <div class='line'>Rough hew them how we will!”</div> - </div> - </div> -</div> - -<p class='c004'>For the surgeon’s far more than the physician’s successes depend -upon the <i><span lang="la" xml:lang="la">vis medicatrix naturæ</span></i>, and he who is best versed in physiological -and pathological processes, and administers the surgical art -accordingly, will secure the best results.</p> - -<p class='c004'>They who neglect their surgical cases from ignorance, carelessness, -or a wanton disregard of the great pathological dicta of the day, can -find no justification in these teachings, for the truth, as embodied in -the author’s closing words, puts all such to shame and confusion: “A -good deal of skill is required in order to neglect wounds well. This -‘neglect’ of course implies a proper understanding of the processes -with which one is dealing.”</p> - -<div class='chapter'> - <span class='pageno' id='Page_118'>118</span> - <h2 class='c005'>Obituary.</h2> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c003'> - <div>DR. J. Q. A. STEWART.</div> - </div> -</div> - -<p class='c004'>On the 25th ultimo this accomplished physician and estimable -gentleman died at his home in Farmdale, Ky. He had been in failing -health for something more than a year. His ailment was Bright’s -disease, and the end was precipitated by uremia.</p> - -<p class='c004'>Dr. Stewart was born near Louisville, Ky., in 1829. In 1849, having -secured a good common school education, and graduating in law, he -went to the gold fields of California, where he sojourned for seven or -eight years. Returning to his native State, he entered upon the study -of medicine, and graduated from the Kentucky School of Medicine in -1859. He began practice in Daviess County, Ky., but after a few years -moved to Owensboro, where a larger field of usefulness and fuller success -awaited him.</p> - -<p class='c004'>In 1878 Dr. Stewart was called by Governor John B. McCreary to -the position of Medical Superintendent of the Kentucky Institution -for the Training of Feeble-Minded Children. It was here that the -chief work of his life was done. And it was here that he served -humanity and the State with honor, with ability, with fidelity, and -with an earnest, self-sacrificing devotion to the welfare of these rejected -waifs of humanity which entitles him to place and rank among the -higher philanthropists of our philanthropic profession.</p> - -<p class='c004'>In the care of the feeble-minded Dr. Stewart added to his executive -work the habits of a careful student, and became one of the best known -alienists of the land. His address as retiring President of the Kentucky -State Medical Society in 1894 was an able and scholarly treatise -upon the management of the feeble-minded. It was received with -great favor by the Fellows, and has since been the subject of high -encomiums from doctors, lawyers, and political economists.</p> - -<p class='c004'>After sixteen years of State service Dr. Stewart purchased the old -Kentucky Military Institute near Frankfort, where he established the -“Stewart Home for the Feeble-Minded.” The venture was successful -beyond expectation, and here in the bosom of his family he passed -serenely and blissfully the closing years of his gentle, useful, and -beautiful life.</p> - -<div class='figcenter id001'> -<img src='images/i035.jpg' alt='' class='ig001' /> -<div class='ic001'> -<p><span class='sc'>Dr.</span> J. Q. A. STEWART.</p> -</div> -</div> - -<div class='chapter'> - <span class='pageno' id='Page_119'>119</span> - <h2 class='c005'>Notes and Queries.</h2> -</div> - -<p class='c009'><span class='sc'>The Surgery of the Thyroid from a Neurologic Standpoint.</span>—In -a suggestively written paper in the January number of the American -Journal of the Medical Sciences, Dr. J. J. Putnam uses the following -words: “We are rather in the habit of assuming that the removal of -large portions of the thyroid does no harm, provided it does not cause -myxedema. But the probability is that we shall learn to recognize affections -which lie between myxedema and health, as well as peculiarities of -development and disorders of nutrition for which the thyroid is more or -less responsible.” ... That this is a statement of fact will hardly be disputed -by any neurologist, but that it expresses a truth that has as yet been -insufficiently impressed on the profession generally is another fact the -importance of which is not likely to be overestimated. It is only within -a comparatively brief period that we have learned that the thyroid had any -definite function and our knowledge of its physiology is still very far from -being exhaustive. The dangers also of interference with it are as yet also -only partially known, but it is certain that they are not confined to the -operation itself. The cases of sudden fatal dyspnea occurring hours after -an apparently prosperous operation in Graves’ disease, recently reported -by Debove and others, are in evidence of this, and Dr. Putnam adduces -other important facts