Universidad de Buenos Aires. Facultad de Derecho y.

The American practitioner online

. (page 16 of 109)
Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 16 of 109)
Font size
QR-code for this ebook


propriety of excision is approved by the profession generally.

Dr. A. M. Vance : It has never been my fortune to operate on a
case of so-called idiopathic aneurism. 1 have operated three times for
traumatic aneurism of the femoral artery, and in one of the cases I
attempted to excise the sac, which I must confess is a very tedious
and diflBcult operation to perform. It happened that there was an
immense aneurism involving both the artery and vein, so that both
had to be taken away. The man recovered and was exhibited before
a meeting of this Society several years ago. The aneurism was due to
a piece of steel having entered the femoral, passing through. The
other cases were the result of gunshot wounds, both of which have
been shown to this Society. In one case there was a large aneurism
of the femoral, which was tied on each side and the sac cleaned out.
In the other the femoral was tied in Scarpa's space. All the patients
recovered.

Dr. T. L. Butler: I had the pleasure of seeing Dr. Roberts' case,
and simply desire to congratulate him upon the result.

Dr. W. O. Roberts: In former years I tried the treatment of
idiopathic aneurisms by compression, both digital and instrumental,
and never had any success. I remember as a student, and peihaps
others present can recall instances where compression was tried in
cases at Dr. YandelPs clinics by relays of students, who worked with
the patients until the part compressed would become so tender that
the patients could stand it no longer — and yet no decided improvement
resulted. I can not say that I have ever seen any marked benefit
result from that method of treatment. I remember, however, one case
treated by Dr. Yandell by means of the Esmarch bandage with perfect
recovery. In that case the tumor was small, and the Esmarch bandage
was allowed to remain on for three quarters of an hour. I had charge
of the case at the time, and the man had a complete cure. No trouble
followed the use of the bandage. But a number of cases of gangrene
have been reported following this method of treatment, and I have
always been afraid of it since. It is claimed that where failure has
resulted from treatment by compression, that it is very apt to also
follow treatment by means of the ligature, but I have never seen that
occur.



Digitized by



Qoo^z



130 The American Practitioner and News.

I have never attempted to extirpate an idiopathic aneurism. This
was the old operation ; it was first done in the fourth century, and up
to the eighteenth century no other operation was attempted. The
Hunterian operation was first performed in 1785. I have never had
occasion to do either the Basdor, the Wardrop, or the Annel operation.
I have confined my work so far to the Hunterian operation. I have
seen extirpation done in one case by Halsted. The patient was a
negro with a very large tumor of the first portion of the axillary, rather
involving the first portion of the axillary and third portion of the
subclavian. I understand the patient got well, although the operation
took a long time. In this case he had to tie the viens as well as the
arteries. It is the only case of total extirpation of the aneurismal sac
that I have ever witnessed.

Case in Pediatrics. Dr. H. A. Cottell: About three weeks ago I
had a case in pediatrics which shows how easy it might be to miss the
diagnosis utterly in the convulsions of children. A child fifteen
months old had a little spasm previous to the time I saw it ; the spasm
did not amount to much, and I was satisfied it was due to indigestion.
The convulsion was easily controlled with bromides and chloral, and
the child went along in as good health as before.

Two weeks from that time I was called in haste to see the child
about ten o'clock in the evening. When I reached the patient it
looked as if the game was up. The child had been in spasm's for more
than an hour. It was almost pulseless, totally unconscious, face drawn
to one side, and there was a peculiar clonic spasm of the upper extremi-
ties which we so often see in acute hydrocephalus. I noticed that the
abdomen was considerably ballooned. Of course I made a very
unfavorable prognosis. I ordered calomel, two grains on the tongue,
and gave chloral by enema. I told the father that the disease had gone
to the brain. I thought it a case of eflFusion. I said the child would
probably die in a few hours, but if it did not die before midnight or
was not very much better, to telephone me. The next morning about
seven o'clock I was again called to see the child. I was surprised that
the child was still living. The bowels moved in an hour after I was
there the evening before, the child had awakened from coma, the con-
vulsions had ceased, and it had gone into natural sleep which lasted till
morning. Indeed, it showed little or no signs of having been sick the
night before.



