Universidad de Buenos Aires. Facultad de Derecho y.

The American practitioner online

. (page 71 of 109)
Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 71 of 109)
Font size
QR-code for this ebook


to any appreciable degree.

The last case which I shall report shows the dangers of delay and
as well why we have trouble in getting the consent of patients for
operative work at the proper time.

Case 4. I saw Mr. L., aged thirty-nine years, in consultation ; the
case was a strangulated indirect inguinal hernia ; taxis had been unsuc-
cessful. There was a disagreement as to operative work in case a reduc-
tion could not be made under anesthesia. The patient's mind was
biased against an operation ; further consultation was had, and, what
proved to be unfortunate in the end, a reduction of the mass was
accomplished under anesthesia. A truss failed to do successful work,
for immediately following a free action from the bowel the same day
the hernia again descended into the scrotum. Taxis again failed even
under anesthesia. Forty-eight hours afterward I saw the patient again
with several consultants. Circulation was 154, respiration 38, and
a slight elevation of temperature. By this time the patient asked for
an operation. An unfavorable prognosis was given, but an attempt at
relief was undertaken.

The tissues were divided down to the sac ; from the sac the usual
fluid accompanying a strangulated hernia — which in this case was exces-
sive — was removed, and some fecal matter was found free in the sac ;
the gut had a small opening about one and a half inches below the
point of strangulation, and at numerous points the necrosis was so far
advanced as to require at least five inches of the gut to be resected.
The anesthetist had to give the patient strychnia and nitro-glycerine
from the beginning of the anesthesia, and when the gut was divided
the shock to the patient was alarming at once ; however, the operation
was completed as rapidly as possible, but the patient succumbed with-
out gaining consciousness from the anesthesia. This case illustrates
what we have to contend with in the country.

So, frequently when operative work would promise excellent results
we must wait and hear exclamations about the ** cruel knife " and the
" cutting doctor," and then, as the end is nearing, we are told, " Well, if
there is any chance at all, go ahead and operate.*'

Surgery in such cases usually brings the art into disrepute in local
communities, and in the majority of cases needing operative work in
the country we find them advanced to that point where there is no

11



Digitized by



Qoo^z



138 The American Practitioner and News.

other chance for recovery whatever, and that chance is reduced to the
minimum by being put oflF as the very last resort.

The laity is not always at fault, for oftentimes the family physician
never loses an opportunity to deplore surgery, and sometimes I fear his
deplorations are due to the fact that he does not do such work, and,
rather than to have it done, he prefers to trust to medication. Let us
as country doctors get rid of old fogy conservatism, any way to that
degree so that we will do or have done what is best for our patients, and
let us never depreciate that branch in our profession that does so much
to restore health, prolong life, and alleviate suflFering. .

Flbmingsburg, Ky.

Heports of Societies*



KENTUCKY STATE MEDICAL SOCIETY.*

[CONTIMUBD FROM PAGE 98.J

** Etiology and Treatment of Pneumonia," by Dr. Frank C. Wilson,
Louisville.

" Treatment of Lobar Pneumonia," by Dr. John G. Cecil, Louis-
ville.

Discussion, Dr. George W. Beeler : I have no criticisms to make
on the papers read by Dr. Wilson and Dr. Cecil. Those papers are
conservative. There are a great many things I would recommend with
which I have had experience. But I want to say this, when I began
the practice of medicine the treatment was blood-letting, and later
blistering, and still later the use of veratrum viride. I have bled
hundreds of patients with pneumonia and pleuro-pneumonia, and I
can say that my experience with tartar emetic and the lancet, too, was
a good one. After years of experience along that line there came to be
considerable opposition in the schools by leading professors to the use
of tartar emetic, bleeding, and blistering. It was easier to follow their
teaching. So I have not bled a patient for a long time. But I would
not hesitate to bleed if I had a case demanding it. I have bled patients,
seventy years old and over, and they recovered. When I practiced
that system I was more successful than of later years. A paper was
read at Shelbyville a few years ago in which a doctor spoke of the
pneumonic germ and the modem treatment, the supporting treatment,

* Meeting held in Louisville, May 17, 18, and 19, 1899.



