Universidad de Buenos Aires. Facultad de Derecho y.

The American practitioner online

. (page 33 of 109)
Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 33 of 109)
Font size
QR-code for this ebook

Elizabeth's Hospital, Guy Wheeler Hamilton, A.B., M.D., of New York.

The exercises were conducted with the usual esthetic accompani-
ments of music, eloquence, and flowers, and the youngest brood departs
with Alma Mater^s fondest wishes and best hopes.

Digitized by


The American Practitioner and News. 285.

Hotes an5 Slueries-

Thb Operative Treatment op Goitre.— Kocher (^Correspondenz-
blattfur Schweizer Aerzte, No. 18, 1898) publishes the results of six hun-
dred cases in which thyroidectomy has been performed at Bern in the course
of the past three and a half years. Of these cases four hundred and fifty
were treated by the author himself, and the remaining one hundred and
fifty by his assistants. This is an additional report to one of one thousand
cases published early in 1895. In accounting for the large number of thy-
roidectomies performed for the removal of goitre since February, 1895^
Kocher asserts that thyroid extract is not more eflfectual than iodine as an
internal agent, and that consequently the use of the former in the treatment
of goitre has not diminished the proportion of cases needing operative inter-
ference. Thyroidectomy, which in Kocher's practice has been found an
almost absolutely safe operation in uncomplicated cases of simple goitre^
is held to be indicated by e;ccessive development of nodular growths in the
thyroid gland in all instances of cystic disease, and whenever there is a.
suspicion, however slight this may be, of malignancy. The chief indica-
tion is dyspnea, due to compression and consequent stenosis of the trachea,
a condition which can not be remedied or even relieved by medicinal treat-
ment. As the most serious and, in uncomplicated cases of goitre, the only
danger attending thyroidectomy is the fatal action of a general anesthetic,,
Kocher during the last two years has used cocaine locally on all patients-
submitted to this operation, with the exception of young children and very
nervous or sensitive subjects. The following are dwelt upon as important
points in the author's method of performing thyroidectomy : A curved skia
incision across the front of the neck, the convexity of the curve being
downwards; the stemo-hyoid and sterno-thyroid muscles are detached at
their lower extremities from the sternum, and not divided high up in the
neck, while the omo-hyoid is left intact ; the enlarged gland, after division
of its fibrous capsule, is raised from the trachea and drawn out of the
wound, so that the thyroid vessels are put on the stretch and freely ex-
posed before the application of ligatures ; the isthmus, after its exposure,,
and after ligature of the vessels running transversely along its upper and
lower borders, is forcibly compressed by forceps, so that the colloid mate-^
rial is forced out and the isthmus is reduce<l to a narrow, fibrous band.
Since 1883, when it had been proved by both surgical and pathological ex-
periences that total removal of the thyroid gland is certain to result in the
development of the condition called cachexia strumipriva, Kocher has not,,
except in case of absolute necessity, performed a complete thyroidectomy^
Since he has attended to this rule, and has endeavored, even in the most

Digitized by


284 The American Practitioner and News.

unfavorable cases, to save some portion, however small, of the diseased
gland, he has met with cachexia strumipriva in four cases only out of i,5cx>
in which thyroidectomy had been practiced. In the rare cases in which it
may be found necessary to remove the whole of the gland, the threatening
cachexia may be averted by the administration of thyroid extract. The
series of 600 cases with which this paper deals includes eighteen cases of
malignant goitre, eleven cases of strumitis, and fifteen cases of Basedow's
disease. In six of the eighteen cases of malignant disease thyroidectomy
had fatal results. The operation was also fatal in two of the eleven cases
of strumitis, and in two of the fifteen cases of Basedow's disease. Of the
remaining 556 cases in which thyroidectomy had been performed for the
removal of ordinary colloid goitre, one only was fatal, and in this single case
death was the result, not of the operation itself, but of the action of chloro-
form. The high death-rate after thyroidectomy for malignant goitre is due,
Kocher states, to the complicated nature of such cases and the frequent
necessity for removing portions of the trachea and esophagus, and also of
such important parts as the internal jugular vein, the common carotid
artery, and the spinal accessory, pneumogastric, and sympathetic nerves.
The dangers attending excision of the thyroid gland in cases of strumitis
and of Basedow's disease are attributed in the former to suppuration of the
diseased gland and septic infection, and in the latter to the faulty general
condition of the patient. — British Medical Journal,

