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kins Bulletin, January, 1899).

* Read at the meeting of the Kentucky State Medical Society, May, 1899.



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2 1 o The American Practitioner and News.

According to Mattersock and Powler, forei)3^ bodies are found in
only about four per cent of operative cases.

Renvers collected from the literature four hundred and fifty-nine
autopsies on cases of appendicitis, in sixteen of which there were
foreign bodies.

Fitz, in his series of one hundred and fifty-two cases, found them
in twelve per cent.

Dr. James F. Mitchell collected fourteen hundred cases from various
sources in the last ten years, with seven per cent of true foreign bodies.

Comparing the individual experience of the gentlemen referred to
as having been interviewed by me with these statistics, one is inclined
to believe that most likely some of the so-called foreign bodies included
in these tables were really fecal concretions. Owing to the striking
resemblance of fecal concretions to different forms of seed, they might
very readily be mistaken for them. Sometimes it requires a careful
chemical examination to distinguish between fecal concretions and
gall-stones.

Mitchell calls attention to an interesting case of Dr. W. L. Rogers,
of Memphis, bearing on this point. His patient, a man twenty-two
years old, had had an attack of hepatic colic, with intense pain in the
region of the gall-bladder, jaundice, fever, etc. A few days after this
trouble subsided symptoms of appendicitis set up, and when the acute-
ness of the attack had disappeared, three small nodules could be felt at
the side of the appendix. The appendix was removed, and, upon exam-
ination, was found to contain three bodies, looking exactly .like gall-
stones ; and such they were thought to be until examined chemically
by Dr. Brown, who found that they contained no cholesterin, no bile
nor salts, but were composed mostly of organic matter, with carbonates
and sulphates of calcium and magnesium.

Foreign bodies have frequently been met with in autopsies made
upon persons who had died of other diseases, and who had no symp-
toms of appendicitis during life, and the appendix containing the for-
eign body showing no evidence of disease.

J. F. Mitchell, in his paper referred to, quotes from Heveries
Memoirs de P Academic Royal de Chirurgie, 1743, the following: "One
notices sometimes in opening the bodies of persons who during life
have eaten a great deal of game, there is collected in the intestines,
and especially in the cecal appendix, a great quantity of shot, without
these persons having had the least inconvenience."



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Holmes (New England Quarterly Journal of Medicine and Surgery,
1892) reports a case in which there was found in the appendix of a man,
dead of pneumothorax, one hundred and twenty-two robin shot. The
man had no symptoms referable to the appendix during life.

Warren Coleman, of New York (Press and Circular, August ai,
1895), in an autopsy found a bone five-eighths inch in length and one-
fourth inch in circumference which had extended, blunt end foremost,
up to the extreme end of the appendix, completely filling its cavity.
The bone was entirely surrounded by mucus, and there was no sign of
inflammation within or without the appendix.

Foreign bodies have also been met with in the appendix when the
abdomen had been opened for other causes, and the appendix in a
healthy condition. Dr. McBurney found two grape seed in a healthy
appendix of a woman on whom he was operating for the removal of an
abdominal tumor.

Such evidence goes to show that the appendix will tolerate the
presence of a foreign body without symptoms so long as it does not
produce injury to its structure from which infective processes may
take place.

When a foreign body once gets well into the cavity of the appendix
it is very apt to remain there, owing to the weak expulsive force of the
appendix ; and while it may not give rise to trouble immediately, it is
almost certain to act as a nucleus for a concretion, which will in time
cause some form of trauma. Consequently it is always wise, when one
is found accidentally, to remove the appendix.

Seeds of various kinds, which were formerly thought to be so fre-
quently met with, are now known to be very rare, fecal concretions
having been mistaken for them. The form of foreign bodies most fre-
quently met with are heavy bodies, such as shot and sharp-pointed
bodies, as lumbricoid worms, bones, and pins.

