uraemia are cardiac. In ' fact the case becomes
largely cardiac in the later stages. The mere fact
that the general condition of the patient improves
after decapsulation does not establish the validity
of the operation. As factors of hygiene and rest
are invariably associated with surgical procedure,
it is possible that the resulting benefit may to
some extent accrue from those sources. The re-
sults of experimentation demonstrate that within
a period of three months and a half after de-
capsulation a new, and in most cases, a tougher
fibrous envelope has taken the place of the or-
iginal capsule. This fact may account for the
many relapses and deaths after a period in cases
operatea upon and in chronic cases, at least it
narrows the prospect of improvement to a period
of months. ā (N. Y, Medical Journal, June 4,
1904.)
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July, 1904.
PROGRESS OF MEDICAL SCIENCE.
323
SURGERY.
Under the charge of
MAX BALLIN.
Hepato-Cholangio-Enterostomy ā Hepato-
cholangio-Enterostomy is an operation Kehr per-
formed for the first time in a case of total oblit-
eration of the hepatic, common and cystic ducts,
where total retention of bile (gray stool-deep
icterus) threatened early death. The patient
was a woman 54 years old. In a former opera-
tion the gall bladder had been removed on ac-
count of inflammatory adhesions. No cancer
had been found, but all the ducts seemed to be
tightly imbedded in inflammatory adhesions.
Drainage of the gall-ducts was impossible, a
simple cholangio-stony-opening of biliary ducts
of the liver ā would have given a complete biliary
fistula, so Kehr excised an elliptical piece, 6:2
cent, from the lower edge of the liver, deepened
the hole with the themocautery, opening some of
the biliary ducts in this way and sutured the
whole liver wound into an incision (6 cent, long)
of the duodenum. After operation icterus dis-
appeared, stool became bile-colored, and patient
improved in weight. Kehr warns one not to em-
ploy this operation in obstruction of cancerous
nature, but only in the few rare cases of total
inflammatory obstruction of the gall ducts.
Trephining Under Local Anesthesia ā Heid-
enhain had very satisfactory results in two
cases of trephining, by the use of Braun's method
of local anesthesia. In both operations, a large
piece of the skull was resected, and the incision,
chiseling, etc., was entirely painless. Braun's
solution consists of:
Cocain, hydrochlor 05 gr. i.
Aq. destill 10 5iiss.
Add 1:1000 Adrenalin Solution.
Drops 15.
Fifteen drops of this solution, injected in the
subcutaneous tissue, is sufficient to anesthetize in
half an hour an area the size of a dollar. This
anesthesia will last for hours. Injection of the
solution right on the bone renders the bone and
the dura mater senseless in 30 to 45 minutes.
It seems that the addition of Adrenalin enables
one>to use more cocaine, without causing cocaine
intoxication.
Heidenhain thinks that even on the skull 2-2 ^^2
grains of cocaine can be used, combined with
Adrenalin, that is: 20 Cc. or 5 drachms of the
above solution. As a precaution against toxic
action of the cocaine, he keeps the patient in a
horizontal position, during the operation and for
one hour afterwards, and gives some strong
coffee with whiskey as an antidote. (Zentralblatt
fur Chirurgie, 1904, No. 9. L. Heidenhain.)
Operations in the Thoracic Cavity with the
Aid of Sauerbruch's Air-Chamber ā One of
the main dangers of an intra-pleural operation is
pneumo-thorax. Double-sized pneumo-thorax
is fatal. One-sided pneumo-thorax, if caused by
a very large opening of one pleural-cavities, is
also very dangerous, because it causes compres-
sion of the mediastinum, heart and the other
lung.
Pneumo-thorax is not so dangerous in em-
pyema operations, because the lung is already
compressed by the pus, but is very dangerous in
operations for abscess in the lungs (unless ad-
hesions exist between lung and pleura) and in
operations on pericardium and heart and on the
endothoracic part of the esophagus.
