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become generalized. I saw one case, however, where the stomach
seemed to be secondarily affected.

Symptoms. In most instances the disease has already existed for
some time when the patient seeks medical advice. It is but seldom
opportunity is given to study the symptoms in their incipiency. All
agree that at first they are vague and variable. The patient gives a
history of pain more or less severe, and persistent in the left iliac
region; digestive derangements, alternating looseness of the bowels
with constipation, and a certain degree of emaciation. After some time,
while these symptoms continue or are aggravated, other symptoms are
superadded. In a few instances a sudden intestinal hemorrhage alarms
the patient and a physician is summoned, when symptoms which had
hitherto escaped attention are likely to be found out. Abnormally fre-
quent defecations and bloody discharges containing mucus (sometimes
tenacious and glairy) are often complained of.

The feces may come away in small, hard lumps like sheep's dung,
and, for considerable periods, are insufficient in quantity. Careful
inquiry or observation will now and then reveal the fact that the dis-
charges have been flattened, although the seat of constriction of the
bowel is at the sigmoid flexure and not at a lower point. Sooner or
later obstinate constipation sets in, and continues to be the habitual
condition, although occasionally a spontaneous diarrhea may give tem-
porary relief.

There is always tenderness over the sigmoid, but the abdomen may
become distended, tympanitic, and tender to such a degree as to render
an examination exceedingly painful, or, for the time being, impossible.
The tenderness can sometimes be demonstrated only on deep and steady
pressure, while at other times it is complained of even on the slightest
touch. This difference is to be explained by the presence or absence



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372 The American Practitioner and News.

of inflammation, fulness or emptiness of the bowel, and finally by the
elevation or descent of the growth into the true pelvis. Pain in the
region of the sigmoid is also a contant symptom. I can not recall a
single case in which it was not present. It is not always strictly local-
ized in this region, but may extend beyond the part aflFected. The
character is described by the patient as lancinating, burning, bearing
down, or cramping, and one patient would simply complain of ** pain,"
and no amount of questioning could elicit a more definite description.

As the disease progresses a tumor forms. This is a diagnostic fact
of supreme importance; however, it is not always easy to make out,
but on the contrary the tumor may be exceedingly diflBcult to find.
It may be quite small, and, as already noted, does not attain great size.
It may be but ill-defined, and sometimes quite movable, almost floating.
At other times it is fixed because of adhesions to contiguous parts.

Eichorst judiciously remarks : " It is well to remember that not only
does the volume of the tumor seem to vary, but also that a tumor which
at times is easily made out may all at once disappear and baffle all
efforts at detection, being for the time completely hid under coils of
intestine distended with fecal matter."

Leube states that a frequent change in the position of the tumor,
and in the distinctness with which it can be felt in consequence of the
shifting of the intestinal convolutions over each other, a temporary
accumulation of feces, etc., is, to a certain degree, characteristic of
intestinal cancer, and pro tanto of cancer of the sigmoid.

Melena and losses of fresh blood per anum, especially in connec-
tion with other symptoms, constitute a valuable indication of the exist-
ence of malignant disease, but not as to its seat in the abdomen.
Usually the fresher and the more fluid the blood, the lower in the intes-
tinal canal will be its source. Intestinal hemorrhage generally occurs
late in the disease, and, as a rule, only after ulceration of the neoplasm
has set in.

The discharge of pus or sanious matter, either with the blood or
during defecation, and having a peculiar but characteristic odor, is
strongly confirmatory of the diagnosis of malignant disease. Even at
a comparatively early stage the rectum is found to be habitually empty,
which naturally suggests the existence of an obstruction higher up.

In cancer of the sigmoid flexure, as well as in cancer of certain other
parts, the temperature is likely to fall below the normal. It may not be
so in the earlier stages, but in course of time, as the ravages of the



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The American Practitioner and News. 373

disease increase, as nutrition becomes more and more impaired, the
temperature falls to a sub-normal degree. This decline in bodily heat
is not necessarily very great, but its significance lies in its persistence.
Of course, inflammatory complications may arise from time to time ;
toxemic conditions may develop and bring with them thermometric
excursions of more or less considerable elevation and duration.