and arguments against any too venturesome surgery -of the thyroid gland. Among these are the experiments of Halsted, showing -that excision of the gland in dogs had a serious and very evident disturbing -effect upon their offspring, and that even very slight operative -interference produced hypertrophic changes and apparent increase of secretion -in the gland itself; and the observations of Kocher of goiter and -cretinism inherited from parents with no disease other than impaired thyroid -function are also cases in point. Still another fact brought forward by -Putnam is the one that removal or atrophy of the thyroid in infancy -checks the growth and function of the reproductive organs, and gives rise -to the various disturbances of development that follow the suppression of -this very important function. The close relations of the various internally -secreting glands, the thyroid, the testicles and ovaries, the suprarenal -glands, and the pituitary body, for this it seems probable must be included -in this category, are revealed in many pathologic conditions, and the thyroid -as the largest, and presumably the most important, has apparently a larger -part in the disturbances than any of the others. It seems to be involved -to some extent in many cases of acromegaly; its relations with the genital -development have already been mentioned, and its implication in many -pathologic conditions of organs is probable and is strongly suggested by -<span class='pageno' id='Page_120'>120</span>the clinical history in certain cases of Graves’ disease. Seeligmann has -indeed recently reported a case of this affection apparently closely associated -with genital disorder in which he obtained decided benefit from the -administration of ovarian extract, thus adding another suggestion to the -therapeutics of the disorder.</p> - -<p class='c004'>When any organ is removed, as Putnam says, two factors are set in -operation which may have more or less important effects upon the system -generally. One of these is the action of toxins, the other is the effort of -the organism to adapt itself to the new and changed conditions. The first -of these is important enough in the case of removal of the thyroid gland, -but the other, from what we are beginning to know of its physiology, must -be even more important. Because the function of the organ is already -deranged, it does not necessarily follow that matters will be remedied by its -removal. The operation may only make a bad matter worse. The mortality -of thyroidectomy, according to Poncet, is from fifteen to thirty per -cent, which is alone enough to induce caution. When the facts brought -forward by Dr. Putnam are also considered, the known and the possible and -hinted though yet unknown effects of thyroid ablation, there is still more -reason for prudence and hesitancy in this operation.</p> - -<p class='c004'>Of course when a goiter has become a dangerous mechanical embarrassment -to important functions, or when a tumor exists in the thyroid -that by its growth and situation has become a threatening danger, the case -is clear, and operation may not only be justifiable but necessary. It is in -such affections as Graves’ disease, in which thyroid operations are still -somewhat popular, that we are likely to have not only useless but dangerous -surgery, and the time seems to have come to emphasize the cautions -implied in Dr. Putnam’s paper. The theory of hyperthyroidization in this -disease, though it has apparently much in its favor, is not yet sufficiently -demonstrated, and even were it so, would not form a justification for any -indiscriminate or frequent practice of operative interference. Graves’ disease -is not by any means a hopeless disorder under medical treatment, even -in its advanced stages; it is therefore impossible to say when surgery is -indicated as a last resort. When the facts of its absolute inefficiency in -perhaps the larger proportion of instances in which it has been tried, the -immediate dangers of the operation which are not slight, and the remote -ones pointed out by Dr. Putnam, are all taken into consideration, it would -seem that it ought to be relegated to innocuous desuetude.—<cite>Journal of the -American Medical Association.</cite></p> - -<p class='c009'><span class='sc'>The Treatment and Prognosis in Graves’ Disease.</span>—This short -article is prepared solely with the view of eliciting from medical men who -have met with cases of exophthalmic goiter in their practice, the results of -their observations regarding many points of interest in connection with -this curious disease. I do not intend to give a systematic description of -the affection in question. This can be found in any good modern text-book. -<span class='pageno' id='Page_121'>121</span>Described many years ago by Parry, Basedow, and by others more recently, -it is much better understood and more widely known than formerly.