Chapter II: Part 2

Dr. Larrabee made a point to which considerable importance should be attached, viz., that it would not have been an easy matter to have divided the cord in this case. I think practically he presents the case exactly right. When a cord encircles the child’s neck twice, then branches off and goes under the arm, then branches off over the back, it presses the neck so tightly and the conditions are such that it would be a very difficult matter to get one’s finger beneath the cord at the neck and divide it. It is not such an easy matter to sever a cord under these circumstances as one might suppose. I believe the majority of obstetricians content themselves, when they find the cord is encircling the neck, by simply making an effort to stimulate uterine contraction, and to deliver the child as rapidly as is consistent with safety to the mother, and while so doing take the precaution to support the head, to hold it up well against the vulva and prevent undue traction on the placenta.

It is seldom that we fail to resuscitate a child born under these circumstances. The cord as a rule is not encircling the child so tightly so as to prevent our ability to resuscitate it.

Dr. Bailey has correctly stated that arrest of pulsation in the cord does not occur until after delivery of the head, and we have a limited time then to stimulate uterine action and to disengage the body of the child and release the cord from the neck. Contraction and arrest of pulsation of the cord do not occur prior to that time as a rule. I can conceive it possible that it might do so, but as soon as the head is delivered, contraction then is so great that unless the cord is very long there is an arrest of pulsation and the danger commences. Fortunately we have recourse to stimulating uterine action, and have a chance to deliver the child in the manner I have suggested with sufficient promptness.

I am satisfied Drs. Bailey and Bullock recognize all the dangers of premature separation of the placenta in an uncontracting uterus. In the primipara I can not believe that a slight cupping of the uterus, or the premature separation of the afterbirth, would be a matter of any very great moment. We are all agreed as to the dangers which may occur from separation of the normally attached afterbirth prematurely in the absence of uterine action.

In the primipara we know how very closely the perineum, unless it is lacerated, hugs the neck of the child, and to isolate and cut the cord under such circumstances is a very difficult matter. I do not attach much importance to not cutting the cord, although if I could feel it around the neck of the child and could sever it I would not hesitate to do so.

_Protrusion of the Rectum._ Dr. W. O. Roberts: To-day at my clinic at the University of Louisville a man presented himself complaining of hemorrhoids. I put him on the table on his back, drew his legs up to make an examination, and he strained slightly, had an action from the bowel, and passed out about four inches of his rectum. After examining it carefully to see whether or not there were any hemorrhoidal masses about it, or a tumor of any kind, I started to get some vaseline to assist in replacing his rectum, when he drew it back himself as though he had a string fastened to it. He did not touch it, but simply drew it back. I turned the table about so the class could see the prolapsed rectum, and he shot the rectum out and drew it back four or five times. It is a very peculiar and unique condition to me, and I would like to inquire if the members have ever encountered a condition of the kind in their practice.

_Discussion._ Dr. J. M. Williams: This is undoubtedly a case of prolapse of the rectum with a lax condition of the connective tissue. It may be from continually coming down, and I have no doubt that the bowel comes down after each defecation; there is some kind of an action by which the patient controls the rectum. It may be that contraction of the sphincter muscle starts the rectum upward, and then it simply follows its course. I can offer no other explanation of the condition. Certainly if the bowel comes out four inches there would be considerable tension upon the mesenteric attachment. It seems entirely possible that this phenomenon could be influenced and controlled by the diaphragm and abdominal muscles, and this may be the solution of this unique case. I have never seen a case of this kind.

