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denum within four inches of the stomach, seriously interfering with
peristalsis, and of course with that function which depends upon it.
Here are two cases of ante-operative adhesions of the intestine which,
had they been observed after the operation, would have been attributed
to the operation. I can recall other similar cases.

There are some other features to which I would direct attention for
a moment. I believe instead of handling the viscera too much, we fre-
quently do not handle it enough, and very often unsuspected complica-
tions are overlooked and permitted to remain because of lack of com-
pleteness of our exploration.

Let us take up gradual impairment of nutrition with associated
nervous phenomena, which are classified under the head of neurasthe-
nia. We once looked upon neurasthenia as purely a neurotic affection.
I think nobody so recognizes it to-day. Formerly we were disposed to
look upon the condition as having a reflex origin, and many were the
cases oi>erated upon for relief of this condition which was supposed to
be due to intra-pelvic states, which, upon operation, were not demon-
strable. We now know the remarkable control of the sympathetic sys-
tem over the function of nutrition, and we know that in these intra-
pelvic diseases there is always impairment of peristalsis; there is always
impairment of the nutritive function due to lack of proper nerve con-
trol. We know that in many of these cases removal of the offending
organ from the pelvis results in restoration of the functional power of
the nervous system, and in restoration of this feature of nutrition. The
most pronounced effect of this nerve control over the alimentary canal
is to be found immediately following an operation, when we notice
complete arrest of peristalsis, which comes coincidental with pain ; for
instance, following removal of the appendages. It is only after this
has subsided that we get normal peristalsis and the bowel moves on.

Where there is impairment functionally of the bowel, we nearly al-
ways have a pre-existing history pointing to this fact, and we nearly
always have that auto-infection which we recognize as the underlying
factor of these neurasthenic cases. The fact that these systems have
become loaded down with uric acid — urea — xanthin and paraxanthin,
the fact that these poisonous products are absorbed and thrown off* by
the bowels should lead us to consider that many of these cases of neu-
rasthenia are nothing more nor less than stercoremia. When the cause
is removed the patient will often recover promptly.



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1 86 The American Practitioner and News.

The criticism in the paper lays most heavily upon the specialists;
we are too strictly specialists, and as soon as we get through with our
surgery we seldom see the patient again, I am impressed with the
importance of the criticism ; it is the kind of a criticism that sets the
profession to thinking; it causes us to reflect that we are to a certain
extent held responsible for the -final result in operative cases ; in any
event, that the responsibility should not be borne entirely by the physi-
cian after the immediate effects of the operation have safely passed.

Dr. Jas. S. Chenoweth : From surgery alone we are apt to expect
too much in those cases suffering from depressing nervous conditions.
Few surgeons could now be found who would advise operation for
simple nervous affections without there were evidences of pathological
lesions. I would not operate upon any case where I could not find
some indication of disease for which the surgery was to be undertaken.
Surgery of to-day can promise, in cases not presenting too grave
pathological conditions, not to leave the patient with any discomfort
as a result of the operation itself, save in a few exceptional cases.
Perfect technique in the abdomen, with little handling of tissues not
diseased, with small incision, small amount of trauma, without drain-
age, and careful suturing, will give us almost no trouble from adhesions
or other post-operative accidents, hernia, etc.

As to the matter of adhesions, I certainly think adhesions are more
the friend of the surgeon than to be feared by him, as a protection
against advancing infections. In clean surgery, with perfect technique,
we do not need to fear adhesions. As to ante-operative adhesions,
like Dr. Reed I have seen and operated upon two cases which exhib-
ited them in marked degree.

By removing diseased structures in the pelvis we can relieve a great
many cases where they are associated with nervous conditions, but we
have little to expect from operations in purely nervous affections.

