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He was fifteen years of age, and was very much under size. His mother
died of consumption; one brother, he says, has catarrh; his father
seems fairly healthy.

This boy four years ago slipped in a creek and hurt his ankle while
on his way to school. He went on to school, and three days afterward
his ankle began to hurt him very much ; it swelled considerably, and
the boy has been a cripple ever since.

Some months after he was hurt the doctor lanced a swelling on his
leg, and since then his leg has been lanced two or three times, and the
discharge has kept up until he was practically worn out. He was greatly
emaciated and had no color.

I amputated his leg to-day and show the specimen. The ankle was
very much enlarged and firmly ankylosed, the foot twisted outward, and
the heel drawn upward. He had an immense ulcer on the inner and
anterior part of the leg just above the ankle ; there were a number of
scars on the anterior part of the leg, and a curve of the tibia could be
felt. I amputated at the junction of the middle and upper third.
After taking the leg oflf, I curetted the inside of the bone of the stump
and removed all of the medullary substance.

The specimen I present is the tibia with the astragulus at-
tached — a well-marked case of osteo-myelitis with bony ankylosis of
the joint.

Discussion, Dr. A. M. Vance : This is certainly one of those cases
of acute inflammatipn of the bone beginning as an osteo-myelitis.
There has been a fight between nature and the disease, and it fell to the
lot of Dr. Roberts to save the boy's life by amputation. There seems
to be an ankylosis between the astragulus and the tibia.

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58 The American Practttzoner and News.

Conservatism about the lower end of the tibia is being less and less
observed all the time in chronic bone diseases on account of the per-
fect prosthetic apparatus we are able to obtain. I am sure the boy will
be aWe to walk better with an artificial limb, and the result will be
more perfect than if conservatism had been practiced, and this was
really out of the question in this case.

Dr. H. H. Grant : This is a condition which almost certainly was
not primarily tuberculous, and probably began simply as an acute
inflammation, and it is only unfortunate that the boy was not under
the care of Dr. Roberts early enough to have obviated the necessity
of amputating the leg so high up. The remaining portion of the
medullary canal is probably diseased, and there may possibly be infec-
tion of the knee-joint through the medullary canal, so that amputation
below the knee will fail to relieve, the case.

I have seen a number of cases of this kind, and unquestionably
amputation is demanded in a great majority of instances. Operative
steps at the ankle-joint, aside from amputation, are usually unsatisfac-
tory ; excision of the ankle-joint results in a stiff" joint, which is far less
satisfactory than an artificial limb, and in many instances where incis-
ion and resection are undertaken in these cases it is not successful,
and amputation afterward is necessary.

Dr. J. G. Cecil : The specimen is exceedingly interesting, and sug-
gests to my mind this question, which I would like Dr. Roberts to
respond to in his closing remarks. In cases of so-called sprain in
tuberculous children, as this evidently is, what is the best line of
management of the case in the beginning? Dr. Vance will remember
a case that was similar to this which resulted in excessive destruction
of bone about the ankle under treatment which was deemed the best
and most practical at that time. It is a question of interest to those of
us in general practice who run across sprains, etc., as to what would be
the best line of treatment to adopt in order to prevent such extensive
destruction as we see here resulting in conditions which necessitate
such an extensive operative procedure.

Dr. W. O. Roberts : In answer to Dr. Grant : This is the second
case of the kind that I have operated upon within the last month ;
both of them presented the same condition of the medullary canal, and
in the other one the leg was amputated at about the same point, the
medullary canal being thoroughly curetted. It has been my experience
that such cases get well without any further trouble. We have to be



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The American Practitioner and News. 59

careful in cleaning out the medullary canal not to go through the head
of the tibia and open the knee-joint. Such an accident has happened
in a number of instances, followed by destruction of the joint.

In reply to the question asked by Dr. Cecil : The indication is per-
fect rest until all symptoms have subsided. Treat all sprains in tuber-
culous subjects with perfect rest, whereas in non-tuberculous subjects
it is my practice to get them up walking about as soon as possible.

