J. M. (James Mitchell) Foster.

The Chicago medical journal and examiner online

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method, which was used with delight by
the child, and much to the relief of the
parents. It continued to work successfully
under my observation as long as the tube
was worn.

Regarding the exact position ; the angle
has varied in different cases, but from 45^
to 90^ seems necessary to obtain the best
results. The child is held on its back in
the arms of the nurse, the legs elevated,
and the head left to hang over the arm.
Then it may take the mouth of the feed-
ing-bottle, suck through a tube from a
glass or feed from a spoon. The only
difficulty is encountered when the child is
again placed in the upright position, which
posture it must not be permitted to regain
until it has been made to swallow three or
four times after the vessel of liquid has



been taken from its mouth, in order to
swallow all the fluid which has gravitated
into the pharynx and naso-pharynx. After
they have learned this they will readily
swallow several times, so as to force the
liquid remaining in the throat into the
stomach before the upright position is
again taken, and then there is no trouble.
The patient can be inclined without incon-
venience for a minute or more, although
much less than this only is necessary.

There is no danger of the tube slipping
out unless one of too small size has been
inserted, when it would become a fortunate
accident, permitting the selection of a
proper size for re-introduction.

70 MoMBOB Strbbt.



EDITORIAL.



SURGERY OF THE BRAIN.

With the long-established operation of
trephining in cases of injury to the brain,
and the recent advances in thoracic and
abdominal surgery, it seemed as if the
fields open to surgery had been about all
cultivated, but with the report of Macewen,
made at the last meeting of the British
Medical Association in Glasgow, in August,
and the more recent report in the Congress
of Physicians and Surgeons in Washington,
last month, of the work of Mills and Weir
and Horsley and others, it seems estab-
lished that it is no longer necessary to
stop with trephining the skull; that the
brain itself may now be invaded in some
cases not only with safety, but with
surprising advantage. Whether the lovers
of notoriety will be as reckless hereafter
in brain surgery as they seem to have be-
come in abdominal surgery remains to be
seen. With some, evident desire for noto-
riety seems so irresistible that in all proba-
bility the near future must witness the
passage beyond a line of safety into the
wide domain of uncertainty and risk, and
sometimes to the detriment of the pa-
tient. . ^^^f^
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THE MEDICAL JOURNAL AND EXAMINER.



If laparotomy, to verify diagnosis, be
justifiable, will not some reckless or inju-
dicious diagnostician want to verify a diag-
nbsis of compression of the brain, and feel
more free to trephine the skull, only to
find that his supposed case of compression
proved to be but the stupefaction pro-
duced by alcohol ? It seems to be as dif-
ficult as ever to avoid excessive conserva-
tism on the one hand and reckless surgery
on the other. Now that prudent surgeons
have shown that surgery may advance
somewhat beyond what were supposed to
be its limits of safety, the doors have been
opened for the imprudent ones. How
soon shall the reports of the first victims be
looked for? Scylla may be avoided, but
let not Charybdis claim the escaped as
victims.



THE OUTBREAK OF YELLOW •
FEVER.

The outbreak of yellow fever in Florida
has yet given but little indication of abate-
ment. The lateness of the season, at its
beginning, gave some hope that the reap-
pearance of the disease might not be at-
tended by such distress as characterized
its occurrence on some former occasions,
but that hope has not been realized, and
the suffering, distress and demoralization
have been great. Whilst there has been
no general epidemic of it, yet the disease
has not been confined even to the State of
Florida.

Aside from the fatality and the suffering
which have resulted from the disease, and
the monetary loss which attends the inter-
ruption of commerce, three important facts
have been made apparent by the recur-
rence of the disease this season: First,
that the unsanitary conditions of many
parts of our Southern States remain as in
former years, notwithstanding the great
advance in sanitary science in the last few
years, and that those conditions, when ac-
companied by high thermometric and low
barometric states, are favorable for the



spread of the disease. Second, fhat so far
the National quarantine laws have betn
inadequate, and have failed to prevent the
importation of infected persons or prop-
erty. Third, that notwithstanding the lib-
eral provision made by the Government
for investigation regarding the cause of the
disease, no practical results of value have
been attained, and that our ideas of its
pathology and therapeutics are little, if
any, in advance of what they were a quar-
ter of a century ago.

