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is the amorphous digitaline (Merck); it is soluble in water. I have
given one eighth to two grain doses. It does not produce nausea. It
seems to me that this has some very decided advantages over the other
preparations of digitalis, and none of their disadvantages, and if I use
digitalis at all this is the preparation I give.

Any doctor who has seen pneumonia simply in private practice
would have a very different idea of the disease if he were to see a num-



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The American Practitioner and News. 93

ber of cases, for instance, in the city hospital or any one of the infirma-
ries. To carry out the point made earlier in my remarks, simple rest
and the management I have outlined, will yield much better results
than the unnecessary, useless drugging.

LOUISVIW-E.

HEMORRHOIDS: CAUSATION AND TREATMENT.

BY O. L. JONES, M. D.

There is no disease known to the medical profession that was so
exclusively in the hands of the itinerant, until the past two decades, as
the one to which I refer, and to say that they reaped an abundant har-
vest is but mildly expressing it, and many of the unsuspecting that
were treated by the charlatan after a time realized the depletion of
their bank accounts and their condition not benefited.

We are indebted to Mathews, Kelsey, and Allingham for their inves-
tigation of cause and treatment of diseases of the rectum, and under
their teachings we can happily say that the average physician, under
proper training, can promise an absolute cure with the proper treat-
ment applied.

For simplicity we will divide hemorrhoids into two classes, viz:
Internal and external, and probably, we might say, a mixed variety.
Their location will decide the class to which they belong, and I believe
the treatment should be the same, regardless of location.

Now, as to the cause there is a diversity of opinion, but I think
clinical evidence will bear me out when I say most cases are due to a
varicosity of the hemorrhoid plexus primarily, followed by inflamma-
tion and infiltration of plasma. ^

We find this efiect on the venous distribution in an overloaded rectum
and in pregnancy.

It is true there are cases in which we can not assign a cause, but
that does not prove that no cause exists, but to the contrary, for every
effect there must be a cause.

The treatment is mainly surgical. In fact, I believe it to be the
only curative treatment. We can palliate by applications of cold or
heat, ointments of various kinds, which will allay the inflammation in
time, but you still have the diseased condition present, and at an inop-
portune time your patient will return to you in a worse condition than
before.



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94 ^^ American Practitioner and News.

After deciding on an operation, and having gained permission from
your patient, the question for you to decide is. What operation shall we
do; shall we inject hemorrhoids with carbolic acid? No; my objection
to this method is this: (i) It may result in embolism. (2) It may be
followed by violent inflammation and sloughing. (3) It may be
followed by dangerous hemorrhage. (4) It may be followed by sepsis.

I think there are but two methods that deserve our attention :
(i) Clamp and cautery. (2) Ligature and excision.

Of the two, the latter is my preference: (i) Because a cut will heal
more readily than a burn. (2) It is less liable to be followed by a
stricture. (3) It is less liable to be followed by hemorrhage.

The instruments I use are a Cook's speculum, Mathews' pile-for-
ceps, a bistoury, and a strong silk ligature to throw around pile ; and
when this method is used properly we need not fear any bad results,
but, on the contrary, a cure can be guaranteed.

Fort Worth, Tkx.

^leports of Societies^



THE LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.*

Stated Meeting, January 13, 1899, the President, Thomas Hunt Stucky, M. D.,

in the chair.

Detached Retina. Dr. J. M. Ray: This specimen is an eye
removed from a man about forty-five years of age, whom I first saw
in the late spring or early summer of 1898. He applied to me
because of sudden blindness in one eye. On examining the eye I
found that he had a detached retina involving the lower and inner
portion of the retina. I told him that I did not know of any treat-
ment which would be of any avail. Tension of the eye was normal,
and he complained of no pain. I saw nothing more of him for two
months, when he returned, stating that his eye had gotten worse. I
found that he then had a complete detached retina, the vitreus filled
with floating bodies. The man again passed from my observation, and
I saw no more of him until in November, 1898, when he came back
complaining of pain in the eye. On examination I found him suffer-
ing from an attack of hyalitis and cyclitis, very much ciliary injection,
and a minus tension in the eye. The eye had begun to soften. The

♦ Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.