Dr. Turner Anderson: I do not know that I have seen a great many
women who were harmed by having their ovaries taken out. On the
other hand, I have seen a good many cases that were not. helped by any
line of treatment that the general practitioner, surgeon or anybody else
adopted ; I have seen these absolutely cured, made, happy and comfort-
able, restored to society, to home companionship, by operation. T had
the pleasure of seeing Dr. Battey do his third normal ovariotomy. The
subject was a Mrs. Q., in* this city, and the operation was performed in
1875. This patient was a confirmed neurotic, and more than that, she



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was a chronic invalid. Dr. J. Marion Sims was here, and this patient
was examined by him at the Gait House. Battey examined the
case and suggested that he would operate upon her; that this was the
character of case in which his operation of normal ovariotomy should be
done. This patient had not been able to sit down for a number of
years ; she could walk about and enjoy a certain measure of quiet, but
could not sit down. A careful exploration of the intra-pelvic organs
revealed the fact that she had a displaced ovary. We see such cases
quite frequently. Battey did his operation. He opened the peritoneum
behind the uterus, made his incision in Douglas' cul-de-sac, and had a
great deal of difficulty in removing the ovaries, but it was finally
accomplished. Dr. Murdock, of Pittsburgh, was present and gave ether.
That woman was benefited. It was a normal ovariotomy; she did not
suffer from cystic disease of the ovaries ; she had no intra-pelvic process
which would produce adhesions, etc. ; she was profoundly neurotic and
a chronic invalid. She recovered after the operation and became
entirely well, and was able to do what she had not done for years, to sit
down. I can not say that I have seen a great many women who have
been so very markedly harmed by our operative procedures ; but on the
other hand I have seen a large number, which I presume is the obser-
vation of every other surgeon, who had resisted all other methods of
treatment at the hands of surgeons and general practitioners, who were
entirely relieved by operation.

Dr. Thomas Hunt Stucky : I was struck with the unanimity of the
way in which the surgeons apologized for their work. My paper was
not intended to be a criticism of the work of the surgeon up to the
present time, but rather as a comment upon the improvement in their
work now as compared with five or more years ago. When the first im-
provement in abdominal technique manifested itself I do not know, but
it is a noticeable fact that within the last three or four years there has
been a very marked lessening in the amount of after-disturbances upon
the part of patients. If I were compelled to make a criticism of the
abdominal surgeon's work, it would be this: the abdominal surgeon,
after receiving the patient from the physician, operates, sends his patient
home, with no instructions to the physician, and no advice or sugges-
tion as to the after-treatment.

I believe where both ovaries are removed very good results are
obtained and have been obtained by the administration of ovarian
extract. I believe that in all these neurasthenias which we encounter j



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1 88 The American Practitioner and News.

the trouble is primarily an auto-intoxication, and the condition is per-
haps one of lithemia, and the disturbances resulting therefrom are
exaggerated or augmented by the pathological condition.

It is a reflection upon the surgeon as well as upon the physician
who has referred the patient, to have after-complaints as to the non-
fulfillment of promises of cure. Cure does not mean the completion of
the operation and healing of the wound, and I believe it would be bet-
ter to the patient and greater justice to the surgeon and the physician,
if the chain of after-eflFects necessarily following would be fully ex-
plained. There should be a free exchange of opinion between the
surgeon and the physician after the operation has taken place.

I would like to make one comment upon what my friend. Dr.
Vance, has said about the hypodermic syringe. The criticism prac-
tically is a just one, but Dr. Vance in a thousand years could not make
me believe that any progressive practitioner of to-day is using opium
by the mouth, by suppositories, or by local application for the ameliora-
tion of these pathological conditions. None of us at present use
much opium, except for the alleviation of pain.

As to the question of adhesions, I simply reported these cases as a
result of observation. I have had no chance to hold other autopsies
upon such patients. Within the last few months a case was operated
upon in my own practice for secondary adhesions. But the purpose of
the paper was to produce, if possible, a more cordial relationship, to
impress upon the surgeon, if within my power to do so, the absolute
necessity of following these patients beyond the line of the operation,
after the operation has ceased, to give some after-attention to the pa-
tient, to instruct the general practitioner to whom the patient is returned
what is necessary to bring about the restoration which the surgeon
believes is going to take place. I believe the surgeon's work is only
half done when he operates upon a patient and then turns the case
over to the physician. LOUIS frank, m. d., Secretary,



Glycolytic Enzyme in Muscle. — Brunton and Rhodes. Glycolytic
enzyme in muscles. (Cent. /. Physiol, 1898, p. 353.) Juice squeezed out of
muscles by hydraulic pressure, when perfectly fresh, exerts a distinct glyco-
lytic action on diabetic sugar and dextrose. It loses this property in a
few days. They are undecided as to whether it is transformed into a
zymogen or simply decomposed. — The Dominion Medical Monthly,



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The American Practitioner and News. 189



HcpiciDS anb 3ibliograpI|y.