Digitized by



Qoo^<i



The American Practitioner and News. 1 39

and the stimulating treatment. He said that he remembered under
the old treatment of blood-letting, tartar emetic, and blistering the per-
centage of recoveries was much larger ; it occurs to me that he said the
proportion was about 17 to 8 per cent. In regard to salicylate of soda
and ergot, I have never had any experience with them. I should sup-
pose the salicylate of soda would be a good remedy. It is an anti-
pyretic. As to the coal-tar preparations, I agree with the gentlemen
who have preceded me, I would not give them. Some years ago I had
five cases in one family, and I am inclined to believe in infection
because I had these five cases in one family, and they were all followed
up with malaria. Quinine was scarce, and we used cinchonidia a
great deal as a substitute. To those cases I gave cinchonidia, Dover's
powder, acetate of potash, and muriate of ammonia, and they all got
well. I am satisfied of one thing, that we used to bleed a great many
patients who would have recovered without blood-letting. And I am
satisfied, too, that we now often lose our patients because we fail to
deplete. When I first entered practice, and when I was attending
lectures I listened to a great many eminent men, such as Dr. Wood,
and they recommended blood-letting when we saw the case early.

Dr. p. J. Yager, Campbellsburg : These two papers show a great
deal of intelligence and a great deal of research and a great deal of
practical and close observation. I have no criticism to make of them.
I was delighted at the exhibition they give in defining pneumonia,
the history of pneumonia, the treatment of pneumonia, the remedies
used, and all the able discussion of the time when I lived and worked
away back there. I have taken a step forward, and I can now reason-
ably endorse what they say. The gentleman knows my history exactly.
We have tracked the snow together with the lancet in our pockets,
and I have no doubt we could go in the same track in treating
pneumonia. He tells you strictly and strongly that he doubts very
much whether there have been as many cases saved by the modern
methods of treatment, according to the number of cases treated.
When our country here was full of timber and damp air and malaria,
and all the materials which bring about such a result as pneumonia in
the human body, that disease was more prevalent, and I doubt very
much whether they have the success now that we had in the days of
old. I remember that I hardly had a case of pneumonia but I would
feel disposed to take out my lancet and pierce the vein and let the
blood flow. There is another feature about this. Just as soon as the



Digitized by



Qoo^z



140 The American Practitioner and News.

patient would be in pain in pleuro-pneumonia and would make a
noise with every breath, I would take out my lance, and in a little
while he would say, ** Oh, how much better I feel! How good I feel I
That is the beginning of a new life." There are cases now that come
up in which it is just as necessary to use the lance as ever before. I
have bowed to sentiment many times when afterward I was sorry for
it. I am willing to take to the new systems and plans, but I am not
willing to use strychnia as the best stimulant. I do not believe that
is the best stimulant in these cases of pneumonia, and as to opium,,
that is dangerous to use to any great extent.

Dr. Snyder : The paper was full of wholesome truths and practical
ideas. Any man who proposes to keep up with the progress of time
would not for a moment think of depleting his patient at the present
time. We have enumerated the remedies that support the patient. If
we do not understand the action of those drugs, then as men dealing
with life it is our duty to study up the action of them. The lancet may
have served its purpose, but those days are past. I feel that I have
been benefited and strengthened, and I think everyone of us has been
benefited.

Dr. Stucky: It is with a feeling of hesitation that I arise to discuss
these admirable papers, after the addresses of my distinguished prede-
cessors. In the first place. Dr. Wilson's paper, in dealing with the
abortive treatment of pneumonia by the use of ergotin and the salicy-
late of soda, gave to us the doctrine instilled into me as a student
twenty years ago. I have either used these drugs wrong or they da
not act as we believe they do. I can not see how ergotin by its action
upon the vessel wall is going to exercise a sufficient local influence,
notwithstanding its constringing influence, notwithstanding its con-
tractile power, to relieve a hyperemia which may not only be active
but decidedly passive in character. I can readily see how the salicy-
late of soda may be a defibrinizer and an antipyretic, and may exercise
an antiseptic influence,.but in the management of pneumonia I believe
the doctrine laid down by our forefathers has been amplified ver>'
materially by elimination. They say they do nothing but deplete, but
we can deplete equally as well through the skin, diaphorosis, or through
the kidney, or better still through the alimentary tract. I believe in
every case in which there has been an interference with oxygena-
tion we find an interference with oxidation. There is hepatic
torpor. There must be an unloading of the liver. Carbonate of



