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soaked in an antiseptic fluid. This is covered with a layer of iodoform,
antiseptic or sterile dry gauze, and the whole is well enveloped in an
ample covering of dry sublimate or sterile gauze. The film of rubber
tissue will preserve the underlying clot in a moist condition, and the
outer dressings will absorb and render innocuous the surplus of blood
and serum. Possibly from force of habit I prefer for the first iodo-
form, and for the more ample covering, dry sublimate gauze. This
dressing may be allowed to remain on until cicatrization is completed,
or, if the outer dressing should have become hard and stiflF from the
dried blood or serum, it, or even the whole, may be removed and
replaced under strict antiseptic precautions ; but it is best to leave the
wound undisturbed as far as possible.

The utility of this method of the moist blood-clot dressing has
been more prominently brought to the attention of the profession in
its application to the treatment of destructive wounds in bones, by
which their integral parts are preserved independent of the presence
or absence of a sufficient covering of deep soft parts or skin. The
blood-clot being made to fill up the defective space made by operation
or injury in the bone, the tissue takes the place of the skin.

That this principle in the treatment of wounds is susceptible of
larger application than has been heretofore in vogue I have been con-
vinced for some time, and, acting upon this belief, I have for several
years applied it successfully to the treatment of lacerated wounds of
the soft parts, with destructive loss of tissue, on various parts of the
body ; but it is more especially that I desire to call your attention in
this short paper to its application in the treatment of wounds in the
ends of the fingers, where the soft parts have been severed or pulled
loose from the bone, leaving it exposed without any soft tissue as a
cover. We are all aware that such wounds of the phalanges were
formerly doomed to amputation; but in these wounds, when the
exposed end of the bone was not over one-fourth inch, I have
succeeded, by milking the blood Jfrom the finger, in forming a clot over



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the bone, and by the use of this moist blood-clot dressing obtained
excellent results and the preservation of the finger in its entirety.

We all know what the loss of the tip end of an index finger or
thumb means. These results have been gratifying to me, and it is
astonishing with what rapidity the blood-clot is transformed into new
living tissue, a week or ten days being sufficient to eflFect the trans-
formation. To obtain a properly shaped clot, it has been my habit, as
the blood flows, to blow iodoform upon it from a powder blower, which
favors the formation of the clot and stops the flow of blood at such
points as is necessary, the minute film of iodoform helping to preserve
the clot while the rubber tissue is being applied.

Should the exposed bone be over one-fourth inch, I do not believe
it possible to form a perfect clot over it. In these cases it has been my
custom, instead of dissecting back the soft parts sufficiently to get a
•covering and then cutting oflF the bone, I have, in order to save as
much of the finger as possible, cut the bone back to a sufficient point,
-and then formed the blood-clot over it as described above. In the soft
parts, where the tissues have been scooped out by machinery, the
surgeon's knife, or otherwise, it is a very simple process to fill the
•defect with a blood-clot up even with the skin, and by the use of
the moist blood-clot dressing have it to heal in one half the time and
with much less trouble than with ordinary granulations.

I/BBANON, KY.

THE PREVALENCE OF AMETROPIA AND HETEROPHORIA, WITH
REMARKS ON EYE-STRAIN.*

BY A. G. BLINCOE, A. M., M. D.

When I first heard of eye-strain as a cause of nervous diseases I
:supposed that cases of it were rare and only found occasionally. I
thought perhaps a number of cases might have to be examined before
one would be found with a refractive or muscle error. But after I had
been doing refractive work for some time, and had examined the eyes
of quite a number of suspected persons, I was astonished to find every
^ne with either refractive or muscle error, and sometimes both. These
cases, however, were those complaining of some of the symptoms indi-
^cating eye-strain. I then became curious to know about how many
people have refractive or muscle errors, and looked for some statistics
-on the subject to see if I could get any information that would enable
me to make an approximate estimate of the per cent of mankind that

* Read at the May meeting of the Kentncky State Medical Societyr 1899.