But even in such cases, where there was a febrile rise of temper-
ature at some time each day, the average temperature of the whole
twenty-four hours would be decidedly, though not dangerously, subnor-
mal. This is a point of value in the diagnosis of internal malignant
disease, but it is of no assistance in determining its exact seat.

In going over the symptoms complained of by my patients suflFering
from sigmoid cancer, I am reminded of two which cause a great deal
of inconvenience and even distress: First, excessive dryness of the
tongue, which was not due to a glycosuria nor to sleeping with the
mouth open, nor to unusual losses of water from the system, either by
the kidneys or intestines. This symptom continued in some cases
even to the very last. The second is intense burning in the rectum,
not only during and for some time after defecation, but for days and
weeks, the patient describing it by saying that it felt " like he was on
fire inwardly." Toward the close of the disease the cancerous cachexia
becomes pronounced. Emaciation is extreme, and the hydrops cachec-
ticum is usually well marked. The mode of death, if no grave com-
plications cuts the disease short, is asthenia.

Complications are quite numerous. One of my patients died of
acute nephritis culminating in uremia. Dechamp states that " perfor-
ation of the bladder is one of the most common complications of sig-
moidal cancer." It did not occur in any case I have seen. Circum-
scribed peritonitis, stercoral abscess, obstruction, and finally septicemia
complete the list.

Diagnosis, A positive diagnosis is impossible in the incipient stage,
and is always more or less diflBcult even in the fully developed disease.
In the absence of appreciable tumor the possibility of intestinal tuber-
culosis naturally suggests itself. The co-existence of tuberculosis of the
lungs, especially in a young person, would decide the question. When
tumor has been found it is to be diflferentiated from fecal accumulation
(coprostasis), which may give rise to a doughy, irregular enlargement.
Confounding the one with the other is a mistake very easily made.
The diagnosis of tumors of the mesentery, omentum, and kidney may,



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374 ^^^ American Practitioner and News.

in some instances, present such difficulties that their diflfierentiation from
sigmoid cancer can be established only by an exploratory laparotomy.

Wunderlich gives an account of a case in which the apparent symp-
toms of intestinal cancer, nodular tumor, severe lancinating pains, and
passage of flattened feces were all ultimately found to have been pro-
duced by an aneurysm of the iliac artery.

According to Leube the distinction between the carcinomata of the
transverse colon and the carcinomata of the ascending colon, descend-
ing colon, and sigmoid flexure consists in the slight or complete
immobility of the latter tumors, the most movable of them being car-
cinoma of the sigmoid flexure, since this portion of the bowel has a
long mesentery, and is therefore capable of undergoing displace-
ments.

Duration. This is more protracted than in other varieties of inter-
nal cancer. Mathews gives it as of about four years, and I think this
is the general opinion of those who have given attention to this
subject.

Treatment. The medical treatment must necessarily be unsatisfac-
tory. The indications are to keep the bowels open by means of ene-
mata and mild laxatives, to relieve pain, to improve nutrition as far as
practicable, to support the failing strength, to treat symptoms and inter-
current complications as they arise. The fulfillment of these indica-
tions offers abundant opportunities for the exercise of sound judgment
and therapeutic skill. Yet the power of medicine to retard the progress
of the disease is almost as completely lacking as the ability to cure it.
However, surgery may, at least in some cases, by operative measures,
achieve greater and more speedy results. Among these may be counted
relief from pain and mitigation of other distressing symptoms, and pro-
longation of life attainable in no other way. So far as I know there is
no case recorded as permanently cured, even by surgical means. That
great improvement and more or less lasting stay in the progress of the
malignant process can be obtained by surgery is demonstrated by the
case of Dr. Fred Lange. At a meeting of the New York Surgical Society,
November 23, 1892, he presented a specimen of carcinoma of the sig-
moid flexure of the colon, together with the patient from whom it had
been removed nearly eight months before, and who appeared to be in
good health. No trace of the recurrence of the disease had at that time
been found. (Annals of Surgery, Vol. xvii.)

L0UISV11.1.E.



