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are about double the former size ; her shoulders and neck are becoming very much
more plump, and her chest is so much broader that she can scarcely wear the clothing
worn before. She is looking very much better. But nothing seems to dissolve the
uric acid crystals as yet. F. E. Doane, M. D.'

Kansas City, Mo.



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American Practitioner and News.



NEC TENUI PENNA.'



Vol. XXVIII. Louisville, Ky., October 15, 1899. No. 8.



Certainly it is excellent discipline for an author to feel that he must say all he has to say in the
fewest possible words, or his reader is sure to skip them ; and in the plainest possible words, or his
reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain
way ; and we want downright facts at present more than any thing else.— Ruskin.



Original Clrticlcs*



CERVICAL TUBERCULAR ADENITIS.*

BY F. C. SIMPSON, M. D.

It is met with at all ages, more frequently in childhood and about
maturity, occasionally met with in middle life. One of the special pre-
disposing factors in lymphatic tubercular enlargement is catarrhal
inflammation of the mucous membranes. You will find that slight
catarrhal inflammation will frequently be followed by swelling of the
cervical glands, especially so in the young subject, who early in Jife has
shown some hereditary predisposition. You take a child with a con-
stantly recurring naso-pharyngeal catarrh. The bacilli lodged there will
find their way to the nearest gland. Of course, if the child is in good
health, the local resistance would be active enough to throw ofi" any
invasion of the glands. Just the reverse occurs where the system is so
weakened ; the gland is not able to resist the bacilli, and, the field being
good, the little microbe goes to work. When one set of lymph glands
are diseased, other glands are likely to follow. You have cervical glands
most frequently diseased, and when diseased you may have bronchial
trouble without tubercular deposit taking place in the lung. It is not
an uncommon thing to find glands involved and find no tubercular
lesion in the lung. You may have glands in the axilla diseased. You
see this more frequently when cervical glands are involved. As a rule,
the enlarged glands produce very little local disturbance. They
usually remain quiescent, or soften and are evacuated, giving little or

• Read before the Louisville Medico-Chirurgical Society, June 16, 1899. For discussion sec p. 292.

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282 The American Practitioner and News.

no trouble. You will find these subjects anemic and debilitated, espe-
cially early in life. Most of these cases are free from discomfort,
except those of a febrile character. They complain more from the
deformity than of any physical pain.

Enlarged lymph glands are to be recognized as tuberculous only
when the bacilli are found in them, or where inoculation in animals
results in tuberculosis. The tubercular nature of the glands may be
inferred if you have tuberculosis in some other portion of the body.

In the diagnosis of tuberculous lymph glands syphilis should be
excluded. Syphilitic enlargement of the glands of the neck are not
very common, and when you do find them they are hard, and seldom sup-
purate. They are, as a rule, uniform in size. Another point to be
considered is enlarged glands in patients at middle life, as that is the
time you find malignancy so frequent. You find when several glands
are affected one or two are larger than the rest. They may vary in size
from a pea to a walnut, and some as large as a hen*s egg. Usually you
find two or three glands fused together, making one large gland.

You may find inflammation of the cellular tissue, which renders the
gland adherent to the neighboring parts. You may have resolution,
which occurs most frequently, or it may go on and form an abscess.

In regard to treatment, you must exercise sound judgment. If the
glands are small and freely movable, you leave them alone. Your duty
is to build up the patient by giving tonics, such as iron, cod-liver oil,
hypophosphites, etc. Fresh air, sunshine, good ventilation constitute
the most efficient and curative treatment. Send these patients to the
seashore if they can afford it ; send them to the country where they can
get good fresh air. So far as local treatment is to be used, you may
expect very little. Tine, iodine painted over the glands was supposed
to be of benefit at one time. Do not use it. Experience does not show
that any of the ointments do good.

It is important to keep these glands covered and protected, and a
protective plaster is useful. A plaster I often use is one made of bella-
donna and mercurial ointment spread on a piece of lint and kept in
place by a bandage. Never poultice these glands until pus is formed and
evacuated, as you may have a large abscess formed, which is to be depre-
cated. As soon as pus is formed, make a free opening so as to insure
good drainage. Always encourage suppuration after you open the
abscess. This is best done by hot dressings.



