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indeed, no other known source of contact with infection could be dis-
covered.

Dr. Turner states that on one occasion when called upon by the
local municipal board of Brent Pelham, Eng., to investigate an
epidemic of diphtheria at that place, he found in the cottage in which
the first cases occurred a pet kitten had previously suffered from a



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The American Practitioner and News. 371

throat aflFection, which was attended by swelling of the neck, foul dis-
charges from the nostrils, and "running" at the eyes.

Similar accounts are received from abroad as well as in this country^
so that the identity and transmissibility of diphtheria from lower
animals to human beings seems very probable. A disease has been
observed in swine, sheep, horses, cattle, and dogs which appeared
exactly similar to hum^n .diphtheria. May I here incidentally state
that hair, fur, wool, and feathers are active carriers of infectious
material? I have in these desultory remarks avoided earth, air, and
"water, not because I think the subject either unimportant or already
exhausted. I can not conclude, however, without adverting briefly to
the subject of contagious diseases and the principle of isolation now
so generally insisted upon by sanitarians.

In 1887 I witnessed London rid herself of an epidemic of scarlet
fever which had prevailed there to an alarming extent for some three
months. The Metropolitan Asylums Board had equipped itself with a
number of hospitals, and was able to let it be understood that a refuge
was ready for any one who could not with safety to themselves and
others be nursed at home, and thus isolation has been found not to be
.impracticable by the processes at the command of health boards.

Even though many of the wealthy classes of London sent their
children, yet even among this class the need of isolation is yet insuf-
ficiently appreciated, and the art of maintaining it is too little studied
for the arrangement of a private house to insure against the diffusion
of contagion.

Until private dwellings or sick-rooms are much more methodically
ordered than they are now, popular sentiment had better be educated
to admire rather than contemn the growing disposition of persons in
good circumstances as well as in bad to go where they will not poison
others, and will incidentally be rewarded by being more surely healed
than if they stayed at home.

In certain diseases depending on a known specific poison the laws
governing the multiplication of such poison, the condition under which
it can retain its infectivity, the pabulum, so to speak, on which it lives^
the vehicles by which it is distributed, all demand more attention than
they have received. Do all the so-called filth diseases, many of which
are said to be contagious, really require isolation? Is it not the filth
which. should be isolated, and not the unfortunate sufferer from filthy
environments?



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372 The American Practitioner and News.

When all existing doubts have been removed, and when we are able
to say, unhesitatingly, here is a case in which neither disinfectants or
the utmost attention to cleanliness will safeguard the healthy if
brought in contact with the sick, the consent of the people to enforced
isolation will no longer be withheld.

LOUISVILLB.



A REPORT OF TWO HUNDRED AND SEVENTY-SIX INTUBATIONS.*

BY W. B. PUSEY, M. D.

I submit herewith a report of two hundred and seventy-six intuba-
tions done for the relief of membranous laryngitis. The cases are clas-
sified according to the age of the patient, and the percentage of recov-
eries for the diflFerent ages is given. Of the whole number, 134, or 48.5
per cent, recovered.

There were thirty-five under two years of age, of which twenty-three
recovered, a percentage of 65.7.

In view of the commonly accepted belief that the younger the patient
the fewer its chances, this percentage is at least unique. The youngest
of my cases were eight months of age ; of these there were four, three
of which recovered. There were three others under one year of age,
with two recoveries. Nearly all of these children were at the breast or
bottle-fed, which fact certainly had something to do with the very sat-
isfactory results.

In many cases trouble comes from improper feeding, it being a diffi-
cult matter to teach the attendants and the patient the proper method;
but with infants at the breast, when the mother is once shown how the
little one should be fed, it is not likely that a mistake will be made.

There were 44 cases two years of age, with 18 recoveries, or 40.9
per cent. Between three and four years there were 105, with 46 recov-
eries, or 43.8 per cent. Between five and seven years there were 78,
with 38 recoveries, or 48.7 per cent. Between eight and nine years
there were 12, with 7 recoveries, or 58 3 per cent. Between ten and
twelve years there were 2, with i recovery, or 50 per cent; and over
twelve there was one who recovered.