The essay of the evening, ** Endometritis," was read by Lewis S.
McMurtry, M. D. [See p. 41.]

Discussion. Dr. William Bailey : I scarcely think any subject of
more interest could be introduced to the Society, and I am obliged to
Dr. McMurtry for introducing it and discussing it so we.ll. I want
simply to make a few remarks as a general practitioner, and say that
I believe there is no more harmful practice than the ordinary oflBce
examination of women by general practitioners. I believe for the
most part it would be well if the ordinary examining instruments in
the general practitioner's room and the examination and treatment of
women for so-called endometritis by the general practitioner were
abolished. There is no question but in the majority of cases that his
treatment does harm rather than good. The opportunities that he has
for infecting the woman, if she is not previously so, the manner in
which he keeps his instruments in his ofl5ce, his absolute failure to
properly sterilize them, often his own physical condition and the want
of cleanliness about his hands — all these, it seems to me, make it a
serious question whether the general practitioner ought to be allowed
to make such examinations in his oflBce at all or not. For the most part
I have no doubt it will be admitted that these troubles are produced by
micro-organisms, and also for the most part micro-organism from
without it may be. If the conditions are favorable for the development
of septic troubles after abortions, etc., I would say that the conditions
are lost by which the vagina has been protected before that. The
conditions are such that the acid secretions of the vagina do not con-
tinue, and hence the possibility for a favorable nidus for the develop-
ment of bacteria is much greater.

I shall never be old enough to forget the case Dr. McMurtry alluded
to, where I left an admirable woman in good condition at four o'clock
in the morning, with a negro nurse in charge, who asked me before I
left the apartment when she should " give the douche." I charged her.



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6o The American Practitioner and News.

in the presence of the patient, not for her life to undertake any such
thing until I had given her permission, intending that such permission
never should be given. When I returned during the afternoon of the
next day the woman had had three injections, three vaginal douches,
with a fountain syringe which had no doubt been hanging in the closet —
not simply in the bath-room but in the water-closet — and had been used
indiscriminately for the vagina, for the rectum, and for any other pur-
pose that might be advisable or for which it could be used, and within
twenty-four hours from the time of delivery the patient's temperature
was over 105° F. and scarcely was below that for the ten days she lived,
and with the most complete infection that I have ever seen. As stated
by Dr. McMurtry, there were no limitations at all, and no conditions that
would even warrant him in curetting the uterus, with a general septic
infection that seemed out of all proportion to the local conditions. So
I would put my face strongly against vaginal injections under such cir-
cumstances and under such surroundings. I do not mean to say that
vaginal injections or douches are improper after abortion or after labor
if properly administered, but as the general practitioner often finds his
patient attended by an ignorant, dirty, filthy nurse, I think in any such
case it is better to trust to nature and drainage than to have such
douches made. It is a wonder to me that woman is not more often
infected than she is. Nature certainly makes considerable provision,
as the essayist has stated, by drainage and by natural conditions opposed
to infection, until changed condition of the vaginal secretions makes
infection more liable. But of all the sources of infection I apprehend
most is that coming from gonorrhea. While gonorrhea in the male is not
regarded by most men as a matter of great importance, yet to my mind
woman suffers much more than she will from syphilis. I believe if I
were a woman I would rather take my chances with syphilitic inocula-
tion than with gonorrhea. I think many of the radical operations that
the surgeon is called upon to perform upon the female at the present time
are dependent upon gonorrheal infection, and I am especially obliged
to the doctor for his remarks concerning the protective influences ; and
I believe that whan it comes to treatment of an infected uterus, that it
ought to be in skilled hands, not in the hands of the general practi-
tioner, and I for one am ready to give him that opportunity*

Dr. T. S. Bullock : I merely want to say a word in regard to the
statement made by Dr. Bailey that he thinks the ofl5ce chair and office
examinations by the general practitioner should be abolished : I thor-



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. The American Practitioner and News. 6i

oughly agree with him if the uterus is to be invaded, if you are going to
introduce speculums, etc.; but I do not see any reason why these instru-
ments should not be made as thoroughly aseptic in the doctor's office as
in the surgeon's operating-room. The point I desire to make is this, I do
not see any occasion whatever for the specialist or the general practitioner
to introduce any instrument into the vagina in making an examination,
but it should be done with the index finger. The bimanual method
will give him all the information that he could obtain by the introduc-
tion of a speculum, a sound, or by any other method.