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are ametropic or heterophoric. Being a general practitioner, and con-
sequently not very extensively supplied with ophthalmic literature, I
was unable to get a very large 'mass of statistics, but found that four
diflFerent observers had in a total of over 4,000 examinations under
atropia, especially in school children, reported less than five per cent
of emmetropic eyes. These examinations were made years ago when
the smaller refractive errors, the correction of which is now giving
such satisfactory results, were probably not considered, and no muscle
tests at all were made ; so that if heterophoria had been taken into
consideration, it is more than likely that this small per cent of perfect
eyes would have been still further reduced.

Since seeing these statistics, I have in talking to some of my patients
sometimes remarked that probably nine out of ten or possibly nineteen
out of every twenty of us have defective eyes. I did not then suppose,
however, the condition to be so very general as it would seem to be from
the following:

In a very interesting paper read at the last meeting of the American
Medical Association by no less an authority than Dr. Geo. M. Gould, of
Philadelphia, entitled " A Pair of Mathematically Perfect Eyes," he
says:

" Absolute emmetropia, a mathematically perfect pair of eyes, does
not, I believe, exist. A perfect leaf has not been found, nor absolute
symmetry in any organic thing. The report of perfect emmetropia is
a confession of negligence or unskillfulness. I have made such reports
myself, and can therefore speak dogmatically. If such a diagnosis has
been made without a mydriatic, the negligence deserves a much harsher
naming."

In the discussion of another paper at the same meeting. Dr. B. Alex.
Randall, also of Philadelphia, a man of very large experience, says :

" When I hear of hosts of cases that are emmetropic, I am skeptical
as to all the rest ; I must say, as a result of my investigations, that true
emmetropia is almost an unknown quantity."

I have seen no statistics of muscle errors except the one hundred
medical students examined by Dr. Tiffany, in which he found fifty-
seven per cent of heterophoria. It is not contended, of course, that all
cases of ametropia or heterophoria cause serious nervous or other
troubles. I think there are many persons who go through life with
refractive or muscle errors without suffering serious inconvenience from
them. I am prepared to believe this from the fact that after examining



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many elderly people for presbyopia I have often found ametropia or
heterophoria which had seemingly never caused any of the troubles
usually arising from these conditions; yet these very people might
have enjoyed more vigorous health if they had had their eyes properly
attended to in early life.

On the other hand, I have seen many younger persons suflFering from
asthenopia, etc., who dated their troubles from a spell of sickness.
It seems, therefore, that in strong and healthy persons eye-strain may
show no marked symptoms ; but if these persons become weakened by
disease or otherwise the symptoms may then make their appearance.

In regard to this matter Hotz says : " Many eyes can endure a great
amount of strain with impunity, while others are so constituted that
their powers of endurance are quickly exhausted. One person may
need glasses for the correction of a small amount of ametropia, while in
another the correction of a much higher degree is unnecessary, and
glasses would be superfluous. We can not draw the line at a certain
amount of ametropia, but should correct it, no matter how slight in
degree, whenever it leads to disturbances of which eye-strain constitutes
the most frequent cause."

That a large number of persons do suffer from this cause I have
from my own experience in the last seven years not the slightest
doubt. I have myself treated about two hundred cases of headache
and other nervous troubles by correcting refractive and muscle errors,
with the result of about forty per cent cured and fifty per cent bene-
fited, making a total of ninety per cent cured or benefited.

Many others of much larger experience have reported equally as
good or better results from the same treatment.

In an editorial in a leading eye journal of September, 1898, the
writer says : " It is the conviction of many scientific minded and careful
men that eye-strain has a great deal to do with fiinctional gastric
troubles, with anemia, with the origin of glaucoma, cataract, etc,

" We directly relieve ten times the suffering every day by refraction
that we do by operations, and we prevent a hundred times that
amount."

Now, if these views are not overdrawn we would hardly exceed our
duty to our patients if we should advise every one suffering, not only
with any of the functional nervous diseases but with any chronic gastric
or intestinal derangement not accounted for by other causes, to have
his eyes examined by a competent refractionist.



