and approved for publication by the Committee
on Publication of the Council.
impossibility for it to empty itself except
by vomiting. The patient will complain of
dizziness after meals and the belching up
large quantities of gas. Physical exami-
nation will show emaciation, a sallow
skin, an enlarged abdomen and tender-
ness over the stomach and liver. The
bowels may be loose a few days and then
constipated and the patient expresses him-
self or herself as being: bilious. Many
nervous symptoms will arise.
The blood takes up the toxic products
formed in the stomach. The food will
sometimes remain in this organ several
days before it is vomited. When ejected,
it will be sour and will contain bacteria,
undigested food, lactic and butyric acids
and large quantities of gas.
Thirst causes these cases to drink large
amounts of liquids. More or less pain
accompanies these troubles. Pressure
against the pericardium may disturb the
heart's action while pressure on the dia-
phragm may be the cause of a hacking
cough. The pelvic organs may be also
displaced by the abdominal distention.
A feeling of lassitude from the im-
proper digestion will accompany these
chronic cases.
Diagnosis : The left side of the abdo-
men will protrude more than the right
side. The abdominal muscles will be
seen to be flabby and relaxed. The
patient will perhaps get along for several
days. Then he or she will vomit exces-
sive quantities of food, more in quantity
than has been taken in several meals.
The odor of the vomitus is characteristic.
398
GASTROPTOSIS-NEWARK.
Jour. M.S. M.S.
Fermentative changes in the food taken
will be noticed. Large amounts of gas
escape from time to time from the rectum
and by mouth.
By succussion we will hear fluids splash
in the stomach. By inflating the stomach
by means of bicarbonate of 5oda and tar-
taric acid the gastric area can be marked
out. A test-meal will show us the diges-
tive capacity of the stomach, the amount
of acids present, bacteria, etc. The gas-
tro-diaphane is a great aid to the stom-
ach specialist. The presence of the elec-
tric light in the stomach tells us the size
of this organ and its position, A tumor
in the anterior wall of the stomach will
show as a dark area.
If there is a pyloric stenosis, the body
of the stomach may be distended until if
feels like a hard tumor. In gastric ulcer
there will be more or less blood in the
vomit.
Treatment: This is the most import-
ant part of my subject. Hydro-therapy,
electro-therapy and dietetics are growing
in favor both among the laity and among
the medical profession. In gastroptosis,
with dilatation and prolapse, we must first
remove the inflammation and tenderness
before we can manipulate the .organ.
This can best be done by applying large
fomentations over the stomach. These
should be applied one-half hour after each
meal. The duration of each application
is twenty minutes. Unquestionably a dry
diet, as zwieback or toast, is best.
Each morning the stomach should be
washed out, using some antiseptic, as lis-
terine or soda-bicarbonate. The mouth
should be carefully washed and the teeth
kept clean and in good condition. All
food must be chewed thoroughly. This
not only prepares the food for digestion
but promotes the flow of saliva. My
practice after using the lavage tube a few
times is to give a test-meal. Withdraw
contents in one hour and make a chemi-
cal analysis to be sure in what way diges-
tion is altered. It is very important to
know what acids are secreted and what
foods are digested.
To tone up the muscles, order a cold
sponge bath mornings or a coki plunge
bath, if the patient is young and reacts
well. Occasional sweat baths are needed
to rid the system of toxic poisons. To
strengthen the abdominal muscles proper
breathing exercises should be taught.
Galvanism should be used once a day.
This is a valuable treatment to strengthen
the nerves and to control secretions.
These latter can be increased or decreased
at will. Place the positive pad (6 by 8
inches in size) over the stomach and the
negative over the middle dorsal vertebra.
Turn on from eight to ten milliamperes
for ten minutes. This will lessen the
secretions of fluid in the stomach.
Then use the Faradic current with elec-
trodes in the same position. Use as
strong a current as patient will bear for
ten minutes. On alternate days I use a
small electrode over the motor points of
the stomach and abdomen, making the
muscles contract vigorously. Proper
massage is also very useful in toning up
the muscles and increasing the peristaltic
action of the stomach.
Place the patient on his back on a hard
table, with legs flexed, hips elevated,
abdominal muscles relaxed. Stand on
the right side of your patient. Place the
right hand firmly on the left inguinal
region and have patient take full inspira-
tion. During expiration press firmly
backwards and upwards with the hand
and fingers in such a manner as to lift
the stomach to its normal position. Re-
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GASTROPTOSIS— NEWARK.