The atmospheric pressure in the pleural cav-
ity averages ā 7 Mm. Ilg. Two ways exist for
preventing collapsing of the lung in opening the
pleura :
First ā Causing over-pressure through the
trachea, so that the intra-bronchial pressure is
greater than the atmospheric pressure. Second ā
Exclusion of the atmospheric pressure from the
opened pleural cavity. In using this second
method, Sauerbruch constructed a large pneu-
matic cabinet, in which a constant negative pres-
sure is maintained, by means of a suction-pump.
In experimenting, the animal's head is outside of
the chamber, which closes air-tight around the
neck of the animal. The other part of the ani-
mal, the surgeon and assistants are inside the
chamber. The animal breathes under atmos-
pheric pressure, the opened pleura is under nega-
tive pressure. The result is that on opening the
pleura, the lungs do not collapse, but keep their
normal volume.
The first method was also tried in experiments.
The animal's head was brought into a chamber,
in which over-pressure existed, but the other
method seems to be preferable. Miculicz expects
a great future for endothoracic operations on
lungs, heart and esophagus through the aid of
these methods, which so far have been tried on
animals only. This same line of study is being
pursued in several of the large university clinics
of Germany and is given much space in recent
literature. (Deutsche Medinische Wochen-
shrift, Nos. 16 and 17. J. voNr Miculicz,)^
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yVJiOogle ā
324
PROGRESS OF MEDICAL SCIENCE. Jour. M. S. M. S.
GYNECOLOGY AND OBSTETRICS.
Under the charge of
B. K. SCHENCK.
Early Signs of .Pregnancy. ā Every ad-
dition to our means of diagnosticating pregnancy
during the early weeks, is welcome. Johnson
describes a sign which he has never found in any
condition other than pregnancy and cites cases
which, unsuspected by the patients, were differ-
entiated by it. This sign consists of an intermit-
tent hardening and softening of the portio-va-
ginalis, with often a change in color from a pale
violet to a pinKish hue. The changes in con-
sistency are apparent to the touch, while the al-
terations in the color may be observed by means
of a speculum.
The author points out that these signs are
probably the early manifestations of what are
subsequently recognized as the intermittent con-
tractions of the pregnant uterus and are prob-
ably due to the necessity for some change in the
uterine circulation, incident to the nourishment
and growth of the impregnated ovum, through
physiologic intermittent congestion of the gen-
erative system.ā (Jour. A. M. A., Feb. 20, 1904.)
Sepsis During the Pucrperium.ā In writing
of the frequency of puerperal sepsis one hundred
years ago, Horocks states that it was so common
that Nisbet defined pregnancy "as a certain in-
flammatory disposition of the body or nearly ap-
proaching it." Fever, following parturition, was
the rule and not the exception. Horocks divides
fever during the puerperium into the following
groups: (1) Puerperal fever or puerperal septi-
cemia of the worst and generally fatal type; (2)
puerperal sapremia, which is usually accompanied
by an offensive discharge and which is generally
recovered from; (3) puerperal pelvic cellulitis;
(4) puerperal pelvic peritonitis, non- fatal usually;
(5) puerperal pyemia, often a late stage of any
of the preceding, fatality deoendent on the viru-
lence of the infection; (6) phlegmasia dolens, now
believed by many to be due to sepsis; (7) milk
fever; inflammatory; often transient; probably
septic; non-fatal. ā (Br. Med. Jour., Feb. 13,
1904.)
Supra-Vaginal Amputation in Hysterectomy.
ā Despite the old saying that "figures never lie
but liars sometimes figure, ' statistics, especially
when collected from a large number of sources,
are worth something. Ilayd cites the collective
death rate of hysterectomy by the supra-vaginal
method as 5.67o, while that of panhysterectomy,
he says, is 9.6%. The work of individual opera-
tors is of course much better, in both these pro-
cedures, than these figures would indicate.