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I believe that there are many persons who suflFer from eye-strain^
unconsciously perhaps, who are in a debilitated condition on account
of it, and therefore more susceptible to disease germs, and consequently
more liable to take certain diseases and less able to cope with them
when attacked.

I am further convinced that many persons suffering from consump-
tion and other chronic debilitating diseases might be benefited, to some
extent at least, by having their eye-strain, if any, corrected, thereby
relieving them of one factor — a loss of nerve force due to the eye-
strain — in causing their debility.

In a paper read at the last meeting of this Society I reported sev-
eral cases that tend to bear me out in this latter opinion. Several of
them who had made no complaint whatever of any eye trouble were
found ametropic or heterophoric, and since wearing their correction a
year or more have improved materially in general health and strength^
and some of them have gained from fifteen to thirty pounds in weights
Several persons to whom I have related the case of the young man
who had been going on crutches for two years and laid them aside
within a year after putting on glasses for headache, have laughed at the
idea of a pair of spectacles enabling a cripple to go without his
crutches ; but when we bear in mind the fact that it is the nerve force
which runs the human system, and that the glasses simply stop a leakage
of this force caused by the eye-strain, and allow the system to build up>
it does not seem so absurd after all.

One of the cases of epilepsy that I reported last year has had no
attack now for over fifteen months. He had such strong external
muscles that graduated tenotomies seemed in his case to do but little
good. I finally, at the suggestion of Dr. Valk, of New York, did com-
plete tenotomies of both external recti, and afterwards shortened both
internal muscles before his muscle balance became normal.

Another case of chronic epilepsy having spells about once a week,
for which I simply fitted glasses in December last, has had but two
attacks since. This patient has also been entirely relieved of his head-*
ache and dyspepsia since he began wearing his glasses.

Bardstown, Ky.



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ONE HUNDRED AND THIRTY-TWO OALL-STONES REMOVED
WITHOUT OPERATION.*

BY EDWARD SPEIDEL, M. D.

Lecturer on Obstetrics ; Clinical Lecturer on Gynecology, Hospital College of Medicine^

Louisville, Ky,

Cholelithiasis, the condition leading to the formation of gall-stones,
is beginning to be recognized as a very frequent disorder in the experi-
ence of medical men, and the fact that in many cases the diagnosis is
only made post-mortem, by finding the gall-stones in the gall-bladder,
proves that perhaps many of the obscure abdominal symptoms pre-
senting themselves in our patients may be due to that condition. The
treatment at the present time is almost entirely surgical, and the
results of such treatment are very promising; but the laity still have a
great horror of operative work, and in consequence many suflFerers from
this condition try one physician after another and one watering-place
after another with only temporary or partial relief, but still refuse the
panacea oflFered them by a surgical operation. The following case,
presenting possibly the severest form of this trouble, was relieved
entirely by the method outlined in this paper, and the principle of
treatment should be applicable to other cases.

On the 17th of September, 1898, the patient, a lady fifty-five years
of age, consulted me with the following history :

She had been sick for the past five years with colicky pains in the
abdomen, increasing in severity in the last two years, and for the three
months preceding the day upon which she called at my oflBce they
occurred regularly two or three times a week. The attacks were pre-
ceded by a chill, and ended with fever and sweats. An attack often
lasted for twenty-four hours ; did not end suddenly, and was followed
by intense jaundice and pigmentation of the conjunctivae. The pains
were felt in the right hypochondriac region, and the patient always
noticed a swelling there during an attack. Carlsbad salts had been
taken every morning for a year. The patient had been at French Lick
Springs, and had been under other treatment without relief. She had
finally been advised to submit to an operation, but absolutely refused
to accept the suggestion. The patient showed a deeply jaundiced
skin, deep pigmentation of the conjunctivae, tongue heavily coated, body
emaciated. Temperature 99.5°; no history of constipation, but stools
clay colored. Examination of the abdomen showed a slight enlarge-

•Re&d at Uie May Meeting of the Kentucky State Medical Society, 1899.