399
peat this process several times. General
friction and kneading should also be
given. For neurotic conditions nothing
will tone up the nerves as well as static
electricity. Give the static positive head
breeze twenty minutes daily in cases of
insomnia or where the patient is suffer-
ing from melancholy. Give the positive
spinal breeze with some sparks as a tonic
for the sympathetic system. Teach the
patient to be regular in his habits and to
look on the best side of life.
Drugs are of little benefit. Nux
vomica may be used as a nerve tonic, bis-
muth and charcoal to stop fermentation,
and aromatic cascara to keep the bowels
loose. These are about all the medicines
needed. A proper diet and the keeping
the stomach clean is a much more rational
treatment than to rely on pepsin and
cathartics. Children should be taught to
eat slowly and to chew the food thor-
oughly. We as physicians prescribe too
much and teach too little. In order to be
well one must have a good digestion.
We eat too much and too rapidly. If we
would have a stropg body, and a clear
mind, we must choose our food with care
and study the laws of m^istic^tion and
digestion. We must eat to live and not
live to eat. We must cultivate a cheerful
disposition. Laugh and grow fat is a
good axiom.
A physician must teach these principles
if he would cure chronic cases. Much
time and patience is needed. If a physi-
cian has not the time to properly treat this
class of cases, he should not assume
charge of them. Patients will have relief.
If the busy physician does not do them
justice, they will resort to patent medi-
cines and the various nostrums. Can we
blame them?
DISCUSSION.
H. O. Walker, Detroit: Gastroptosis, as has
already been stated by the writer, is of very
great frequency. At the same time he did not
take into consideration the possible ptosis of
the other organs and contents of the abdom-
inal cavity. An experience of opening the
abdominal cavity a great many times teaches
us that certain symptoms can be due to one or
the other of these conditions. I did not hear
the doctor mention anything about the much
vaunted support of the abdominal wall with
trusses. Gastroptosis and dilatation of the
stomach are somewhat different. You may
have a dilatation of the stomach without gas-
troptosis and you can have it with gastrop-
tosis. Symptoms arising from gastroptosis
such as an accumulation of food in the stom-
ach causing pyloric kinking with its accom-
panying fermentation, etc., are common evi-
dences of the difficulty. Patients, after they
get to bed and lie down, are able to relieve
themselves of the distressing symptoms, and
I know of a number of cases where the most
comfortable position they could get into was
lying on an inclined plane with the feet up, in
that way the stomach would become emptied
and relieved. In gastroptosis food may be
carried in the stomach for a long time. I
have known of instances where that was de-
termined from an examination of the content->
that had been eaten two weeks before.
The doctor made no mention of surgical
treatment of gastroptosis. The general treat-
ment, dietetic, etc., is all right and proper and
should be resorted to, but at the same time in
many of these cases you fail to relieve by any
such treatment. Then comes the time when
much can be done to relieve his condition.
Washing out the stomach is only a temporary
expedient, but does not cure. The mechanical
contrivance of a gastro-enterostomy will do
the work. 1 reported two years ago at Kansas
City, at the meeting of the Mississippi Valley
Medical Association, a number of cases that
I had operated upon by this method with very
good results. I call to mind one case that
I operated upon a while ago of a woman who
had been a victim twelve years to this trouble.
She was extremely emaciated and a confirmed
neuresthenic. She would gef along for sev-
eral days and do pretty well, and all of a sud-
den would vomit up a quart or more of foetid
material. Her physician who had her under
charge knew something of the work I was
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400
TYPHOID FEVER— WILSON.
Jour. M. S. M. S.
doing in this direction and had her see me.
We saw her together with a neurologist, and
after examining her there was no question
what this woman had. She had marked gas-
troptosis; we could easily distinguish the
splashing sound below the umbilicus. The
nicest way to determine gastroptosis is to in-
troduce a stomach tube and inject air through
it, when the outline of the stomach can be
readily determined. In comparison, it is bet-
ter than the electric light, which looks pretty
but it is not as accurate as you get it by the
distention with air; air will do it; you do not
need to use any chemical. This woman is
practically cured. I could relate a number of
cases that have been benefited by this surgical
procedure. You simply make a sewer from
the stomach into the small intestine and let
the contents out.