If the disaster of this year should result
in securing better sanitation in future in
the Gulf States, and greater security for
the inhabitants of them, the lesson of this
year, calamitous as it has been, will not be
without some compensating aspect, and
some basis for hope for future immunity.



THE CONGRESS OF AMERICAN
PHYSICIANS AND SURGEONS.

The first of what is contemplated as a
triennial congress of physicians and sur-
geons, to \\t, held in Washington, occurred
in that city on September 17, 18, and 19.
In accordance with the announcement
previously made, the congress was com-
posed of most of the National societies of
the various special departments of the
medical profession, which held separate
sessions of those societies during the day,
and met in general congress during the
evening. The attendance, whilst not very
large, was fairly representative of the better
element of the medical profession of our
country, and a number of prominent phy-
sicians and surgeons from Europe were
present, and participated in the work of
the congress, and of the various socieiies.

The scientific work, whilst it was not all
of equal merit, was, both in the congress
and in the societies, of such a character
as to be a fair index of the most advanced
ideas of medical and surgical science of
the day.

So many societies being in session at the
same time made it an exceptionally diffi-
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cult occasion for securing accurate re-
ports of the work done in the different
societies, but from the report of the repre-
sentative of the Journal and Examiner^
and from those of some of the weekly
journals, we are enabled to give in this
issue an epitome of the work of the con-
gress, and of societies composing the con-
gress, and the by-laws which are to govern
the next congress.

Whilst this one adds one more to the
multiplicity of medical organizations in
this country, it will have an advantage
over all of the others in the fact that it is
to occur but once in three years. If some
of tTie other organizations should not call
their members together more frequently
than every three years, it might prove a
boon to the medical profession, even if
there should prove to be fewer offices to
be sought.



SOCIETY REPORTS.



CONGRESS OF AMERICAN PHY-
SICIANS AND SURGEONS.

First Day— Morning Session.

The First Tri-ennial Meeting. Held in
Washington, D. C, on September 18,
19, and 20.

The meeting for organization and to
receive the report of the Executive Com-
mittee was held on September 18.

It was called to order by Professor Wil-
liam Pepper, of Philadelphia, as Chairman
of the Executive Committee, who made a
report of the work of that committee.

Dr. John S. Billings, of the United
States Army, President of the Congress,
then took the chair and responded in a
brief address.

Dr. Samuel C. Busey, of Washington,
Chairman of the Committee of Arrange-
ments, welcomed the Congress, and dwelt
upon the advantages which that ciiy offers
as a place of meeting for scientific socie-
ties.

The following are the by-laws adopted :



1. This organization shall be known as
the Congress of American Physicians and
Surgeons.

2. It shall be composed of national as-
sociations for the promotion of medical
and allied sciences.

3. It shall hold its sessions tri-ennially
in the city of Washington, D. C.

4. The officers of the Congress shall be
a president, vice-president, a secretary, a
treasurer, and an executive committee.

5. The president shall be elected by the
executive committee, of which be shall ex
officio be a member. He shall preside at
the sessions of the Congress. He shall
deliver an address.

6. The presidents of the participating
societies shall be ex-officio the vice-pres-
idents of the Congress.

7. The secretary and treasurer shall be
elected by the executive committee. They
shall be ex-officio members of the executive
committee.

8. The executive committee shall be
composed of one member from each par-
ticipating society; and said member shall
be elected by the various societies at the
next annual meeting subsequent to the
Congress. It shall be charged with all
duties pertainingto the organization of and
preparation for the ensuing Congress, in-
cluding the election of all officers, and of a
committee of arrangements. It shall super-
intend the publication of the transactions
of the Congress.

9. The expenses of the Congress shall be
divided between the participating societies
in proportion to their membership.

10. The admission of new associations
to participation in the Congress shall be
by unanimous vote of the executive com-
mittee.

First Day — Evening Session.

Professor Reginald H. Fitz, of Boston,
read a paper on " The Treatment of Intes-
tinal Obstruction," followed by one on the
same subject by Professor N. Senn, of
Milwaukee.



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THE MEDICAL JOURNAL AND EXAMINER.