_Epileptiform Seizures in an Infant Aged Ten Months._ Dr. J. A. Larrabee: I have been considerably interested and I may say annoyed by a case that has been under my care recently. It is in a family which is decidedly neurotic, and in which there is possibly, without history or committal, a taint of specific disease. It is not very unusual to have epileptic manifestations in children at an early age, but the case I desire to report is, I think, somewhat anomalous. There have been, for a period of fourteen days, eleven petit mal seizures in every twenty-four hours in an infant ten months old. These seizures have not apparently concerned or involved the integrity of the child in any respect. The intellectual functions, so far as intelligence is written upon the face of an infant, do not seem to have been affected. The infant is just as well apparently as if it did not have every hour or so an epileptic convulsion. The attacks present the usual phenomena of true epilepsy. The duration of these attacks is from one to two minutes, accompanied by the usual phenomena, flushing, unconsciousness which is perfect, the attack then passes off and the infant is well again.

This condition of affairs having been going on for a period of fourteen days in this case without any impairment in the general health of the infant, or in its nutrition, certainly points, I think, to a specific cause. I have often had cases, not quite so remarkable as this, where the tendency has been neurotic or specific in character, which improved under appropriate treatment; but this case has resisted all treatment, even specific treatment by the inunction of mercurials and the administration of the iodides.

The condition is still in progress, the infant having eleven seizures in every twenty-four hours, not exceeding this number and not falling short. I have witnessed several of them, and they are perfectly characteristic of epilepsy. An older child in the family passed through an ordeal of paroxysms, was unable to walk for three years, and this child has been restored under treatment, and that treatment has been antisyphilitic. One child in the family has been lost, and the history is that it died from scorbutus. The family is decidedly neurotic, and I suspect a specific taint.

The case has been exceedingly interesting and even annoying to me because I have been unable to make the slightest impression upon it by treatment in lessening the number or severity of the paroxysms. I am pursuing the same line of treatment that I did in the case of the older child which recovered, and believe I have sufficient ground for specific treatment, but so far it has not been productive of relief.

The peculiarity about the case is that the occurrence of these paroxysms has not so far interfered with the nutrition or the general health of the infant. In this respect I think the case is somewhat remarkable.

_Discussion._ Dr. T. S. Bullock: I would like to ask if Dr. Larrabee gave the bromides in the case he has reported.

Dr. T. H. Stucky: Have you tried the bromide of gold and arsenic?

Dr. J. M. Ray: In connection with Dr. Larrabee’s case I recall one that I saw several months ago in a child a little older than his which gave a peculiar history. The mother brought the child to me, the history being that the child complained of having something the matter with its ear. I examined the ear carefully. No inflammatory or other disease was present about the structures of the ear; hearing was perfect, and the drum membrane was intact. The child at this time was three years of age. The history that the mother gave me was about as follows: The child had never complained of earache; she had never noticed any defect in hearing, but sometimes two or three times a day the child would apparently be interested in her toys or in something about the room, and all at once she would scream and run to her mother and say that the house was turning over, that there was a bug in her ear, etc. This would happen several times a day, and on several occasions the child had fallen over apparently unconscious, or in a state of partial unconsciousness.

After looking into the ear carefully and not finding any evidence of disease, I referred the case to the family physician, and in talking the matter over with him he suggested that these attacks were probably petit mal. He put the child upon bromide of gold and arsenic, and a prompt recovery resulted. The last I heard from the case the attacks were few in number, occurring at long intervals and slight in character, although at one time they occurred two or three times a day.

Dr. T. H. Stucky: I have seen several cases of epilepsy in children, but never saw one in a child so young as that reported by Dr. Larrabee. I have followed out the usual routine, giving bromides and other remedies with varying results; and later, following the suggestion of Dr. Buchman, of Fort Wayne, have tried combination mentioned by Dr. Ray, viz., the bromide of gold and arsenic. I believe the latter to be especially indicated and exceedingly serviceable where we have reason to suspect a taint, as mentioned by Dr. Larrabee, getting as we do the sedative influence of the bromide, the alterative influence of the gold, and also the well-known effects of the mercury contained in the combination.