Digitized by



Qoo^z



The American Practitioner and News. 131

Here is a case in which I gave the gravest prognosis, yet the child
made a prompt recovery.

Such cases go to show the profound systemic disturbance which
may follow from gastro-intestinal irritation, and also counsel us to go
slow in making a grave prognosis.

Discussion, Dr. William Bailey : I would only speak of one ques-
tion in regard to the first case, viz., as to whether any influence was
exerted by Dr. CottelPs treatment, evacuation of the bowels taking
place one hour after the administration of calomel, whether the case
would not have done as well without the calomel. As a rule I do not
believe we find that purgation takes place in one hour after the
administration of two grains of calomel on the tongue. Probably as a
result of the gastro-intestinal irritation nature itself brought about
relief. I do not think the calomel did any harm, but I doubt very much
whether the purgation one hour after the administration of calomel, as
stated, was due to this simply.

Remarks on Appendicitis, Dr. A. M. Vance : Last Saturday I had
occasion to operate upon a man which illustrates a rather unusual
phase of appendicitis, an abscess which was located entirely back of
the peritoneum, and the pus was evacuated in the loin, and an enterolith
was taken out, proving the diagnosis. At the same time Dr. Roberts
was called to the infirmary to operate upon a little boy for appendicitis.
Before the operation could be performed the boy died. The same
afternoon about five o'clock I was called to New Albany to see a boy
with appendicitis. Before I could reach there he was dead.

I mention these cases in proof of the fact that a good paper ought
to be written upon the subject of appendicitis, as there is much yet to
be known concerning it. These two children make seven cases that
have died from this disease in the last twenty-four months in and about
Louisville, and certainly there ought to be a better understanding
among physicians in regard to these cases, because I am sure if these
seven children had been operated upon, a fair proportion would have
recovered. It does seem to me with the amount of literature on this
subject which we already have and our present knowledge of the disease
ought to make us see that the sooner such patients are operated upon
the better the chance of saving their lives.

Dr. L. S. McMurtry : I observed in the Medical Record last week a
communication from Dr. John A. Wyeth, reporting a case of suppura-



Digitized by



Qoo^z



132 The American Practitioner and News,

tive appendicitis discharging at the umbilicus. It was reported as an
exceptional feature of the disease. Three years ago I had a similar
case. Dr. Vance saw the patient with me. The patient was a girl of
fifteen, who had been brought from her home in the southern part of
the State. She was emaciated in extreme degree ; the abdomen was
enlarged, and a small stream of pus was trickling through a pin-point
opening at the umbilicus. I operated at once by incision in the median
line, and found the largest pus cavity I have ever seen. After evacuat-
ing the pus and irritating thoroughly, I made use both of tubes and
gauze for drainage. The cavity was several months in closing, but the
process, of repair was active and continuous, and healing was complete.
This girl was so long ill before operation, and so reduced by prolonged
suppuration and sepsis, that she was for a long time stooped. Last
June she called to see me and was rosy, erect, and had developed
beyond all traces of her severe illness of three years ago.

I am reminded in this connection of another unusual pointing of
appendicular abscess, which occurred in a case treated in consultation
with Dr. Cecil. The patient is a maiden lady of thirty-five, and had
suffered for several months with pain in the right lumbar region,
without any definite symptoms being present. There was nothing to
be found anteriorly to suggest appendicitis, and perinephritic abscess
was suspected when we detected deep fluctuation posteriorly. This
lady is the subject of organic heart disease so pronounced that we did
not care to anesthetize her. With local anesthesia I made an incision
through the right lumbar region at the point of fluctuation. The pus
flowed freely and was of the characteristic intestinal odor. Drainage
was established, and complete recovery followed.

These cases illustrate the varied and devious routes of pointing
in suppurative appendicitis.