A Text-Book of Puthology. By Ai«frbd Stbngbl, M. D., Instructor in Clinical
Medicine in the University of Pennsylvania; Professor of Clinical Medicine in
the Woman*s Medical College, etc. With 372 illustrations. 848 pp. Price, cloth,
$4.00; half morocco, $5.00. Philadelphia : W. B. Saunders. 1898.

The author has in this work presented the subject of pathology in a
practical form and constantly from the point of view of the clinical pathol-
ogist. We are assured that considerable parts of the work were first
prepared and used as the basis of demonstrations upon clinical pathology
for students of medicine.

The discussion of methods of examination have been mostly excluded,
as likewise has the pathology of the skin and the organs of special sense,
these being matters presented in special works so much more completely
than is here advisable. The illustrations* are well executed, though few of
them in colors.

When one finds a concise work on pathology reaching such dimensions
as this, he feels to express the wish that discovery in that line has about
reached its limit, unless something may be revealed to himself. We know
nothing so complete in this line produced this side the ocean. d. t. s.

An lotrodoction to Pathology and Morbid Anatomy. By T. Henry Green, M.
D., F. R. C. P., Physician and Special Lecturer on Clinical Medicine at Charing
Cross Hospital, etc. Revised and enlarged by H. Montague Murray, M. D.,
F. R. C. P., Physician to Outpatients and Lecturer on Pathology and Morbid Ana-
tomy at Charing Cross Hospital. New (eighth) American edition. Thoroughly
revised from the eighth English edition. By Wai^TON Martin, Ph. B., M. D.,
Assistant Demonstrator of Anatomy, College of Physicians and Surgeons, Colum-
bia University, etc. Illustrated with two hundred and sixteen engravings, six
, in colors, and a colored plate. 582 pp. Price, $2.50, net Lea Brothers & Co.

1898.

Several changes have been made in the arrangement of the text in
this edition. Several new illustrations have been added and alterations
made in the arrangement of the text.

The work is essentially a treatise for students, and this means, not in
contradistinction from practitioners, but teachers who might need larger
and more elaborate works.

As the production of successive editors and revisers and other most
competent teachers whom they have called to their assistance, its quality
may be expressed in the announcement that this is the eighth American
from the eighth English edition.

It is the text-book of the English-speaking peoples, with sway scarcely
disputed. What a startling impression would have been produced, could



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190 The American Practitioner and News.

this work have been flashed on the medical world only twenty years ago!
The most pronounced change has, of course, occurred in regard to bacteria
and the means of defense possessed by the system.

In 1882 the reviewer wrote a short article for the New Orleans Medical
Journal, entitled "The R61e of the Leucocyte," taking the ground that the
leucocytes were the ants, the bees, and the watchdogs of the system, the
guards, the builders, and the scavengers. Dr. Matas, who was then the
editor, accepted it for the leading article of the next issue. But before it
came out the journal had passed into the hands of a coterie of young
physicians, and they voted the article too fanciful for publication in a sober
scientific journal. At that time nothing had been published in this country
of Metschnikoff *s wonderful discoveries. The " R61e of the Leucocyte,"
however, went on record in the Southern Journal of Pharmacy, an obscure
pharmaceutical journal of New Orleans. But Metschnikoff has filled the
world with his fame. We must not, however, waste the reader's time, and
will only add ** Pathology and Morbid Anatomy," Green, eighth edition.

D. T. 8.

A Manual of Venereal Diseases. By Jambs R. Hayden, M. D., Chief of Clinic and
Instructor in Venereal and Genito- Urinary Diseases at Columbia University, New
York, etc. With fifty-four illustrations. 304 pp. New York and Philadelphia:
Lea Brothers & Co. 1898.

In this little volume is given, in a clear and compact form, a practical
working knowledge of gonorrhea, chancroid, and syphilis. If the author
has contributed little that is new, he yet nurses no fads.