I believe where anemia is very marked in these cases, and there is a feeble heart action, and we are fearful of the depressing effects of the bromides alone, that in the use of the bromide of strontium and gold we gain a decided advantage, getting as we do the sedative as well as the cardiac influence of the strontium salts. Dr. Marvin demonstrated this conclusively before this society in a statement made by him in regard to the action of strontium salts in digestive disturbances, especially those conditions characterized by marked flatulency. If this be true, and we have reason to believe it is, it appears to me that the bromide of strontium and gold would be even better than the bromide of gold and arsenic in cases such as Dr. Larrabee has reported.

Dr. J. A. Larrabee: The case is reported not to demonstrate any unusual manifestation of epilepsy, but on account of the exact regularity and periodicity of the seizures, and the age of the patient, coupled with the fact that the treatment which seems to be indicated has not been followed by relief. In looking up the literature of the subject I find that cases of this character are usually attributed to a specific cause.

In answer to Dr. Bullock’s inquiry: I have used the bromides in this case without any effect whatever. Of course epilepsy in the child is nothing new, but this case presents some peculiarities. There is a decided neurotic tendency in the family, which may have some bearing upon the case. The child is going along having the number of seizures stated each day without any evidence of disturbance of nutrition or impairment of general health, which is rather remarkable. Some of the attacks are almost grand mal, most of them petit mal, and I am convinced that the trouble is due to specific taint.

The next move I make will be to put the child upon the bromide of gold and arsenic.

JOHN MASON WILLIAMS, M. D., _Secretary_.

Abstracts and Selections.

THE INFLUENCE OF THE ORGANISM UPON TOXINS.—Metchnikoff (_Ann. de l’Instit. Pasteur_, November 25, 1897,) has applied the method of comparative pathology to the question of the mechanism by which the animal organism prepares antitoxins, and the laws which regulate their production. By growing bacteria and lowly fungi upon culture media containing toxines he was enabled to show that the virulence of the latter was in most cases diminished and sometimes destroyed. In any case these microbes have no influence in the production of antitoxins, and the idea of preparing them by this means must be abandoned. The animal organism alone being capable of producing antitoxins, the next point was to find out whether this was a property common to all animals, or limited to the superior. Metchnikoff found that the injection of large quantities of tetanus toxin into scorpions and the larvæ of other arthropods produced no antitoxin. The toxin remained for months in the blood or tissues without losing its properties; similar results were obtained when it was taken into the alimentary canal of the leech. It was hence shown that even those invertebrates in which antimicrobic phagocytosis is most marked are utterly incapable of producing antitoxins. Coming next to vertebrates, no power of producing antitoxin is possessed by fish or amphibia; it first appears in reptiles, but not in all kinds. Thus tortoises, like invertebrates, can retain tetanus toxin in the blood for a lengthened period without forming antitoxins; it is in reptiles that the production of the latter is first observed, but in them only when they are kept at a temperature higher than 30° C. If the temperature is 20° C. the results are just the same as in tortoises and invertebrates. The establishment of the antitoxic property in these cold-blooded animals is not attended with any rise of temperature, and the same is true in warm-blooded animals such as fowls. With regard to the last-named animals, whose power of producing tetanus antitoxin was first demonstrated by Vaillard, Metchnikoff has some new and important observations. He finds that practically all the toxin injected into the peritoneum passes into and remains in the blood, none of the organs being toxic after their blood has been washed out. To this an exception is found in the case of the genital organs, ovaries, and testicles, which possess the power of fixing some of the circulating toxin. This they share with the leucocytes, to the toxicity of which that of the blood is due. After a while the toxic power of the blood diminishes, and after passing through a neutral period it becomes antitoxic. It is now found that with the exception of the generative organs, none of the organs when freed from blood possess any antitoxic power. The genital glands are found to be markedly antitoxic, but the author brings evidence to show that the antitoxin is not manufactured by them, but is absorbed from the blood, so that in the fowl the antitoxic property resides solely in the blood. Metchnikoff concludes that it is not possible to accept the idea that natural immunity depends on antitoxic power, and he further points out that the latter is evolved in the history of the animal kingdom at a much later date than the phenomena of phagocytosis.—_British Medical Journal._