Dr. Wm. Bailey : As a doctor, not as a surgeon, I want to speak of
some recent experiences in connection with appendicitis. About six
weeks ago I was called, because I was not a surgeon, to see a case in
consultation that had been under observation but a few hours ; that
was three o'clock in the afternoon. The patient was operated upon
before five o'clock, and made a satisfactory recovery. A week or ten
days ago I was called in the night for the same reason to see a child
suffering with appendicitis. The parents absolutely refused to have a
surgeon called, because they did not want the knife used ; but the
patient getting no benefit from medical treatment, by the joint advice



Digitized by



Qoo^z



The American Practitioner and News, 133

of the attending physician and myself the patient was operated upon
the next day, and is now ten days in convalescence. Last Thursday I
saw another case under exactly similar circumstances, the patient
having what was thought to be colic in the afternoon of Wednesday,
and had received two or three hypodermic injections of morphine
and getting some degree or comfort therefrom. The man really was
out attending to business two or three hours on Wednesday, then went
home as he was suffering some pain, not having, however, any elevation
of temperature at that time ; but during the night more or less reaction
came on, and I saw the case yesterday afternoon (Thursday) at three
o'clock ; he was operated upon at four o'clock, and reports are satis-
factory to-day. As a doctor this is my recent experience with appen-
dicitis.

Dr. H. A. Cottell : Dr. Vance suggests that a paper be written on
the subject of appendicitis which would be of benefit to the every-day
doctor. I know of no one better qualified than Dr. Vance to do so.
I hope he will write a paper and present it before this Society on the
Indications for Operation in Appendicitis. In the first place, in a great
many cases of appendicitis the diagnosis in the beginning is extremely
obscure. If you can make out a tumor, it is in such cases as usually
get well without operation. If there is not a tumor you do not know
whether you have an appendicitis or not until it is perhaps too late for
the surgeon to operate. Problems of this nature are always in the
way of the physician. My experience with appendicitis has been very
peculiar. I have seen a good many cases. Most of them have gotten well
by expectant measures. I recall four recent cases, two in ray own prac-
tice, the third seen in consultation ; the fourth was practically under my
care, a child with appendicitis in which the surgeon was called and re-
fused to operate. Perhaps he was not called in early enough. If the sur-
geon would tell us when he ought to be called, it would be of immense
advantage to the doctor. If he says as soon as the patient has pain in
the right iliac fossa, it would mean that over one half the cases of ordi-
nary colic would call for a surgical consultation. There ought to be some
rules laid down for the doctor, formulated by the surgeon himself, in
order that the golden moment may not pass by.

Dr. L. S. McMurtry : In view of the remarks just made by Dr. Cottell,
I deem it my duty to say a few words in reply. In the first place, I am
sure when the doctor declares that we very much need information
as to when operation should be done in appendicitis and when the



Digitized by



Qoo^^



.134 The American Practitioner and News.

surgeon should be called, that he has for the moment forgotten the
numerous papers and discussions upon these points with which the
medical literature of the past five years is teeming. It is generally
conceded that a surgeon should be called as soon as appendicitis is
suspected, and that the question of operation should receive attention
as soon as the diagnosis is made. The consequences of delay and
expectancy are well known ; they are illustrated by the report which
introduced this discussion. The way to look at this question is to
consider whether, measured by results, timely operation is as danger-
ous as delay and expectancy. In skilled hands, with proper environ-
ment, the operation of opening the right iliac fossa is of minor danger
in comparison with the results of perforation, infection, and suppuration
characterizing this deadly disease.

The influence of such remarks, emanating from so distinguished a
teacher and practitioner, is harmful ; and convey very inaccurate ideas as
to when a surgeon should be called and the indications established for
operation in appendicitis. That subject has been so thoroughly dis-
cussed, and there is such unanimity of opinion among physicians and
surgeons, that there is no place for further argument.

Dr. A. M. Vance: I recall two more cases I have had where appen-
dicitic abscesses made their way to the umbilicus; both were in
children and both were girls. In both cases the abdominal parietes
had been dissected up from the peritoneum over the whole extent of
the anterior surface from loin to loin. Both of them recovered after
opening the abscess below the umbilicus. I remember perfectly well
the case Dr. McMurtry mentioned, which was a little different from
the two just referred to, because in his case the pus was intra-peri-
toneal. In both my cases it had opened between the peritoneum and
the muscular wall, and had dissected its way to the point of least
resistance, which was the umbilicus. I certainly must agree with Dr.
McMurtry that there has been written within the last few years more
upon the subject of appendicitis than any other surgical subject, and
there is a most pefect consensus of opinion as to what should be done.
I am sure just as soon as the diagnosis of appendicitis has been made,
that the surgeon ought to be called.