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pupil dilated well under a mydriatic, and under hot applications the
pain subsided. In a few weeks he had a relapse. This was a little
more severe, the pain lasted longer, but under antiphlogistics it grad-
ually subsided in two weeks. Three or four days before Christmas he
had another attack, accompanying which there was a great deal of
pain. The eyeball was soft and the anterior chamber had become
very deep. The iris began to recede into the vitreus. Tension was
still minus in that eye.

I advised the man to have the eye removed ; it was useless, painful,
and, after some parleying with me, he finally consented to the opera-
tion. It has been hardened in formol solution, frozen, and then divided
in a horizontal direction, and here is the specimen. It is of no especial
interest except that it shows very prettily the detached retina which is
present, and here seems to be a large rent in the retina. There is no
growth present in the eye ; I did not expect to find one, but the speci-
men shows an opening through the retina.

The peculiar interest in the specimen seems to be its bearing on
the pathology of detachments of the retina. There have been a great
many theories advanced with reference to the causation of detachment
of the retina. It is claimed by some that it is due to an extravasation
under the retina. It occurs, as a rule, very suddenly, and if there is
any exudation under the retina with any amount of serum, it seems to
me that it would be rather slow in its formation. The history of detach-
ment of the retina as a rule is that there is a sudden defect in the field
of vision. The exudation theory does not explain those cases that
occur suddenly. In a traumatic case it might possibly occur from sud-
den hemorrhage under the retina. In the idiopathic cases the exuda-
tion theory does not explain them. Another theory is that it is due
to contraction of the vitreus, and Nordensen claimed there was always
present a rupture of the retina. Several writers who have examined
many such eyes deny that rupture is present. This specimen bears
out the Nordensen theory. In the first place there is contraction of
the vitreus; fibers extend through the vitreous body and draw the
retina away from its attachment to the choroid. Contraction has
gone on until it has drawn the iris back from the anterior chamber and
the latter is filled with albuminous fluid. Between the retina and
choroid there was also a certain amount of albuminous substance.
There is a large rent in the retina just at the site of the original
detachment at the lower and inner side.



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96 The American Practitioner and News.

Discussion, Dr. William Cheatham : According to an article I read
recently, we may have detachment of the retina with intra-ocular
growths where there is decreased tension. The gentleman reported a
series of cases of ocular growths which behaved just as Dr. Ray has
stated. My observation has been similar to that of Dr. Ray, viz., that in
most cases where we have an intra-ocular growth there is an increased
tension. In some instances, however, these cases behave just as do
intra-cranial growths. As the growth presses upon the eye, there will
be pain, then the eye accommodates itself to this increased tension just
as the brain does in an intra-cranial tumor. Pain will subside, then
the growth extends a little further, pain recurs, and, as the eye accom-
modates itself again to the increased pressure, the pain again subsides.
When the first attack of pain occurs I always suspect an intra-ocular
growth. The gentleman who reported the cases to which I have
referred stated that the growths sprang from the posterior part of the
eye, and the iris receded in the latter stage of the disease just as it did
in Dr. Ray's case. He could not explain this. In some of his cases
the growth had broken through the posterior part of the eyeball. He
closes his article with the statement that in eyes which have been
blind for any length of time, especially in eyes with detached retina,
with pain, you can feel sure there is an intra-ocular growth. Once, on
a visit to Dr. Noyes' hospital, he showed me a detached retina with
rupture, and he says that they nearly all rupture. One of the first
things I would have suspected in Dr. Ray's case would have been a
growth of some kind, and that is why I asked him why he was so sure
there was no growth.

Dr. S. G. Dabney : My experience has been similar to that of Drs.
Ray and Cheatham concerning intra-ocular growths. I showed a sar-
coma of the choroid before a recent meeting of this Society, and read a
paper upon that subject some time ago. In the case which I reported
at that time the lady has become perfectly well. In her case tension was
decreased at first. The glaucomatous attacks came on from time to
time; there was also a very deep anterior chamber peripherally. This
is not hard to explain ; it is due to contraction from the cyclitis pull-
ing back the periphery of the iris. The central portion is seldom
contracted. Absence of tension or decreased tension certainly does
not exclude the possibility of an intra-ocular growth. As a rule, how-
ever, in intra-ocular growths the tension is increased. It would appear
to me that in Dr. Ray's case the detachment was due probably to an



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old cyclitis that produced fibrillar changes in the vitreus, and detach-
ment resulted from contraction of these fibrillae.