The greatest mortality is between the ages of two and four years,
an age at which the child can offer decided and effective resistance, and
is still not old enough to be amenable to persuasion.

• Read before the Kentucky State Medical Society.



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The American Practitioner and News. 373

In the last seventy cases in this report antitoxin was, with few
exceptions, given. The greater number of them were seen only when
the relief for laryngeal stenosis was imperative. In some the antitoxin
had already been given, but had apparently had no effect in staying the
progress of the trouble. In others, whose condition demanded imme-
diate relief, the antitoxin was given after the insertion of the tube, and
in these cases the tube was removed on the third to fifth day, whereas
without the antitoxin it would have remained in from five to eight days.
There have been several of these cases in which antitoxin was given
where the tube has become occluded by the membrane. In a few the
tube was coughed up and found to be completely blocked. In two
cases the tube was removed after death and found closed by the mem-
brane, and in one case the tube was removed when the patient was all
but dead, and from the condition of the tube it seemed that what air
entered the child's lungs must have gotten in around the tube.

In many cases of membranous laryngitis the necessity for operative
interference could be obviated by the administration of antitoxin if
given early enough ; when there is marked hoarseness and incipient
dyspnea, even when there is decided dyspnea, calling into active play
the accessory respiratory muscles, it sometimes acts as if by magic, but
unless the case is under close surveillance and within easy reach it is
not well to risk the latter condition. The most common accident that
has occurred in this series is the pushing of the membrane down before
the tube. It has happened several times, but in one case only was it
attended by serious results.

Ordinarily the condition is immediately recognized, and the string
being still in position the tube is withdrawn, and the first expiratory
impulse brings up the offending membrane. In the one case men-
tioned this did not occur, and it was only after more than an hour's
effort that it was dislodged by means of a loop of malleable wire. Of
course the impaction could not have been complete. But the frequent
introduction of instruments by the side of the membrane gave a
chance for some air to enter the lungs. This patient died five hours
later from exhaustion.

It sometimes happens when the tube is removed that the stenosis
recurs, and it is necessary to reintroduce the tube. This may occur
almost immediately, and for that reason it is best to have another tube
prepared.

In a number of cases in this report the tube was reintroduced from
one to twelve times, but in one case only was it impossible to leave it



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374 '^^^ American Practitioner and News.

out. This was a case, three years old, of malignant diphtheria, with
membrane in nose, pharynx, on tonsils, and in larynx. The antitoxin
was g^ven, but in a few hours, the dyspnea having increased greatly,
the tube was inserted. On the fifth day it was removed, but on account
of the great difliculty in breathing it was almost immediately reintro-
duced. From that time on it was removed at intervals of from three
to nine days, never being left out longer than forty-five minutes, usually
from five to fifteen minutes, until it had been removed twenty-eight
times. The last three times the tube was removed there was such dif-
ficulty in replacing it, on account of the great swelling and obliteration
of the landmarks, and the child came so near dying each time, that a
tracheotomy was decided upon. The tracheotomy tube has now been
worn about one month. All eflForts to leave it out have so far proven
futile.

Lonisvii«i«B.

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



Reports of Societies.



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.*

Stated Meeting, October 6, 1899, Thomas C. Evans, M. D., the President pro tem.,

in the chair.

Barton^ s Fracture. Dr. A. M. Vance : I exhibit an X-ray photo-
graph of the forearm of a man forty-five years of age who came to me
two weeks ago. He had fallen on the street after slipping up on a
banana peel. He said that he fell upon his right hand, but when he
came to the oflice there was no displacement of the bones of the wrist,
nor was there any swelling. Dr. Nettleroth, who examined the man in
my office, said that he thought there was a fracture, but was unable to
make out any of the distinct signs. A temporal y support was put on,
and I saw the man the following morning. The swelling was great,
there seemed to be no displacement, but there was considerable ten-
derness about the radius. I suspected that the radius was broken.
The man was sent to Dr. Butler, and a fluoroscopic picture was taken,
which I saw, and I very much doubted the possibility of a fracture
because there was no displacement or other sign of fracture. How-
ever, I treated the case as one of fracture. The next day a plate was

* Stenograpbically reported for this journal by C. C. Hapes, IrOuisville, Ky.