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ment of the liver and tenderness in the region of the gall-bladder. The
urine was very dark, almost the color of molasses ; had a sp. gr. 1032,
acid reaction, and gave a marked reaction with nitric acid color test for
bile. It also showed calcium oxalate crystals microscopically. A
gall-stone had never been noticed in the passages, although constantly
watched for. The patient presented the typical symptoms of chronic
catarrhal cholangitis, and treatment was begun for that condition.

The trouble was brought on by errors of diet, resulting, it was
judged, in a chronic catarrhal condition of the stomach and intestines,
and aflFecting the common and cystic ducts by contiguity. In that
condition we have a hyperemia and hyperplasia of the gastro-intestinal
mucosa, the membrs^ne being covered by a tough yellowish-white
mucus with pus cells. In very severe cases the mucous membrane is
even found mammillated, that is, thrown into folds. It was concluded
that one or all of these conditions could be present in this case, and
that accordingly a plug of mucus and possibly a fold of the mucous
membrane occluded the common duct and imprisoned the contents of
the gall-bladder. It was also supposed that in consequence of the
retention, that the bile was in a more or less inspissated condition.
The restoration of the gastro-intestinal mucosa to a fairly normal
condition should result in the removal of these obstructions in an
increase of the lumen of the common duct and a release of the matter
imprisoned in the gall-bladder. The final result in this case probably
establishes the correctness of this idea.

The patient improved gradually under treatment; the colics were
less frequent and of shorter duration, and on the 25th of October the
urine showed a sp. gr. of loio, with only a trace of bile. The feces
were dark colored. By the 12th of November the patient had not
suflFered with colic for two weeks, but was now troubled with intense
itching of the skin upon retiring at night. This was diagnosed as due
to a deposit of bile pigment in the tissues. On December 3d the patient
had a severe attack of the colic, beginning early in the morning and
lasting until 6 p. m. At that time she had an intense pain and desire
to go to stool, and then passed the gall-stones that are exhibited in
connection with this case. The patient collected the 132 shown in the
bottle, and claims that quite a number escaped from the bowl of the
water-closet before she realized what had occurred. A few small stones
were passed in the succeeding days, but since the 7th of December
none have been noticed ; the patient has been entirely free from colics ;



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the pigmentation of the skin is disappearing, and her general health is
improving in every respect. Upon examining the gall-stones in the
bottle it will be found that two of them are very much larger than the
others. It is the writer's idea that the cystic duct was occluded by
the two large stones, the smaller ones being imprisoned above them in
the gall-bladder. It is also concluded that in the beginning the com-
mon duct was occluded by the greenish thick mucus that was passed
with the feces at times in the early treatment of the case.

Treatment was begun with a calomel purge, followed by a saline,
and the patient put upon a simple but nutritious diet. She was
instructed to drink three large glasses of buttermilk daily, and to
increase the quantity as she became accustomed to it. The patient
not relishing the other things allowed her, soon consumed a quart of
buttermilk daily. The patient drank a glass of hot water at bed-time
and upon arising and with each dose of medicine ordered. In addition
to this, she was instructed to take a hot bath at bed-time twice a week,
remaining in the hot water for fifteen minutes. Three times a week at
bed-time a high rectal enema of normal saline solution, temperature
110° to 120°, was to be used.

For the attacks of colic • she was given a mixture containing two
and one half grains each of antipyrine and phenocoll mur. to the dose,
such a dose to be taken every half hour with hot water until relieved,
the hot bath and rectal injection being used at the time also. In the
interval the patient was put upon ten grains of salicylate of strontium
three times daily. During the last two months the medication con-
sisted of increasing doses of tr. chionanthus virg., the prescription
being varied by the addition at times of one of the tonic bitters, as
nux vomica and columbo, again by the addition of arsenite of
copper, and in the last month by the administration of nitro-muriatic
acid with the chionanthus. During the last month, on account of the
intense itching, the hot baths were used every night.