I was struck with Dr. Knapp's article in Norris & Oliver's System
of Diseases of the Eye, in which he describes retinal detachment as a
symptom, not a disease. It would seem to be a symptom if cyclitis
produces a rupture and consequent detachment of the retina. I have
had occasion to look up the subject lately, and have read Schobl's
article in the same book. He takes the ground that all of these cases
can not be explained upon the same hypothesis ; that the trouble in one
case may be due to a hemorrhage, where the symptoms come on sud-
denly; in another case there may be an effusion between the retina
and choroid ; in a third case it may be due to contraction.

It would be interesting, and, perhaps, throw some light on the pres-
ent case, had Doctor Ray seen this man previously and had known
more of the history of the eye before the attack mentioned.

I have in mind now the only case of detached retina I have seen
which I thought would get well. Four weeks ago next Monday a boy
fourteen years of age, under size, anemic, bad general health, over-
worked and ill-fed, came to me, stating that on the Saturday previous
he had begun to get blind in one eye. I had examined his eyes several
times within the last few years, and knew he was subject to 3 or 4 D.
near-sightedness. I looked into the eye and found a well-marked
detachment at the outer and upper part of the retina. Realizing
that in most cases, if the trouble begins in the upper portion of the
retina, it usually sinks by gravity, and the whole is gradually involved,
I told the family that the boy would probably lose his eye, yet there
was a forlorn hope that it might be saved, and we would put him
under treatment. He was also the subject of rheumatism. I put him
to bed that evening and gave him salicylate of soda and put a band-
age over both eyes. I did not examine the eye again for several days>
when I was very much gratified to find that the retina had become
reattached. He is still in bed, and it is now four weeks since the treat-
ment was begun. The only medical treatment has been salicylate of
soda; but the hygienic treatment and rest in bed, I think, is of the
most importance. He has had absolute rest in the recumbent position.
I examined the eye again this afternoon, and the retina is still in
proper position ; there are no symptoms of detachment, and sight in
the eye is about as good as it was before the detachment occurred.
We know the difficulty in these cases is to prevent the retina from

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98 The American Practitioner and News.

becoming again detached. I believe it is not very rare for this
sequence of things to take place as I have described. That is, under
rest in bed, salicylate of soda or pilocarpine, the retina may become
perfectly attached, but is liable to fall again when the patient gets up
and walks about. I shall keep this boy in bed at least three weeks
longer, and hope by that time no further trouble will occur.

The points of interest in the case are, first, the age of the patient ;
second, the detached retina which promises a cure.

Dr. C. Skinner: Does syphilis play any part in the etiology of
detached retina ?

Dr. J. M. Ray: I do not know that syphilis is an etiological factor
in detachment of the retina. Frequently the starting point, however,
is a localized choroidal inflammation, and probably syphilis is the most
important factor in the production of choroidal exudates. I can readily
see why, in cases where there is an exudation, the retina will become
lifted up and become detached.

I never saw this man until he presented with partial blindness.
He said that the eye had never given him any trouble, and he had
never seen a doctor until he began to have this defect in vision. I
first saw him in the spring or early summer. I had just heard a paper
read at the Chicago meeting of the Western Ophthalmological Society,
by Stillson, in which he reported several cases of detachment of the
retina cured by puncturing the sclera with the galvano cautery, and
was inclined to try it in this case. There were but few opacities in the
vitreus, and it looked like a good case for this method of treatment. I
told the man I would watch it awhile, intending later to suggest treat-
ment by cautery ; but subsequent events showed that no amount of
scleral puncture would have had any influence in reattaching the
retina.

