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to pass from under observation. Never retain a pessary if it is causing the
least discomfort. Daily vaginal douches are necessary. Never introduce a
pessary unless the uterus is freely movable and can be replaced by manipu-
lation. Never fail to seek the cause of the misplacement and endeavor to
remove it. The pessary alone will not cure. — Ibid,

Organism AL Contents of the Lungs. — Barthel {CentralbL /. Bakt,
xxiv, 11-12) submits Diirck's statement that the healthy human lung is,
during life, rich in bacteria to a searching examination, and comes to the
following conclusions: (i) The finer bronchioles and the air vesicles are
free of organisms; (2) the trachea and the bronchi of moderate caliber
exhibit upon their surface both pathogenic and non-pathogenic organism ;
(3) as compared with the flora of the mouth and fauces, there are more
pathogenic organisms in the trachea and bronchi. This difference in pro-
portion may be due to the multiplication within the bronchi of the patho-
genic varieties, which are known to grow better than the merely sapro-
phytic ones at the temperature of the body, and also to the excretion of
these organisms during disease into the bronchi from out of the blood
stream or lymphatics, an event the possibility of which has been demon-
strated. These organisms tend to be removed by the ciliated epithelium,
and to be rendered inert by freshly-secreted mucus; but if their epithelium
or the mucous follicles be in any way injured, the bacilli gain entrance into
the substance of the lung. The diplococcus lanceolatus appears to be more
often present than all other varieties, and to be one of the most virulent. —
Ibid.



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Special. ZTotices*



In cholera infantum the Imperial Granum Pood has proved of priceless value,
being often the only nutriment found suitable and capable of being retained. Thou-
sands of lives have apparently been saved by its use, and it has seemed to possess not
only nutritive but medicinal value, so immediately soothing and quieting was its
effect. This shows the vital importance of such a nutriment, one that is pure, natural,
and unsweetened, and that can be easily and quickly assimilated even when the
digestive powers are impaired by disease.

We are in receipt of a beautiful lithographed pamphlet from the ever-enterprising
Mr. Henry, of Louisville, who, in a letter, informs us of his now being the principal
owner of the famous French Lick Springs, of Indiana ; capacity, 500 guests. The
celebrated Spa " Pluto,'* America's Aperient, he will introduce at once through the
medical press as the most saline hydrogogue eliniinant and intestinal antiseptic akin
to Carlsbad, without the accompanying nausea and thirst.

E. N. Campbbi«i«, M. D., Good Hope, 111., says: I have used Aletris Cordial in
threatened miscarriage, and find it one of the finest and most efficient preparations
that it has been my privilege to prescribe. Aletris Cordial should be used more than
it is, although it is largely prescribed, yet like its twin sister, Celerina, it is not pre-
scribed often enough to prove its efficiency. Most all cases that these preparations
are used in are of a chronic t3rpe, and those that require patience to relieve ; hence, if
these two remedies are taken regularly and persistently, according to the case, they
will satisfy all concerned.

Whbn Pain Is Dominant. — A number of years ago, in a conversation with my
old friend, Professor Stucky, of Louisville, he told me that he used far less morphine
now than formerly, and that he was able to combat the factor of pain as successfully
in the majority of cases without it as he did with it. He urged me to give antikamnia
to my patients who had neuralgia, la grippe, rheumatism, locomotor ataxia, and dys-
menorrhea, instead of using morphine. I acted on his suggestion, and have been
able to relieve this class of patients as effectively and without producing the evils
that result from the exhibition of opium or its alkaloids. Antikamnia possesses ano-
dyne, antipyretic, and analgesic virtues, and has been thoroughly tried by able ther-
apeutists. Professor Shoemaker, of Philadelphia, has found it very valuable in rheu-
matism, migraine, or neuralgic headache, and many other nervous affections.

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

Wet 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.

LUt No. J 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, I1.25 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^bs Wood Passbtt, Secretary, cor. Sixth and Charles streeU, St Joseph, Mo.



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THE



American Practitioner and News.



'NET TENUI PENNA.'