In regard to douches after labor : I think they should be absolutely
condemned unless there is some indication for their use in the way of
fetor to the discharges, or infection exists from the instruments or the
hands of the accoucheur ; otherwise I think the douche is harmful and
should never be employed.

I agree that the introduction of sounds, the curette, etc., in the
office of the general practitioner should be thoroughly condemned, and
I also thoroughly indorse the statement that when the uterus is to be
invaded, no matter where it is done, every precaution should be taken
to have every thing as thoroughly aseptic as if the abdominal cavity
were to be invaded. But I do believe that there are cases where the
curette is one the most useful and valuable instruments that we have
in skilled hands.

Dr. Louis Frank : The subject is such an enormous one that it is
difficult to know just where to begin in discussing it. I take it one of
the main points in the paper is the prevention of endometritis and the
prevention of infections generally. I heartily agree with what has
been said in this line, although I am inclined to think that instrumen-
tation about the uterus has been condemned rather too much. I do
not believe it is the instrumentation itself that does the harm, as I
believe in skilled hands any number of sounds can be passed daily, for
that matter, without doing any harm ; but it is the abrasions about the
endometrium, thus facilitating the entrance of micro-organisms, that
does the harm.

There is never any occasion to use the sound either in office prac-
tice or any other work for the purpose of examination.

As to the curette : It is one of the most valuable instruments that
we have, and one we could hardly get along without, and its use should
not be confined to cases of endometritis — by endometritis I mean a true
nflammatory condition of the uterus itself — but in those cases where we



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6 2 The American Practitioner and News.

have a subinvolution, where the organ is large and heavy, curettage for
the purpose of getting drainage and reducing the size of the organ by
depletion is a very satisfactory procedure.

There is never any indication to introduce gauze into the uterus
except for the purpose of drainage, and in cases which are not septic I
take it no one would introduce gauze at all. In septic cases it is a
wise plan, and one which should always be followed — the introduction
of gauze or rubber drain. But it is in those cases of infection after
abortion which have existed and continued for some time where the
curette proves of most value.

I diflfer with Dr. McMurtry in regard to packing the uterus in puer-
peral cases : I would pack in these cases not for the purpose of drain-
age but for the purpose of shutting oflf fresh areas from infection, as we
would pack to shut oflf fresh areas in the cavity and prevent infection
of the peritoneum. This is equally true in cases following abortion or
labor where infection has taken place. In these cases I believe much
good can be done by packing tightly with gauze, the gauze being
removed and subsequently irrigation being practiced. I have seen
cases where the infection was purely localized, and where the infection
was not only localized in the endometrium but where infection existed
in the cervix and where there were abcesses about the cervix following
labor. The indications, of course, in such cases are very clear.

As to the use of the douche subsequent to labor : I do not believe
it is ever necessary, and by its use we practically admit that our meth-
ods of dealing with the case have been imperfect, except, I will say, in
cases where some one else has attended the patient, or where criminal
abortion has been. induced; but in the ordinary normal cases, or even
in abnormal labor, where instrumentation has been used, the douche is
never indicated. Its use is but to acknowledge imperfection in our
technique, and I would not use irrigation or douches here any more
than I would after an abdominal section. If infection already exists,
irrigation or douches are absolutely necessary, otherwise there is no
indication for such a procedure.

I am sorry that Dr. McMurtry did not limit his remarks, as the field
is so wide and there are so many things which might be discussed that
to do so intelligently would occupy too much time.