</p> - -<p class='c004'>Opinions differ radically as to its real nature. The best modern authorities -regard it as a pure neurosis, and functional only in character, although -organic changes often develop during its course in the heart, thyroid gland, -and elsewhere. Some still speak of it as due to changes in the medulla -oblongata; others again look upon functional and structural changes in the -thyroid gland as the real cause of the malady. My own experience -inclines me to view it as a neurosis pure and simple, although marked and -characteristic structural changes supervene during its course, and may -become permanent. Probably in the near future we shall learn more as to -its exact nature. Already it is satisfactory to note that cases are far -earlier and more frequently recognized, and that their treatment is more -successful.</p> - -<p class='c004'>From their first appearance its special features attract attention. These -are few in number, and easily borne in mind: 1. An unusual and more or -less constant rapidity of the heart’s action; 2. The early presence of more -or less protrusion of the eyeballs; 3. A marked enlargement of the thyroid -gland; a tendency to tremors or tremblings under very little, and sometimes -no excitement, although this always increases it. It is not surprising that -these indications of exophthalmic goiter which develop more or less -rapidly and become often most distressingly marked, should cause much -anxiety to the patients and their friends, as well as to their medical -attendants.</p> - -<p class='c004'>With regard to the duration of ordinary chronic cases (for acute ones -are seldom met with), what has been the experience of those who may read -this article? I have never met with an acute case, but have seen months -and one or two years pass before there was more than a partial improvement.</p> - -<p class='c004'>One case, a very bad one, in which the patient’s circumstances were so -poor that she worked on during her illness, when she should have had care -and rest, recovered completely. But so serious was this case, that the sight -of both eyes was entirely lost from the excessive protrusion of the eyeballs -during the disease. When I first saw her, which was years after her -recovery, the story of her case was intensely interesting, but most sad.</p> - -<p class='c004'>Then as to the frequency with which relapses occur in this disease, it -would be interesting to get the experience of good men. Many speak of -relapses being frequent, even after apparently complete recovery has taken -place. Others think them not of so common occurrence.</p> - -<p class='c004'>There are also many points of great interest in connection with the -prognosis. One of these is the probability of the recovery being perfect. -My own experience has been that the lighter or milder the case the greater -the probability of a perfect cure.</p> - -<p class='c004'>Another matter of interest is in connection with cases in which the -symptoms greatly abate, the health indeed appearing to be perfectly -<span class='pageno' id='Page_122'>122</span>restored, but in which the exophthalmos and thyroid enlargement continue -noticeable; whether in such patients very slight causes may not lead to a -return of the disease. From what I have seen, the conclusion appears -correct, that provided the heart’s action is normal as to frequency, and not -too easily disturbed, these cases are not specially likely to have a second -attack, which is tantamount to saying that, provided the heart’s action has -become normal, any other relic of the illness is comparatively unimportant.</p> - -<p class='c004'>I have observed, too, more or less scleroderma present when the attack -has not been by any means of a serious character, and when afterward the -general health became all but perfectly restored. This is an interesting -concomitant. It would be desirable to have others give their experience as -to its occurrence in cases they may have attended.</p> - -<p class='c004'>Then as to the effects of pregnancy during the course of the disease; -some high authorities speak very strongly as to its great danger. Others -remark that the affection has improved during gestation. This is another -matter on which fuller information would be most useful.</p> - -<p class='c004'>As to the percentage of fatal cases, this is hardly as yet to be determined -so as to be useful to the practitioner. My own cases have led me to the -conclusion that every particular case has to be regarded <i><span lang="la" xml:lang="la">per se</span></i>, that is, if -the symptoms are light and comparatively trifling, and show signs of -abating, the prognosis is favorable, while under an opposite state of things -it is the reverse.