Vol. XXVII. Louisville, Ky., May i, 1899. No. 9

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the
fewest possible words, or his reader is sure to skip them ; and in the plainest possible words, or his
reader will certainly misunderstand them. Generally, also, a downrigrht fact may be told in a plain
way ; and we want downright facts at present more than any thing else.— Kuskin.



©riginal drticlcs*



DISLOCATION OF THE CERVICAL VERTEBR/G, FOLLOWED BY
MANIA AND DEATH : REPORT OF A CASE.*

BY THOMAS L. BUTLER, M. D.
Demonstrator of Operative Surgery and Surgical Dressings ^ University of Louisville.

In lieu of a written paper I want to report a case that was of unu-
sual interest to me, and I think will be more or less interesting to most
of the members, as it has several unique features.

The patient, Mr. W. W., aged thirty years, was admitted to the City
Hospital on the afternoon of November 12, 1898 ; he was first seen by
me about six o'clock in the evening.

The history of his injury was about as follows : He had been follow-
ing his occupation, that of Western Union lineman, during the day.
In the afternoon he was inspecting a line from the rear of a train. As
I understand it, he was riding on the rear platform with his face toward
the door of the car, looking upward inspecting the line. This, I believe,
is the reverse of the usual order. He lost his balance and fell back-
ward, striking on the back of his head, bending his neck forcibly for-
ward.

When seen by me there was little or no evidence of bruising other
than a few scratches on his face. His head was drawn slightly to the
leftside; the right pupil was normal ; the left was dilated but respon-
sive to light. There was complete paralysis of motion in his right leg.
Sensation was apparently unimpaired. There was a modified function
of the right arm which seemed to be particularly noticeable as regards

•Read before the I«oui«ville Medico-Chirurgical Society, April 7, 1899. Per discussion see page 346.



26



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330 The American Practitioner and News.

abduction. His face was markedly flushed, about the condition seen
from an overdose of atropia. I have no record of his pulse, tempera-
ture, etc., at that time, but taken two hours later it showed tempera-
ture 99° F., pulse 90, respiration 28. The head could be brought over
to the median line, that is, it could be brought straight, with great
pain to the patient, but it could not be bent to the right side.

In putting him on the examining-table \vl the erect posture it was
found that the head could be rotated slightly, and we could get fairly
good antero-posterior movement. Putting my finger in his mouth, an
irregularity of the posterior pharyngeal wall could be distinctly felt.

The patient was seen again at 9:30 p. m. with Doctor Roberts. We
agreed as to injury of the cervical vertebrae with probably an intra-
cranial complication, and thought it best to wait further developments.

The chart shows that at 10 p. m. same date the patient was very
restless, with a pulse of 120. I neglected to state that the patient's
mental condition was only fairly good. He would answer questions
when asked, but not always in a rational way. He had no idea of his
whereabouts, thinking that he was in Eminence, Ky., this being his
temporary home and about where he fell off the train.

The next morning, November 13th, at 8:30, pulse 64, temperature in
the axilla 99.8° F., respiration 30. He had slept but little during the
night, but was quiet most of the time. He had perspired freely during
the morning hours. He voided his urine involuntarily, which he did
throughout the entire time. At 6:30 p. m. the same day his pulse was
64, temperature in the axilla 99.25° F., respiration 20. Doctor Barker,
of the City Hospital staff, telephoned me later in the evening that he
thought paralysis of the right arm was getting more marked, and we
determined to operate the next morning.

November 14th, morning of the operation, at 9 o'clock his pulse was
64, temperature in the axilla 99.8° F., respiration 26. The patient
had a fairly good night, having slept several hours. He was given an
enema, which was followed by a large fecal evacuation ; he was then
brought into the operating-room. The blush of which I have spoken
was very marked at this time, not only on the face but almost over the
entire body, especially on his back. We cut down over the cervical
vertebrae, and found quite a marked separation of the first and second
vertebrae; the posterior, capsular, and right lateral ligaments were
torn ; there was slight displacement to the right side, that is, the first
cervical vertebra was displaced somewhat to the right. I do not see



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• The American Practitioner and News. 33 1

how this could be true in a marked way without a fracture of the
odontoid, which he evidently did not have. By manipulation, exten-
sion, and counter-extension we were able to get the vertebrae in very
good ]K>sition, and tied the first and second together by passing a heavy
silk ligature underneath the posterior arch of the first cervical, through
the spinal foramen between the bone and the dura, and underneath both
spinous processes of the second cervical vertebra. The parts were
gotten in good position and maintained by a stout silk ligature. There
seemed to be a slight separation between the second and third cervical
vertebrae, but it was only slight, and no attention was paid to it.