Mitchell collected from the literature thirty-five cases in which pins
were found. In two of these cases the appendix was found in a hernia
sac, one being the case reported by me to the State Society in 1896,
and the other a case operated on by McBurney in 1888 : " Boy, ten
years old, had had for some time what appeared to be an inflamed irre-
ducible right inguinal hernia, the contents of which were thought to be
omentum. At the operation the contents were found to be a much-
inflamed and thickened bulbous appendix, the enlarged distal end being
one-half inch in diameter. In this mass, the points piercing one side



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212 The American Practitioner and News.

and the heads the other, were two black pins, which lay close together."-
As Dr. Mitchell says, "one would naturally suppose such a foreign
body as a pin in the appendix would lead to rapid perforation ; but
while this is generally the case, it is not always so. All types of appen-
dicitis may result. Some give rise to only mild symptoms, and may
lead to chronic appendicitis, with recurrent attacks " (such was the
case in seven of the cases he collected), " or with long-continued pain,
or only a feeling of uneasiness in the right iliac fossa, which may last
for months or years (two cases). Most often, however, there is rapid
perforation, an abscess formation following the first appearance of
symptoms. Pin generally lies straight in the lumen, long axis parallel
to that of appendix, and perforating with its point. In two instances
it was crosswise and perforated one wall of the appendix with its point
and the other with its head. In the majority of instances where pins
were found the patients were males, and in no instance did the patient
remember having swallowed a pin."
Louisvii:.i,K.

OVBRPRBSSURB IN SCHOOL WORK: SOME PHYSICAL
EXPRESSIONS OP SCHOOL STRAIN.

BY WILLIAM B. MEANY, M. D.

The golden mean of school work still remains an unrealized though
not unpractical possibility, and it is not even clear that we shall soon see
the end of complaints, discussions, and reforms relating to this subject.
The precise co-efficient of study which agrees with fair bodily health
is indeed an uncertain quantity, regulated by diverse personal peculiar-
ities. Its fixation must be ordered in each case by a special rule.

In arranging a system of education, however, it is both possible and
needful to allot to the average intelligence an average amount of mental
eflfort, which will duly provide for the requirements of education and
health. It is further very desirable and not difficult in allotting tasks
to keep in view the leading constitutional characters, as well as any
marked personal aptitudes or disabilities such as are illustrated by the
learners in every school. We are aware that these facts are, to a greater
extent than is commonly known, recognized by judicious teachers
throughout the country. It is equally true, however, that, whether
from a fault in the system or in those who administer it, evidences of
overwork are far from uncommon.



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The American Practitioner and News. 213

It should also be kept in mind that school children are not inva-
riably well fed, and come from unsanitary environs where wholesome
air is a rarity, and it may consequently be necessary in certain cases to
evoke somewhat cautiously the eflForts of a brain incompetent through
hunger.

This reminds us of a form of punishment so often adopted by inju-
dicious teachers. No one, probably, has seriously denied the need of
some form of correction, but in applying it, however, some regard must
be had to the type of the child under correction. The objection to such
as imply confinement indoors is a somewhat important one in case
where the culprit is some poorly-nourished youngster, to whom fresh
air is a luxury, or in any case where the punishment is frequently
repeated.

Neglect of simple rules like these and those touched upon already
will probably account for some obscure and fatal ailment involving the
brain in childhood, whose cause is commonly overshadowed by a gen-
eral condemnation of the constitutional type.

School Strain. Nerve-storms or nerve-explosions is a phase of child-
study which deserves most serious attention, because of the factors
which go to make up the environment of the child — the one of school
strain presents.

The important question of school hygiene and physical training is
one which the State can influence more than any other factor in envi-
ronment, and, as the State is responsible for the welfare, comfort, and
care of both mind and body of the child, the establishment as a part of
the public school curricula a department of study for inculcating modern
ideas of physical training, conjoined with school and domestic hygiene,
should obtain.

