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The American practitioner online

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appropriate doses and at short intervals until the temperature is suffi-



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326 The American Practiiianer and News.

ciently reduced is safe and reliable, and it should be given whenever
the temperature rises above 103° F. The patient should be encouraged
to drink cold water freely. The full bath and wet-sheet pack are
recommended by some high authorities, but there are many objections
to their use. In addition to the fright and excitement caused by the
bath, the depression and shock which follow are sometimes alarming.
The only cases in which I think the full bath advisable are those in
which the patient has very high temperature and violent delirium.

The pharyngitis and tonsillitis, which are almost always a complica*
tion, should be treated by frequently spraying the throat with a mixture
of equal parts of peroxide of hydrogen and lime-water. This has a
decidedly soothing effect upon the pharyngeal mucous membrane, and
relieves much of the diflficulty of deglutition. The same mixture should
occasionally be sprayed into the nasal passages also for its detergent
eflFect. The use of peroxide of hydrogen, as above described, mate-
rially lessens the danger of infection by the secretions from the throat
and nose.

To allay restlessness, especially at night, chloral hydrate is the most
acceptable remedy. Opium should be studiously avoided in the treat-
ment of scarlet fever, for the reason that it lessens the activity of the
renal secretion and thus increases the danger of nephritis.

The next most important indication in the treatment of scarlet fever
is, as far as may be, to prevent the profound anemia that usually fol-
lows in the course of the disease. Iron in some palatable form should
be given from the start, notwithstanding the old adage, " never give
iron in fever." The ammonio-citrate of iron in one-grain doses, sus-
pended in simple syrup, is a pleasant medicine. It is my custom to
give this form of iron throughout the course of the fever. I believe that it
prevents, in a measure, the deterioration of the blood and lessens the
danger of complications and sequelse. I believe that the use of iron as
above indicated aids materially in maintaining the function of the
heart, and thus the better function of all the organs of the body.

Nephritis is, of course, the most dreaded sequel of scarlet fever, to
prevent which we should do every thing in our power. In addition to
controlling the temperature by keeping it below 103° F., and supportive
measures by the administration of iron, we should be careful to see that
a sufficient amount of easily digested food is taken to sustain the vital
forces. Liquid diet, such as soups, milk, and broths, should be given.
The patient should be carefully guarded against drafts of cold air. He



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The American Practitioner and News. 327

should be kept in bed, and under sufficient cover to promote the action
of the skin, which may be facilitated by drinking freely of hot lemonade.

With quinine and phenacetin to control temperature, chloral hydrate
to induce sleep, and iron as a supportive, we can meet the leading indi-
cations in the disease, and by frequent inunctions the desquamations
from the skin are prevented from floating about in the air and spread-
ing the infection. Thus we may sum up the management of typical
cases of scarlet fever.

For fear of being tedious I shall not, in this paper, discuss the treat-
ment of the various complications and sequelse. My aim has been
rather to present a few practical measures of treatment, with an eye to
the prevention of dangerous complications and sequelse.

I/OniSVILLB, Kv.



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



2leport5 of Societies*



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.*

Stmted Meeting, September aa, 1899, the President, William Cheatham, M. D.,

in the Chair.

Case of Appendicitis. Dr. T. S. Bullock : This appendix illustrates
how much dame^e may be done, and how disproportionate the symp-
toms may be in appendicitis, or there may be practically no symptoms.
The patient, a man sixty years of age, was seen first on Monday after-
noon complaining of pain in the right side, but an examination at that
time revealed an absolutely relaxed abdomen, no muscular rigidity, with
pain not in the region of the appendix, but in the region of the umbilicus.
I did what I think was improper at that time, gave him an hypodermic of
one-quarter grain morphine. This did not relieve him, and I saw him
the next day. At that time he was still suffering excruciating pain,
which had been unrelieved by the opium. Examination then revealed
tenderness at McBumey's point and some muscular rigidity. I had
him removed to the Infirmary and operated the next day. The appen-
dix was gangrenous for at least one and a half inches from its base,
though the man had had no prior symptoms to the Monday morning
mentioned, and it also contained several enteroliths.