Among the advantages of the former method
are less post-operative suffering, shorter con-
valescence and less difficulty in operating. Hayd
believes that supra-vaginal amputation meets
nearly every indication as it can be applied to
every conceivable kind of tumor, regardless of
the length of the pedicle or the depth of exten-
sion into the pelvic tissues. It makes a clean
and ideal piece of surgery and is the operation of
choice, excepting in those cases where drainage
must be provided or where the cervix, for other
reasons, must be removed.ā (^m. Jour, Obs.,
January, 1904.)
Renal Decapsulation from the Standpoint
of the Pathologist.ā Van Cott and Murray
report the results of a series of experiments, un-
dertaken for the purpose of determining the ef-
fect of decapsulation upon normal kidneys and
the relation of collateral circulation on atrophy
of the kidney. Sixteen operations were done on
eight cats; in part, the capsule was stripped off
and the organ replaced; in others, the decapsul-
ated kidneys were implanted between the muscle
and the integument. As a secondary operation,
the vein alone, the artery alone, and the two to-
gether were ligated. The uniform result was a
positive injury to the normal kidney. The con-
clusions are: (1) on teleologic grounds, the
renal circulation can not be restored by decap-
sulation; (2) no amount of circulation would re-
store the covering of the cortex; (3) chronic
nephritis being a local expression of a general
disease, will yield only to such treatment as is
calculated to cure the general disease.ā (.1/rd.
Nezvs, May 21, 1904.)
Renal Re-decapsulation.ā Edeboh Is states
that after the capsule has been removed from a
kidney a new one forms, more vascular tlian the
original. He cites an instance in which he re-
moved this new formed capsule at a second opera-
tion, two years after a double decapsulation. The
patient was a male, aged 26, who suffered from
chronic Bright's disease. After the first opera-
tion there was little or no improvement. Two
years later the symptoms became more severe and
Edebohls repeated the double decapsulation. The
kidneys were found to be the same size as be:
fore, but were distinctly less dense and less fri-
able. The capsules stripped off readily. The
operation was done as a last resort, the patient
being in an uremic condition. Death resulted in
five hours.ā (Med. Record, May^l, 1904.>
Digitized by VjOOQIC
July, 1904. PROGRESS OF MEDICAL SCIENCE. 325
PHARMACOLOGY AND THERAPEUTICS.
Under the charge of
W. J. WILSON, JR.
Organo-thcrapy in Pancreatic Disease. ā As their use when the soporific eflFect is preceded by
the result of experimentation carried on to test a stage of stimulation. In the cardiac form, he
the value of organo-therapy in pancreatic disease, has used with success H grain doses of powdered
Cilaessner and Sigel come to the following con- digitalis combined with l-25th grain of morphine
elusions: hydrochlorate. In the intestinal form, he uses
Threoidin has an unfavorable influence upon sulphonal in divided doses, beginning with a 4
the symptoms of pancreatic disease. grain dose in the early afternoon and repeating
Pancreon has a slight influence on nitrogen ab- two or three times throughout its course. No
sorption and no influence on fat absorption. matter whether large doses have been tried, and
The influence of pancreatin on both was plain, found useless, one will often be agreeably sur-
nitrogen absorption arising from 52.2% to 56.7%, prised with the effect of these drugs in the small
fat absorption arising from 40.9% to 68.5%. doses advised. ā (Berl. Klin. Woch., March 14,
Much more evident was the favorable influence 1904.)
when besides pancreon or pancreatin large doses Atropine Poisoning.*-Stalberg describes
of sodium bicarbonate were employed With the ^ ^^^^^^ ^^^^ .^ ^^^ following words: Upon ar-
former nitrogen absorption increasing from 54.5% ā¢ , t r j *t. *ā¢ * w t s.