My gastro-enterostomies have been made by
the McGraw elastic ligature.
W. E. Bessey, Grand Rapids: In regard to
the remedy this gentleman spoke of and the
use of a remedy in dilatation of the stomach,
I wish to speak of one that is a tonic to in-
voluntary muscle fibres. It is valuable in all
cases of dilatation of the heart, stomach or
uterus because it tones up the sympithetic
nervous system (which gives tone to all the
functional organs) — I refer to the active prin-
ciple of Black Cohosh, or Cimicifuga Racc-
mosa — Cimicifugin — which — combined with
nux vomica — is a most wonderful permanent
tonic to the involuntary muscles. Ergot is
spasmodic in its action. This is a continuou^
tonic, (it is not spasmodic) It is also seda-
tive or calmative and removes the irritability
so often found present in weak conditions of
the hollow muscular organs. Those who have
not used it will be surprised at the good effect
it will have in all relaxed muscular organs. I
merely mention this incidentally, but do not
wish to take up any time discussing it at any
length. However, I may say that the active
principle in it is a gum; you cannot use an
extract such as Parke, Davis sometimes make.
unless it is an alcoholic extract, then it is all
right; if it is a watery extract it will not ex-
tract the gum, therefore the tincture or the
alcoholic extract is the only thing in which
you get the active principal cimifugin so that
it has any value whatever as a therapeutic
agent and then you have a remedy that is in-
valuable in just such a tonic relaxed and irri-
table conditions of the hollow muscular or-
gans.
LARYNGEAL COMPLICATIONS OF TYPHOID FEVER.*
W. L. WILSON,
St. Joseph, Michigan.
The title of this paper was suggested
to me by the difficulty I had in finding
any literature on the subject while I was
treating three cases of typhoid fever, fol-
lowed by laryngeal complications. These
three cases all occurred within a few
weeks of each other, although I had never
before, nor have I since, seen laryngeal
complications following in the wake of
typhoid fever.
Text books on the practice of medicine
and even works on laryngology bestow
♦Read before the Section on General Medicine
at the annual meeting of the Michigan State
Medical Society at Grand Rapids, May 27, 1904,
and approved for publication by the Committee
on Publication of the Council.
but a passing notice upon them, so that I
gained the impression that they were in-
frequent and unimportant. On looking
into the subject more fully, however, I
jRnd that the recognition of laryngeal
lesions complicating typhoid fever is not
of recent origin. Louis, in 1829, refers
to cases of this kind. Since that time
Keen has collected 207 cases of typhoid
affections of the larynx. More recently
DuPuy, of New Orleans, has made
extensive researches through the litera-
ture on this subject and reports 256
cases as the approximate number pub-
lished during the past ^f^ijg[ht,;]^'ears.
Digitized by '
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September, 1904.
TYPHOID FEVER— WILSON.
401
Surely this number of cases, of a com-
plication always grave and very fre-
quently fatal, proves that the laryngeal
affections of typhoid fever deserve more
than a passing notice. Statistics show
that from 11 to 26 per cent, of all fatal
complications are due to affections of the
larynx. There is a difference of opinion
as to the true nature of these affections
and their cause. The majority of obser-
vers are of the opinion that they are true
typhoid lesions, identical with those of
Peyer's patches, and that there is a true
metastasis of the poison to the lymphoid
tissue of the larynx; but since typhoid is
a polymorphous disease, showing a predi-
lection for lymphatic tissue wherever dis-
tributed, it may be possible to have a pri-
mary localization of the disease in the
adenoid deposits of the larynx. Sev-
eral cases of this kind have been reported.
While in most cases these affections are
caused by the Eberth bacillus and its
toxines, they may sometimes be of pyo-
genic or of streptococcic origin.
Dorsal decubitus is considered a pre-
disposing factor. The effect of gravity,
leading to venous stasis and softening of
tissues along the posterior wall of the
larynx, might result in abrasions of these
parts, thus permitting the entrance of in-
fecting organisms.
Pathologically, these affections may be
grouped into three varieties: (1), sub-
mucous laryngitis with involvement of
the deeper tissues; (2), ulcerative laryn-
gitis; (3) laryngeal perichondritis. Prac-
tically it is difficult to separate these
forms as one may overlap the other. Peri-
chondritis followed by necrosis of the
cartilages is the most frequent form of
laryngeal complication and the cricoid is
most frequently involved.