« Stenogrmphically reported for thU joum*l by C. C. Mapes, Louisville, Ky.



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328 The American Practitioner and NewL

The case is only interesting in so far as it shows how much damage
may be done and how few symptoms may be present.

Dr. L. S. McMurtry : The case reported by Dr. Bullock is interesting,
and illustrates a most valuable point in the symptomatology of this
many-sided and many-formed disease — appendicitis. The case illus-
trates a class that becomes more interesting the more we study them ;
cases where it seems to the laity and the patient's friends that it is
folly to operate upon a man who evidently is not sicker than this, who
has the symptoms of ordinary colic ; a case where the patient and the
surgeon himself will be lulled into a sense of security by the fact that
there is no rigidity of the abdomen, where the bowels have moved freely ;
with a pulse and temperature that remain almost normal— an array of
symptoms that seems absolutely inconsistent with so much pathology
within the abdomen.

Dr. A. M. Cartledge : Two or three years ago I had occasion to call
attention to what this case seems to illustrate, that excessive pain in
the initial stage of appendicitis without muscular rigidity is a sign of
early death of the appendix from strangulation,. and it is striking that
some of these cases are very much like strangulated hemise in that
there is no time for inflammatory reaction, a sudden blocking of the
terminal artery of the appendix arid sudden death of the organ. This
is the most misleading type of cases with which we have to deal, and I
know of nothing so valuable in suspecting them as the intensity of the
pain. Given a case of sudden and great intensity, pain being the domi-
nant symptom, without any especial muscular rigidity that we rely so
much upon to make a diagnosis, I would believe from my experience that
such a case demands earlier operative interference than any other class.
There are other cases where death of the appendix takes place from
primary eschemia, in which there is also intense pain.- Again, we meet
with the same thing in severe forms of infection. There is no doubt
but we have to deal with varying degrees of infection here, both in
intensity and character. Sometimes the organ dies with great rapidity ;
but I believe most of these cases are cases where strangulation occurs
either from torsion of the appendix twisting the appendiceal artery, or
a septic thrombus first of the vessels over the base, cutting off the cir-
culation, causing great pain and enough inflammation to give rise to
tenderness and muscular rigidity, all of which is misleading and shows
that we can not prognosticate in these cases ; but all these symptoms,
in my judgment, betoken a virulent course of appendicitis, and the



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The Americait Practitioner and News* 329

most of such cases die. No symptom is as valuable as great pain in the
initial stage.

Tumor of the Neck, Dr. A. M. Cartledge : The following case was
operated upon six days ago. An old gentleman sixty-seven years of
age, with the history of having had an epithelioma removed from his
lip a year ago, presented a letter from his physician stating that the
glands beneath the jaw were involved, and advised that the patient see
me. I found the old man with an enormous mass of cancerous glands
beneath the jaw and extending to the median line, lapping over the jaw
up to the angle and probably down to midway of the neck. They were
very deep, and seemed to extend behind and beneath the sterno-cleido-
mastoid muscle.

My first impression was that the case was entirely inoperable.
There did not seem to be any tendency to recurrence in the scar on the
lip; the surgeon in Indiana who performed the original operation
seemed to have gotten an excellent result. Finally I told the man if
he was willing to submit to an extensive and probably dangerous oper-
ation, I would attempt the removal of the mass. He consented, and,
after studying over the case, the first thing I did was to ligate the
common carotid artery ; I then proceeded without the loss of a great
deal of blood to extirpate the mass, which had pushed the tongue up
the floor of the mouth; going downward I found that the outer glands
went along by the internal carotid and jugular vein a distance of two
and a half inches. I resected about two and a quarter inches of the
internal jugular vein with the growth.

The man went on the table in good condition, and did very well
after the operation until the third day, when he developed a little
mental dullness. He seemed to be not quite himself; he would get up
out of bed and walk about the room, etc. Yesterday morning it was
discovered that he had lost the use of his right hand, and by noon it
had extended to the right leg, so that paralysis was rather -complete in
the upper and lower extremities of the right side.