Cassaripe in the Treatment of Corneal Ulcers, Dr. Wm. Cheatham :
A new medicine has recently been introduced for the treatment of
corneal ulcers and other infectious conditions of the eye, viz : Cassaripe.
My attention was first called to it by an article, by Risley, in the Phila-
delphia Medical Journal. I have used it in a case of ulcer of the cor-
nea from exposure ; there was also paralysis of the eyelid ; the boy had
had typhoid fever; he also had enlargement of the parotid gland; the
disease itself may have affected the nerve. There was paralysis of the
lid which left the eye open, and it was subjected to considerable irrita-



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The American Practitioner and News. 99

tion from particles of dust, etc. There finally developed an ulcer on
the lower part of the cornea. Under atropine and warm water, cassa-
ripe five per cent mixture with vaseline cereate, the ulcer healed nicely.

I had another case, a woman who had a conical cornea with an
ulcer; the conicity pointing downward and outward, the lower part of
the cornea being extremely thin. I used cassaripe in this case with
excellent result.

Cassaripe is obtained from the bitter cassava-plant. **The natives
in making cassava bread grate the root, and a milky juice exudes.
This is acid, and is supposed to be very poisonous. The juice is con-
centrated to a semi-solid known as cassaripe, heat destroying its
poisonous qualities. Its use by me was suggested while in the tropics,
by learning that it was used commonly as a preservative, a solution
poured over meat seeming to preserve it indefinitely. Theodore Met-
calf Co. imported some for me two or three years ago, as none could
be found in this country. In using it I often incorporate atropin or
pilocarpin with happy results. In large, sloughing ulcers in old persons
it has given more satisfaction to me than any thing I have ever used."
(Chandler.)

Discussion, Dr. J. M. Ray: I notice at the last meeting of the
American Ophthalmological Society, Dr. Risley, of Philadelphia, read
a paper in which he recommended cassaripe ointment in the treatment
of corneal ulcers. I asked some of the local druggists if they could
get me a supply, but failed. I dropped the matter for the time being,
but later secured some of the ointment, and have used it in two cases
of ulceration of the cornea. It has only been a short time since its
use was commenced, and I can not say much about its eflFects.

Dr. F. C. Simpson read a written report of a case, as follows:
Mrs. Artie A., aged eighteen years. Married in December, 1897 5
became pregnant in March, 1898. Family history fair; mother
dying of consumption at the age of thirty-two years. Father died of
pneumonia at the age of thirty-five. Has one brother, aged twelve,
whose health is good. I saw her on July 9th. She complained of
pain over abdomen ; had been sufiering since July 4th. She thought
it was an attack of colic, as pain came on at night, after spending the
day out on a picnic excursion ; she having eaten a very great quantity
of diflFerent things on that day. Pain had gradually increased since



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lOO The American Practitioner and News.

the 4th. I was sent for on July the 6th ; was out of the city. Dr.
Hays saw her on the 6th and 7th. He gave her opiates, being under
the impression it was an attack of colic. I did not see her until July
9th. I was of the opinion she was suflFering from uterine pains, as the
uterus was contracted and she was having intermittent pains. I exam-
ined over abdomen ; found her tender. Thinking it due to the continu-
ous contraction that had been going on for four previous days, I
allowed it to pass out of my mind as its being caused by any other con-
dition than an effort of uterus to empty its contents. On July loth,
Saturday, I was called at 5 A. m., by the husband, to come at once ;
that his wife had had a miscarriage. I arrived half an hour later and
found the contents of the uterus had been expelled in toto. I exam-
ined placenta, and, so far as I know, it was all passed. I examined
over abdomen to see if uterus had contracted properly. To my sur-
prise I found a very tender and swollen abdomen. I fail to understand
what could cause such condition. Later in the day I diagnosed
peritonitis, as the abdomen became very painful and board-like. I
gave a very unfavorable prognosis. I called in Drs. Bullock and Vance,
July nth, Sunday. They agreed she had peritonitis, but could not
understand the cause for it, giving as their opinion that it was either
due to ruptured tube or perforation of uterus, possibly from criminal
abortion. It was possibly suggested she might have appendicitis, but
that was very remote. Dr. Vance declined to operate, as she seemed
to be in shock, pulse being very weak and fast. She had only slight
temperature during the three days I was in attendance, not above 101°.
She was moved to City Hospital on July nth, Sunday, Dr. Frank in
charge. He was in the dark about the cause. She went on from bad
to worse, and died on July 12th. Autopsy was held on July 13th, and
found ruptured appendix with large number of enteroliths. The uterus
was in good condition ; no evidence of any criminal eflFort, every thing
in good condition ; found few clots in uterus which were not decom-
posing. In this case it was certainly puzzling to make a diagnosis, and
the complications were of the kind to completely mask the more im-
portant and prominent symptoms of appendicitis. I believe if I had
thought for a moment that appendicitis existed or was possible the
first day I saw the case, I might have found some of the characteristic
symptoms. The error in diagnosis is one that any of the Fellows
might have made, as the conditions only pointed to an eflFort to get
rid of what was in the uterus.