THE TREATMENT OF TUBERCULOSIS WITH TUBERCULIN R.—Dauriac (_Progrès Médical_, December 4 and 11, 1897,) reports the results of the employment of Koch’s tuberculin R. in various cases of tuberculosis; fourteen of these presented local affections, such as suppuration over the sternum, enlarged cervical glands, ulceration of the skin, etc. All of the patients were satisfactorily cured. In a second paper he describes the results in fifteen cases of pulmonary tuberculosis in various stages of the disease; all were greatly improved, and many are described as cured. One of the cases was insufficiently nourished and clad, had no fixed residence, and, when the treatment was commenced, large cavities were found at the apices of both lungs. A case is also described in which, in addition to pulmonary tuberculosis, lesions were present in the kidneys and the bladder. This patient also made a complete recovery. The treatment, in spite of these brilliant results, is supposed to be most applicable to the earliest stages of the disease, and it is suggested that it would be advisable to detect the presence of tuberculosis by injections of minute doses of the original form of tuberculin. The treatment is usually commenced with a dose of 1/500 mg. This should be increased daily until a dose of 10/500 mg. is reached; this then should be increased 1/50 mg. daily until ⅕ mg. is reached, and this increased ⅕ mg. daily until 1 mg. is given. This can then be further increased if considered desirable, the maximum dose being about 20 mg. The immediate effects of the injections are usually _nil_. With doses in excess of ⅗ mg. a slight elevation of temperature is occasionally observed. Local reaction is extremely rare. The subsequent effects consist in reduction of fever, cessation of sweats, increase in appetite, and disappearance of tuberculous lesions. As none of the patients reported in this paper was admitted to the hospital, but simply came three times or less frequently a week to the dispensary for injections, improvement could not possibly have been due to any alteration in their hygienic surroundings.—_The Philadelphia Medical Journal._

CESAREAN SECTION BY TRANSVERSE INCISION OF FUNDUS.—Braun (_Centralbl. f. Gynak._, No. 45,) has had experience of Fritsch’s cesarean section, the operation being the second of its kind ever recorded. Fritsch bases his practice on the course of the secondary branches of the uterine arteries which run horizontally, so that a longitudinal incision down the front of the gravid uterus can not fail to cause free hemorrhage. He is accustomed to extirpate diseased fallopian tubes completely, snipping a wedge-shaped piece out of the uterine cornu. Bleeding is always free, but the tying of a suture passed antero-posteriorly under the bleeding vessel stops it at once. The ligature lies at right angles to the vessel, the most favorable position. Hence Fritsch conceived the idea of making an incision straight along the fundus from cornu to cornu, in order to extract the fetus in a cesarean section. Braun publishes full notes of his own case. The patient was a rachitic primipara with a universally and irregularly contracted pelvis. The conjugata vera was two and three-quarter inches. Labor pains had set in. Care was taken to antevert the gravid uterus sufficiently, the upper part of the wound being held together with forceps during delivery of the child. Then the transverse incision was made. Braun found that it bled as much as the longitudinal incision in cesarean sections where he had operated during labor at term or in relatively early pregnancy. The placental site did not lie near the fundus. The delivery of the fetus, which was living and weighed six pounds, was neither harder nor easier than through a vertical incision. The wound in the fundus was under four inches long after the fetus had been extracted. The sutures had to be placed close together, fifteen deep and eight superficial being applied. Ergot was given after the abdominal wound was closed, as there was hemorrhage. The patient made a good recovery.—_British Medical Journal._