At 5:30 the evening of the operation, November 14th, pulse 96, tem-
perature 103.8° F., respiration 34; at 9:15 P. m., pulse 96, temperature
101.4® F., respiration 30. Patient very restless that night.

On November 15th, at 9 a. m., pulse 84, temperature 102.4° ^-i respi-
ration 30; at 9 P. M., pulse 80, temperature' 102° F., respiration 26.
The temperature had been as high as 103° F. during the day.

November i6th, 9 A. m., the patient had had a good night, sleeping
nicely, only awakening to ask for water ; pulse 80, temperature 102°, res-
piration 24. During the day the patient passed his feces involuntarily,
which he continued to do throughout the entire time. The wound
was dressed and the gauze drainage removed.

November 17th, 9 a. m., pulse 74, temperature 98.8° F., respiration
30. The patient had had a bad night; he was delirious most of the
time ; this delirium was marked throughout the entire time from this
period on to the end. I never saw him after this when he was able to
give an entirely sensible answer to any question, although the attend-
ants stated that he frequently answered rationally.

I now found that the patient had been on quite a spree for some
time previous to the injury, and we then thought this probably was
'delirium tremens, but the subsequent history of the case rather rules
this out. Later on in the case the man had to be tied to the bed to
keep him from tearing oflF the bed-clothes. He would always answer
when spoken to, and seemed to desire some one close by him all the
time ; this was about the only way he could be kept quiet.

November i8th, 19th, and 20th to the 22d, the pulse range was from
70 to 90, temperature from 98.4° F. to 100° F., respiration from. 20 to 30.
Sometimes the temperature was slightly higher than stated. The eye
symptom remained the same as when first seen. About this time the
arm began to improve, which improvement steadily increased until he



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332 The American Practitioner and News. •

was able to put his hand on the top of his head without any trouble ;
but he never seemed inclined to use his right arm as he did his
left.

From November 23d to 30th inclusive the pulse range was 70 to 80,
temperature practically normal, respiration 18 to 20. Only once
during that time did the temperature go as high as 99° F. About
December ist he began to move his head ; he could raise his head up,
and in fact get almost any motion ; this improved gradually until he
could use his head freely, move it to the right side, or put it in almost
any position desired.

The man went along until December nth with pulse, temperature,
and respiration about normal. He was very delirious, and seemed to be
getting more so all the time ; he also grew more noisy. He now could
not draw the right leg up, but if it were placed in a flexed position he
could straighten it out. This is about as far as improvement in leg
progressed.

From December nth to 15th his temperature ranged from 97° F. to
99.6° F., with a steadily increasing pulse. On December 19th his pulse
had risen to 108, temperature loi" F. December 21st his pulse was ico,
temperature 102° F., respiration 26. The same day his pulse went up
to 156, with a temperature of 105° F., and on the following day the
patient died; just before death the temperature registering 108° F. in
the axilla. I will state here that the wound had suppurated quite a
good deal, especially during the last few days.

A post-mortem was held, at which I was not present, but it showed
practically little or no trouble with the brain. I suspected that there
was some serious lesion of the intra-crapial structures, and that perhaps
I had not done my whole duty in not opening cranium, but the post-
mortem showed no trouble with the brain except some evidence of
congestion. The wound about the neck showed hardly any tendency
to heal. The ligature was in position, but there was considerable dis-
placement. The ligature had cut its way through the soft tissues and
into the bone, and had really cut off* part of one of the spinous proc-
esses of the second cervical. There was apparently no injury to the
cord. The ligature was in position, showing that there had been no
harm done to the dura, the ligature being clearly between the dura
and the bone. There was no fracture, but separation and incomplete
dislocation.