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Discussion. Dr. Turner Anderson: I agree with the doctor that
this was one of those complications which may occur during the
progress of gestation where any of us might fail to make a correct
diagnosis.

Dr. J. L. Johnson (present by invitation) : I feel that the only
mistake was that an exploratory incision was not made for diagnostic
purposes. I think it is always justifiable where we are at a loss to make
a diagnosis, especially in such a case as this. Any of us under such
circumstances would be likely to make an error in diagnosis. An ex-
ploratory incision might have been the means of saving the patient's
life.

In lieu of the essay, Dr. J. B. Marvin made some remarks on **The
Pathology and Treatment of Pneumonia." [See p. 88.]

Discussion. Dr. J. E. Hays: What do you think of the value of
ammonia in the treatment of the pneumonias?

Dr. J. B. Marvin : I accord it only a secondary place. The carbon-
ate, muriate, and aromatic spirits have all been recommended with the
idea not only of a cardiac stimulant but as great resolvers of fibrin.
I question very much whether they dissolve any fibrin. I think they
will stimulate the heart, but the dose required is so great that you run
greater risk of irritating the stomach than you do of stimulating the
heart, and if we have a better cardiac stimulant, it should be used.
You have all seen cases of pneumonia where crises have occurred, still
the lung was apparently solid. That does not measure the severity of
the attack nor does it measure the duration of the disease ; so I
seldom use ammonia; if I do, it is in the simplest form possible.

Dr. H. A. Cottell : Dr. Marvin has given us the freshest and best
views with reference to pneumonia. It has not been my observation,
however, that pneumonia in this recent epidemic of grip has been any
thing like as fatal as it was tjiree or four years ago. At that time, to
encounter a case of pneumonia was practically synonymous with sign-
ing a death certificate. In this recent epidemic of grip I have not seen
more than two or- three cases of pneumonia, and these were very
manageable. I was not aware that there had been many fatal cases of
acute croupous pneumonia. Of course there have been many cases
of catarrhal affections of the lung, which, in old or feeble patients,
have proved fatal, and this is perhaps the cause of the fatal statistical
showing.



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I was impressed with the pathological presentation of the subject
by Dr. Marvin, that we can have pneumonia from four or five specific
causes. Why not ? There is a traumatic pneumonia and a pneumonia
from breathing ammonia gas, chlorine, etc. I suppose the strepto-
coccus and possibly the staphylococcus, if they get into the air-cells of
the lung, may bring about symptoms which we would call pneumonia ;
symptoms similar to those produced by the pneumococcus. We might
also have a similar condition from the diphtheria bacillus. But the
question arises in my mind, would the clinical history be the same in
each case ; would we have the crepitant rale in the early stages ; would
there be brickdust sputum, consolidation, chest, voice, bronchial breath-
ing, etc.? I think the conclusion is a legitimate one that we may
have pneumonia from half a dozen specific causes, but it would be
very interesting to trace out the clinical history in each case. I do not
know that this has been done, but it might enable us to make a differ-
ential diagnosis perhaps without appealing to the bacteriologist or mi-
croscopist.

As to treatment, I agree with Dr. Marvin in the **let alone" side
of it. I think patients are drugged altogether too much in pneu-
monia. I am not in the habit of using any of the coal-tar derivatives,
quinine, etc., after I have made the diagnosis. I let the fever alone.



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 12 of 109)