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I watch the patient*s heart and respirations. I am inclined to Dr.
Marvin's view, that the circulatory phenomena are high tension rather
than low tension. I do not often use digitalis in pneumonia. There
may be conditions which call for it. The physician's finger should
determine the question as to whether digitalis is indicated in every
case. I do not know that it is worth while to spin any theories in
regard to high or low tension. When you have a feeble, rapid pulse,
you may give digitalis ; when you have a slow pulse, no matter how
feeble it is, do not give digitalis ; when you have an intermittent pulse,
if you are giving digitalis, stop at once. It has been my rule in the
treatment of pneumonia to depend very largely upon full doses of car-
bonate of ammonia and strychnine.

Dr. J. G. Cecil : Following the line of thought suggested by the
remarks of Dr. Marvin, it seems to me that we shall either have to
change our ideas of the pathology of pneumonia or else the nomencla-
ture. The question is whether we are calling some things pneumonia
which are not, or whether we are misnaming things that are pneu-
monia. I believe that croupous pneumonia is a specific disease, due



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principally to the effect of the pneumococcus of Frankel, together with
such additional causes as exposure to cold, etc. We see many cases of
anomalous pneumonia, and this is the explanation of cases that are
apparently aborted. I have always doubted that true pneumonia could
be aborted.

The suggestions made by Dr. Marvin in regard to this and other
diseases in connection with their causation are of extreme interest to
me. We all see cases of typhoid fever start out as pneumonia. The
question is, do we really have a pathological condition of the lung
which would and should be regarded as pneumonia, or is it something
else? Can such a condition result from the bacillus of Eberth ? I have
not been disposed to question the nature of croupous pneumonia as
long as I get the old-fashioned classical symptoms of pneumonia.
Recently, in the epidemic of grip which is just now subsiding, I saw
one case which occurred in a young woman twenty-two years of age.
She had the ordinary symptoms of grip; after partial recovery she
exposed herself by going out in the evening, and a short time after-
wards was taken to bed with the ordinary classical clinical signs of
pneumonia. I regarded it then as pneumonia, and believe now that it
was. It ran a course which was typical of pneumonia, every symptom
present needed in making a diagnosis — crepitant rale, dullness on per-
cussion, bronchial breathing, brickdust sputum, pleuritic pain, etc.
The ice bag applied to the seat of pain gave prompt relief, and I can
confirm what Dr. Marvin has said in regard to the value of this
method in all cases in which I have used it. I use it now to the exclu-
sion of all other topical applications, and it usually gives prompt relief
from pain. She was also given the old-fashioned liquid Dover^s pow-
der, which had a very pleasant effect ; under its influence she was able
to sleep ; the fever ran along 103° to 104° F. for several days, with a
good pulse, ranging from 100 to 120; she made a prompt recovery with
no other medication except stimulants and a heart tonic. I always
give, whenever I make a diagnosis of pneumonia, full doses of strych-
nine from the beginning with whisky. The disease in this case ran a
course of four days under these conditions, then terminated without
the ordinary signs of crisis. There was not the diarrhea, there was not
the critical sweating, but simply a gradual decline of the disease, with
nothing to account for it except the ice bag and other treatment indi-
cated. She made a good recovery with some dullness remaining in the
affected lobe. The question arises in a case like this, did we have a



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true pneumonia or not? If we are to determine by the symptoms
present, it was certainly a case of true croupous pneumonia. In such
cases I am simply disposed to admit that grip is a predisposing cause,
and the pneumococcus is really the actual cause.

In regard to the other diseases, what we may say of one is practi-
cally true of the others, as erysipelas, diphtheria, etc. I am not dis-
posed to agree that, when we find rapid respiration, dyspnea, rapid
pulse, and cough, without the characteristic brickdust sputum, without
the other classical signs of pneumonia, that we are justified in calling
the case one of pneumonia. We will have to get another name for the
disease or else change the name of pneumonia. It is an interesting
study, and I have no doubt it is a field in which we will see wonderful
development in the near future.