LABOR IN MATURE PRIMIPARÆ.—De Koninck (_Revue Medicale_, Louvain, October 30, 1897,) has compiled an instructive memoir on labor in primiparæ married for some years and relatively mature (twenty-eight years Bidd and Pourtad, thirty-two Ahlfeld). De Koninck gives thirty as the earliest year coming under “maturity,” the “_primipares agees_” of French authorities. He sets aside as curiosities certain cases of primiparæ almost “aged” in the English sense of the term, such as Cohnstein’s two women aged fifty and Steinmann’s woman aged fifty-two. It appears that in a genuine uncomplicated case of delayed impregnation the advent of the catamenia is always found to have occurred late in youth. Out of 401 such cases menstruation was retarded till twenty in 39, till twenty-four in 4, and till twenty-six in 1. As to the retarded first pregnancy, abortion, ectopic gestation, twins, and special renal mischief are relatively frequent. Above all, lingering labor is specially common, statistics even exceeding guesses and _a priori_ reasoning in this respect. In 12 out of 17 noted by De Koninck labor lasted from forty to fifty hours, the remaining labors being yet longer; 1 exceeded ninety hours. Feebleness of uterine contraction is absolute from first to last, and independent of any obstetrical combination. They also cause far more physical and mental exhaustion than the vigorous contractions of a young uterus, and at the same time are more painful. There are discrepancies in the “pains” seen in mature primiparæ of the same age, probably homologous with the great variations in the age of menopause observed in otherwise normal women. The uterus may be older in one woman aged thirty-five than in another of the same age. The forceps and other obstetrical operations are often required in the mature. Most of the above facts are easily explained. The excess of male infants borne by mature primiparæ (thirty per cent) is a less explicable phenomenon. Hecker considers the predominance of male infants as a speciality of all primiparæ, but Rumpe turns attention to the fact that in a family of children the predominance of males is commoner the further the mother is from her first menstrual period.—_Ibid._

KINESITHERAPY IN HEART DISEASE.—Colombo (_Gazz. Med. di Torino_, 48, N. 39, 40, 1897,) pleads for a more general use of kinetic treatment in heart disease. Even in advanced cases he seems to think such treatment is very advantageous. Milder forms of treatment, for example, the Swedish method of gymnastic exercise, should be started at first, and afterwards more active methods, for example Oertel’s, can be tried. The action of the Swedish method is most marked upon the peripheral vessels, while Oertel’s system acts more directly upon the heart itself, so that dividing heart disease into disease of central or cardiac, and that of peripheral or vascular origin, the different methods could be applied accordingly. The Swedish method, moreover, has this advantage, that it can be applied in severe cases which can not leave their beds. Barie (_Sem. Med._, November 12, 1897,) advocates the treatment of heart disease by Swedish gymnastics. The aim of the exercises is to facilitate the work of the heart by increasing its contractile power and by lessening the peripheral resistance. The exercises are a series of regulated, combined, or alternating movements of resistance or opposition. The movements employed fall under the main groups: (1) Kneading, rubbing, or stroking of the muscular masses in the limbs and abdomen; (2) movements of circumduction which facilitate the circulation in the main venous trunks; (3) movements which favor respiration. The exercises are very varied, and accomplished by means of passive and active movements, numerous different manipulations, and by special apparatus. The average duration of the treatment ought not to be less than an hour a day during three months of each year. The treatment is suitable for cases of dilatation, hypertrophy, fatty degeneration, chronic myocarditis, and various neuroses and functional affections of the heart. Such symptoms as shortness of breath, palpitation, insomnia, cephalalgia, giddiness, gastric phenomena, edema, ecchymosis, cyanosis, improve or disappear under treatment. The pulse-rate is lowered, but rises again as soon as treatment is interrupted. Rational application of the treatment does not exclude internal treatment by ordinary medical means, and the two methods may often be employed simultaneously with the best results.—_Ibid._