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The American Practitioner and News. 283

It should not be forgotten that in adults a cure is to be hoped for
by suppuration, while in children there is a strong tendency to resolu-
tion. In pursuing our general and local treatment toward a cure, we
should see that the original cause of trouble is not maintained, such
as the naso-pharynx and tonsils. Excision is only indicated when one
or two glands are involved and the tumor is superficial and movable.

The objection to operating is more glands are involved, and as soon
as one is removed another of greater depth presents itself. So in the
major portion of these cases let the glands alone, pursue your general
treatment, and they will get well. In my service at Masonic Home,
extending over ten years, I met with a number of these cases, and not
a one was operated on, and not one suppurated. I have never had one
to suppurate in a patient under ten years.

In looking over the literature of the past few years I find that a
great many of the surgeons are refusing to operate only on a few
selected cases, as I tiave stated above in my paper.

LOUISVII,I,E.



See our Special OfTer to new subscribers on one of the advertising pages.



LISTBRISM AND BACTERIA.

BY W. SYMINGTON BROWN, M. D.

As a prelude, allow me to say that I entertain the highest respect
for Lord Lister as a scientific surgeon. Next to the discovery of anes-
thetics, his campaign against dirt has done more to elevate surgery
than any other agency in our day. At the same time I believe that
his theory about deleterious microbes in the atmosphere, which Sir
Joseph tried to destroy by carbolic acid «pray, is a fallacy. In an address
delivered before the International Medical Congress at Berlin, he says :

**As regards the spray, I feel ashamed that I should have ever
recommended it for the purpose of destroying microbes in the air. If
we watch the formation of the spray and observe how its narrow initial
cone expands a.s it advances with fresh portions of air continually
drawn into its vortex, we see that many of the microbes in it, having
only just come under its influence, can not possibly have been deprived
of their vitality. Yet there was a time when I assumed that such was
the case, and, trusting the spray implicitly as an atmosphere free from



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284 The American Practitioner and News.

living organisms, omitted various precautions which I had before sup-
posed to be essential. . . If, then, no harm resulted from the admission,
day after day, of abundant atmospheric organisms to mingle unaltered
with the serum in the pleural cavity, it seems to follow logically that
the floating particles of the air may be disregarded in our surgical
work, and, if so, we may dispense with antiseptic washing and irriga-
tion, provided always that we can trust ourselves and our assistants to
avoid the introduction into the wound of septic defilement from other
than atmospheric sources."

Carbolic acid spray has long since been abandoned. Our distin-
guished confrSrey Dr. Marcy, still pours a stream of diluted oxygen over
the patient's abdomen during a laparotomy, though with what object
in view I confess is a puzzle to me. Atmospheric air is as full of
microbes as it ever was; but we no longer fear them during a surgical
operation. As Miss Florence Nightingale once said, when asked
whether night air was good for patients to breathe, "What other kind is
possible after sunset?'' The medical profession is still scared by the
presence of bacteria on the patient's skin and the surgeon's hands. Dr.
Howard Kelly has enunciated an elaborate regimen for the latter, with
which you are all familiar, terminating in a permanganate dye, to be
removed by a solution of oxalic acid. According to some bacteriolo-
gists, deep-seated microbes still impudently remain on the operator's
hands after all this heroic ablution.

Bacteriology is based on the assumption that certain acute diseases
are due to the influence of specific micro-organisms. I believe that the
presence of bacteria is a result and not the cause of a disease. In
other words, bacteriologists put the cart before the horse. Infectious
diseases generate peculiar poisons, some of which may be accompanied
by bacteria ; but we possess no satisfactory proof that they constitute the
primary cause of the disease. Injections of bacteria are accompanied
by a portion of the fluid in which they live, and it seems more rational
to conclude that the poisonous secretion is the cause of the disease.