Gout. — SchmoU {Centralb,/. inn, Med,, October 22, 1898) discusses the
theory of this disease. He says that one point in Garrod's views as regards
gout remains true, and that is the richness of the blood in uric acid dur-
ing the attack. The necroses of tissue in which uric acid crystals are de-
posited constitute a new fact discovered by Ebstein. Some authors have
shown that gouty patients are unable to maintain a nitrogenous equilib-
rium in spite of a sufficient supply of calorics and an adequate nitrogenous
■diet. It is not known in what form the nitrogen is retained. Before and
■during the attack of gout a nitrogen deficit accompanies the nitrogen reten-
tion. Garrod has endeavored to explain gout by a diminished excretion of
uric acid, Ebstein by an increased formation, and PfeiflFer by an increased
production, together with something else. Reliable analyses have shown
that the excretion of uric acid on the gouty varies within normal limits.
For a long time uric acid was looked upon as an incomplete oxidization
product ; now it is generally believed that it is derived from nuclein and
the alloxan group. Feeding with nuclein or with thymus has been shown
to increase greatly the excretion of uric acid. Uric acid arises through the
oxidization of the alloxan group: (i) Cells perishing in the body leave
nuclein, from which uric acid is derived. (2) Uric acid is also derived from
the alloxan group supplied, such as theine, caflFeine, etc. (3) In the gouty
•deposits of uric acid may be dissolved, and so increase the excretion of uric
y acid. It is very difficult to estimate the last-named factor. As regards the

Digitized by


The American Practitioner and News. 285

second, feeding with pure nuclein and thymus shows that about one fifth of
the allaxan bases thus supplied are oxidized into uric acid, and the other
four fifths disappear in the body. The latter may be built up into nuclein,
or the alloxan bodies may be split up in the alimentary canal. Another,
and the most probable view, is that the bases are absorbed and are con-
verted into uric acid, which latter if not excreted by the kidney is changed
into urea. It is impossible yet to say whether the uric acid formation is
increased or diminished in gout. In a gouty patient fed with thymus the
excretion of uric acid was increased from 0.5 to 1.3 g. This would show
that the richness of the blood in uric acid was due to increased formation.
This increased formation would appear to be due to increased cell destruc-
tion. Pfeiffer and others have shown that during the attack of gout an
increased amount of uric acid is excreted. The necrotic processes described
by Ebstein will explain the cell destruction with escape of nuclein as men-
tioned above. The cause of these necrotic processes is as yet unknown.
The author would look upon them as caused by the retained nitrogenous
metabolic products. The questions remaining to be solved are: (i) What
substances are retained in the body in gout ? and (2) under what conditions
are they retained ? — Ibid.

Pathology of Syphilis. — Adami (Montreal Medical Journal, June,
1898) discusses the nature of the different stages and forms of syphilis.
His conclusions may be summed up as follows: (i) In certain cases there
may be an absence of the primary cutaneous or epithelial manifestations of
syphilis. (2) Individuals may fail to present either primary or secondary
symptoms that are recognizable, and yet eventually develop definite ter-
tiary lesions. (3) When the subject is relatively insusceptible, it is pos-
sible that the disease may be limited to the primary cutaneous lesion, not
followed by secondary lesions. (4) In syphilis, like tuberculosis, the con-
genital form of the disease begins at what may be termed the secondary
stage of the acquired disease — for instance, the stage of general dissemina-
tion of the veins. (5) Sjphilis under proper treatment, if not a self-limiting
disease, is at least one which can be healed, so that many of the lesions
recognized as tertiary are truly the indications of the old healed syphilis
and not signs of progressive or latent disease. (6) If the disease has not
completely died out and remains latent, the resistance of the tissues of the
organ is such that in most cases it does not tend to light up again ; there is
so considerable a local reaction that the infection and consequently the
spread of the process tend to remain strictly localized, and the germs do not
become disseminated through the blood. Thus, neither the blood nor the
secretions contain the virus. (7) In a very small number of cases the reac-
tion of the tissues may be so lessened, and the virus retain or gain so high
a virulence, that either it causes ulceration, or in other ways becomes dis-
seminated and capable of causing infection even late in the tertiary stage.
(8) In the liver of a newborn infant presenting externally evidence of the

Digitized by


:286 The American Practitioner and News.