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1 he American Practitioner and News. 375

TRBATMBNT OP DIPHTHERIA.

BY V. U. MOSS, M. D.

In this effort of mine the experience of twenty years' practice in
medicine shall give shape and essence to the discussion of the treat-
ment of diphtheria. You need not expect any infallible cure to be
announced herein ; nor shall all the opinions of the great masters be
epitomized ; but this is intended to be a faithful account of my treat-
ment of this disease and my reasons therefor.

In the outset I will accept the prevalent opinion with regard to the
causation of diphtheria; that is, that the Klebs-Loeffler bacillus finds
lodgment in some solution of continuity in the fauces or nasal
mucous membrane, principally in the regions enumerated, but it is not
impossible for the bacillus to find access to the body and blood of an
individual wherever any kind of a wound exists. The most frequent
point of all for the initiation of the micrococcus diphtheriticus is the
tonsil. Before the general system displays any evidence of disease,
before any constitutional disturbance whatever appears, the Klebs-
Loeffler bacillus finds a lodging-place in the throat. There it multiplies
and remultiplies until the development is sufficient to contaminate the
blood, when the chill and fever appear. The bacilli continue to
increase, causing a deposit of membrane in and upon the structures
attacked, accompanied by sloughing and -suppuration in the mucous
membrane and contiguous tissues. The ptomaines resulting from the
quick dissolution of so many bacilli, together with the sphacelating
structures of the throat, speedily contaminate the blood, which, becoming
unfit* for nourishment and repair to the bo^y, death overtakes it. Upon
the theory that diphtheria is first a local disease, and from its original
point of inoculation gradually develops and poisons the whole organ-
ism, is based the treatment adopted in this essay. If diphtheria can
be arrested in its progress at any point, provided that septicemia has
not hopelessly overwhelmed the animal structures, a cure may reason-
ably be hoped for.

When upon examining the throat of a suspected child there is reason
to believe that diphtheria is present, give the patient two doses of
calomel, containing two grains each, to be given two hours apart.
This amount is intended for a child six years of age. The doses
should be proportioned to the age and strength of the individual. The



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376 The American Practitioner and News.

calomel should not be given in a pill nor in a capsule, but must be
so administered that it shall come in contact with the throat as much
as possible. Begin early to wash or mop the throat verj' gently with a
saturated solution of chlorate of potassa every hour and a half or two
hours during the day, and not so often during the night.

Three or four drops of the tincture of chloride of iron should be
given about four hours apart. If pain in the stomach is brought on
by the iron, discontinue its use at once.

One to two teaspoonfuls of whisky should be given every two or
three hours. If the whisky causes a headache or restlessness and
seems not to improve the patient's feelings and appearance, it is best
to give no more of it.

The patient should be kept comfortable and reasonably quiet. It
is best that the recumbent position be insisted upon from first
to last, except when the child frets and worries itself too much. If it
provokes an unmanageable fellow that is not very bad oflF to confine
him, then allow more freedom in exercise, watching him closely for
any signs of fatigue or fainting. The sick-room should be kept at a
temperature ranging from 65° to 70° F., with good ventilation, avoiding
any draught of air upon the patient. The food may be as much and
as rich as the digestive apparatus can successfully dispose of. The
bowels should be kept open, but not any more than is required during
health. When a day passes without a movement from the primaviae,
give four quarter-grain doses of calomel every two hours, followed by
a sufficient dose of some saline to act on the bowels.

Quinine should never be given in a case of diphtheria, not even in
a suspected case. Quinine paralyzes the ameboid movements of the
white blood cells and nausea^tes the patient, thereby interfering with
proper ingestion of food to keep nutrition up to the healthy point.
The leucocytes have a phagocytic action ; that is, they arrest any
bacteria or cocci that take up lodging in the living tissues of animals.
They appropriate to their own digestive organs the bacilli that would
be dangerous to the animal economy. They are the sentinels guarding
the outposts of life's citadel. Should their strength be paralyzed, their
efficiency as protecting agencies would be correspondingly affected.
The microbic invasion, if unrestricted in its march through the blood,
would soon overwhelm the party attacked, and nothing but death could
be looked for. Keep quinine out of your patients, and give the white
blood cells full and free opportunity to defend the organisms from its



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The American Practitioner and News. 377

microscopical foes. Avoid giving a great multitude of drugs. The very
simplest treatment compatible with safety will be the most successful.