We must look to improved personal hygiene, especially during the
training of the young, if we desire to see all classes of bread-winners
so reared that they may enter upon the struggles of life both mentally
and physically fit. And if this be so with the bread-winners, is it still
not more necessary in regard to the genesis of the future race ?

We are all familiar with instances where children have entered
school with a well-poised mental and physical balance, but who, under
adverse conditions, became stunted and dwarfed, both in mind and
body, after a protracted attendance of school.

These adverse conditions, omnipresent in our school system, is a
commentary on civilization, as they cause anomalies of which school

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strain is a factor in this direction, and the child who is liable to nervous
storms, express themselves in emotional displays, restlessness, explo-
sions of anger, nagging propensities, egotism or convulsive tendencies,
which may at the onset be destitute of moral or mental significance.
They are removable by removing the school strain and its consequences.
If strengthened by protracted existence they intensify moral and phys-
ical degeneracy. Attention to these physical states by providing suit-
able training, conjoined with strict observance of the laws of hygiene
and indoor sanitation, will prevent the development and is oftentimes a
cure of these conditions and the resultant moral or mental deterioration.

School work should be adapted to the condition of the child ; and,
no matter what excuse may be made for the practice as a part of our
school system, it is unjust to require the feeble to exceed their powers,
that they should be expected to rival their robust companions in walk-
ing, running, bicycle riding, gymnasium exercises, or field sports.
Schools should be provided with a dynamometer for testing muscular
insufficiency ; these tests should be made quarterly during the scholas-
tic term, or oftener as individual cases may demand.

School Hygiene. The subject of school hygiene, with intelligent
physical training, is one of the most important subjects which can be
presented in the public school system, for without proper observance
of the laws relating to health the child is inhibited from intellectual
training, and, in proportion as the public school service masters the
subject and carries the principles out in a practical way, by the observ-
ance of tact in its administration, will we find children improve under
its care and become strong and hearty, mens sana in corpore sano.

Eye Strain. We have every reason to believe that in some of the
early expressions of school strain a period of stress is marked by eye
strain. These two conditions are so intermingled that by the potent
or benign influences of hygiene and physical training prevention on
the one hand and a cure on the other obtains.

We shall not consider at this time errors of the refractive apparatus
of the eye, so often brought about by the stubborn persistence of school
boards and others in following a medieval ** system " of school hygienics,
for when errors of refraction exist without the adoption of suitable
prophylactic or mechanic measures for their correction, it places the
eye under a corresponding disadvantage and precipitates all the sooner
a failure of clear and comfortable vision, and oftentimes with results
disastrous to sight.



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The American Practitioner and News. 215

Of all the ready methods of measuring the health standard of a
people, I know of none on which reliance can be more safely placed
than on the number of those whose vision is impaired.

The use of glasses is not in itself objectionable, on the contrary, to
be commended, but the increasing demand for glasses among those
who have hardly passed their first youth is a diflFerent matter. So far
as this depends upon causes that are preventable (not by the reckless
and injudicious use of unsuitable glasses) calls for serious consideration.

Imperfect light, bad print on unsuitable paper, impure atmosphere,
faulty ventilation, overheated and crowded school-rooms, unwholesome
water supply, lack of suitable recreation halls and ground, ill-fitting
school furniture, too long continuous study hours impair muscular
tonicity, so needful to keep up eye-tension for acute visual require-
ments.

Official statistics, the results of examinations made by competent
investigators in all parts of the civilized world, conclusively prove
what an important bearing the question of light and ventilation alone
has to do with the health of school children, and discloses the fact that
myopia increases with attendance of schools. It is generally believed,
both in England and in this country, that hypermetropia greatly exceeds
the occurrence of myopia. I am not altogether inclined to this opinion,
for we are rarely in a hospital — ^and I may add in private practice —
consulted about slight degrees of myopia, as it gives little or no incon-
venience. On the other hand, a very slight degree of hyperopia may
incapacitate the seamstress, mechanic, stenographer, clerk, student, or
those who work at close range, so that whereas we get all degrees of
hyperopia, we are only applied to in the higher degrees of myopia.