-secondary stage, there may be several varieties of lesions : (a) Well-defined
gummata; (p) miliary gummata with generalized fibroid changes affecting
circumscribed areas ; {c) miliary gummata and fibrosis affecting the whole
organ, which is thus enlarged; (d) generalized atrophic cirrhosis without
much evidence of gummata, but associated with icterus, edema, etc., the
liver being granular and contracted. Hence the changes in the liver in
-congenital syphilis resemble the tertiary rather than the secondary stage of
the disease. (9) The liver of acquired syphilis may present two conditions :
(ci) Cicatrices and fibroid changes which are indications of a previous syph-
ilis no«¥ healed; {b) the lighting up again of an obsolescent syphilis from
old foci in which the virus has remained latent. (10) Progressive syphilis
is characterized by the same succession of pneumonia, whether it be studied
a few months or many years after the primary infection. Anatomically and
histologically there is no valid distinction to be drawn between secondary
and tertiary syphilis. — Ibid.

SuLPHONAL Poisoning.— Wien (BerL klin. Woch., September 26, 1898)
relates a fatal case of subacute poisoning in a woman, aged thirty-two, suf-
fering from paranoia. The patient received mostly three doses, each of 0.5
grain, at intervals of an hour and a half on each of thirty-one days,
with occasional intermissions. The urine was examined daily, and the
patient had been treated previously with about the same doses with no ill
effect. When the sulphonal was discontinued the patient had become
quiet, but this was not the result of any sulphonal narcosis. Her general
condition was good. Thirty-six hours later the symptoms of sulphonal
poisoning appeared. They consisted at first of gastric symptoms, with
pain and vomiting, and later paralysis and hematoporphyrinuria were
noted. It appears to the author probable that the poisoning was due to a
•cumulative action. Besides the ataxia there was paralysis in the arms and
legs, probably due to a peripheral lesion. A notable fact in this case was
the late appearance of the hematoporphyrinuria, which occurred eight days
after the onset of the intoxication symptoms. Albuminuria and other evi-
dence of a toxic nephritis appeared later. The pulse-rate fell toward the
end to sixty-eight as a result of changes in the myocardium. At the
necropsy a nephritis and cystitis were found. The heart muscle showed
degenerative changes, and the pericardial sac contained an excess of fluid.
The author maintains that the great danger in sulphonal poisoning lies in
the irreparable changes found in the heart. In the stomach there were
small hemorrhagic erosions, and the organ presented an hour-glass contrac-
tion due to old ulceration. Nine tenths of the cases of fatal sulphonal
poisoning have occurred in women. Although the number of cases of
poisoning by sulphonal is small considering the frequency with which it is
used, yet precautions must be taken. The use of this agent must be as
limited as possible, and intermissions of even four or five days are too
.short. The author thinks that when symptoms of poisoning have already

Digitized by


The American Practitioner and News. 287

appeared, transfusion — or, failing that, infusion — of saline solution should
be tried. Camphor should be used in case of the least threatening of car-
diac failure. Efforts should be made to promote the excretion of the sul-
phonal by diuresis, etc. — Ibid.

Labor Complicated by Parasitic Twin. — Shaver (Richmond Journal
of Practice, January, 1898) publishes the report of a labor where the mon-
strosity recalls the case of ** Posterior Dichotomy : a Three-legged Boy,"
described and figured in the British Medical Journal of June 11, 1898. A
primipara, aged eighteen, appeared to be pregnant of twins, but two hearts
could not be detected by auscultation. The presentation was occipito-
anterior ; the maternal parts were very dilatable. After the head was born,
labor was delayed and a hand was detected presenting. This was replaced,
and the shoulders were bom, when another delay occurred, the thighs being
flexed and the feet presenting along the trunk. The hips were finally born,
and the child was found to be closely attached to another, which was finally
delivered. The first child, the " autosite," was a girl ; the parasite an aceph-
alous monster attached by a broad base occupying the region from pubes to
sacrum in the autosite, the nates being obliterated. The parasite was much
the larger, and Shaver distinctly states that it possessed a penis and testes,
possibly clitoris and inguinal ovaries, since the sex is, according to the
experience of others, invariably identical in twins of this kind. The mon-
ster seems to have been thrown away, we must note, after a bold flap ampu-
tation ; it had two feet and one hand, but no arm nor leg. The funis was
•common to parasite and autosite. The rectum of the living: child was found
about iaalf an inch from the anus, where it gave off a branch gut to the par-
asite ; this was cut and stitched and the wound closed. The child was neg-
lected and died on the fourth day. — Ibid,