LOUISVII*I*E, Ky.



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The American Practitioner and News. 333

A CASK OF EXTRA-UTERINE PREGNANCY: OPERATION:

RECOVERY.*

BY LEWIS S. McMURTRY, A.M., M. D.
Professor of Gynecology aud Abdominal Surgery in the Hospital College of Medicine^ Louisville.

Increasing experience in the operative treatment of extra-uterine
pr^nancy has demonstrated the truth and accuracy of Mr. Lawson
Tait's observations. All forms of gestation originating outside the
uterine cavity are primarily and essentially of the fallopian tube. All
former teaching that ectopic pregnancy was of various types, tubal,
ovarian, and abdominal, has fallen to the ground, and this entire subject,
of such vital surgical import, and formerly so complicated and obscure,
has been made simple and clear. This result is wholly due to the
labors of one man, Mr. Lawson Tait, and will ever remain an imperish-
able monument to his genius. Like most eminent advances in our
art, but little has been added to his original elucidation of the subject ;
and, despite all dispute and controversy, the true pathology and treat-
ment, as presented by Mr. Tait, are confirmed by increased research and
surgical experience.

Ectopic pregnancy was formerly so confused with other supposed
hemorrhagic peri-uterine tumors as to mislead altogether the student
of intra-pelvic pathology. Under the varieties of hematocele, blood
accumulations within the pelvis were attributed to various causes;
now we know that except in rare instances all these are due to rupture
of the gestation-sac of tubal pregnancy.

Various causes have been assigned for the fertilization and devel-
opment of the ovule in the fallopian tube instead of in its normal hab-
itat, the endometrium. According to Webster, tubal pregnancy may
be attributed to the fact that in the earlier type of mammalia the uterus
was bicornate, which type is represented in the human subject by the
fallopian tubes ; that in some women there is structural reversion to
the former type, and therewith the liability to tubal pregnancy. While
this theory is rather plausible, it does not explain the process satisfac-
torily. The views of Mr. Tait upon the mechanism of the process
accord more with established pathology and clinical observation than
any as yet offered. Mr. Tait attributes this accident to a desquamative
salpingitis, which by denuding the mucous membrane of its epithelium
begets a condition of the tubal mucous membrane analogous to that
of the endometrium after menstruation. This explianation of the

* Reported to the Louisville Medico-Chirurgical Society, April 7, 1899. For discussion see page 335.



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334 '^^^ American Practitioner and News.

etiology of tubal gestation is, however, problematical for the most part,
but accords more with clinical facts than any other theory. The com-
mon clinical observation that tubal pregnancy is so often preceded by
a period of sterility tends to corroborate this view of the subject.

The treatment of tubal pregnancy has not been improved by any
modification of Mr. Tait's methods as yet oflFered to the profession.
From the very nature of the accident, and the fact that cases are pre-
sented to the surgeon in every phase and stage of the process of rup-
ture and circumjacent inflammatory changes, the diagnosis as^to details
of complications must of necessity be perfected after the abdomen is
opened. No better illustration of this fact could be found than in the
case I herewith report ; the gestation-sac was so attached to the colon
by adhesive peritonitis that in separation even with the utmost care
the intestinal coats were stripped through to the mucosa. Seeing the
precise extent of injury to the intestine, it was accurately repaired at
once, and did not in the least complicate the patient's recovery. Such
precision of operative technique can only be attained when operation
is done by supra-pubic abdominal section.

The specimen I here present, and which has furnished the sugges-
tion of these remarks, was removed in a case at my clinic at Gray Street
Infirmary one week go. The patient, a white woman twenty-two years
of age, was referred to me by her physician a few days preceding. She
was suffering with an active peritonitis, and had been quite ill for
three weeks. Upon examination the pelvis was found to be packed
with a firm mass, and the uterus pushed far away to the right side. Two
menstrual periods had been missed, but the history as to tubal rupture
was vague. The diagnosis was based in great part upon the shreds of
decidua which appeared in the sanguineous uterine discharge existing
at the time of my examination.