I ascribe the successful outcome in this case to the fact that the
gastro-intestinal tract improved rapidly under this treatment, as shown
by the appearance of the tongue. The obstructing mucus in the
lumen of the common duct was being gradually removed, if it is correct
to suppose that the small masses of green mucus voided with the rectal
enemata at times came from that source. Furthermore, on the day
upon which these stones were passed, the patient had drunk an unu-
sually large quantity of buttermilk, which may have been a factor in



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the case. She was taking the antispasmodics mentionjed before, with
the reflex peristalsis induced in the small intestine by the hot rectal
enema. Upon examining the stones in the bottle you will find two of
them much larger than the rest. It is claimed that the cystic duct
was occluded by these large stones, and that after they were forced
out, the smaller ones escaped with little difficulty.

As to the therapy, the strontium salicylate was given for its anti-
septic, antifermentative, and especially for its cholagogue effect, it
having the property of not only stimulating the hepatic cells ta
increased secretion, but to increase the fluidity of the bile also, thus
offering ^vis a tergo to the other means used in rendering the biliary
passages patent. Chionanthus virginica is an officinal drug ; only four
lines are devoted to it in the last dispensatory. It is used extensively by
the eclectics, and is indicated especially in lithemic conditions. It was
given throughout in combination with one drug or another for its
stimulating action upon the hepatic cells, and under its use the feces
became darker in color, and bile began to disappear from the urine,
Arsenite of copper and nitro-muriatic acid were given in combination
with one or the other of the above drugs, and the vehicles of course
changed frequently in order to keep up. the interest of the patient.
Every dose of the medicine was taken with a large glass of hot water,
and a gradual improvement was brought about in the gastro-intestinal
tract, as evidenced by the clearing up of the tongue.

The high rectal enemata were not only intended to cleanse the
bowel of fecal matter, but when it is considered that the patient soon,
was able to retain a half gallon of normal saline solution of a temper-
ature between iio° and 120° from bedtime until the following
morning, it may readily be imagined that the moist heat produced by
its presence would have a beneficial effect upon all the organs in the
abdominal cavity, causing besides a reflex peristalsis that should affect
the stomach duodenum and bilary passages favorably. The hot
immersion baths were begun when the intense itching was added to
the other symptoms, and not only afforded considerable relief for that
trouble, but no doubt also had a favorable effect upon the local con*
dition.

That the diet was an important feature of the case should be
evident to every one. It was restricted within reasonable limits, and
the use of buttermilk advised. The patient cared but little for the
other articles of diet allowed her, and soon subsisted to a great extent



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upon the buttermilk. On the day on which the stones passed she had.
consumed an unusually large quantity of it.

Nearly all text-books recommend morphine in suflBcient doses to-
relieve pain in the paroxysms. It was determined to rely upon other
means in this case, as the after-eflFects of the morphine, constipation,,
etc., would interfere greatly with the other treatment. The combina-
tion of antipyrine and phenocoU muriate was resorted to, and with the
rectal enemata readily controlled the pain.

The mortality from cholecystotomy has been reduced to a minimum
by the recent advances in abdominal surgery, but the laity has not
learned as yet to view these procedures from the standpoint of the
surgeon, and so the general practitioner is bound to meet with cases
that refuse an operation. In such instances if it is a case of cholangitis,
that is, the condition leading to the formation of gall-stones, then a cure
should follow the means suggested ; when gall-stones actually exist, a
fair measure of success should result from this treatment.

To the surgeon the writer recommends this procedure as a post-
operative treatment in surgical cases, to restore the aflFected parts ta
their normal condition, and thus prevent a recurrence of the ailment
for which the operation was performed.

I/OUISVII*I,B.



Heports of Societies*

KENTUCKY STATE MEDICAL SOCIETY.*

Discussion of Cerebrospinal Meningitis, Dr. Marvin, Louisville r
I open the discussion with considerable embarrassment, feeling that
it is a subject that I know very little about, and concerning which
I can hope to tell you very little that you do not already know. I was
so unfortunate as to miss hearing the first papers, so I can not traverse



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 56 of 109)