Metchnikoflf, a celebrated scientist, advanced the phagocyte theory
that the function of certain cells was to absorb or destroy dangerous
microbes — a convenient loophole through which to explain why some
surgical cases, in which no antiseptic precautions were employed,
nevertheless did well ; but the phagocyte theory at present has few, if
any, supporters. Lord Lister says, ** I can see that while the measures
to which I have referred are, so far as they go, highly valuable, it must



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The American Practitioner and News. 285

be in itself a very desirable thing to avoid the direct application of strong
and irritating antiseptic solutions.**

Dr. Bantock, of London, recently read a paper before the British
Gynecological Society, entitled " The Modern Doctrine of Bacteriology,
or the Germ Theory of Disease, with Special Reference to Gynecology,"
which should be read by all surgeons who treat diseases peculiar to
women. He says :

** In a case in which the whole perineum and vulva were in a state
of extreme irritation from the relaxed or irritable state of the bowels —
due to the exposure of the mucous membrane of the rectum — and
without any precaution beyond wiping the surface with a warm, wet
sponge, I secured union by first intention, the diarrhea ceasing from
the moment of the completion of the operation. I dissect out vulvo-
vaginal glands, obliterating the cavity in stages; I remove growths
from the vulva, stitching up the wounds, and have never failed to
obtain union by first intention. I sew up a bilacerated cervix, and have
yet to record a failure. ... I have, either by accident or of set purpose,
opened the small intestine, the rectum, urinary bladder, and vagina in
abdominal operations, in which the bacillus coli must, for a shoft time at
least, have had free access to the peritoneal surface, without any harm.
And if I obtain these good results by the adoption of simple cleanli-
ness, in the common, every-day acceptation of the term, and such
arrangements as any well-ordered private house can atford, where is
the necessity for all those elaborate precautions which we hear of, . . .
the sterilizing of instruments and dressings, the spraying of the room
for an hour or two before the time of operation, and so forth — precau-
tions and preparations so eloquently satirized by Mr. Treves in The
Ritual of an Abdominal Operation ? "

For many years I have protested against the employment of cor-
rosive sublimate as a disinfectant in the abdominal cavity, or even in
the vagina. Weak solutions are more readily absorbed than strong
ones, and, consequently, are more dangerous. I have also abandoned
the use of carbolic acid on account of its irritating effects on the
bladder and kidneys.

It appears to me that the r61e played by bacteria in disease is at
least an undecided question. It seems more probable that deadly dis-
eases result from chemical changes occurring inside and outside of
organized bodies than that they are due to bacteria. We possess no
reliable evidence that chemical transformations ever produce new forms



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286 The American Practitioner and News.

of life. Theoretically, the thing is not impossible ; practically, it has
not been demonstrated. Eggs from organized parents constitute the
law of life. Animal secretions may be beneficent or poisonous, but
they do not produce life. Hydrocyanic acid is one of the most deadly
poisons. Does any one suppose that its action depends on the presence
of microbes?

We all are indebted to Lord Lister for his painstaking advocacy of
cleanliness, and he also deserves our thanks for the candor and manli-
ness with which he acknowledges his mistakes.

Stonkham, Mass.

Kcports of Societies.



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.*

Stated Meeting, June 2, 1899, the President, William Cheatham, M. D., in the Chair.

An Embryo at Six Weeks, Dr. Turner Anderson: I present a
specimen which has interested me very much, and which I recovered
from an abortion, an ovum at six weeks. I obtained the exact date of
the last menstrual period, and, based upon this information, it would
make the specimen presented, the ovum, at six weeks of utero-gesta-
tion. It is rare I think that we see a specimen which illustrates the
development of the ovum as typically as this; it is not often that we
obtain a specimen as small as this. We have all seen pictures of these
conditions in books, but it is not often that we have an opportunity to
observe the specimens themselves.

This was a spontaneous abortion, perhaps caused by disease of the
endometrium ; there was a history of chronic endo-uteritis. The
woman had suflFered from leucorrhea, perhaps a uterine leucorrhea, and
there had been a great deal of hypersecretion. She had previously
borne several children.