Upon opening the abdomen the results of long-established peritoni-
tis were apparent. The omentum capped over the pelvic basin, and all
peritoneal surfaces were adherent. Separating adhesions, a large dis-
organized blood-clot was scooped out, and the ruptured sac here pre-
sented was separated. In this step of the operation, as already stated,
extensive denudation of the intestinal wall was unavoidable. The
ovarian vessels were carefully secured and ligatured, and the sac cut
away. After separating all adhesions the injured intestines was sutured,
the toilet carefully made, all organs restored to normal position, and
the abdomen closed. An examination of the specimen shows the point



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The American Practitioner and News. 335

of rupture of the sac. The fetus was not found in the blood-clot, and
had doubtless been digested by the peritoneum. The tube, it will be
observed, is enormously dilated, forming the large sac, and thickened by
superimposed layers of inflammatory exudate. The patient had been
reduced to a very feeble state by hemorrhage and peritonitis, and I
utilized with great advantage intravenous transfusion of decinormal
saline solution during the operation. She reacted promptly, and her
condition has been most excellent through the first week of convales-
cence now passed. Her recovery is now fully assured.

LOUISVII,I,B.



Kcports of Societies*



THB LOUISVILLE MEDICO-CHIRUROICAL SOCIETY.*

Stated Meeting, April 7, 1899, the President, Thomas Hunt Stucky, M. D.,

in the chair.

Dr. L. S. McMurtry showed two specimens: first, ectopic gestation ;
second, an appendix. [See page 333.]

Discussion. Dr. T. S. Bullock : There is only one point to which I
desire to call attention, and that is with reference to the remark made
by Dr. McMurtry as to the site of impregnation. I believe that the
most frequent site of impregnation is in the tube, and that these ectopic
gestations are caused by some interference with the passage of the
impregnated ovum to the uterus, and that all extra-uterine pregnancies
are primarily tubal.

Dr. Turner Anderson : It seems to be the accepted idea in the pro-
fession that all those conditions that we used to designate as extra-
uterine hematocle, etc., are now regarded as cases of ectopic gestation.
I think it would be a little diflScult, however, to determine the ques-
tion from the gross appearance presented by the specimen whether we
have a case of hematosalpinx or an extra-uterine pregnancy. Unless
we had a demonstration, if it were possible, by the microscope of the
chorional villi there must be some doubt as to the exact nature of these
cases. In this case it looks as though there were a direct communica-
tion with the distal extremity of the tube, and pregnancy must have
occurred in the ampulla, that the end of the tube was open, and the

* Stenoffraphically reported for this journal by C. C. Mapes, I^ouisville, Ky.



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336 The American Practitioner and News.

gestation progressed, as also did some inflammatory process in the tube,
until there was a thickened mass which became adherent and walled
over by the omentum. Unless one had great experience he would not
recognize by putting the finger on this specimen that it was one of
ectopic gestation. I suppose the microscope would settle the question,
and we ought in that way to difierentiate between an ordinary dilated
tube and a case in which gestation has occurred and the chorion has
developed to such an extent that the elements which enter into the
gestation process would present themsjelves. I recently showed before
the Louisville Surgical Society a specimen where there was a tube in
which was a large blood-clot, the distal extremity firmly adherent and
entirely obliterated, the tube very much dilated. It was simply a blood-
clot. Perhaps that was a case of ectopic pregnancy, but I was under
the impression that it was simply a case which we recognize as hema-
tocele. The fact that the other tube and ovary were in such a healthy
condition that the doctor did not, deem it wise to remove them shows
that this woman had perhaps never been infected, and that she did
not have an ordinary case of chronic salpingitis.

Dr. Louis Frank : Like Dr. Bullock, I am inclined to accept the
theory advanced by Lawson Tait that all of these cases of hemato-
salpinx or hemorrhage into the tube itself are undoubtedly due to im-
pregnations in the tube. I do not believe that we ever have hemor-



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 38 of 109)