The subject of this paper was the diag-
nosis and medical treatment of the acute
internal, mechanical varieties of intestinal
obstruction. The only causes recognized
were strangulation from adhesions, vitelline
remains, peritoneal slits, pockets, and
rings; intussusception, twists and knots,
abnormal contents, strictures, and tumors.
The evidence presented resulted from an
analysis of 295 cases collected from medical
literature since 1880.

Professor Senn first directed attention
to irrigation of the stomach as practiced
by Kussmaul. He said the mechanical
effects of such a measure were limited to
he segment of intestine below the ileo-
caecal valve. Experiment and clinical ex-
perience united in demonstrating the fact
that the ileo-caecal valve is impermeable to
fluids. Why should we use fluid in at-
tempting the mechanical correction of a
mechanical cause below or above the ileo-
caecal valve ? Again, all efforts at over-
coming the ileo-caecal valve by rectal injec-
tions result in serious injury to the dis-
tended colon. Why, said he, should we
not for diagnostic, and more particularly
for therapeutic, purposes, resort to the
lightest, the most compressible, substance
known — hydrogen gas, perfectly harmless,
non-toxic, non-irritant ? Experiment has
shown by means of a manometer that a
pressure of one-fourth of a pound to two
pounds to the square inch is adequate to
force hydrogen gas from anus to mouth;
consequently the alimentary canal is per-
meable to hydrogen inflations. This means
of investigation would show that it re-
quires a pressure of from eight to twelve
pounds to produce a palpable injury to
any of the coats of the intestines; but
when fluids are forced beyond the
ileo-caecal valve the surgeon invariably
finds on post-mortem examination longi-
tudinal rents in the serous coat. When
the hydrogen gas is forced from anus to
mouth no tangible injury has been pro-
duced anywhere.

Enterotomy, so frequently practiced in



the past, he hoped had become obsolete.
He meant Nelaton's operation. It is
true, distinguished surgeons of to-day favor
enterotomy in cases of acute intestinal
obstruction in all instances where they are
unable to ascertain the seat and character
of the obstruction. They believe that, for
the time being, an outlet for the accumula-
ting intestinal contents places the intestinal
canal in a favorable condition for subse-
quent radical measures.

Colotomy is indicated in all cases of in-
testinal obstruction below the ileo-caecal
region, where the obstruction has been
caused by conditions beyond radical meas-
ures, or the general condition of the patient
does not warrant the most serious opera-
tion of abdominal section.

Lumbar colotomy is an obsolete opera-
tion — in fact, scarcely any surgeon will at-
tempt to make an extra peritoneal colotomy,
in these days of safe abdominal operations.
In cases, for instance, of cicatricial contrac-
tion, of harmless obstruction, unattended
by indications of gangrene or perforation,
the surgeon can safely make the obstruc-
tion harmless, and at the same time more
efficient by resorting to enterostomy. In-
stead of spending an hour or an hour and
a half in the process of suturing, as prac-
ticed in Europe, the surgeon can by a
simple device unite the bowel above and
below the seat of obstruction by approxima-
tion with perforated decalcified bone plates,
more especially in cases of inoperable
obstruction, where carcinoma and sarcoma
have gone beyond their legitimate field and
beyond the surgeon's reach.

DISCUSSION.

The President called upon Professor
William Pepper, of Philadelphia, to open
the discussion, but he declined in favor of
Mr. Arthur Edward Durham, of London,
England.

Mr. Durham said he desired, at the out-
set, to express the pleasure he felt in coming
here amongst his American confreres and
meeting with such a cordial reception.



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The subject of intestinal obstruction was
not altogether strange to him. There is
no class of cases more dangerous, more
serious, and which more urgently call for
prompt, skillful, surgical treatment than
cases of intestinal obstruction. He could
most cordially agree with Dr. Senn that a
surgical operation should be performed as
soon as the diagnosis was made; but it was
exceedingly difficult to make a diagnosis in
such cases. In fact, he knew of no class
of cases in which the diagnosis was more
difficult, and he would venture to go a step
farther, and say he had seen cases from
time to time in which the surgeon was
justified in operating before the diagnosis
was made — in other words, to operate
in order to establish an accurate diagnosis.
The difficulty lies in knowing what the
cause of the obstruction is, and locating
its seat.