Serum Diagnosis in Typhoid Infection. — Tarchetts (^Gazz, degli
Osped e. delle Clingy November 6, 1898), in addition to observations on
Widal*s reaction from the diagnostic point of view, has experimented in
seven cases, with a view of determining what relation, if any, exists between
the intensity of the agglutinating power and the gravity of the infection.
According to Courmont, with slight fever and slight agglutinating power,
the prognosis is uncertain, so also with high fever and high agglutinating
power. High fever and low agglutinating power is a bad indication, low
fever and high agglutinating power good. The author has worked the sub-
ject out thoroughly, and finds himself unable to corroborate Courmont's
statements, and quotes cases in support of his opinion. When relapses
occur he found that there was an increase in the agglutinating power.
The degree of agglutination appears to be closely related to the resisting
I)ower of the organism and the modality of the infection. No safe prog-
nostic conclusion can be drawn from comparison of the temperature chart
in relation to the degree of agglutinating power. — Ibid,

Digitized by


288 The American Practitioner and News,

Special notices*

The Treatment of Obesity.— To illustrate the rapid reduction of flesh produced
by thyroid treatment, the following case, taken from an article by Dr. M. Weiss, of
Vienna, published in the Wiener Medicinische Wochenschrift^ No. 41, 1898, will prove
of interest: "A hotel-keeper, forty-five years old, a gourmand and heavy drinker,
presented the typical picture of the plethoric form of obesity : Symptoms of stagna-
tion in the abdominal organs, bronchial catarrh ; weight one hundred and three kilos.
During thirty-six days he received ninety-six tablets of iodothyrine. In order, how-
ever, that in this case of obesity from overfeeding the action of iodothyrine should
not be neutralized by immoderate eating and drinking, it was considered necessary to
supplement the medicinal treatment with an appropriate regimen. The times of
meals were therefore regulated, fatty and sweet foods were permitted only in small
quantities, and the supply of alcoholics was reduced to one half or one liter of beer,
and one quarter liter of wine pro die. All severe muscular exertion was avoided at
the beginning of the treatment. The results of this treatment were excellent. The
reduction of the bodily weight after the first week amounted to five kilos, after the
second to eight and a half, after the third to ten and a half, and after the fourth to
twelve kilos. The symptoms of stasis had in great part disappeared, the condition of
bodily strength was satisfactory, and the patient was able to take walks of several
hours' duration and to make a tour through the mountains."

ViN Mariani in Exhaustion. — We have had occasion in numerous instances to
administer **Vin Mariani'* to business and professional men who complained of
being gradually run down. The work of the office, the cares and worry entailed by
business, and the physical flaccidity brought on by overwork, all seemed to give way
completely in a marvelously short space of time, despite the fact that the subjects
continued uninterruptedly at their usual occupations. The notable fact to be
observed is that in each instance the eflFect was permanent. But it must not be
forgotten that, in order to make this result a lasting one, it is necessary to keep the
patient upon a prolonged course in the use of "Vin Mariani." There is no doubt
whatever that this preparation has proven itself a boon to mankind. — The St. Louis
Medical and Surgical Journal.

We call the attention of our readers to the advertisement of the Robinson-Pettet
Company, Louisville, Ky., which will be found on another page of this issue. This
house was established fifty years ago, and enjoys a widespread reputation as manu-
facturers of high character. We do not hesitate to endorse their preparations as being
all they claim for them.

LABOR SAVING : The American Medical Publishers' Association is prepared to
furnish carefully revised lists, set by the Mergenthaler Linotype Machine, as follows :

List No. I contains the name and address of all reputable advertisers in the
United States who use medical and pharmaceutical publications, including many new
customers just entering the field. In book form, 50 cents.

List No. a contains the address of all publications devoted to Medicine, Surgery,
Pharmacy, Microscopy, and allied sciences, throughout the United States and Canada,
revised and corrected to date. Price, $1.25 per dozen gummed sheets.