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The American Practitioner and News. 375

made, which also showed no evidence of a fracture, but the print
shows it to be a Barton's fracture, the second one that I have ever seen.
There is also a fracture of the styloid process of the ulna. There was
no displacement, and the case illustrates that a print is necessary
oftentimes to make out a fracture when the fluoroscopic picture is not
distinct.

I remember about ten years ago having an opportunity to get a
post-mortem examination on a woman who had sustained an injury to
the wrist, and a specimen of Barton's fracture was obtained. The case
reported to-night is the second case in which I have seen this condition
verified, but I idoubt not this form of fracture occurs much more often
than the text-books lead us to believe or than we suspect ourselves.

Discussion. Dr. T. L. Butler : As Dr. Vance stated, we looked at
this man's arm through the fluoroscope, and could detect no evidence
of a fracture. Every thing was in perfect position, as the photograph
shows. After taking the picture and developing it, I again overlooked
the fracture, not that the negative did not show it, because it does upon
close examination. But I examined the negative before it was dry,
and sent word to Dr. Vance that there was no fracture. It was not
until the print had been made that it could positively be seen that
there was a fracture, and then on close examination of the negative it
could be distinctly seen. The picture exhibited was taken with the
splints on, which prevents it being as plain as it would have been
otherwise.

Dr. A. M. Cartledge : I would like to again call attention to the fact
that the X-rays introduces an entirely new phase to the subject of
fractures, so far as the medico-legal status of the thing is concerned,
for it shows up fracture after fracture that we could not determine by
any of the ordinary means. I reported several cases some time ago
where a fracture was suspected but could not be definitely determined
by the usual methods of examination, and the X-rays showed it to be
present. In one case there was a fracture of the wrist shown by the
X-rays, when it appeared from a physical examination that there was
but a dislocation with possibly rupture of some of the ligaments. In
another case it appeared there was a fracture of the radius ; the X-rays
showed that there was a fracture of both bones below the elbow. We
should impress upon the lay mind as much as possible that we can not
always diagnose a fracture, because somebody may bring around an



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376 The American PracHHoner and News.

X-ray machine afterward and demonstrate that a fracture is present,
which puts us in a bad light. I think the time is coming when we
shall all have to put these machines in our offices for use in every case
of suspected fracture, as well as in many other conditions.

Ovarian Cysts, Dr. A. M. Cartledge : I have encountered two cases
of ovarian cysts within the last ten days which present some peculiar
features.

Case I. The first case was a young girl, not quite fifteen years of
age, who first noticed the presence of a tumor within the abdomen
about January ist of the present year. The tumor had grown very
rapidly until it filled the entire abdominal and pelvic cavities, pressing
the diaphragm upward and causing enormous distension of the abdomen.
Her feet were swollen, and, as far as we could judge in a negress, there
was well-marked cachexia ; roof of the mouth and lips pale, and there
was considerable emaciation.

This girl had the facial expression of an ovarian cyst, and, while
examination showed it to be fluid, there was such great tension of the
abdomen that it was impossible to get any sensation by palpation of
the cyst wall beneath, making the diagnosis somewhat difficult. The
ordinary physical differentiation between ascites and an ovarian tumor
was fairly well present, i e,, the examination showed that there was a
tumor in the anterior aspect of the abdomen. I could detect a little
resonance on one side, but even an ascites may be so tense at times that
this will be the case. Examination per vaginam seemed to show that
the uterus was displaced to the left slightly, although this examination
was extremely difficult to make.