Ulcerations appear next in frequency
and may precede or follow the perichon-
dritis. These may be true typhoid lesions
or may be due to secondary infection by
any of the pyococci.
These ulcerations show a marked pre-
dilection for the posterior laryngeal sur-
faces and are most likely to be found in
the lymphoid deposits of the larynx, sit-
uated more especially at the base of the
arytenoids, posterior plate of the cricoid
and in the ventricular bands. Oedema
of the larynx may exist with either of the
above forms or may occur without any
involvement of the deeper parts. The
laryngeal invasion occurs in the most in-
sidious manner; a mild grade of inflam-
mation being followed by a stenosis which
means a struggle with death. The onset
is usually during convalescence but may
occur during the third week. The initial
symptoms are simply hoarseness, some
difficulty of breathing and possibly of
swallowing, and slight cough, and may
be attributed to the patient's weakened
condition until the supervention of dys-
pnoea awakens the mind of the attendant
to the gravity of the case.
In cases of perichonditis, where pus
has formed, there are of course in addi-
tion the symptoms of septic infection,
rapid pulse, chills, fever and sweats. In
the milder forms of inflammation, sprays
of soothing and astringent properties,
steam inhalations of menthol in tincture
benzoin compound, adrenalin chloride
and cocaine sprayed into the larynx, may
be sufficient, but when stenosis once sets
in, tracheotomy is the only resort. Intu-
bation is not practicable in the majority
of cases. The mortality in any event is
high in these cases, but the favorable re-
sults which follow operative interference
offer such a contrast to the high mortality
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402
TYPHOID FEVER— WII^ON.
Jour. M. S. M. S.
without operation, that there can be no
doubt of its propriety.
I will here give a brief outline of three
cases which have occurred in my own
practice. The iRrst case was that of a
young soldier twenty-three years of age
w^ho had been sick with malarial fever in
Cuba for three weeks before coming
home. Two weeks after his return, he
was stricken with a w^ell marked and very
severe attack of typhoid fever. The tem-
perature ran unusually high, there was a
profuse diarrhoea and the nervous symp-
toms were particularly marked. There
w^as active delirium, requiring restraint,
followed by low mutering delirium, car-
phologia and subsultus tendinum. During
the second week an extensive bronchitis
set in and continued throughout the
course of the fever. About the twenty-
eighth day there was a slight remission
but the temperature still kept quite high
and did not touch the normal point until
the thirty-eighth day. During the sev-
enth week he complained of sore throat
and hoarseness, but the bronchitis had
disappeared. Examination showed the
mucous membrane of the larynx inflamed
and swollen, and the vocal cords red-
dened. The soreness continued in spite
of sedative and astringent remedies and
was now accompanied by rapid pulse and
profuse sweats and increasing dyspncea.
As the dyspnoea grew worse, I called Dr.
B. in consultation. Examination showed
the larynx congested and some swelling
of the lateral walls above the glottis, but
the main obstruction appeared to be be-
neath the glottis. I lanced the swollen
parts ateve the glottis, but with no result.
We then concluded that tracheotomy was
the only resort, but upon returning to the
room we found that in our absence the
patient had coughed up some fcrtid pus
and seemed greatly relieved, so much so
that we decided not to operate at that
time. On visiting him next morning,
however, I found his breathing worse
again. The pus he had coughed up came
from the place I had scarified above the
glottis, while the main collection was be-
neath and beyond reach from above. On
again consulting with Dr. B. we con-
cluded to perform tracheotomy at once
and without giving any anaesthetic. The
patient struggled so hard however that
we found it impossible to do so and were
obliged to give him enough to quiet him.
Just as I cut into the trachea he ceased
breathing and all efforts to restore respi-
ration proved unavailing and he died on
the fifty-seventh day from the time of
taking to his bed.
On opening the larynx after his death
and cutting down through the perichon-
drium, there w^as a discharge of about a
teaspoonful of foetid pus, and the pos-
terior part of the cricoid was found to be
necrosed.
The second case was that of a street
railroad conductor, aged 30 years. The
fever in this case was also of a very sev^ere
type and the nervous symptoms were
very prontinent. During the whole
coure of the fever there w-as an extensive
bronchitis.