List No. 2 is furnished in gummed sheets, for use on your mailer, and will be
found a great convenience in sending out reprints and exchanges. If you do not
use a mailing machine, these lists can readily be cut apart and applied as quickly as
postage stamps, insuring accuracy in delivery and saving your office help valuable time.

These lists are furnished free of charge to members of the Association. Address
Chari,B8 Wood Fassett, Secretary, cor. Sixth and Charles streets, SL Joseph, Mo.

Digitized by



..\ \

i-7- '

American Practitioner and News.


\ Vou XXVII. Louisville, Ky., April 15, 1899. No. 8

^ / Certainly it is excellent discipline for an author to feel that he must say all he has to say in the

=i ' fewest possible words, or his reader is sure to skip them ; and in the plainest possible words, or his

^. I mderwill certainly misunderstand them. Generally, also, a downright fact may be told in a plain .

^y ; aod we want downright facts at present more than any thing else.— Ruskin.

©riginal Qrticles^


M. D.. LL D.

The Doctorate Address of the Medical Department of the
University of Louisville, 1899.

^^'^y^ssor of Physiology^ Histology^ and Clinical Diseases of the Nervous System in the University.

" Or worn by slowly rolling years,
Or broke by sickness in a day,
The fading glory disappears,
The short-lived beauties die away."

Like a mighty reservoir with countless eflBuents, the Infinite source
of Being expresses itself in human lives. Some lend themselves to
homely uses ; some turn the wheels of industry ; some guard our life
^^d property; some ornament our grounds in babbling brooklets or
^ystal sheets ; some leap heavenward in fountains and diflFuse them-
selves in pearly drops and rainbow-tinted mists ; but each is useful
i^ Us day and way, subserving the Infinite purpose. Of all the
nianifold forms through which the Infinite finites itself, man is most
"august and complicate." A common man is a marvel, a great man
is a miracle. But the mystery of being clears not for all our scrutiny,


Digitized by


290 The American Practitioner and News.

nor will the meaning of life or the mission of death be evei more than
a riddle and a guess.

" I am ; how little more I know,
Whence came I ? Whither do I go ?
A centered self which feels and is ;
A cry between the silences :
A shadow birth of clouds at strife
With sunshine on the hills of life ;
A shaft from Nature's quiver cast
Into the future from the past ;
Between the cradle and the shroud,
A meteor's flight from cloud to cloud."

The dead man whom we commemorate to-day was a physician, a
surgeon, a writer, a soldier, an orator, a teacher, a sage, and a philan-
thropist. His State, his city can boast no greater name, nor do the
annals of American medicine present a more vigorous, original, and
versatile figure. Listen, gentlemen of the graduating class, while I
sketch the character and note the work of this many-sided man.

David Wendell Yandell was born on the 4th day of September,
1826, at Craggy Bluff, his father's countrj- home, six miles from Mur-
freesboro, Tenn., a spot whereon was afterward fought one of the
bloodiest battles of our civil war. The ancestors of the Yandells came
from England and settled in South Carolina. Whether they were of
Captain Christopher Newport's importation or not we do not know ;
but that they were chivalry of the chivalrous is well attested by the
fine intellect, manly beauty, personal courage, and gentlemanly bearing
of all who have held this honored name. David W. Yandell came of a
family that for two generations at least had been distinguished in medi-
cine. His grandfather. Dr. Wilson Yandell, was the most noted phy-
sician of his locality, and practiced his profession in three or four
adjoining counties. His father was the eminent Dr. Lunsford Pitts
Yandell of blessed memory; a pioneer of medical educs^tion in the
West, a professor in Old Transylvania, a founder of our own dear Uni-
versity — the compeer of Caldwell, Drake, Gross, Cobb, the Flints,
Rogers, Miller, Powell, Palmer, and Bayless. A scholar, a teacher, an
orator, a writer of grace and power, a connoisseur in art, and a savant
in science ; gentle, earnest, pious, modest, he was to the faculty what
John the Evangelist was to the sacred college, and a Gamaliel to
whose learning and wisdom ** five thousand men who had formed his
classes paid the deepest homage of respect." He died as he had

Digitized by


The American Practitioner and News, 291

lived; and like Archimedes, Sydenham, Mozart, and Velpeau, ** would
not sufier himself to be interrupted in his work by any thing but
resistless fate."

His mother was Susan Juliet Wendell, whose father, David Wendell,

Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 33 of 109)