Dr. J. G. Cecil : There is one point in the management of endome-
tritis mentioned by Dr. McMurtry which has not been suflSciently
emphasized, and may be properly referred to under medicinal treatment



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The American Practitioner and News. 63

I mean by that, constitutional or internal medication. Cases of endome-
tritis are sometimes advantageously treated without recourse to topical
applications, curettage, etc., and under such circumstances a number
of things occur to us, and there is a line of treatment which should be
emphasized more than it is : I refer to rest in bed, and especially to the
use of purgatives. As we know, nearly all quack medicines which are
advertised and used so extensively, if they have any virtue, it lies in the
fact that they are purgative in character. There is undoubtedly some
good effect which comes from the use of some quack medicines, and
this can generally be attributed to the fact that they are purgatives.

I believe in many cases as good or even better effect as far as the
final outcome of the case is concerned may be obtained by rest in bed,
at any rate limiting the amount of exercise to be taken by the patient
suffering from endometritis, putting her in a favorable condition as far
as position goes for relief of the congestion and other conditions which
obtain, favoring drainage, etc., at the same time prescribing vigorous,
active purgation. I believe that rest with purgation, without local or
topical applications or injections, with hot water or otherwise, we can
get along in many of these cases that are simple in character in a most
admirable way.

I have recently seen a case that I recalled to mind, as Dr. McMurtry
was reading his paper, in a young courtesan who had from all I could
gather indulged in excessive venery. She came to my office, and was
suffering with violent congestion of the uterus and its appendages, so
that an examination was extremely painful to her, and it looked at first
blush as though the young woman had extensive trouble about the
appendages especially. I told her to go home and go to bed and obtain
rest, especially from the cause of the trouble ; I think I also prescribed
a warm douche, not relying much upon this, however, but emphasized
most strenuously the free use of Rochelle salts. It was a surprise to me
to see how rapidly that patient recovered; within three or four days she
was entirely well. As far as I know now she has no involvement of
the uterus or its appendages, although she probably will have sooner or
later if she continues her profession as a prostitute. The result in this
case impressed itself upon me very much, and I believe that we will
accomplish more by rest and free purgation than by the old-time treat-
ment of applications of tincture of iodine, nitrate of silver, carbolic
acid, etc. By the rest and purgation much good can be done, and cer-
tainly little harm can result. LOUIS frank, M. D., Secretary.



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64 The American Practitioner and News.



KcpictDS anb 3ibUograp(|y*



Text-Book of Histology, Including; the Microscopic Technic. By Dr. Phu^ip
Stobhr, Professor of Anatomy at the University of Wuertzburg. Second Amer-
ican from the eighth German edition. Translated by Dr. Emma L. Bbilstbin,
Director of the Laboratories of Histology and Embryology, Woman's Medical
College of Pennsylvania. Edited with Additions by Dr. Ai^prbd Schafbr,
Demonstrator of Histology and Embryology, Harvard Medical School, formerly
of the University of Ziirich. With 292 illustrations. 424 pp. Price, $3.00. Phila-
delphia : P. Blakiston's Son & Co. 1898.

If the fabled genii could offer the student a choice of wishes, the med-
ical student, contemplating the enormous task that grows apace before him,
would express his wish for a return of the days of Methusaleh. This
remark is suggested by the fullness and magnitude of this work, which
has now to be added to the list of preparatory studies, that is, preparatory
to the practice of therapeutics.

The author starts out as if teaching a child its alphabet, even giving
directions for dusting the microscope, so that the student may know that
he has made the right start. The work then develops with a scientific
thoroughness, conciseness, and clearness of expression that declares the
master and leaves little indeed to be desired.

During the ten years of its existence it has passed through six revised
editions, and has been translated, besides English, into Italian, French, and
Russian. The cuts, besides being abundant, are executed in the most
superior style, and the whole book, both in its matter and method, is sure
to continue to make its impress upon scientific medical thought and teach-
ing. D. T. s.

The Principles and Practice of Medicine. Designed for the Use of Practitioners and
Students of Medicine. By Wiluam Osi^BR, M. D., Fellow of the Royal Society;
Fellow of the Royal College of Physicians, London ; Professor of Medicine in the
Johns Hopkins University, etc. Third edition. 1181 pp. New York: D.Apple-
ton & Co. 1898.