The temperature reached normal on the
twenty-eight day, but the cough still con-
tinued severe and he complained of sore
throat and hoarseness. During the next
two weeks he gained in strength, but the
sore throat still continued in spite of all
measures to relieve it.
Examination showed the walls of the
larynx and the ventricular bands inflamed
and swollen, and the vocal cords con-
gested.
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Septembbr, 1904.
TYPHOID FEVER— WILSON.
403
On the forty-second day I was called
by telephone saying that he was choking
to death. Before I reached him, how-
ever, he coughed up about a teaspoonful
of pus, so that when I arrived his breath-
ing had become easier, though still some-
what labored. He continued to cough up
pus for eight days and had profuse sweats,
and more or less inspiratory stridor, and
on the fifty-first day of his sickness he
died.
This was a case of abscess of the
larynx and his extreme emaciation and
weakness, together with the presence of
areas of consolidation at the apices of the
lungs and a tubercular history, incline me
to the belief it was of tubercular origin.
The third case was that of a young
lady twenty-two years of age, but was
not of such a severe nature as the others.
The temperature was not high, no diar-
rhoea, and no severe nervous symptoms,
and the fever reached normal on the
eighteenth day. On the twenty-fifth day,
however, I was summoned hastily, the
patient being reported as choking to death.
For two days previously she had com-
plained of sore throat and hoarseness. On
examination I saw it was a case of oedema
of the larynx. I applied a strong solution
of cocaine and scarified freely and in a
short time she was breathing easier. The
swelling gradually subsided under sprays
of cocaine and astringents and she after-
wards made an uneventful recovery.
This complication occurs more fre-
quently than perichondritis or abscess of
the larynx, but it is the only case I have
ever seen in an experience covering quite
a large number of cases of typhoid fever.
Study of Hemagglutinins and Hemolysins. —
Conclusions:
1. The employment of the constituents of the
blood corpuscles of one species of animals, laked
blood and stroma, for the injection of other
species of animals, results in the production of
definite specific bodies — ^lysin and agglutininomit.
2. In a strongly hemolytic serum, the rapid
solution of the corpuscles masks the appearance
of the agglutination, which may be demonstrated
in preparations kept on ice at 3° Centigrade, or
by the use of inactivated serum.
3. In an immune serum, capable of uniting in
high dilutions with the erythrocytes originally
employed, the lysis in these dilutions is frequently
absent, even though agglutination takes place,
owing to the lack of sufficient complement in
the diluted serum. The addition of excess of
complement, in the shape of fresh normal serum,
always avails to cause the solution of the cor-
puscles in the same dilutions in which they are
agglutinated.
4. Bordet's view that the stroma is responsible
for the lysis and Nolfs view that the stroma is
responsible for the agglutination and the laked
blood for the lysis, are both confirmed by the
demonstration of both agglutination and lysis
from the injection of both laked blood and
stroma.
5. Contrary to Van Dungern's view, the split-
ting up of the blood corpuscles by the use of
distilled water does not result in the destruc-
tion of the substances in the corpuscle producing
lysis and agglutination.
6. Finally, the phenomena of agglutination and
lysis cannot be separated from each other by the
injection of the constituents of the blood cor-
puscle; but these phenomena seem to be insep-
arably connected. (The Journal of Medical Re-
search, May, 1904, W. W. Ford and J. T. Hal-
SEY.)
The Dysentery Group of BaciHi.— There are
at least three distinct types of bacilli which
are factors in epidemic dysentery. Or we
might divide them into two groups:
1. The true Shiga group.
2. The group of mannite fermenters.
This latter group is divided into two types,
one fermenting mannite alone in peptone solu-
tion, and the other maltose and saccharose also.
When the agglutinating characteristics of these
bacilli and their susceptibility to immune sera
are studied carefully, we find that each of the
three types differs from the others. Here again
the mannite and maltose types, through their
stimulating in animals abundant common agglu-
tinins and immune bodies, seem more closely al-
lied to each other than to the Shiga type. (The
Jourml of Medical Research, May, 1904, W. H.
Park, K. R. Collins and M. E.-Goodwiji).
Digitized by VjOOQIC
-404
EDITORIAL.
Jour. M. S. M. S.
The Journal of the
Michigan State Medical Society
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