</p> - -<p class='c004'>As to treatment, what has succeeded best in my hands has been enjoining -upon patients the necessity of a great deal of physical rest, at least ten -or twelve hours a day if possible, and the avoidance of all mental worry. -On this, great stress should be laid. These patients require abundant -nourishment. Galvanism in my hands has been found most useful; -employed twice a day and so applying the poles that the current may go -from the back of the neck through the thyroid gland, and the heart, and -even (the current being made very weak) through the eyeballs. This current -has been continued for months, and in some cases for a year and a -half, with good effects. Sometimes tincture of digitalis has been useful in -moderate doses, ten or twelve minims three times in twenty-four hours, in -some cases, and useless in others. Iron has been found of great value and -persisted in for a long time. As a nerve-tonic, strychnine in small doses has -been exceedingly beneficial. Quinine, if used, should, unless malaria complicates -the case, be used in small doses only, such as 1½ grains three times -a day, with the iron and strychnine.</p> - -<p class='c004'>I know that many of the matters I have mooted in this paper have -been quite recently discussed by Drs. Ord and McKenzie, of London, in an -excellent article on exophthalmic goiter in the fourth volume of the new -System of Medicine edited by Allbutt, but a still wider discussion on the -matters alluded to, and on many others, by practitioners who have met -with and treated such cases, will do much good, and tend to make the care -of such cases more pleasant and the results of treatment more satisfactory. -<em>Walter B. Geikie, M. D., C. M., D. C. L., in Philadelphia Medical Journal.</em></p> - -<p class='c009'><span class='pageno' id='Page_123'>123</span><span class='sc'>Dangers of the Nasal Douche.</span>—Lichtwitz (<cite>Sem. Med.</cite>, November -26, 1897,) deprecates the routine prescription of the nasal douche in all cases -of hypersecretion of the nasal mucous membrane. Irrigation is called for -only when the nasal fossæ require clearing of pus and crusts, for instance in -idiopathic ozena. This affection is mainly limited to the nasal fossæ properly -so called, and irrigation is in such a case the most fitting form of procedure. -An ordinary syringe or enema syringe with suitable nozzle should be -used. In all other nasal affections irrigation is inadequate or useless; it is -even dangerous. Repeated flooding of the mucous membrane may give rise -to olfactory lesions. Antiseptics are highly injurious and pure water is badly -borne; the physiological solutions of sodium chloride, sod. bicarb. or sod. -sulph. are the only harmless liquids. In numerous cases irrigation has -caused the sense of smell to be temporarily or permanently diminished or -lost. Distressing frontal or occipital headache may result owing to the liquid -passing into the sinuses. The injection of irritating liquids may even set -up inflammation of these cavities. The most skilful and careful irrigation -is insufficient in many cases to prevent the resulting headache. A very -grave complication is the penetration of the liquid into the middle ear, -suppurating otitis media occasionally supervening. In acute coryza, especially -in children, douching should never be practiced. In one such case -known to the author mastoiditis followed irrigation of the nasal cavities. -The predisposition to otitis is increased after retro-nasal operations, in particular -after ablation of adenoid vegetations. For eight years the author -has given up all irrigation after pharyngo-tonsillotomy, and during that -period has met with no case of post-operative complication.—<cite>British Medical -Journal.</cite></p> - -<p class='c009'><span class='sc'>Antipyrin.</span>—In July of this year the antipyrin patent, held by the -Hochst color-works, will expire by limitation, it having run its course of -fifteen years—the span of life allowed to a German patent. During these -fifteen years the monopolists have sold the drug at about $12.50 a pound, -but it will, of course, fall considerably in price the moment the manufacture -and sale are permitted competitors. It is anticipated that it will shortly -fall to at least half its present price, when the usual convention of the principal -competitors will be called and the inevitable trust formed, leading to -a consequent rise in price. It is rumored that a number of chemical -works are busy with the manufacture of antipyrin, so as to be prepared -with it immediately upon the expiration of the patent.—<cite>Philadelphia -Medical Journal.</cite></p> - -<p class='c009'><span class='sc'>Professor Robert Koch</span> has been invited by the Indian Government -to make another stay in India for the purpose of studying the epidemic -and endemic diseases of man and beast so prevalent there. Koch is now -engaged on work that will keep him in German East Africa for some time, -probably about a year, and does not think of leaving until he has concluded -it.</p> - -<div class='chapter'> - <span class='pageno' id='Page_124'>124</span> - <h2 class='c005'>Special Notices.</h2> -</div> - -<p class='c009'><span class='sc'>Rheumatoid Arthritis.