I mentioned the cases in my report simply to emphasize the fact
that in the last twenty-four months I had known of seven children
dying from appendicitis, where the surgeon was not called until they
were moribund or dead, and that perhaps all could have been saved by
timely operative interference.



Digitized by



Qoo^z



The American Practitioner and News. 135

As to Dr. CottelVs idea that those cases where an abscess or tumor
forms are the ones that get well without surgery, this is certainly
an error, because I am convinced that a proportion of these cases die
from rupture of the abscess into the peritoneal cavity.

Dr. H. A. Cottell: In the first place, I did not understand that an
abscess is always formed in those cases of appendicitis exhibiting a
tumor. Do not some cases terminate by resolution? Again, there
may be an abscess which may discharge by the bowel or bladder, with
no evidence of pus breaking into the peritoneal cavity. I believe that
cases in which we find a decided tumor, where the bowel is empty, no
fecal matter being present, and no gas, may and do terminate by what
we used to call resolution, no abscess being formed. In such a case
the diagnosis of appendicitis may be made, and such cases often get
along without surgery; but there are a great many cases where the diag-
nosis is extremely obscure. Experts in abdominal surgery like Drs. Mc-
Murtry and Vance might make a diagnosis where I would be deceived.
There is certainly and necessarily a great deal of obscurity and uncer-
tainty as to the diagnosis of appendicitis in the early stages, and it seems
to me the surgeons ought to tell us, if they can, how to make it. Per-
haps they will reply that when we even suspect a case of appendicitis,
call a surgeon.

The appendix vermiformis has been regarded as a sort of anatomical
mystery; for a considerable time all kinds of theories were advanced to
account for it. Evolutionists say it is a remnant of lower animal life.
I used to be inclined to that opinion, but of recent years I have come
to the conclusion that it is an especial dispensation of providence for
the benefit of the surgeon.

Dr. F. C. Wilson : Those cases of appendicitis which give us the
most trouble are what have been termed the catarrhal form, those that
resolve without suppuration. We recognize them as suspicious cases
because inflammation of the appendix can sometimes be made out dis-
tinctly, and yet the evidence of suppuration is not suflScient to justify
us in calling the surgeon.

I want to emphasize one particular feature in the care of these
cases ; supposing that the evidence of inflammatory action will subside
without becoming urgent enough to seek the surgeon, what is the
proper course to pursue in dismissing the case ? In order to illustrate
and emphasize this, I want to mention one case that occurred in my
own experience, where I believe I erred in the way in which I dismissed



Digitized by



Qoo^^



136 The American Practitioner and News.

the case. I was called to see a young boy and recognized his case as
one of appendicitis. I told the mother that if there was no change for
the better the next morning (I saw him during the night) that I would
insist upon a surgeon being called. The next morning, perhaps
unfortunately, the boy was better. The inflammation seemed to sub-
side, and finally resolution took place without the necessity for an oper-
ation. When I dismissed the case I said to the mother, '*most likely
these symptoms will recur, and if they do, there ought to be no delay
in a surgical operation." In that mode of dismissing the case I recog-
nize now that I made a serious mistake. I ought to have said to
the mother, now if these symptoms recur, send for me without any
delay, without mentioning the surgeon's name in connection with it.
Six months later that boy was taken sick in exactly the same way; the
mother was afraid to send for me, because she knew what my advice
would be. She sent for another physician who had not seen the
patient before, and who knew nothing about the previous attack. He
watched the case for several days, and finally came to the conclusion
that a surgeon ought to be called; one was called, but he decided that it
was too late, and the boy died.

I simply want to caution physicians against falling into the same
error that I did in their mode of dismissing these cases. Be careful
not to alarm the mother by putting into her head the idea that an oper-
ation will certainly be needed. Simply caution her to call you as soon
as the symptoms recur, as most likely they will recur sooner or later.
We know that recurrent cases of appendicitis sooner or later reach the
point where the surgeon's knife is needed, as death results without it.