There is a great deal that is suggestive in what Dr. Marvin has said,
because of the many things which start out as one thing and terminate
as another. Typhoid fever starts out in many different ways. We
have all seen typhoid fever start out exactly like meningitis and
obscure the diagnosis for several days or a week, and then finally drop
into the old-fashioned typhoid fever and pass through an otherwise
typical course. In a case of that kind are we justified in saying that
it began as a meningitis? What effect the typhoid fever poison has, or
whether it is the effect of the typhoid fever poison on the meninges, is
quite another question; but, if it should not run the usual course of
meningitis, are we justified in diagnosing this disease? Is it not
simply an exaggerated manifestation of the condition of the brain or of
the meninges produced by the typhoid fever poison which is circulating
through the blood ? The same thought applies to cases of pneumonia
which exhibit evidences of typhoid fever.

I can not but believe that pneumonia is a disease which it is impos-
sible to abort. I do not believe it can be aborted any more than can
measles, smallpox, or any other specific disease which has a history and
runs a course which is recognized as the course of that particular
disease.

In regard to the treatment, I am quite in accord with the sugges-
tions made by Dr. Marvin. I believe the less we treat these cases the
better they do. Certainly, so far as treatment is concerned, we have
no specific whatever in the treatment of pneumonia. My practice has
been to sustain the heart, to maintain the strength of the patient,
proper feeding, and wait. I do not fear an ordinary range of fever in



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pneumonia. I do not think it is a matter of as great importance as it
is in typhoid fever. A course of fever with a temperature of 105° F.
will not kill a man in four or five days. Just now we have a friend
who is in a g^eat deal of trouble, and Dr. Marvin's talk has suggested
to me that possibly some light may be thrown upon the case. This
child had what we thought was scarlet fever, and it is possible that Dr.
Marvin will admit scarlet fever into his new pneumonia class. The
little girl is three years old, and had exposure from two cases of scarlet
fever in the family. She suffered a high fever, while the scarlatinal
rash covered the body. She had a warm bath to control the nervous
symptoms and also to induce freer expression of the rash. The next
morning she had not a sign of rash anywhere upon her body. She did
not have fever. She was up about the room at play. In two or three
days she developed high fever again.' Her temperature since then, now
ten days, has been ranging from normal to 105° or 106° F. in the axilla,
which means 107® F. in the rectum. The fever varies in various ways,
it runs up and down, regardless of antiphlogistic measures, regardless
of the time of day, or any thing else. She has to-day some symptoms
of broncho-pneumonia, rapid pulse, rapid respiration, 60 to 65, without
cyanosis, with a cough which is not characteristic, yet she presents
some of the conditions usually found in broncho-pneumonia. Probably
in ten hours her temperature will drop to 99° or 100° F., the cough will
cease, and respiration become normal. What condition can be existing
in that child now ? Is it possible that she has some one of the varieties
of pneumonia mentioned, and due to scarlatinal poison, that does not
show any symptom which is constant, that does not exhibit the usual
characteristics of an ordinary attack?

Dr. F. C. Wilson : There are only one or two points that I care to
touch upon. I believe that many cases of pneumonia have present the
characteristic organism, and many others that are classed as pneumonia
have not. I further believe that those cases in which the organism is
found are the ones that are generally looked upon as communicable or
contagious. You see many instances where the disease simply runs
through whole families, contracted one from another, and in such cases
no care has been taken to destroy the sputum of the sick ones. Much
is yet to be learned about the pathology, classification, etc., of pneu-
monia. Those cases met with which run a typical course, commencing
with a chill followed by high fever, some cough, little or no pain,
where the sputum soon becomes red, brickdust in character, respiration



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rapid, face suflFused, temperature running up to 103-4-5° ^- — ^^ these
cases a physical examination will disclose slight dullness on percus-
sion, with the presence of a decided, unmistakable crepitant rale — it
seems to me, are the ones that we can safely say are pneumonia. We
do not get that group of symptoms in other conditions.