^ , , . Ā« J^ , ā¢, ā¢ , rival, I found the patient on his feet; at times at-
to 58%, fat absorption 43.7% to 58.7%, while with ^ ' ā¢ * ā¦ 4U *. *u
, , * , . . r ^nf tempting to stagger across the room; at others
the latter the nitrogen increase was from 53.1% .. , *i.- ir xut.j
r , Ā«, Ā«/ stooping and supporting himself on the bed post,
to 62Vc. fat absorpfon from 37.9% to 69.8% ^^.^ ^^^^ ^^^^ ^.^^ ^^jj,.^ā^ ^^^ ^^^^.^^^ ^^^ ^j,^
The employment of alkali alone has only a ^^^.^^ ^^^^^^ ^^ ^^^^.^ ^^^^^^ ^^^ ^^^^ ^.^^
slight favorable mfluence. A^^j^^j^ ^^^ ^^^^^ ^^^^ somewhat an expression ol
Pancreatin and sodium bicarbonate had shown ^ 'i-i. /ā¢ ^.i j t.
. ,; . . , , .. , terror. Ihe fingers were restless, and he was
.tĀ«lf the best of the combmed preparations- ,āātiāā3ā buttoning and unbuttoning the vest,
(Berl. Kl,n. Woch.. April 25, 1904.) suspenders, etc. He several times bent under
Pneumonia in Children. ā Place the child the bed as if in search of something. He was
in a room having fresh air, and admit all the semi-delirious, and chattered continually and in-
sunlight possible. The temperature of the room coherently. Several times he exclaimed: "Let
should be 68Ā° to 72Ā° f. There are three methods ol me bark ; I want to bark." His voice was husky,
eliminating toxins ā ^bowel, skin, and kidneys. He and his mouth, tongue and pharynx parched. He
used tincture aconite one drop with spirits of had a constant desire to micturate and passed a
raindercrus one-half drachm, at intervals of one quantity of urine every few seconds. The tem-
hour until diaphoresis sets in, also hot mustard perature was normal; pulse, 120. The patellar
foot bath. If fever persists, sponge surface with reflexes were exaggerated. Morphine and pilo*
alcohol and tepid water every half hour. With carpine muriate were used as antidotes. ā (Jour-
temperature of 105Ā°, watch for nervous symptoms, nal Med. Sc, March^ 1904.)
Combat fever at this stage with cold bath at p^r acute bronchitis, in the dry stage, use
temperature of 70-80Ā°. Take good care of . ac- g^^ ^^jjj^^ ^^^p ^ 5j^^
tion of bowels. Food and water should be given g^^. jp^^.^^. ^q ^^'
in sufficient quantity, and the child should be al- q ^-j^i^ amomi 20 3v
lowed to rest as much as possible.ā Fischer, AT. Syrupi q s ad 60 ?ii
Y. Med. Rec., April 23, 1904.) ^q sinnamomi. ' '
Insomnia.ā Feilchenheld divides insomnia m. Sig. Teaspoonful every 2 or 4 hours. For
into three forms, the cerebral or neurasthenic an adult, if the cough is painful, add Codeinae
cardiac in which there is functional or organic Sulph. gr. 2 to 4.
heart disease, especially transient dilatation of the ^^ ^^^ j^^^^ ^ ^^^
heart, and intestinal, dependent upon gastro-in- ā¢ v, ā¢ , Ā« *
. , -, . t . L .1. ir ^- r ā¢ā Ammonii chloride 2 Sss.
testinal trouble in which the formation of gas is g^^.. -^^j^j 2 3ss
one of the chief symptoms. In treatment, he g^^. Sarsaparilia*'compV.V.V.60 Jij'.
considers hygienic and hydrotherapeutic measures j^.j gig. Teaspoonful 3 times a day.
of first importance. He advises the uses of very 1
small doses of narcotics, and mentions morphine, *Note the unusual symptoms, frequent mictu-
codeine and sulphonal in particular, interdicting ration and normal temperature. ^
Digitized by LjOOQIC
326
PROGRESS OF MEDICAL SCIENCE.
Jour. M. S. M. S.
DERMATOLOGY AND SYPHILIS.
Under the charge of
A. p. BIDDLE.
A Diagnostic Syndrome For Intra-Cranial
Ssrphilis. ā In a paper read before the Hudson
County (New Jersey) Medical Society, Dr.