The diagnosis of ovarian cyst was made and the patient operated
upon. My incision came immediately down into the tumor sac, for the
simple reason that it was adherent everywhere in front to the parietal
peritoneum, and an enormous volume of fluid was liberated in this
manner. The sac was then separated, and this enormous one-sac
tumor was found to have its origin in a small dermoid of the right
ovary not larger than my fist, with hair, bone, and structures of this
nature in it.

The case is a little out of the ordinary in that this enormous cyst
has formed within the last ten months. I do not believe that I exag-
gerate when I say that the cyst weighed seventy-five or eighty pounds.



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The American Practitioner and News. 377

Case 2. The second case was operated upon the same day, the
patient being a woman forty-six years of age, whose facial expression
was that of carcinoma. She looked pale ; one could almost see through
her ears ; her pulse was weak ; she had a bronchial cough which she
said had been present since she was a girl; she was not able to walk up
a flight of stairs, and was altogether a very unpromising subject.

Diagnosis of an ovarian cyst was easily made, because the abdomi-
nal walls were relaxed, and the cyst could be felt through them. As
already stated, there was great pallor, a feeble pulse of 130 to 140 to the
minute, and the cough, which she said was no worse than it had been
for twenty-years, all of which were interesting and puzzling features of
the case.

I operated upon her, and found the explanation of this woman's
marked anemia was that there had been a great hemorrhage into one
large sac of the multilocular cyst ; she had bled at least half a gallon
probably within the last two or three weeks, as there was an enormous
blood-clot which seemed to be fresh. I have frequently seen evidences
of hemorrhage into the sac of an ovarian tumor, discoloring its contents,
especially where the tumor had rotated around its pedicle, but have
never before seen such an extensive hemorrhage as this into the sac.

There has not been an untoward symptom in either case, and my
only reason for reporting them is that they are a little out of the usual
run. The stitches have been taken out in both cases; this is the tenth
day since the operation, and the patients are practically well.

The Advisability of Inducing Premature Labor in a Syphilitic with
Prolapse of the Uterus and Bladder. Dr. T. S. Bullock : Dr. Windell
asked me to see a case with him ten days ago, a woman about twenty-
five years of age. She had been under his care several years ago for
specific trouble, and in the interim she has had several vulvo-vaginal
abscesses. The right labia is very much infiltrated and swollen ; the
lower portion is indurated and of a dusky red color ; there is no fluc-
tuation and no evidence of any suppurative process at the present
time, but the tissues seem to be of very low vitality. She had a baby
four or five years ago, and has had several miscarriages since. When
her baby was born the labor was extremely difiicult, and she sustained
almost a complete laceration of the perineum.

I found upon examination of the patient that the bladder was pro-
lapsed; she had quite a large cystocele, with the condition of the

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378 The American Practitioner and News.

perineum before described. I found further that she was pregnant
probably seven or eight months, and the physiological changes which
take place in the mucous membrane of the vagina were markedly exag-
gerated, so much so that the tissues were almost black. I told the doctor
that I would like to examine the patient further, and had her come to
my office subsequently. When I put her in the chair for examination
I found that the uterus for at least one third above the internal os was
prolapsed, the bladder being dragged down with it, and the woman was
in a most distressing condition. She could not assume the erect posi-
tion without this pregnant uterus coming out, and I feared if this condi-
tion of things were allowed to continue that there might be quite an
amount of destruction of tissue of the right labia — in fact, I did not
know what the result would be to the mucous membranes. She has
constant pain from interference with the bladder, and I have been
seriously considering the propriety of inducing premature labor. She
is syphilitic; she has had a large number of miscarriages; and it seems
to me, in view of the fact that great pressure would be incidental to
labor, that the woman would stand a better chance to escape destruc-
tion of tissues which would in all probability follow labor at term, if
labor is induced, and I would like to hear an expression of opinion
from the gentlemen present. I have talked over the matter with two
or three of my medical friends, and they agree with me in the course
of procedure that I contemplate, viz: the induction of premature
labor.