As to treatment and the effect of treatment : The question of the
duration of pneumonia has been raised. I may have some radical
views upon that subject, because I have always believed that in some
instances pneumonia could be aborted. I have believed that for many
years, and am sincere when I say I have seen cases aborted that no one
could tell from other cases that have gone through the typical course
of pneumonia, and the various stages have been cut short, whether as a
result of the treatment or simply the result of nature's efforts I will
not undertake to say. I have seen cases that commenced with a chill,^
that have been followed by high fever, that have given slight dullness
on percussion over a certain area of the lung, that have shown decided
rusty sputum, where the symptoms have all disappeared in twenty-four
to forty-eight hours. So far as I could judge, so far as anyone could
say, those cases were just as much pneumonia as other cases which
have gone on, and, at the end of forty-eight hours, developed consolida-
tion, bronchophony, and all the physical signs of pneumonia. Of course,,
there are several stages of pneumonia, the stage of congestion, state of
consolidation, state of resolution, etc., that are usually recognized. The
first stage is the one in which we get the crepitant rale. There is not
yet consolidation, there is not yet exudation more than suflficient ta
simply agglutinate the surfaces of the air-cells, there is not yet exuda-
tion enough to become solid in those spaces, and it seems to me if any
efforts at abortion are to be made they must be made at that time. If
we pass that stage then no efforts can ever accomplish abortion. Now
the question is, what efforts can be made in that direction? I have al-
ways relied upon a preparation of ergot to accomplish something in
that line. We know it is a fact about the action of ergot that it
contracts the blood-vessels, the arterioles; that it cuts off the supply of
blood to certain portions of the system, and there is this peculiarity in
the action of ergot, that its first effect is upon those portions of the sys-
tem where it is needed ; it does not contract other arterioles of the sys-
tem, but only that portion of the system supplied with dilated arteri-
oles. If ergot has its effect in that direction, it seems to me that some-
thing may be accomplished by its administration. I believe that in the



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use of it I have accomplished something. I can look back over my
own experience at scores of cases which have gone through that
course, which have been, as far as I could judge, typical cases in
the first stage of pneumonia, which have been cut short at the end of
forty-eight hours. I believe further that even if success is not met
with, even if you do not see this result accomplished, you have lost no
ground, you have simply given the patient a chance to abort the
disease, and if you do not succeed at the end of forty-eight hours you
can still go on with the usual course of treatment. I am satisfied that
in many instances I have at least limited the extension of the exudation
and caused the case to run a more favorable course.

Dr. J. B. Marvin : I have seen very few deaths from pneumonia dur-
ing the present outbreak, but the death reports of the city show a very
large number. I do not classify those cases having fever, pain, rapid
respiration, rapid pulse, that are so quickly cut short, as pneumonia. I
believe it is a mistaken diagnosis to call such cases pneumonia. I
think my friend, Dr. Wilson, has been a little " cross-eyed '* for some
time on aborting typhoid fever as well as pneumonia, and I hope
he will see the error of his ways and reform. I believe it is just such
cases as are prevalent now, which I do not consider genuine pneumo-
nia, that are spoken of as being aborted.

I did not attempt to take every thing into consideration in my
former remarks, but the investigations of Klein and a number of others
have proved that in genuine cases of pneumonia, with the pathological
changes that we find in croupous pneumonia, there has been frequent
absence of the pneumococcus of Frankel, and they have found other
bacilli, and out of these investigations grew the remarks that I made.

LOUIS FRANK M. D., Secretary.



Hypodermic Injections of Saline Solution in Eclampsia.—
• Poucet and Vinay {Sem, Mtd,, June i, 1898) report the following case: A
woman in the sixth month of pregnancy was attacked with eclampsia, and
her general condition was extremely serious, with complete coma, sup-
pression of urine, high temperature, etc. Abortion was induced, the child
being dead when born ; ^% pints of normal saline solution were then
injected hypodermically. Recovery was rapid and complete. — British
Medical Journal,



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HepieiDS (xvXi Bibliograpt^y.



A Text-Book of Obstetrics. By Barton Cook Hirst, M. D., Professor of Obstet-
rics in the University of Pennsylvania. With 653 illustrations. 846 pp. Price,
cloth, J4.00; sheep, $5.00. Philadelphia: W.B.Saunders. 1898.