Digitized by



Qoo^z



1 he American Practitioner and News. 141

ammonia I would eliminate from my armamentarium of drugs to
be used in pneumonia. We have all experienced often enough the
irritating influence it has on the stomach. We have all had the
nausea and gagging, and why should we throw out the chief entrance
of support to the animal economy. Of cold I most heartily approve,
exercising as it does the constringing influence ergot has, if it has,
and besides, being a decided sedative and great ameliorator of pain.
Stimulation should be had from the start, without waiting until the
heart is weak. Keep the heart supported so that it will not become
weak. Oxygen is of the greatest value, relieving pain, supporting the
heart, increasing the distension and chest expansion, and giving the
patient the greatest comfort.

One word regarding Dr. Cecil's paper. I am in most hearty accord
with every thing he said. I believe sex, nationality, nativity, environ-
ment, and occupation each has an influence, so that every case of pneu-
monia stands out as a distinct case, for which we can not prescribe a
proscribed treatment.

Dr. W. W. Richmond, Clinton : I wish to say a word in reference
to salicylate of soda and ergot. Twenty years ago I was in the habit
of using ergot in those cases in which I believed the disease could
be modified. I must say, with these old friends of mine, that I have
never yet, in a case in which I believed the symptoms could be mod-
ified, found any thing which answered the purpose so well in my hands
as veratrum viride. I have seen a number of cases in which the car-
bonate of ammonium was used. To go back to the old plan of dividing
the cases into sthenic and asthenic, I believe there are many cases of
pneumonia which if let alone will get well without treatment, and
again there are many cases which if you do not treat properly will die.
I do not mean to say that we cure all these cases, but we do pursue a
plan and course of treatment by which the symptoms are so modified
that we assist nature to a favorable termination. I do not know any
method by which we so aid these patients as by the early administra-
tion of veratrum viride ; that is, in the first twenty-four to thirty-six
hours. After the lapse of that time we have no use for it. In many
cases where the pulse is strong and the heart active, while we may
relieve the patient with opiates, we are more sure of relieving the
condition without harm to the patient with veratrum viride. It is the
least harmful of arterial sedatives. I regard it as more harmless than
aconite or digitalis, and I have learned in twenty-five years' experience



Digitized by



Qoo^^



142 The American Practitioner and News.

not to place too much confidence in the last named remedy. I believe
the subnitrate of strychnia, if used early, is more reliable. In fact, I
believe it stands at the head of heart stimulants. I have always
been a little skeptical about digitalis, but when using strychnine I feel
I have a remedy that will not deceive me. I do not regard veratrum
viride as so dangerous a drug as the other heart sedatives. When we
give a drug in these cases we want something that will act quickly and
certainly.

Dr. Frank C. Wilson, Louisville, in closing : I have only one word
to say, and that is in reference to the action of ergot. Ergot I think
undoubtedly has a sort of selective action, selecting those arterial ves-
sels that are apt to be in a state of vasomotor paralysis. When you
administer ergot its first action is upon any portion of the circulation
that is in a congested condition, and acting upon that I have seen the
effect of it most markedly illustrated in the results obtained in these
cases. I could recite case after case from my own personal experience,
but of course I would not care to encumber the paper with such details.

** Hernia and its Operative Treatment," by Dr. J. L. Johnson,
Louisville.

Discussion. Dr. T. B. Greenley, Meadow Lawn : I only rise to thank
the doctor for the paper. It shows a great deal of study of the matter,
and I think it is a very able paper.