Discussion. Dr. F. C. Simpson: I saw the patient with Dr. Bullock
and agreed with him that the only thing to do was to bring on prema-
ture labor. Fully one third of the pregnant uterus was protruding
through the vagina, and if this woman is allowed to go on to full term,
when labor pains come on the uterus pressing upon the soft parts will
probably produce a great deal more destruction than is present now.
The entire vagina, and especially the right vulva, seemed to be in bad
condition, and I do not see any thing else to do except to induce pre-
mature labor for the safety of the patient ; and I agree with Dr. Bullock
that this procedure under the circumstances would be entirely proper.

Dr. T. S. Bullock : It seems to me that the chances would be against
the birth of a living child at term ; and if labor be induced, even by the
use of an incubator my experience is that the premature child seldom
survives. It may live a week or longer, but finally dies.



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The American Practitioner and News. 379

The case resolves itself into this: You must either keep this patient
in the recumbent position, keep her in bed with a tamponnade in the
vagina, or you must induce labor. Confinement in bed might make the
labor a little more prolonged, but I do not know that it would have any
other effect, because there is no obstacle to the discharge of the child's
head after it had become engaged in the pelvis. The uterus is low
down, the bladder is dragged far out, and of course there would be no
obstacle to discharge of the head because of the ruptured perineum ;
how it would be before this stage of labor had been reached I am
unable to say.

Dr. J. G. Cecil : Dr. Bullock's report calls to mind a case similar to
this which occurred during my service in the obstetrical clinic of the
University of Louisville several years ago, this being the only case that
I have seen similar to the one reported. The case was that of a woman,
previous history unknown ; I think she had borne several children ; she
was over thirty years of age. She presented herself at the clinic with
a large protrusion through the vulvar opening, certainly as large as my
fist, with a hole in it into which I could introduce my thumb. I ex-
amined it thoroughly, and finally concluded that it was a prolapsed
uterus. She gave no history of pregnancy, but seemed to be suffering
greatly. She had walked to the clinic. There was nothing to be seen
except a rupture of the perineum and the uterine prolapse mentioned,
which seemed to be entirely of the neck of the uterus ; that is, the body
was in place and enlarged, pregnancy being not more than four months
advanced. The body of the uterus could be made out distinctly above
the pubes.

The case was puzzling to me. I thought at first it was a polyp with
a hole in it, or that a cyst had formed and opened. 1 introduced a
sound very gently, which went in certainly six or seven inches. She
was in such a critical condition that she could not be managed at the
clinic, and I sent her to the city hospital, where she miscarried in a
short time, probably on account of this manipulation of mine. I think
she would have aborted any way, and in all probability the case reported
by Dr. Bullock will terminate that way, no matter what treatment he
adopts.

In the management of his case, from the report he has given, I think
he has taken the right view. The woman ought to be put to bed most
assuredly, and with proper treatment there may be such a resolution of
affairs, especially this induration about the vulvar opening, as to permit



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380 The American Practittoner and News.

of the labor without any ^eat destruction, especially since the perineum
is already torn ; and it is more than likely that the child will be poorly
developed and small, so that he would probably be relieved of the
necessity of any interference if this course were adopted. In the event
of any especially dangerous symptoms arising, or ulceration of the
indurated vulva, labor could be brought on at any time.

If I had the management of the case, I would be disposed to put
the patient to bed and do all that I possibly could to relieve the indu-
ration mentioned and to cause a recession of the prolapsed neck.

In the case I have referred to, I am sure the greater part of the
prolapse was simply a prolongation or stretching of the neck of the
uterus.

Dr. Wm. Bailey: There are several other interesting questions 'in
connection with this case. One would be to my mind whether or not
in the later months or stages of gestation there would not be less like-
lihood of prolapse than during the earlier period. We frequently see
a uterus which is prolapsed, the os being almost external, yet when
this uterus becomes pregnant, as the gestation progresses the uterus
mounts up into the abdomen and the prolapsus is oftentimes relieved.
I am inclined, in a conservative way, to agree with the sentiments
expressed by Dr. Cecil, that it would be perfectly proper to put this
woman in bed, and if you can replace the uterus so as to avoid any



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 97 of 109)