The medical profession of the United States and not a few physicians,
perhaps, in Europe have been looking forward with interest to the appear-
ance of the promised text-book on obstetrics by Prof. Hirst. And it is
safe to say that when they have examined the book they will not be disap-
pointed.

The latest work in obstetrics ought to be the best. Progress is con-
stantly being made in the confirmation of experience, knowledge is becom-
ing more certain, and in addition to that the art of illustration and of book-
making is constantly progressing. This work shows art in bookmaking,
and science and practical knowledge in obstetrics at its best.

The industry of the author is exhibited in the most favorable light.
The whole field of reputable literature has been searched for the latest and
the fullest contribution to obstetric art and science. Wise discretion has
been shown in the selection of such doctrines and practices as have met
with the most authoritative approval, with possibly a few exceptions.

The illustrations are so abundant, so apt, and so well arranged that
they almost of themselves form a teaching system of obstetrics. In prac-
tical obstetrics there are not to-day many moot points. In the treatment
of eclampsia there is, perhaps, more difference of view than on any other
matter in the whole of obstetrics.

The author gives statistics as reported by a number of authorities,
showing a range of from two to sixty-six per cent of deaths in institutions
equally reputable.

It is gratuitously rude to intimate falsehood against any of the re-
porters, the most favorable reports being made by such men as Veit and
Winckel. But there is something untold that makes the difference in
results, since the same course of treatment in different hands gives widely
different results. The author favors deep anesthetization with vigorous
purging. Yet it is well known that elimination of substances left in the
blood by defective action of the kidneys can not be made to take place by
the bowel.

It may be that in some sections the doctor is sought when eclampsia is
feared, and that in this way the unpromising cases are guarded by proper
prophylaxis and do not suffer attack, thus leaving the mildly affected indi-
viduals to suffer. Having spoken of the practical aspects of the book in
the high terms it is believed to deserve, a word may be said of the theoret-
ical or philosophical part, one in which the reviewer takes especial interest



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The American Practitioner and News. 109

from having long labored in that field. And he makes bold to say that
in the theory of rotation and presentation the work is the weakest since
the day Hippocrates got his diploma.

For rotation, he says, the cause is that the head, driven through the
funnel-shaped parturient canal, its most dependent portion the tip of the
occiput, first strikes the resistance of the upper portion of the pelvic floor,
which is represented by a curved line or plane running inward, downward,
and forward. This explanation does not touch the cases of rotation in
occipito-posterior positions, nor of anterior rotations of the head in trunk
or shoulder presentations. Nor does it give a definite analysis of the appli-
cations of force in any presentations. In short, it fails totally of being an
explanation. Rotation is in every instance a matter of leverage on the
part of the fetus and of unequal resistance of different parts of the par-
turient canal.

The author's explanation of the frequency of head presentations must
make Hippocrates smile in the land of spirits. This is found, he says, in a
voluntary assumption of that position of the fetus, because it affords it the
greatest degree of comfort and the best opportunity for growth and devel-
opment. Age has hitherto been claimed as the period of wisdom, but this
would give it to the fetus in utero. Of course it tries all positions, first, to
find out which is the most comfortable, and reasonably it should keep on
trying, for otherwise it might miss new positions of comfort developed with
the successive stages of growth. The " best opportunity for growth and
development" it could know only by experience or prescience. Either,
then, the little thing is- a prophet or else transmigration is true.

Possibly with the new phonendoscope we shall be able to talk with the
little fellow and learn something more of the motives for his voluntary
movements. But why do things by halves? Why not go a little farther
and help out the little ones in their nursery traditions and teach that the
doctors bring the babies and that they find them already strung up by the
heels in the tree tops. Pity that a work surpassingly excellent as this is
should not exhibit a clearer and broader conception of physical principles.

D. T. s.

The Sexual Instinct, its \}s% and Dangers as Affecting Heredity and Morals. By

Jambs Foster Scott, B. A. (Yale University), M. D.. C. M. (Edinburgh Univer-
sity), late Obstetrician to Columbia Hospital for Women, etc. 436 pp. Price,
$2.00. New York : E. B. Treat & Co. 1899.