Dr. W. C. Dugan, Louisville : There are several points I wish to
refer to. First, in reference to the use of the truss in children. The
essayist admitted that sometimes you get good results with the truss
in children, and I wish to take exception to that and say that if you
advise the truss in children you will, as a rule, get good results. If
you use a bandage and do not try to force the hernia back, you will
get good results as a rule. In regard to pressure on the cord causing
varicocele, such has not been my experience. I think such a result
could occur only from the abuse of the truss and not from the use of
it, because if you have a truss applied so low down as to press on the
cord as it goes 'over the symphysis pubis, any bad result will be due
to the faulty application of the truss and not to its use. The truss
should be applied, not over the symphysis but over the internal ring,
where the hernia comes out. I admit that if you apply the truss with
such force, and if the truss be of conical shape, you may have absorp-
tion of the tissue and again have bad results. But the truss should not



Digitized by



QiOo^z



The American Practitioner and News. 1 43

be of that shape. It should be broad and with a spring of not sufficient
force to give the patient pain. Of course to go into the operation of
hernia and bring it up, as the doctor has done, requires time, as has
been demonstrated. He has covered the subject thoroughly. He
spoke of the Halstead operation being in its essential features the same
as the Bassini. Again I wish to diflfer from the doctor. In the essen-
tial features the Halstead operation diflFers most widely from the
Bassini. The Bassini operation simply restores the anatomical parts.
If you will study the anatomy and then read up the Bassini operation^
any one can appreciate the strong points in the operation : Making
your incision and opening up the fibers of the external oblique, expos-
ing the cord, as the gentleman has stated, separating it from the internal
ring down, lifting it up, passing your finger around and separating it
from the internal structures, which is the most essential point, as
claimed by McBurney and all operators of modern times, and then
tying the cord very high up. Then there is one point that I think the
doctor did not make strong enough. The sac should not be opened
until you separate it, if possible. Then after reducing the hernia take
the body of the sac up in the hand and pass the finger down into the
cavity, so that the assistant can tie over the finger. This should be
done for two purposes : First, you can not include part of the omentum
or a knuckle of the intestine, which has been done a number of times
by competent operators when they neglected to tie off the sac high up
and tie over the finger. This is a very important point, and one I wish
to emphasize, to introduce the finger to be sure you do not include part
of the viscera. And secondly, it should be done in order that you may
be able to place the ligature well down on the peritoneum, and thus do
away with the infundibulum that nature has left.

Dr. J. D. Maddox, Rockport : Just one word in regard to strangu-
lated hernia and a manipulation which I do not remember seeing or
hearing mentioned, and which, if it had been mentioned, was found on
my part accidentally. It is a manipulation from the outside. Trying
to reduce a hernia with the hips elevated and failing to do it, I reached
above the tumor (or rather below in the position occupied by the
patient), and, accidentally catching hold of the intestine, I succeeded in
pulling it out from below. That is, instead of pushing it out, as we
ordinarily do, I pulled it out with simple traction.

Dr. J. L. Johnson, in closing: In reference to opening the sac, I
said that I had been compelled in many instances to open the sac



Digitized by



Qoo^z



144 ^^^ American Practitioner and News.

before separating it. I think it is advisable to first separate the sac,
but sometimes that is impossible. The gentleman stated that I said
that the essential features of the Halstead operation and Bassini's
operation were the same. I think I did not say that, but I said, having
mentioned the essential features of Bassini's operation, I would pass on
to Halstead's.

** Some Cases of Country Surgery,'* by Dr. C. W. Aitken, of Flem-
ingsburg.

Discussion, Dr. J. B. Bullitt, Louisville : I am sure that I voice the
feeling of all the other gentlemen present when I congratulate the
doctor and deplore, with him, the death of the last patient mentioned.
Dr. Aitken has aptly put it, for these cases are certainly often sacrificed
by the family and family doctor despite the surgeon. It is difficult to
know how to deal with these cases. This is notably true of those
cases of appendicitis in which an early operation would be successful ;
but often these cases do not come at that time, and when the surgeon
is called in as a last resort the patient dies, and he is often said to have
died as a result of surgery. It is an old story and a question that con-
fronts us to-day. The question arises all the time. What is the proper
thing to do under such circumstances? Should the surgeon be willing
to shoulder all the opprobrium that comes to him and surgery in case
of a fatal issue, or should he refuse to operate in these cases in which
surgery is so long deferred ? I believe it would often be better for the
surgeon to say that the case has progressed so far that an operation is
hopeless, and the physician who ha$ recommended waiting should be
compelled to shoulder the opprobrium of the fatality, and the public
would soon come then to understand that when the patient dies from
a late operation the fault is often with the physician and not with the
surgeon. So long as the surgeon is called in late and operates, he will
be blamed in case of death for what is manifestly not his fault. I
know a great many surgeons feel a sort of responsibility and moral
obligation to operate upon these patients and give them any possible
chance. But really it would seem that our duty to humanity under
such circumstances is frequently to refuse operation, for thus we may
eventually do much more for the patients in the future than we can
for the patient at the time we are called upon to do an operation that is
practically useless.