I simply report the case as illustrating one phase of ligation of the
carotid. I think it may be directly connected with that, and the ques-
tion with me is whether it is primarily embolic or thrombotic. I am
inclined to think it is a thrombosis of the terminal artery obstructing
the circulation, or an eschemia, rather, from a plug that has washed
from the distal side of the ligature. The reason for this belief
is that there was a premonition in the way of a heavy intellect, the



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330 The American Practitioner and News.

slow way in which the patalysis came on, first involving the right arm
and hand, then in a few hours involving the lower extremity. I have
not had an opportunity to look up the literature of the subject, but
remember that paralysis from embolism or thrombosis is one of the
things to be expected after ligation of the common carotid. This is
the fifth time that I have practiced ligation of the common carotid
artery, and it is the only case in which there has developed an unpleas-
ant symptom.

Discussion. Dr. J. M. Ray : Would it not have been possible for
the doctor to throw a rubber ligature around the common carotid, and
thus have control of the blood-supply ? I ask the question because,
a short time ago while in New York, I saw a resection and removal of
the superior maxillary for malignant disease ; it was an extensive oper-
ation, but there was little blood lost. The common carotid was exposed^
a rubber ligature thrown around it, the ends being handed to an assist-
ant, and the operation was performed very quickly. Whenever there
was much blood the assistant was notified to pull on the ligature, and
hemorrhage was easily controlled in this way. The operation was
completed, the rubber was removed, and the whole cavity from which
the bone had been removed was packed with gauze. I saw the patient
four days afterward, and she was doing nicely.

Dr. A. M. Cartledge : The plan suggested by Dr. Ray is the one
that is commonly employed in operations requiring the control of the
distribution of the carotid circulation ; it was considered in the case
reported, but the cancerous growth was so extensive that I feared we
might make more or less an incomplete removal, and it was desired to
cut oflF the blood-supply to the mass. Had I known it was possible to
have removed it as completely as we did, I would have practiced the
method spoken of. What I had in view was this, if it were found
impossible to completely remove the growth, permanent ligation of the
artery would lessen the blood-supply and so limit its development.
There are other objections to constricting a vessel the size of the com-
mon carotid in an old man. There is great danger of leaving a weak-
ened spot which may be the source of subsequent trouble. I have never
practiced the compression method, but have ligated the artery in four
other instances, and in no previous case did any trouble result.

The essay of the evening, " Dystocia Due to the Fetus," was read by
Thomas S. Bullock, M. D. [See p. 321.]



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The American Practitioner and News. 331

Discussion. Dr. Turner Anderson : All cases of dystocia occurring in
obstetric practice are interesting. This case is reported in such an intel-
ligent way, the different steps being so carefully recorded, that there is
little left to discuss. That the child was lost, under the circumstances^
I am not surprised. I do not see how the management of the case
could have been improved upon. One thing in connection with the
delivery in cases of this kind must be emphasized, and Dr. Bullock and
his associates recognized it I am sure, and that is, we should have a
fully dilated os before we attempt our manipulations.

Dr. C. Skinner : The case reported brings vividly to my mind a
night that I spent with a patient about ten years ago under the same
condition of affairs, with a primipara. It was impossible to deliver with
forceps. The child was turned and lost during the delivery. It
weighed fourteen pounds.

Dr. E. L. David : There is nothing that I care to say, except to add
to the case just reported that the patient has done uninterruptedly well.
She has not had a temperature of over 99.2° F.; pulse not exceeding 120
to 125 ; no odor to the discharge, which is about normal in quantity,
etc., and every thing indicates a favorable termination.

Dr. W. O. Roberts : In connection with the weight of the child :
Five and a half years ago I was called to see a primipara in labor ; she
had been married twelve years without having given birth to a child.
Dr. Anderson was called in consultation and delivered the woman with
forceps without rupturing the perineum ; it was a head presentation,
and the child weighed exactly fourteen pounds without clothes.
There was nothing abnormal about the child.