Discussion, Dr. T. S. Bullock: I want to congratulate Dr. Ander-
son upon his good luck in recovering this specimen. I have never
seen one younger than this, and it is a beautiful exemplification of the
processes which take place, and which heretofore we have only been
able to study in the lower animals. This is the youngest human ovum
I have ever seen.

* Stenographically reported for this journal by C. C Mapes, Louisville, Ky.



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1 he American Practitioner and News. 287

Dr. Turner Anderson : The knowledge of the processes which take
place in the development of the human ovum is of considerable
importance to the general practitioner and the obstetrician, because it
gives him a better idea of and more assurance in regard to dealing
with the secundines, etc. In this case there was no question that every
thing had passed.

As somewhat bearing upon this question, I will briefly report a case
which shows how difficult it is sometimes to produce an abortion; how
the sound may be introduced into the uterus without disturbing the
ovum. It has been said that to produce an abortion in the early
months of utero-gestation is not difficult; we know that the ovum does
not fully occupy the cavity of the uterus until termination of the
third month ; we know that the internal os is still open up to this time,
and a sound may be passed in before the decidua reflexa has developed
around to close up entirely the orifice. When these things are remem-
bered, it is not so surprising that efibrts even at criminal abortion fail ;
that sounds may be introduced into the uterus and remain there for a
time and are then removed without producing an abortion.

I was particularly struck with the foregoing in connection with the
case which I shall briefly report. I was called upon to operate on a
young woman, thirty years of age, who had been delivered, after a very
hard labor, of a child with forceps. I was asked about fifteen months
afterward to operate for a vesico- vaginal fistula. Urine leaked from
the bladder constantly, and the bladder had contracted very much.

The only evidence that presented upon careful inspection of the
whole interior of the vagina was just up near the os, which had been
lacerated on the right side; just within this lacerated portion I could,
by packing around it, see that urine was flowing from the upper angle
of the laceration. There had been a unilateral laceration upon the
right side.

The condition looked very ugly ; I could not see the rent in the
bladder ; it was high up, constituting a vesico-utero-vaginal fistula. I
could pass the sound into the uterus, tracing the canal on upward, find-
ing that it was pervious, and had no difficulty in making out that there
was a laceration of the cervix which had extended, involving the
bladder wall up very near the angle on the right side.

Before I began the operation the patient had been examined by
several other physicians, who thought it would be necessary for me to
turn the uterus into the bladder ; that the only thing to do would be to let



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288 The American Practitioner and News.

the woman subsequently menstruate through the bladder. There are
cases in which this operation is advisable and is the only thing that can
be done ; such operations have been performed, but the history of these
cases is not satisfactory ; the women are doomed to sufiFer greatly from
the influence of menstrual blood upon the mucous membrane of the
bladder, and they have a hard time.

I operated and succeeded in pulling the uterus down far enough to
pare the edges and close opening in the bladder; then went on and
did a trachelorrhaphy. I completed what I thought at the time a rather
unsatisfactory operation ; I did not feel that it would be successful ;
introduced a drainage-tube into the uterus, which did not seem to go
further than the ordinary depth of the cavity of the uterus, and this
was left in. The drainage-tube came away two days later. The
vagina was douched afterward. The bladder was washed out with
boric acid, and after a time upon examination, to my great surprise, it
was found that I had a complete result ; I had perfectly succeeded in
repairing the fistula by the operation. The woman remained in the
hospital four weeks, and before allowing her to go home I wanted to
satisfy myself that the cavity of the cervix was pervious, so I had her
taken into the operating-room and passed a sound into the uterus.

Now comes the most interesting feature in connection with the
case: The operation was performed on the 15th day of December,
1898. Her menstrual periods had been slightly irregular, her last
menstruation having been November 25th. On December 15th the
operation was performed. Kvery thing went along smoothly, and I
thought every thing was smooth until I was informed that her abdomen
was enlarging very gradually; that she had developed a tumor. I
advised that she be brought back here so I could examine her, when
it was found that she was fully seven months pregnant. A trachelor-
rhaphy had been performed upon this woman, a drainage-tube had been
placed in the uterus, the uterus had been sounded, yet an abortion was
not produced thereby ; all this manipulation was done at a time when
she was pregnant, yet the condition was not suspected. All the data
that I am able to gather in connection with the case, the dates, etc., go
to show that this woman was pregnant at two months when the opera-
tion was performed.