With regard to Ihe observations made by
Dr. Senn, and his suggestions as to treat-
ment, he came to America to learn and con-
fessed that he had learned a great deal in
many places, and in many ways. Insufflation
with hydrogen gas was something new to
him. He would like, therefore, to ask Dr.
Senn what would happen in case the patient
was blown up. He supposed Dr. Senn
would call it a case of *' blow up" then. He
could not see why hydrogen gas on account
of its particular lightness should be better
for insufflation than ordinary air. This he
had yet to learn.

Turning to the treatment. The first thing
is to determine, if possible, the seat of the
obstruction. In cases of acute intestinal
obstruction in which it is evident, or which
we have reason to believe, that the obstruc-
tion exists in the small intestine, he believes
the proper treatment to pursue, when the
symptoms are severe and urgent, even
though an absolute diagnosis is not made, is
to open the abdomen, search for the cause,
and relieve it as best we can. On the other
hand, when the indications are that the ob-
struction is in the large rather than in the
small intestine, there is not the same degree



of urgency, at any rate in a very large pro-
portion of cases, and the procedure to be
adopted must depend upon the seat and
cause of the obstruction. In this connec-
tion he would venture without the slightest
degree of hesitation to take issue with Dr»
Senn. He (Senn) stated that lumbar col-
otomy is an obsolete operation. Now, he
would beg to say it is not obsolete ; it is an
operation that is performed constantly day
by day in Europe. He would endeavor tc^
do the operation in any case in which he
had oc«:asion to do so. He had dealt with
cases in which he had not done the op-
eration, and for which he had a lasting re-
gret that lie did not do so ; therefore, he
would unhesitatingly say that the operation
of lumbar colotomy is not obsolete. Had
time permitted he could quote any number
of cases in which after its performance the
intestinal obstruction had been relieved, the
colotomy wound healed, the patient gone
about and doing well.

Dr. William Miller Ord, of London^
England, said he supposed he had been
called upon as a physician to express the
general inadequacy of that part of the pro-
fession to deal with the subject under con-
sideration, for it usually fell to the lot of
the surgeon rather than that of the physi-
cian to deal with such cases. The physician
is called early in the case ; and in looking
back over a good number of cases of intes-
tinal obstruction the function of the physi-
cian mainly ceased when he has come to
the conclusion that the case on the one
hand is what has been called by our Amer-
ican confrere (Senn) "dynamic" or mechan-
ical obstruction. . He thought there was a
good deal of difficulty attending the diag-
nosis, so much so that in some instances
there is absence of indication of local pain^
offever, or of anything like bloody discharge
from the bowel, that one hesitates as to the
decision. Perhaps the members of the Con-
gress would think him a little wanting in
self-reliance if he should adopt the views
of the first speaker (Fitz), rather than those
of the second (Senn) and Mr. Durham,



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TFIE MEDICAL JOURNAL AND EXAMINER.



and claim a little time. He thought phy-
sicians had seen a good many cases of in-
testinal obstruction in which there had
been either the simple absence of the passage
of the faeces, or there had been a good deal
of pain and vomiting, where everything
pointed strongly to intestinal obstruction,
yet where no tumor nor any amount of ten-
derness could guide one as to the exact lo-
cality of the obstruction ; that in some cases
the use of opium or other narcotic, or the
use of injections, had been followed by
complete relief. He had been present on
several occasions when a man had been
examined over night with an obstruction,
where the physician could find no definite
sign of any local obstruction, and where he
had arranged with the surgeon and his as-
sistants to come the next morning to ope-
rate, and where either from the influence
of narcotics or injections, shortly before the
operation was to be performed, nature had
given relief. He would agree with all the
speakers that when there was satisfactory
evidence that a mechanical obstruction ex-
isted, sooner or later the case must go into
the hands of the surgeon, and the delay
should be only a reasonably short one.

Professor Annandale, of Edinburgh,
Scotland, regretted to say that he had only
heard part of the papers and discussion,
and was therefore unable to deal with the
subject in a methodical way.