</span>—Rheumatoid arthritis is a chronic progressive disease -with an almost hopeless prognosis as regards a complete cure. The most that can -be hoped for is to arrest its progress for a longer or shorter time, and to render the -patient’s life more tolerable by improving his health and relieving the pains in the -affected articulations. Galvanism, massage, baths, and an invigorating diet have -been found of more or less value, as well as the administration of cod-liver oil, -ferruginous preparations, and the iodides. A comparatively new remedy that seems to -have a promising future before it in the treatment of this disease is Lycetol. Judging -from the observations thus far published its use in rheumatoid arthritis is -capable of effecting considerable improvement. One of its distinct advantages is -that, owing to its pleasant taste and freedom from irritating effects, its administration -can be kept up for a long time, a point of great importance in the treatment of -chronic affections, in which remedies must be given for a prolonged period before -beneficial results can be expected. In two cases recently reported by Dr. Paul -Norwood (Times and Register, November 6, 1897), one being a very bad one of -chronic rheumatoid arthritis, the results were very encouraging. A slow but steady -improvement occurred in the second case, while in the first the patient provoked a -recurrence by discontinuing the treatment. In view of the obstinate character of the -affection and its resistance to the remedies heretofore in use, Lycetol should be certainly -considered an eligible remedy in these cases.</p> - -<p class='c009'><span class='sc'>Meeting of American Medical Publishers’ Association.</span>—The Fifth Annual -Meeting of the American Medical Publishers’ Association will be held in Denver, on Monday, -June 6, 1898 (the day preceding the meeting of the American Medical Association).</p> - -<p class='c004'>Editors and publishers, as well as every one interested in Medical Journalism, cordially -invited to attend and participate in the deliberations. Several very excellent -papers are already assured, but more are desired. In order to secure a place on the -program, contributors should send titles of their papers at once to the Secretary.</p> - -<div class='lg-container-r'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='sc'>Chas. Wood Fassett</span>, St. Joseph, Mo.</div> - </div> - </div> -</div> - -<p class='c009'><span class='sc'>Obstinate Constipation.</span>—I used Chionia, a teaspoonful three times a day and -at bed times, in a case of long standing obstinate constipation. The first three nights -I directed a hot water enema to be given every night. This treatment brought about -regular and spontaneous evacuations, and resulted in a complete cure.</p> - -<div class='c016'><span class='sc'>E. T. Bainbridge</span>, M. D.</div> -<div class='lg-container-l'> - <div class='linegroup'> - <div class='group'> - <div class='line'>Lickton, Tenn.</div> - </div> - </div> -</div> - -<p class='c009'><span class='sc'>The</span> phosphates of iron, soda, lime, and potash, dissolved in an excess of phosphoric -acid, is a valuable combination to prescribe in nervous exhaustion, general -debility, etc. Robinson’s Phosphoric Elixir is an elegant solution of these chemicals. -(See advertisement.)</p> - -<p class='c009'><b>LABOR SAVING</b>: The American Medical Publishers’ Association is prepared to -furnish carefully revised lists, set by the Mergenthaler Linotype Machine, as follows:</p> - -<p class='c004'><b>List No. 1</b> contains the name and address of all reputable advertisers in the -United States who use medical and pharmaceutical publications, including many new -customers just entering the field. In book form, 50 cents.</p> - -<p class='c004'><b>List No. 2</b> contains the address of all publications devoted to Medicine, Surgery, -Pharmacy, Microscopy, and allied sciences, throughout the United States and Canada, -revised and corrected to date. Price, $1.25 per dozen gummed sheets.</p> - -<p class='c004'>List No. 2 is furnished in gummed sheets, for use on your mailer, and will be -found a great convenience in sending out reprints and exchanges. If you do not -use a mailing machine, these lists can readily be cut apart and applied as quickly as -postage stamps, insuring accuracy in delivery and saving your office help valuable time.</p> - -<p class='c004'>These lists are furnished free of charge to members of the Association. Address -<span class='sc'>Charles Wood Fassett</span>, Secretary, cor. Sixth and Charles streets, St. Joseph, Mo.</p> - -<div class='pbb'> - <hr class='pb c007' /> -</div> -<div class='tnotes'> - -<div class='chapter'> - <h2 class='c005'>TRANSCRIBER’S NOTES</h2> -</div> - <ol class='ol_1 c003'> - <li>Silently corrected typographical errors and variations in spelling. - - </li> - <li>Anachronistic, non-standard, and uncertain spellings retained as printed. - - </li> - <li>Footnotes have been re-indexed using numbers. - </li> - </ol> - -</div> - - - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of The American Practitioner and News. -Vol. XXV. No. 3. Feb. 1, 1898, by H. A. 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