Dr. T. S. Bullock : The point of especial interest in the case was
the extremely large diameter of the shoulders ; it really looked like a
deformity. I appreciate what Dr. Anderson has said. When I intro-
duced the forceps the os was not entirely dilated, but manipulation and
traction dilated it more than two thirds, when I attempted version, and
the fetus was brought down until I could see the interior border of the
scapula. The arms were somewhat extended above the head, and
trouble was experienced in bringing them down; the bulk of the
child's body interfered materially with my manipulations, and unless
I had had some intelligent assistants I do not believe it would have been
possible for me to deliver the child without mutilating it. The poste-
rior shoulder was delivered with great difficulty, I never experienced



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332 The American Practitioner and News,

as much, and it was this that lacerated the perineum. After the
shoulder was delivered the head came down easily.

Recto- Vaginal Fistula. Dr. L. S. McMurtry : I have a very inter-
esting case under observation at the present time. It is the case of an
unmarried lady about thirty years of age. She has been in my care
only two days. Her physician stated in a note to me that about three
months ago he had introduced a pessary on account of a displacement
of the uterus. She lived some distance from him, and he did not see
her for some days. He was then called to see her on account of some
very serious complaints which she made. He found that the pessary
had been removed because of the pain it gave, and she then had a
recto-vaginal fistula. This fistula is immediately above the sphincter,
it is a little to the left side, and presents the characteristic appearance
of pressure necrosis, and if anyone had encountered it in a woman who
had a history of having borne children, it would have been presumed
due to pressure of the head.

I have never seen the physician who attended the patient and who
referred her to me, hence have not had a chance to obtain details of the
case. I have never known of such an accident, nor have I seen such
an one recorded. I have seen and have removed pessaries that
have been in the vagina for two years, when they have made a groove
in the tissues of the vagina so that the mucous membrane would stand
up around the pessary, leaving a distinct pit where the pessary was
embedded, but I have never before known of an instance in which
there was a perforation of the recto- vaginal septum.

Discussion, Dr. Louis Frank : I do not see how a pessary properly
introduced could produce a fistula of the character described. It may
be the pessary was improperly introduced, and in such event might
produce a fistula.

Dr. T. S. Bullock: I agree with what Doctor Frank has said. If
the uterus were not much enlarged, and the pessary being properly
'introduced, I fail to see how a fistula could be produced thereby. If
the weight borne upon the pessary were- considerable, a recto- vaginal
fistula might be produced, but not in the location described. I have
seen pessaries buried in the sulcus from long existence in the vagina,
but have never seen a recto-vaginal or any other kind of fistula pro-
duced by their presence. I have seen neglected cases where pessaries
have been left for years and nothing of this kind had resUlted ; but in



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The American Practitioner and News. 333

this case, if the pessary were properly introduced, then the fistula
described would have been an impossible result, unless the uterus was
very much beyond the ordinary weight, and unles$ the tissues were
diseased.

Dr. C. Skinner : I can not understand how the pessary could have
produced the fistula in this case. The doctor who introduced it ought
to be fined for using the pessary, but not for the production of the
fistula.

Dr. Wm. Bailey : While I am inclined to state that a recto-vaginal
fistula from the presence of a pessary would be impossible, yet the fact
remains that such a result obtained ; and as this fistula followed the
use of the pessary, it is the natural conclusion that the pessary in some
way was responsible. It may have been that the tissues were not well
supported, the introduction being faulty, even this moderate pressure
which in other cases might not produce a fistula or other inconvenience.
I think it is certainly possible that in . this case it was the result of the
pessary.