In the treatment of intestinal obstruction
it was very important to divide the cases
into two classes, acute and chronic. With
reference to acute cases, he thought it was
perfectly right that everything that medi-
cine could do should be tried, but not tried
too long. As soon as it had been fairly
tried, say forty-eight hours, and the symp-
toms are urgent, then he would say the
case belongs to the surgeon, and the sooner
he opens the abdomen the better.

In regard to chronic cases, he thought the
surgeon might wait until the symptoms had
become acute, then operate at once.

He had listened attentively to what Mr.
Durham had said regarding lumbar colot-



omy. His experience with that operation
had been such, and more particularly in
cases of cancer of the rectum, that he pre-
ferred inguinal colotomy. He meant by
this the performance of colotomy in the left
inguinal region, because he had found it
was not a more serious surgical procedure
as regards risk, and was certainly more
simple in a large majority of cases.

Professor Fitz had nothing new to add
in closing his part of the discussion.

Professor Senn said that all would agree
with him in studying English medical lite-
rature, text- books, and hospital reports, that
English surgeons were exceedingly con-
servative. The time had long gone by
when any theory or method of operation
should be accepted as final, safe, and appli-
cable, unless it had been thoroughly tried.

He could assure our distinguished guest
(Mr. Durham) that hydrogen gas when in-
jected into the intestinal canal never forms
explosive compounds ; that atmospheric air
is never present in the inttstinal canal ;
that the procedure has been tried more
than a hundred times, and has proved thor-
oughly safe and infallible at the bedside.
In one of the first experiments made he
had to submit as (a victim) to the experi-
ment, and would never have submitted to
such a suicidal thing until its safety had
been thoroughly tested on animals.

Second Day.

Professor Roswell Park, of Buffalo,
read a paper on *' Cerebral Localization in
its Surgical Relations." The essay was
devoted principally to the surgical aspects
of the subject, and omitted consideration
of those cases in which operation is dic-
tated by a study of the subjective rather
than of the objective features.

Cerebral Topographical Anatomy, — The
areas which most concern the surgeon are
those which cluster around the fissure of
Rolando. A few bony prominences de-
serve attention in this connection — that at
the point of the nose known as the glabella;
the external occipital protuberance known



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also as the inion ; the point of the vertex
half way between these two — the bregma;
the external angle of the orbit, the tip of
the mastoid process, and the lower border
of the alveolar process of the upper jaw.
The fissure of Rolando has its upper end
about five centimetres back of the bregma,
but does not run quite in the middle line ;
its lower end lies about half a centimetre
behind the auriculo-bregmatic line, and a
little above an imaginary line projected
backward from the superciliary ridge;
thus, the lower end of this fissure will be
found about six centimetres above and a
little behind the external auditory canal, or
about an inch behind the bifurcation of the
fissure of Sylvius. In regard to the con-
volutions, it must be stated that lesions of
the dura-mater overlying motor areas are
not always to be distinguished from lesions
in the cortex beneath. It is enough for the
surgeon that a lesion of some kind can be
located with reasonable accuracy. It mat-
ters not whether this is an old, irritative
lesion, an acute suppurative process be-
tween the bone and the brain, or an abscess
or tumor of the brain itself. The indica-
tion for exploration is just as strong in
either case.

When and Where can one Trephine with
Safety f — The safest rule is to first apply the
trephine over those areas which do not
overlie large vascular channels. After-
ward, the opening may be extended in any
direction, and to any required extent. The
greatest hesitation is with regard to open-
ing one of the sinuses. Two dangers attend
such an accident : one, fatal air embolism;
the other, profuse haemorrhage. The former
danger is almost a theoretical one, and the
other may be overcome by plugging the
sinus or closing its wound with a fine
needle and suture.

Cerebral and Cerebellar Abscess. — Berg-
mann has shown that abscess of the brain
has but one result — death, and that the
surgeon's knife offers the only relief. So
far as we know, there is no such thing as
idiopathic abscess of the brain ; it is al-



ways the result of some external wound of
the head, or some extension from diseased
surrounding bone. The only exceptions
to this statement arc to be found in the
case of pyaemia or tuberculous abscess.
The symptoms of deep brain abscess may
be divided into three groups, according to
causes: i. Those which are inseparable



Online LibraryJ. M. (James Mitchell) FosterThe Chicago medical journal and examiner → online text (page 34 of 63)