I am not specially advocating the old calomel treatment of diph-
theria, but it is of great advantage begun early enough and given
according to the foregoing method. Calomel given loose, so that much
of it remains adherent to the throat, greatly weakens the vitality of the
microbes. When it enters the stomach it slowly vaporizes through the
warmth and moisture found there, and in the form of corrosive sub-
limate rises to the throat and nose, and for many hours exercises a
destructive force against the bacilli in the naso-pharyngeal ramifica-
tions. After the first administration of it no further benefit can be
looked for from it, except as a laxative, and then it must be given in
very small doses.

Where there is much purulent discharge and sloughing with foul-
smelling breath, the throat and nose must be syringed out with a three-
per-cent solution in water of the per oxide of hydrogen (ten volume).
The syringing should be done every two or four hours, according to the
gravity of the various cases.

If diphtheritic croup supervenes, it is best treated by placing the
patient in a room kept moist and at the temperature of eighty-five or
ninety degrees Fahrenheit. Give the child whisky and good food.
Allow him to run over the bed, clad only in a light, short gown, so he
will not sweat too much. Administer eight or ten drops of fluid extract
of Jaborandi, one grain of muriate of ammonia, and ten drops of glyc-
erine every two or three hours. These drugs increase the flow from
mucous membranes and assist in loosening the false membrane.
Should signs of suffocation supervene, give an emetic. Ipecac is pre-
ferred. But should it seem probable that the laryngeal deposit is
loosened some (this will generally be after two or three days of the
treatment outlined), give two grains of turpeth mineral. This is a very
powerful emetic, and should not be administered without plain indica-
tions for it.

When the symptoms of laryngeal obstruction grow more profound
and it is evident that no other means will deliver the patient from
death, you should introduce a tube into the glottis according to the
rules laid down by O'Dwyer, but which need not be described here.
But I prefer tracheotomy.

It is an operation where you have the operating field before you, and
is therefore more satisfactory. No man should allow cowardice to hold



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378 The American Practitioner and News.

him back from opening the wind-pipe in these cases. No other means
oflFers the least hope of recovery. If you should be suddenly called to a
child dying of membranous croup, and not be prepared with a trache-
otomy tube, you can open the wind-pipe anyhow and keep it open for a
few hours by passing a stout silk thread through each side of the
divided trachea and tying the ends behind the neck.

You can obtain a better description of the antitoxine treatment than
I can give you by referring to classical works on that subject. I give
you my own way of treating diphtheria, and not a compilation of the
treatments laid down by the various works on the practice of medicine.
If I have oflFered one thing, however insignificant, that shall give you
light on this all-important subject, I have not written in vain.

R0CKFIB1.D, Ky.



Hcports of Societies-



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.*

Stated Meeting, March 34, 1899, the President, Thomas Hunt Stucky, M. D.,

in the chair.

Rhinoltth Having a Tooth as a Nucleus, Dr. William Cheatham :
This specimen is a rhinolith, and as the encrustations are broken it
will be noticed that its nucleus is a tooth. The patient from whom
this was removed was a woman, fifty-three years of age, who came to me
complaining of tinnitus, and in looking around for some cause of the
tinnitus I examined the interior of the nose. I found the left nostril
occluded, and in the center I discovered this rhinolith. In the attempt
to dislodge it and pull it forward it was pushed back into the naso-
pharynx, and was coughed up.

A peculiar feature is that this rhinolith formed around a super-
numerary tooth. It will be observed that the tooth is rather long and
pointed. I have talked with several dentists, who stated that such
teeth are always double pointed.

Discussion, Dr. S. G. Dabney : It is a well-known fact that rhino-
liths generally form around a foreign body. I have had one or two
cases of rhinolith only in an experience of twelve or fifteen years.
They were removed by getting a hook around them and pulling them

* Steno^aphically reported for this journal by C. C. Mapes, Louisville. Ky.