Digitized by



Qoo^z



The American Practitioner and News. 145

Dr. Dugan, Louisville: I have only one point to make, and that is
I think the doctor should not have gone on and made a resection in
the operation, which only made it that much more hopeless. When
he found the condition of the patient almost hopeless he could have
left an artificial opening and given the people to understand that he
simply opened up the hernial sac. I think that would have been
better. In regard to the first case mentioned, of operation for appendi-
citis, I am exceedingly glad the doctor reported finding those foreign
bodies in that case. I have operated now something over one hundred
times for appendicitis, and have found a foreign body only one time.
Several times I have found enteroliths, and sometimes thought that I
found an orange seed or a lemon seed, but on pressing it between the
fingers I would find it only an enterolith, and not a foreign body. The
doctor is certainly to be congratulated upon the technique in that
case. The responsibility he assumed was very great indeed ; the high
pulse and temperature and the vomiting certainly made it look grave.
I am exceedingly glad he reported the mastoid cases, for they are so
often neglected by the country practitioner, the " country doctor,*' as
he has put it. They can all relieve those cases by simply cutting down
and opening the bone with a chisel. Often one stroke of the chisel
will relieve the pus. I would take exception to one statement of the
doctor, and that is in reference to closing up the wound in gall-
bladder cases. I always leave the gall-bladder open for drainage. It
seems to me very important to have drainage and let the wound heal
by granulation. If you find a stone down in the common duct, it is
recommended that we should not attempt to remove the stone at the
time of the operation, but stitch the gall-bladder to the wound and
wait for the stone to come back. I confess that I lost one patient by
irrigating before the adhesions were sufficiently firm. We should wait
several days until the parts are well united, and then we can irrigate,
fill up the ducts, and invite a return of the stone.

Dr. William Bailey : I shall not presume to discuss the surgical
matters at all, but I want to say a few things from the standpoint of
the general practitioner. I believe that the duty of the physician
should be a conscientious one, and as far as possible it should be an
intelligent duty. There are certain diseases that I think we all
recognize at the present day are largely surgical. To illustrate this I
will ask your attention to the question of diseases involving the
appendix. As a general practitioner I am ready and free to say to you



Digitized by



Qoo^z



146 The American Practitioner and News.

that they can not ask me too soon to bring the aid of the surgeon when
I recognize appendicitis. I believe that evil comes from delay. The
possibilities of recovery are lessened every way. Consequently, when I
am called and recognize a case of appendicitis, I select a conscientious
surgeon and ask him to see the case and ask him to determine, as he is
better able to do, whether operation is proper. And thus I believe I am
doing the best thing possible for my patient. Our duty is determined
by following our convictions as to what is best in the individual case.
As to the propriety of the surgeon refusing to operate because it wil)
do surgery an inquiry, I am not much in sympathy with that sugges-
tion. Here is an opportunity possibly to save the patient's life by
surgery, and even though the chances may be only one in a hundred,
we should honestly give that patient, even at the expense of the reputa-
tion of the physician and surgeon, the one hundredth chance. (Ap-
plause). Gentlemen, when we are confronted by this question, if we
will honestly perform our work and conscientiously do our duty, we
will not regret any false impressions that may be credited.

Dr. J. F. Yager: I arise to endorse my old friend, Dr. Bailey. His
suggestions were of the best and most liberal character. Dr. Bailey
told you the solid trutl^ that in our duty as general practitioners and



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 71 of 109)