" Of making many books there is no end," said Solomon, doubtless as
a prophet speaking of the present day. But what we should have is some
one to say that of making such books as this there should be no beginning.

That a book bearing such a title as this, and pursuing its professed
aims, ought to be written by the most earnest and capable man that medi-
cine knows, and read and pondered by every man and woman capable of
exercising the sexual functions, does not need argument. But the author



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of this work has not made a happy stroke. His style is tedious and
prolix. Proposing to write for the laity, he lugs in a great deal of useless
and irrelevant scientific matter and not a little deserving a more severe
characterization.

The part of the treatise that, whether coming from a brilliant or a dull
man, calls for the most serious attention is that relating to abortion. There
is no question of the enormous increase of this practice, and there seems
to be a most rapidly growing aversion to child-bearing among the more
cultivated classes of women.

The unfortunate single woman who becomes pregnant is condemned to
a fate worse than ** suttee '* that missionaries have sought to make so much
of in India. But what is worse is that it is coming to be regarded by the
public as almost a disreputable thing for even a married woman to show
herself in public while pregnant.

There must come a change in public sentiment, or the better element of
humanity will perish, and only the lower and duller be left to perpetuate
the race. A book like this, if it should happen to be read between sermons,
would work sad havoc in the congregation of some of those missionaries
whose beneficent teachings our pious statesmen and editors are preparing
to shoot out of cannon into the midst of the benighted Philippines and
other heathen. It is to be feared that they would at once call for a
collection to exchange missionaries.

It is to be hoped the press, secular, religious, and medical, as well as
the pulpit, will take up this subject and check this terrible and rapidly
growing evil. d. t. is.

A f1andtN>ok of Hygiene and Sanitary Science. By Gborgb Wii^son, M. A., M. D.,
LL. D. (Edin.), F. R. S. (Edin.), D. P. H. (Camb.), Fellow of the SaniUry Institute
of Great Britain, etc. Eighth edition. London : J. & A. Churchill ; Philadelphia :
P. Blakiston's Son & Co. 1898.

This book has long since gained great popularity in Great Britain, as
shown by the fact that an eighth edition has been rendered necessary.
I^arge portions have been rewritten and others amended and carefully
revised, this having been made necessary by the rapidly increasing interest
in sanitary science. The chapters on the analysis of air and water and
their impurities have been brought up to date, and that on meteorology
has been enlarged.

Extended attention has been given to drainage and the disposal of house
refuse and sewage, and a chapter that ought to have been worth thousands
of lives, if read by the ward politicans too often put in charge of the camp
in our late war, relates to the part played by filth-polluted soil as a breed-
ing-ground for pathogenic organisms.

But bring a crown of oak leaves! The author has the courage to say,
" I have made bold to question the inference that statistical results have in
any measure established the success of Pasteur's antirabic vaccination as



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The American Practitioner and News. 1 1 1

a remedy for hydrophobia, or of serum antitoxins as cure for diphtheria,
tetanus, and other allied diseases." He proves conclusively that Koch's
tuberculin not only does not arrest consumption, but that many of the vials
actually contain tubercle bacilli as well as other contaminating microbes.

Perhaps the eastern editor who sells his signed editorials will find here
that somebody else holds these views besides " obscure interior editors."
Much space is devoted to the eflforts of the anti-vaccinationists who have
lately stirred up a most unreasoning opposition to vaccination.

Altogether, the book is a most satisfactory treatise on a subject outgrow-
ing all others relating to medicine. d. T. s.

On the Origin and Progress of Renal Surgery. With Special Reference to Stoce in
the Kidney and to the Surgical Treatment of Calculous Anuria. Being the Hun-
terian Lectures for 1898, together with a Critical Examination of Subparietal
Injuries of the Ureter. By Henry Morris, M. A., M. B. (Lond.), F. R. C. S.,
Senior Surgeon to the Middlesex Hospital ; Examiner in Surgery in the Univer-
sity of London, etc. 288 pp. Price, $2.00. Philadelphia: P. Blakiston's Son &



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 13 of 109)