When an American physician feels called upon to name the medical
men and institutions that have notable part in giving his science an honor-
able position among the nations, he in no case fails to mention Professor
William Osier and Johns Hopkins University. Dr. Osier's name is one
not only regarded as among the authorities at home, but abroad he has a
seat among the judges.

In a work of this size for students it is not to be expected that large
additions can be made by any one. With the exception of some progress
in treatment, some new remedies introduced, skill and wisdom is to be
shown in the indicated use of knowledge already possessed.



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The American Practitioner and News. 65

The advantage of this work is the authoritativeness that goes with the
well-known learning, experience, and discriminating care of the author, who
cultivates alike the deepest study and the most rational practice.

In this edition quite a number of the articles have been rewritten, and
new matter incorporated in others. The page has been somewhat enlarged
and the letter-press improved by the use of a new and clearer type and a
better class of paper. In its new dress it stands second to none as a text-
book for students and a ready help for practitioners. d. t. s.

Clinical Lectures oo Mental Diseases. By T. S. Ci«ouston, M. D. (Edin.), P. R. C. P.^
Physician Superintendent of the Royal Edinburgh Asylum for the Insane ; Lect-
urer on Mental Diseases in the University of Edinburgh, etc. Pifth edition.
727 pp. Philadelphia and New York : Lea Brothers & Co. 1898.

The author takes the word from the reviewer by saying in the preface,
*'a medical book that is coming out in its fifth edition needs no preface.*^
The reviewer can only add that it needs no review. One thing can hardly
be doubted, no English-speaking physician would call the list of the
highest three authorities on mental diseases without mentioning the name
of Dr. Clouston. The judicious fairness, freedom from bias, broad sym-
pathy, and large experience, added to his intellectual gifts, peculiarly qualify
him as the teacher he is ever3rwhere held to be.

In his style he is not so clear and so superbly classic as Gowers, but he
has a most happy faculty of seeing things as they are and portraying them
as he sees them, without warping them to fit rules and systems.

Sometimes he is a little careless and unclear in his style, as when on
page 534 he says, " I have seen a senile melancholiac of both sexes suffer
intensely from this practice " (masturbation).

In the matter of classification and nomenclature the author recognizes
the fact that suflScient headway has not yet been made in pathology to
allow of a satisfactory arrangement, and that classification and nomencla-
ture in mental diseases must yet be regarded as to a large extent provisional.

The name of the book itself would prove to many somewhat mislead-
ing, for it relates almost wholly to insanity or diseases bordering on it.
And in such respect it occupies a place that is not even contested by any
other. D. T. s.

Manual of Diseases of the 5kln, with the Analysis of Twenty Thousand Consecu-
tive Cases, and a Formulary. By L. Duncan Bui^kley, Physician to the New
York Skin and Cancer Hospital, etc. Fourth edition. Revised and enlarged.
362 pp. New York : G. P. Putnam & Sons. 1898.

In the preparation of this volume the author announces his aim to
retain the simple and elementary character that marked former editions.
The work has been thoroughly revised and much of it rewritten.

We join in the apprehension of the author as to the diflSculties of pre-
senting dermatology at all adequately in such short compass. We believe
this quite impossible without clinical specimens or elaborate drawings.



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66 The American Practitioner and News.

Prom this work one may gain a kind of survey of what he has to learn.
For the purpose of reviving knowledge that has become dim it would be
found doubtless much more useful, or it might be valuable for the treatment
alone, its author being regarded as one of the highest authorities of the
country.

The author himself very generously expresses the hope that it may
lead to the study of Hyde, Duhring, or Crocker, who he rightly claims are
not surpassed by the authors of any country. d. t. s.

A Compend of Obstetrics. Especially Adapted to the Use of Medical Students and
Physicians. By Henry G. Landis, A. M., M. D., late Professor of Obstetrics and
Diseases of Women in Starlings: Medical College. Revised and enlarged by
WiLi«iAM H. Wei^lS, M. D., Adjunct Professor of Obstetrics and Diseases of Infancy
in the Philadelphia Polyclinic, etc. Sixth edition. Illustrated. i88 pp. Price,



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 8 of 109)