Gonorrhea, in spite of all the ado made of retro-injection and the like,
he treats mainly with the old astringent injections of zinc, lead, and
the like, and in such style as would lead to the conclusion that the
thorough and frequent removal of the putrescent pus is what is desired
to be accomplished, which in fact is probably the case.

Chancroids are to be cauterized only with the greatest rarity, which being
supported by all just experience, makes one wonder why the patients of
past ages do not turn upon the surgeons in a regular ghost-fight for all the-
useless pain inflicted with manifest aggravation instead of relief of disease.

He recommends gradual dilatation for the treatment of urethral stric-
ture, and this is where his good sense comes in again.

In the treatment of syphilis he adds nothing, but follows classic lines.

D. T. s.

Cleft Pulate; Treatment of Simple Fractures by Operatloo; Disease* of Jolots;
Aotrectomy; Hernia, Etc. By W. Arbuthnot Lanb, M. S. 278 pp. Price 5
shillings. London : The Medical Publishing Company.

This is a little book, but full of thought, and evidently written by the
author to disseminate the results of his own thoughtful study and observa-
tion. Its originality really entitles it to a fuller review than many a larger
work, and more than space allows. In his first article. Cleft Palate, we



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The American Practitioner and News. 191

note, first, the contention that the pressure of breathing has much to do in
promoting the growth of the nasal cavities, and that by enforced and con-
tinued nasal breathing among children, the growth of adenoids may be
prevented and an increased capacity secured. In the operation for harelip
he urges the use of sutures instead of pins, and criticizes operators for
showing better results than he himself can attain. He contends that less
scars are shown when pins are not used. If pins are reinforced with
gauze and collodion in' such a way as to allow them to be removed in a few
days, it is hard to see the necessity of any scar beyond a white line.

In fractures he dwells with earnestness on. the necessity of exact
apposition not only for the speedy cure of the injury, but to prevent mod-
ification of related joints which takes place when the deformity changes
the direction of the force pressing on them.

In the remaining articles, also, there is much originality, suggestive if
not instructive. d. t. s.

The Care of the Baby. A Manual for Mothers and Nurses. Containing Practical
Directions for the Management of Infancy and Childhood in Health and Disease.
By J. P. Crozibr Griffith, M. D., Clinical Professor of Diseases of Children in
the Hospital of the University of Pennsylvania, etc. Second edition, revised.
404 pp. Price, I1.50. Philadelphia : W. B. Saunders. 1898.

This work is ofiFered by the author as a reliable guide for mothers
anxious to inform themselves with regard to the best way of caring for
their children in sickness and in health. And, in so far as the medical
aspect of the matter is concerned, it is not easy to see how it could be better
done.

The whole work gives evidence of having been produced by one well
informed in his department, experienced and thoroughly sympathetic. It
would be a fortunate thing for the country if every woman entering upon
the duties of motherhood could avail herself of the helpful assistance of a
treatise like this. We bespeak for it a cordial reception. d. t. s.

American Pocket Medical Dictionary. Edited by W. A. Newman Dori^and, A. M.,
M. D., Assistant Obstetrician to the Hospital of the University of Pennsylvania, etc.
Containing the Pronunciation and Definition of over 26,000 of the Terms Used in
Medicine and the Kindred Sciences, along ifvith over 60 Extensive Tables. 548
pp. Price, $1.25. Philadelphia : W. B. Saunders. 1898.

It is the avowed intention of the editor of this little work to develop
the possibilities of the pocket dictionary to a degree not heretofore
attained. A systematic gleaning has been made through the latest med-
ical literature, and the vocabulary is strictly up to date.

A large amount of matter has been inserted in tabular form which will
prove of value to students for memorizing while preparing for examina-
tions, besides serving to group correlated facts in a convenient form for
quick consultation.

One drawback it has in common with Gould's pocket dictionary : One
will need an old copy to refer to, as the publishers have made these too
pretty to use. d. T. s.



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192 The American Practitioner and News.