Further, a myope of one diopter will require no glass at the age of
forty-five (M. i D.+Pr. i D.=0). If the myopia be 4.5 D., then the
patient will hardly require a glass for a reading distance of 22 cm., con-
sequently the oculist is not likely to be consulted in cases of this class.

Most people imagine that those who do not require glasses with ad-
vancing age have very strong eyes. This is proof positive that they
had myopia, though probably you will be unable to convince the
patient of this fact.

Reassembling of Schools. The time for reassembling of schools after
holidays reminds us of the important duties connected with such an
event in the way of preventing infectious diseases among scholars.
It often happens that an outbreak of disease is caused by want of care

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2i6 The American Practitioner and News.

on the part of school authorities, as well as that of the health depart^
ment, or a selfish disregard of the consequences to other children on
the part of parents who send their sons and daughters back from an
infected home without any warning to the teacher.

We would impress upon superintendents and teachers the impor-
tance of making inquiries in the case of all their scholars whether there
has been any illness in their homes, or in the homes from which they
return to school. The health department of a city, or the medical
officer of a district where schools are located, should be compelled by
law to notify superintendents or teachers in charge of schools of any
outbreak of contagious diseases in a household, by sending the names
of all persons affected, as well as the names of children who, from their
surroundings, are likely to suffer from or carry contagion to others.

We should strongly impress upon parents and guardians the straight-
forward avowal and full information respecting cases of disease in their
household or neighborhood, for such a course is of the highest impor-
tance in the interest of their own children.

In schools to which a medical officer is attached it would be an
excellent rule to have all the pupils paraded before him the day or day
after their return to school, when he might carefully note any who •
seemed out of health or condition, and see them daily for the first week
or two of the term. The duty of a medical officer of a school should be
more that of prevention than cure — those questions comprehended
under the head of prophylaxis — thus saving the pupils from dangers of
serious disease, but also from secondary ill-health, which not infre-
quently follows,

Locxsvii:.LE.

2leports of Societies.



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.

Stated Meeting, June 30, 1899, William Cheatham, M. D., President, in the Chair.

The essay of the evening, " Cerebro-Spinal Meningitis,'* was read
by William Bailey, M. D. [See p. 201.]

. Discussion. Dr. J. G. Cecil : The subject is one that has been of
intense interest to me during the past season, especially since the first
of January, 1899. My experience with cerebro-spinal meningitis has



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The American Practitioner and News. 217

been very sad and unfortunate, perhaps not more so than that of others.
I have seen eight cases of cerebro-spinal meningitis during the last
season, and seven of them have died. Possibly there may have been
an error in diagnosis in some of these cases, for in several of them I
only saw the patients a few times, once or twice in two of the cases, in
consultation, and the symptomatology and course of the disease were
not such as to make the diagnosis very evident.

The first case that I saw was perhaps as typical as any seen during
the whole season, in a young girl aged sixteen years, which started out
and followed very closely the line of symptoms detailed by Dr. Bailey.
There was intense headache, especially in the back of the head, not
very much in the spine, but occasionally running down into the spine,
delirium from the start, persistent vomiting from the start, and a fever
which ran a very irregular course, but never very high until late in the
course of the attack. There was no opisthotonos and no very great
evidence of pressure symptoms, such as I take it would result from the
accumulation of large quantities of cerebro-spinal fluid. She had no
squint, and there was very little variation or inequality of the pupils,
but there could be no mistaking the character of the disease after it had
run two days. It was the first case I had seen, and it was two days
before I was fully satisfied as to the nature of the disease. All symp-
toms increased during the latter part of the disease, the fever running
very high (106° F.), and the child died on the fourth day. She had no
convulsion.