Wm. B. Pritchard, New York, states that in
nervous and mental diseases syphilis is of pre-
eminent interest, the most prolific single cause
of disease of the cerebro-spinal system, by in-
ducing underlying structural changes with
varied and widespread clinical manifestations.
Given a patient between the ages of 25 and
45, affected with any form of intracranial
paralysis, which was preceded by headaches,
of nocturnal onset pr exacerbation, associated
with vertigo and with insomnia, the insomnia
occurring during the first half of the night,
the paralysis developing during sleep, both
heauache and insomnia disappearing upon the
onset of the paralysis; the cause is syphilis.
Beyond forty-five or fifty, retrograde tissue
changes are beginning, especially arterial de-
generation, the cerebral symptoms resulting
therefrom resembling more closely those of
syphilis.
Some disturbance of sleep is almost invari-
ably present during the developmental period
of intercranial syphilis; the younger the pa-
tient, the greater the tendency to insomnia;
the older the more marked the morbid soqi-
nolence.
The tendency of syphilitic paralysis to de-
velop during sleep is explained by the fact
that the lesion usually being an obstructive
-enaarteritis, the tendency to occlusion from
thrombus or otherwise is greatest during sleep,
the heart's action being less, dynamically, and
the vis a tergo greatly reduced.
There are other presumably familiar sisrns
by which we are assisted in recognizing a
svohilitic origin for intracranial palsies. Chief
of these signs is the fact of an erratic, some-
times a bizarre, distribution in the paralysis,
due to the fact that, as a rule, there are more
lesions than one. Fuaracious preliminary palsies
or paraesthesiae, coming and going for days
or weeks before a final culmination, are also
highly suggestive. A well-known selective af-
finity on the part of syphilis for certain regions
and tissues can also be utilized with advantage.
The ocular muscles, and esnecially those sup-
plied by the third nerve, are so prone_ to
svphilftic attack that a ptosis or strabismus.
occurrinfiT suddenly in an adult, especially if
preceded by headaches and insomnia, may be
put down at once and quite safely as due to
this cause. Localized tremors in the regions
subsequentlv to be paralyzed are quite often
observed. Finally, a general malaise with men-
tal inertia, and sometimes a cachectic appear-
ance, not explained by any condition of the
"kidney, liver, or other viscera, are of some
significance in association with others of the
symptoms mentioned. ā Medical Record, May
14, 1904.
Alopegia Areata and Diseased Teeth. ā ^To
bring under discussion Jacquet's theory as to
the casual relation between nervous irritation
and alopecia areata, Dr. Mewborn, New York,
presented before a recent meeting of the New
York Dermatological Society a young woman
of a slender, nervous type, a stenographer by
occupation, who presented nothing special in
her previous history except that she has al-
ways sunered a great deal from toothache. In
November last she had an abscess develop in
the right upper molar, for which the tooth was
removed. She wears a gold crown on the left
upper bicuspid and the left upper molar was
badly decayed and caused much pain. The
lower teeth have numerous fillings. She had
been under a severe mental strain in prepar-
ing for a civil service examination and had
worried considerably over the loss of a situa-
tion. About two months ago her mother drew
her attention to a spot of alopecia over the
left ear. Upon examining her head she found
a corresponding patch over the right ear.
There had been no burning or other sensations
in the scalp previously. Upon examining the
scalp a patch about one inch in diameter was
found at the nape of the neck and another
very small one at the vertex in addition to the
other two mentioned.
Dr. Jackson said that if there were any
casual relations between diseased teeth and
alopecia areata, it was strange that alopecia
was not more common considering the num-
ber of individuals having bad teeth.
Dr. Bronson said that since Jacquet's the-
ories were first announced he had carefully ex-
amined the teeth in every case of alopecia
areata with result, as it happens, of finding
that in most of the cases the teeth were more
or less affected. In one very extensive case,
the teeth were in a particularly bad condition.