LOUIS FRANK, M. D., Secretary.



NEW YORK ACADEMY OF MEDICINE— SECTION IN ORTHOPEDIC

SURGERY.

Meetings of December 16, 1898, and January 20, 1899.

Shortened Pectoral Mtiscle, Dr. R. Whitman presented a patient,
a girl eleven years of age, who could not raise her right arm more than
thirty degrees above the horizontal. The cause appeared to be obstet-
rical paralysis. Round shoulders and curvature of the spine were
present. He had advised division of the unyielding contraction of the



Digitized by



Qoo^z



The American Practitioner and News. 137

lower border of the pectoralis major muscle, which presented a thick,
fibrous cord beneath the skin.

Dr. A. B. Judson said that the contraction might have resulted
from a paralyzed deltoid which had failed to give normal lextension to
the pectoral.

Dr. Whitman said that there was a very fair development of the
shoulder muscles, and that the curvature of the spine could not be
relieved until the contraction that prevented the child from lifting her
arm over the head was removed.

Tuberculous Knee and Athetosis. Dr. Whitman presented a girl ten
years of age, who had been under observation for nine years. When
one year old and under treatment for disease of the right knee she had
a convulsive attack, which was followed by right hemiplegia. The
return of voluntary power was accompanied by constant convulsive
movements of the face, arm, and leg, which had continued to the pres-
ent time and had made treatment of the knee a matter of great diflS-
culty. In spite of splints, traction, and plaster of Paris bandages, the
convulsive movements of the leg had f aused severe pain and prevented
repair, so that the local disease was still uncured. But for the youth of
the patient, amputation would have been done. The case illustrated
the advantage and necessity of rest in the conservative treatment of
joint diseases.

Cases of Doubtful Diagnosis. Dr. W. R. Townsend presented a boy,
eleven years of age, who fell from a car three months ago, and had com-
plained of pain in the left hip ever since. Six weeks ago, when he was
first seen, there was symmetry in all the measurements of the lower
extremities, but the aflFected hip showed considerable resistance to motion
in any direction, which could sometimes be partly overcome by persua-
sion and considerable force. Manipulation was painless. He stood
and walked with the left foot, leg, and thigh everted or rotated outward
ninety degrees, and this persisted. By the use of considerable force the
limb could be rolled in, but when released it flew back to its old posi-
tion. Every muscle reacted perfectly to galvanism and faradism.
Tincture of iodine had been used locally, and his locomotion had im-
proved a little. A probable diagnosis of hysteria had been made by
exclusion and because he could with effort stand and walk voluntarily
in a normal manner, and because the bad position could be overcome
by a steady pressure and without causing pain.

11



Digitized by



Qoo^<<i



138 The American Practitioner and News.

Dr. Whitman said that a faulty position of a limb in an impression-
able patient might be considered as a voluntary or unconsciously
selected adaptation to some condition following strain or other injury
of a joint.

Dr. Townsend said that the statement had been made that injury of
the obturator nerve had in some instances caused a similar eversion,
but he had not found any recorded cases.

Dr. G. R. Elliott presented a man thirty-two years of age. The
family history was negative regarding nervous and bony diseases. Five
years ago inability to move the left thigh appeared. When motion
returned to the left thigh, the right was similarly aflFected. Other symp-
toms which still persisted were burning sensations in the feet, espe-
cially in the heels, great difficulty in standing erect and walking, and
rigidity of the spine, preventing him from bending backward. Torus
palatinus was noted, and there were other degenerative stigmata.
The legs were bowed, but otherwise there were no signs of early ra-
chitic changes. The hamstrings were contracted. There was double
hallux valgus and pes equinus. The upper extremities were normal.
There were no sensory disturbances beyond the paresthesias mentioned.
Neurologists had failed to locate any organic nerve lesions. Dr. Elliott
was in doubt in regard to the diagnosis. He did not agree with an
bpiriion expressed by some members of the Section that it was prob-
ably a case of rheumatoid arthritis, a disease which could not present
so much disability with practically no involvement of the small joints,
almost painless from the beginning, and with no deposits about the
joints. The pain that was present and the disability were due to the



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 16 of 109)