The treatment that I adopted, and which my consultant in the case
agreed upon, apparently had no eflFect whatever. There was not the
slightest evidence of any effect except the constitutional or systemic
effects that we would get from the medicines, which had nothing
whatever to do with the course or progress of the disease, or with the
final termination. The treatment adopted was that which is recog-
nized, I believe, as the old classic treatment, viz., purging with calo-
mel to start with, and we succeeded in getting the bowels to move ;
after that morphine by the hypodermic method, the ice coil to the
head, and later on heart stimulants; all of which, as I have said, had
no effect.

Another case which was exceedingly interesting to me, which I only
saw twice, was one in which the diagnosis was very plain at the start.
I gave a prognosis right at the start that was exceedingly bad. I told
the parents, after conferring with the consultant, that I did not think

17



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the child had any show to get well. This was in a boy about eleven
years old, and he had symptoms which resulted probably from pressure,
at least I so thought. He had opisthotonos and quite a deviation of
the eyes, with irregularity of the pupils and a violent chattering
delirium from the start. This boy was treated with opium, with the
addition of ergot. The case was seen in consultation with Dr. Walker.
I do not know how much ergot and opium were used. Cold applica-
tions were also made to the head, as in the other case, with a calomel
purge, and bromide was also given. This boy, after ten days of extreme
illness, recovered, and, as far as I have heard, has had no bad symptoms
whatever following ; there have been no sequelae.

The other cases I have seen have ranged all the way from very
young children, the youngest being only three months old, up to the
last case I saw, which was in a woman sixty years of age. All the
other cases have died ; the only case I saw get well was the boy, eleven
years old, above referred to. In none of them was there very much
fever, except the first case, in which the temperature ran high. In one
case I remember there was a cessation of all symptoms, leading us to
make, as is often done, a false prognosis, giving the people hope and
buoying ourselves up with hope, but the symptoms returned and the
child finally died.

To sum up what I have to say and the result of my experience,
which is limited, but which is more than I have seen during any other
season, a greater number of cases, I must say that I am very much at a
loss yet as to what ought to be done. The diagnosis is not very diflScult
when we are looking for the disease. The prognosis is in my experi-
ence exceedingly grave ; and the treatment, I can not claim any thing
for it at all. I am like Dr. Bailey, I hope that the future will develop
some method of treatment which will be in line of what we believe to
be the pathology of the disease, the serum treatment possibly. I have
not been much enthused with lumbar puncture except as a means of
diagnosis. I can not see much in the future in the way of treatment
from drawing off the fluid from the spinal column. I am constrained
to believe that in many of these cases we have a condition similar to
the dry, fibrinous, plastic pleurisy or pericarditis, and possibly eflFusions
play a comparatively small part of the disease, and that being so in
these cases, certainly lumbar puncture or even the trephining operation,
which I believe has been done and is now being much talked about,
would offer very little hope for relief from the symptoms. The fact is,



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The American Practitioner and News. 219

I do not see how it is possible for surgery to do very much in the way
of a cure.

Dr. A. M. Cartledge : I think I saw a case of cerebro-spinal menin-
Ifttis of the epidemic variety in Louisville during the past spring. I
was not sure, but in reflecting upon the matter now, in looking back
over the case I can not make any thing else out of it. I will briefly
detail the outlines of the case, because I would like to know if the
gentlemen present think the diagnosis was correctly made. I was
called to see J. H. T., aged about forty-eight years, and found him very
restless. This was on Saturday morning, and I had no history other than
this, that on Friday he had complained of headache, which grew worse,
and his physician was sent for, who administered some quinine and per-
haps some other medicine, and later a hypodermic of morphine had
been given by the nurse. When I saw him he was limping incessantly
across the room ; he did not have any tendency to opisthotonos, but it
was the reverse — emprosthotonos ; he went bent up in this way all the
time. He would crawl about the room, then settle down upon his
hands and knees before the fire; whether the warmth of that was
agreeable to him or not I do not know. He would remain there not
over a minute, then would get up again and go toward the wall on his



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 79 of 109)