After a dentist had attended to them, the hair
in the course of a few months was restored;
but a year or so later, the teeth remaining in
fairly good condition, the alopecia recurred.
He' was not yet convinced of the correctness
of Jacquet's etiology though he believed it en-
titled to further consideration.
Dr. Mewborn, closing the discussion, said
that while the evidence as to the connection
between diseased teeth, and other causes of
severe irritation to branches of the cranial
and cervical nerves, with alopecia areata was
not convincing; nevertheless, it was gaining
ground. The experiments of Jacquet and oth-
ers in efforts at producing alopecia areata by
inoculations, made from the scrapings of alo-
pecia, had been uniformly negative. These
experiments have all the more weight from
the fact that some of the inoculations were
made upon Jacquet himself, who must at least
be considered susceptible, he having previously
suffered from an alopecia areata of the beard.
ā (Reported in the Journal of Cutaneous Dis-
eases, June, 1904.) ( ^ r\r-\nl^
Digitized by VjOOQIC
The Journal of the
Michigan State Medical Society
PUBUSHED UNDER THE DIRECTION OP THE COUNQL
Vol. Ill
DETROIT, MICHIGAN, AUGUST, 1904
No. 8
Original Hrticlee
TREATMENT OF THE INTESTINAL FISTULAS BY THE
ELASTIC LIGATURE.*
THEODORE A. McGRAW,
Detroit
I wish in this paper to discuss the
treatment of the severer grades of false
anus and intestinal fistula. That many
cases of fistula will close spontaneously,
or with comparatively slight operations,
is known to every surgeon, but there are
Others frequently met with in which the
repair of the injured bowel pan be accom-
plished only by methods which are the
most difficult and dangerous of all sur-
gery. To meet these cases successfully,
we must have a clear understanding of
the pathological conditions with which
they are associated.
Destructive ulcerations or gangrenous
inflammations of the bowel arise from
many causes; the most common are ob-
structions, from constrictions, volvu-
lus or other causes, suppurative appendi-
citis, tubercular deposits, typhoid ulcera-
tions and injuries of the abdomen. What-
ever the primary cause, the resultant
pathological conditions, due to the
*Read before the Section on Surgery at the
annual meeting of the Michigan State Medical
Society, Grand Rapids, May 25, 1904, and ap-
proved for publication by the Committee on Publi-
cation of the Council.
severe inflammations that accompany all
insults to the peritoneal cavity of a septic
nature, are similar, and, indeed, if we
except the tubercular cases, nearly iden-
tical. Septic infection, which appears
early in all cases, is the determining fac-
tor. It follows, of necessity, upon the
constriction, suppuration or ulceration
which has destroyed a portion of the
bowel. The greater or less severity of
this infection will depend upon the de-
fences which retard or hinder its spread
on the peritoneum. Thus, the gangrene
due to an incarcerated hernia will cause
less damage than one caused by an inter-
nal constriction ā the march of the infec-
tion being retarded by the constriction,
which shuts the affected coil off from the
abdominal cavity.
So, too, the ulceration and abscess due
to appendicitis may be walled in by a bar-
rier of organized lymph, or on the other
hand, that failing to take place, may from
the very beginning infect the whole peri-
toneal cavity.
As a rule, those cases which from the
beginning are accompanied. Ixy a gene^ '^
Digitized by LjOOQIC
328 TREATMENT OF INTESTINAL FISTULAā McGR AW. Jour. M. S. M. S.
infection, die early, and only those sur-
vive for further surgery in which the
general infection has been delayed or
altogether prevented. Even when the
diseased coil has been walled in and
separated from the general peritoneal
cavity, there is a certain slow process of
infection which creeps up the coil and
causes inflammation of the gut above.
This is due, in part, to the interference
in the circulation of the blood in the
affected area and partly to the spread of
the disease by the continuity of structure.
The wall of new structure may protect
the peritoneal surface but can not prevent
the spread of infection on the mucous
surface or in the tissues which lie between