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The American Practitioner and News. 379

out anteriorly. It is a difficult matter to get these foreign bodies out
with any kind of forceps, as they can not be grasped in such a way as
to dislodge them.

Detachment of the Retina Cured by Rest in Bedy Bandage^ and
Salicylate of Soda. Dr. S. G. Dabney : Some time ago, in connection
with a specimen exhibited by Dr. Ray, I reported a case of detachment
of the retina in a boy thirteen years of age. The boy was in ill-health,
anemic, thin, hard-worked generally, and the subject of rheumatism.
On one Saturday he observed that the sight of his right eye was
becoming blurred. He said it seemed as if a black ball was in front of
his eye. It continued to get worse, and he consulted me on Monday,
forty-eight hours after he observed impairment in vision. The ophthal-
moscope showed that it was a case of detached retina. I explained to
the family that the prognosis was nearly always bad in such cases, that
the great majority of them turned out unfavorably, but that there was
a possibility of curing the boy by putting him in bed and keeping him
flat on his back for some time, and giving him some tonic medicines*
With their consent I took the child to the children's hospital and put
him in bed, placed a bandage over both eyes, and began the administra-
tion of salicylate of soda. He was kept in bed continuously for three
weeks. But within the first week the retina had become again reat-
tached. A week or two after getting up he complained of some flashes
of light and other symptoms of discomfort, so the superintendent at
the hospital put him back to bed and kept him there for three or four
weeks, when he was allowed to get up and has had no further trouble.
Probably he was confined to bed longer than was actually necessary,
but I was absent part of the time from the city, and the hospital
authorities wisely erred on the side of excessive care.

I report the case as a cure of detached retina by the rest treatment,
as sight in that eye is about as good as it was before. His vision is
f g. The case is interesting as one of detachment of the retina cured
by the recumbent posture with salicylate of soda and a bandage over
the eye.

Retinal detachment may be due either to an effusion beneath the
retina, or to traction on the retina. It is often attended by retinal
rupture.

Injury to the Eye. Case 2. I saw the following case February 12,
1899. The injury was caused by the explosion of a stove, the lid of the



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380 The American Practitioner and News.

stove hitting the patient, a woman, in the eye. It also mashed her
nose, producing a fracture of the nasal bones. I was asked to see her
because of the injury to the eye. There was a deep cut of the eyelid
and a violent contusion of the eyeball. Examination at the time simply
showed traumatic mydriasis (dilated pupil) and dislocation of the
lens; the crystalline lens had been dislocated downward and outward.
The vitreus was quite hazy, and the patient exceedingly nervous, so it
was difficult to get a perfect ophthalmoscopic picture.

She was put to bed, and heat was applied to the nose, and I believe
the surgeon who was called had taken a stitch or two in the skin to
unite the broken edges. The vitreous humor cleared up under the use
of simple atropine and cold applications, and it has turned out that in
addition to the traumatic dilatation of the pupil, which has remained,
and dislocation of the crystalline lens, she also has a rupture of the
choroid. So there are three results of this contusion.

The woman's sight has improved very much with the clearing up
of the vitreous humor, but it will never be perfect, largely because of
the dislocated lens, and also because of the traumatism inflicted upon
the choroid and retina.

In regard to the traumatic dilatation of the pupil : Those cases are
not very uncommon ; I have seen a good many of them. The books
say they are generally due to a slight rupture of the superficial part of
the iris, but I have never been able to detect such a rupture upon
examination. The dilatation is nearly always permanent, and is some-
times accompanied by loss of accommodation.

Case 3. The other case was a little boy who was hit in the eye
with a whip. He was jumping on a delivery wagon, and the driver
swung his whip back and struck him in the eye. He also has dilatation
of the pupil. He had an effusion of blood into the anterior chamber
and also into the vitreus ; his vision when I first saw him was limited
to light perception. The diagnosis in this case was held in reserve
because a satisfactory ophthalmoscopic examination was impossible;
the blood in the vitreous humor prevented it. I simply used atropine
and cold applications, and kept the boy in bed, which has resulted in
almost perfect restoration of vision, and the blood in the vitreous



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 43 of 109)