Dr. H. A. Cottell : This is another of Dr. Anderson's wonderful cases
of operation during pregnancy without producing a miscarriage, which



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The American Practitioner and News. 289

of course means that the operation was performed with a great deal of
skill.

Dr. William Bailey : I only want to emphasize that it is remarkable
that such an operation could be performed, where the catheter, sound,
and drainage-tube were used, without producing an abortion. If such
cases were common, the professional abortionists would find a great
deal more trouble than now. The case is certainly a very remarkable
one. It may be, however, when the time for delivery comes, it will be
found that the woman was not two months pregnant at the time of the
operation, because we are sometimes deceived as to the time. I
remember a case a short time ago in which I waited three months
after the woman said it was her time to have a baby before she really
was delivered.

Dr. T. S. Bullock: The case is very remarkable, and shows how tol-
erant some uteri are to instrumental manipulation. I ha,ve been im-
pressed with this upon several occasions, never when the ovum was
quite as young as in this case, where we all know that abortions are
usually very easily produced, the hold of the ovum on the uterine sur-
face not being as intimate this early, before formation of the placenta
and the secundines, as it is later. But on one or two occasions in pro-
ducing a therapeutic abortion I have been very much struck with the
tolerance of the uterus, seeming to negative the extra precautions we
ordinarily take in instructing the patient with reference to her actions
during this period. Dr. Anderson will recall several cases in which we
were forced to induce premature labor for therapeutic reasons, where
we had to introduce the bougie several times, leaving it intact twenty-
four hours or possibly longer, two or three separate introductions of
the bougie being necessary before uterine action was aroised suf-
ficiently to dilate the os.

It is remarkable in the case reported, with all the manipulation
necessary to close a vesico-utero- vaginal fistula, with subsequent intro-
duction of a drainage-tube, catheter, and sound to render the doctor
certain that he had not produced atresia of the cervix — it is remarkable,
I say, that an abortion did not result.

Dr. F. C. Wilson : One point, not brought out thus far, is of impor-
tance, and that is the knowledge of fetal diagnosis, as guarding the sur-
geon against mistakes. The patient came to Dr. Anderson represented
as being the subject of a ** tumor,*' and we know that in times past
cases of pregnancy as far advanced as this have been operated upon,



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290 The American Practitioner and News.

or operations have been commenced, only to reveal the true condition
present. Of course surgeons ought not to make a mistake of this kind,
yet it has been done time and again. When pregnancy has advanced
to six and a half or seven months, the fetal heart-sounds can be dis-
tinctly heard, yet in such cases diagnosis of ovarian or fibroid tumors
has been made, and all arrangements have been perfected for an opera-
tion. A better knowledge of fetal diagnosis "would save the surgeon
or obstetrician from such mistakes.

Meningocele, Dr. A. M. Vance: I would like to make a continued
report of a case which was reported to this Society some time ago. I
was called by Dr. Goodman to see a child, five months old, who had a
very large meningocele between the frontal and parietal bone on the right
side. At 10:30 o'clock in the morning I aspirated this meningocele and
drew off" half a listerine bottleful of fluid, probably about half a pint. I
put a skull cap of crinoline tightly down over the child's head. At
twelve o'clock I had a telephone message that the skull cap had come
off". I was very much surprised, and at 3 o'clock went to see the child,
and found the meningocele was as large as it was before aspiration. I
wondered where all this fluid came from, and concluded that the whole
cerebro-spinal system of the child must be distended with fluid, and
relief at the point of the meningocele had allowed the accumulation of
fluid in the deeper parts of the system to fill the sac, showing that the
cerebro-spinal fluid flows in the direction of the cranium.

I proposed then to do a radical operation upon the child, which was

declined. It lived thirteen months, when I saw it again in consultation

with two other physicians. The meningocele was almost as large as

the child's head ; the child was in coma, and had not secreted any urine



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 87 of 109)