Ohsixacis an5 Selections*



Weil's Disease. — Leick {Deut. med, IVoch., October 20, 1898) reports
a fourth case from the Greifswald clinic. The four patients were all
engaged on the same estate, and attributed their illness to contaminated
food, with the exception of the last one. The author draws attention to
the fact that during many years the only cases of Weil's disease have come
from this one place, and have occurred within the last two years. In the
present case a man, aged 28, was seized with vertigo, and a feeling of pros-
tration, with pains in the splenic region. A few days later there was jaun-
dice, loss of appetite, thirst, and diarrhea. On the fourth day vesicles
appeared on the lips, and there was marked epistaxis. Delirium occurred,
especially at night. On admission, there was marked jaundice, as well as
petechiae scattered over the body. Temperature 31.2** C; pulse 112. The
spleen was distinctly enlarged, and the urine contained a little albumen.
Under treatment, mainly dietetic, the temperature gradually fell and the
other symptoms diminished. The pulse fell to 50 beats a minute. Conva-
lescence was slow and interrupted. On the nineteenth day after the onset
there was a relapse, the fever lasting several days. The illness presented
all the characteristics of Weil's disease, including the tenderness over the
liver and the muscular pains. The etiology is very obscure. Bacterio-
logical and other examination of the blood was negative. The author
vigorously opposes the view that Weil's disease is really enteric fever com-
plicated by jaundice. Widal's reaction is absent. He looks upon it as a
disease by itself, of which the specific infective virus is as 3'et unknown. —
British Medical Journal,

Bilateral Ligature of the Internal Iliac Artery. — Qu^nu
and Duval {Rev. de Chir., November, 1898) published the results of a study
of the anatomical relations of the internal iliac artery, and describe a
method, based on these results, of practicing bilateral ligature of this ves-
sel by the transperitoneal operation. That this operation is now one of
practical interest, and not merely a dissecting-room exercise, is shown by a
list of 14 recent cases, in which both internal iliacs have been tied with the
object either of producing atrophy of a pathological growth (enlarged pro-
state, uterine fibroma) or of preventing free hemorrhage during removal of
the rectum and sigmoid flexure for cancer, or during total abdominal
hysterectomy. In five of these cases the operation was performed in the
old way, by double incision, and without opening the peritoneal cavity. In
the remaining nine cases the transperitoneal method was selected, which
ihethod the authors have been led by their personal experience on both the
living and dead subject to regard as the only rational and practical one.



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The American Practitioner and News. 1 93

whether for bilateral or single ligature of the internal iliac ; the operation
in itself is a safe one with regard to both immediate and remote results,
and the circulation is soon completely re-established in the pelvic region
supplied by the ligatured vessel. The abdomen having been opened by an
incision in the middle line extending from a point just below the umbilicus
to the pubic symphysfs, the artery is exposed by a vertical incision of the
posterior layer of the parietal peritoneum. The middle of this incision
should correspond to the level of the upper margin of the sacrum. The
operation is usually found an easy one when performed on the right side,
but on the left side it may be attended with much difficulty when the sig-
moid flexure is short and fixed by a narrow mesentery. In such case it
would be necessary to penetrate both layers of the mesentery, the vessels
to the large intestine being carefully avoided, and thus to divide three lay-
ers of peritoneum before the artery could be exposed. — Ibid.

Treatment of Serpiginous Ulcer of the Cornea. — Lesshaft {Klin,
Monatsbl.f. Augen,, October, 1898) is of opinion that in the treatment of
this condition attention should be directed in the first instance to the lach-
rymal passages, that is, in cases where the ulcer is apparently spontaneous
and not due to trauma. The absence of any manifest dacryocystitis is no
bar to the infective influence on the cornea of bacteria in the nasal duct.
Accordingly he slits up the lower canaliculus and irrigates the duct with i
in 5,000 HgCla daily, washes out the conjunctival sac with the same solu-
tion, and applies a moist dressing with protective to the closed lids. In
addition iodoform is dusted on the ulcer and inner canthus, and atropine is
instilled. This line of treatment he has found immediately effective ; the
ulcer ceases to spread, infiltration becomes less and disappears, and hypo-
pyon absorbs ; scarring is reduced to a minimum. It is only in the event
of the ulcer not yielding to this treatment that he employs and recommends
the galvano-cautery, or, if the ulcer is very extensive, Saemisch's section. —



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 22 of 109)