Dr. A. M. Cartledge : Like the rest of the Fellows who have spoken,
I have never seen such an accident. I have removed pessaries that
were incrusted, that had excoriated the walls of the vagina, yet no
further injury had occurred. I do not know that I have ever heard
this question raised before, and have never seen it in the literature.
The great point of interest in this case is the question of what status
such an instance would present in a medico legal way; what testimony
a man could consistently give. I believe it would be proper to say
that it was impossible for an ordinary pessary to produce a perforation
of the vaginal septum, it matters not whether applied properly or
improperly; that without some co-existing conditions of disease a
pessary could not possibly produce a fistula into the rectum. If the
pessary was responsible in this case, there must have been some pre-
existing condition of the tissues to make the resulting fistula possible.
There is nothing in the literature of the subject to show that a fistula
has resulted from the introduction of a pessary with a woman in good
health.

Cystic Ovaries and Appendicitis. Dr. W. O. Roberts : Last Satur-
day I removed a couple of large cystic ovaries, and before closing the
abdomen I concluded I would look at the appendix. There had never
been, however, any symptoms referable to the appendix. I found three



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334 The American Practitioner and Niws.

large enteroliths which completely filled the canal of the appendix. Of
course the appendix was removed.

I merely mention this case to call attention to the importance of
always examining the appendix when the abdomen is opened for any
condition.

Discussion. Dr. A. M. Cartledge : I think it is always advisable to
examine the appendix when the abdomen is opened for any other
cause. I have removed several appendices when operating for ovarian
disease. It adds nothing to the risk, and we should always remove the
appendix when it is found diseased in operating for other troubles.

Dr. W. O. Roberts : There have been a number of cases reported
where foreign bodies have been found in the appendix when the abdo-
men had been opened for other causes, without any symptoms referable
to the appendix having been complained of.

Report of a Case. Dr. F. C. Simpson : The following case is
reported because of its puzzling nature. In the early part of August I
was called to see a boy aged twenty years, a robust, healthy-looking
boy, who had an attack of malaria. It began with chills. He had
several chills with a temperature of 104° to 105® F., extending over a
period of a week or ten days. He recovered from this attack apparently,
and was able to be out for a week or more. At the end of about a week
he had another chill. I saw him at six o'clock in the evening; he com-
plained of great pain in his head ; he was very restless ; temperature
104.5° P* He slept very little that night. I gave him some bromide
and put him on large doses of quinine, which had broken up the previous
attack. This was Saturday night. On Sunday he still complained of
intense headache, and was quite restless. Temperature 101° F. At two
o'clock on Sunday I gave him an hypodermic injection of one-quarter
grain of morphine to relieve the headache, which it did not. He was
also given some bromide Sunday night, but suflFered all the time with
intense pain in his head. The temperature went up Sunday afternoon
to 104° F. I gave him fifteen grains of quinine that night ; he slept none.
On Monday morning he was still restless, tossing about and complaining
of great pain in his head. Rather early in the morning I gave him
jJij grain of the hydrobromate of hyoscine. At half-past one I saw
him again; he was still restless, and I gave him one-half grain of
morphine hypodermatically. In twenty minutes he went to sleep. In



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The American Practitioner and News. 335

about an hour afterward he had a slight coavulsion. He never regained
consciousness, and died at seven o'clock that evening with no evidence
of return of consciousness.

I was at first worried, thinking he had been given an overdose of
morphine, but there were absolutely no symptoms of such a condition.
I take it he had a cerebral hemorrhage, which is rather unusual in a
boy of twenty years. He had an intense headache for forty-eight
hours, and morphine had no effect upon it.

It would be interesting to know exactly what produced death. No
post-mortem was allowed.

Discussion. Dr. P. C. Wilson : I met with a case to-day in which a
man had been complaining of full habit, some headache, particularly
upon the left side. I had given him bromides, which afforded some
relief. This afternoon he came by the office complaining in the same
way. I opened a vein in his arm and extracted about a pint of blood
^th very considerable relief. This is the first time I have bled a patient
for several years. I believe it to be justifiable and a rational procedure
under some circumstances. Of course the use of the bromides is purely
an expedient ; the other is a little more permanent in its effect. In
those cases of threatened convulsions, threatened apoplexy, I believe
the attack may often be warded off if prompt measures of this kind
are instituted. Of course if rupture occurs, then it is too late to use
bromides or resort to bleeding ; but if either of these can be made use



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 92 of 109)