LIVE FROGS AS AN ANTITHERMIC.—An English practitioner of Constanta, Roumania, writes: On the evening of October 19th I was called to visit a Roumanian boy, six years old, suffering from typhoid fever. I found him _in extremis_, almost pulseless. The child’s head was completely wrapped over with a large white sheet, and as I looked at it this enormous white envelope seemed to be on the move, and while I was surveying this covering there crept from under it a small frog, which quietly sat over the child’s left arm. It seemed quite content. I immediately called the mother’s attention to it and requested her to take the animal away, thinking it had crept there as an intruder. “Oh, no!” said the old lady, “a doctor recommended that a lot of them should be kept to the head to keep it cool.” Seeing the head covering still on the move, I raised it for curiosity, and in a second out jumped about twenty other frogs and hopped away in all directions. I have often heard the expression “as cold as a frog,” but this was the first time I had seen a frog applied as a head-cooler.—_London Lancet._

TREATMENT OF ENDOMETRITIS IN BROMINE VAPOR.—Nitot (_La Gynecologie_, October 15, 1897,) maintains that the correct prophylactic treatment of parenchymatous metritis and chronic salpingitis consists in rapid cure of recent endometritis, which is the starting point of those troublesome diseases. To insure cure a remedy is needed which can penetrate to the deepest recesses of the muscosa, and even the tubes, without dangerous effects. Caustics and fluid preparations do not possess such properties. A gas is required, and it must be freely diffusible, antiseptic, and capable of acting on the epithelium so as to modify without destroying them (“anticatarrhal action”). Bromine emits gas with the necessary qualities; a saturated aqueous solution should therefore be placed in a bottle with double tubing like an ether spray or the chloroform bottle in a Junker’s inhaler. A hollow sound, connected with one tube, is passed into the uterus, while the solution is made to bubble by pressure on a ball connected with the second tube. Thus vapor is propelled into the uterus. Nitot claims the best results, and notes that the advantages of gaseous diffusion over intra-uterine injections or other medication are self-evident.—_British Medical Journal._

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THE ART OF NEGLECTING WOUNDS.

The New York Post-Graduate Clinical Society[2] was recently treated to a moving discourse on the novel subject of “The Art of Neglecting Wounds,” by Dr. Robert T. Morris, one of the instructors in surgery in the Post-Graduate School.

Footnote 2:

The Post-Graduate, Vol. XIII, No. 13, January, 1898.

The author confined his remarks to wounds made by the surgeon when operating, and hints pretty strongly, though he does not say so, that their subsequent treatment even by the surgeon himself might not inappropriately be called “meddlesome surgery.”

For instance: In incised wounds (the margins of which have not been quite approximated) the capillaries begin to develop granulation tissue in the coagulated lymph deposited upon the surface in a few hours if the trophic nerves have not been much injured. This granulation tissue is extremely delicate and will not bear handling. When such a wound is suppurating freely the strong temptation to wipe away the pus with sponge or gauze should be resisted for two reasons, first, “Granulation tissue suffers traumatism whenever it is touched, no matter how lightly, and, as a result of such traumatism, there will be developed exuberant granulation tissue, which will be poorly supplied with blood-vessels. We have in weak granulations, so to speak, what might be called ‘watered stock.’ It is a very common result of our well-intentioned but ill-directed efforts at keeping the wound clean.”

Gauze upon the granulations will injure the tissue still more, since its filaments entangle the granulations, which on removal of the dressing are broken off in small fragments. The device which prevents this injury is a covering of very soft gutta-percha tissue or Lister’s protective silk. But the surgeon who practices this let-alone method, though backed by sound pathological knowledge and therapeutic principles, will not escape the censure of the family or the nurse, and too often allows his sense of neatness to take precedence of his more sober sense founded upon pathological knowledge.

This “neglect” is particularly desirable when epithelium is shooting across the wound. These hyaline cells are so extremely delicate that the slightest touch will damage or remove them to the detriment of the healing process. The dressing on a suppurating wound should be allowed to remain five or six days. Though the ignorant may find fault with the surgeon for such temporizing, he must insist upon it for the patient’s well-being.

Another illustration is drawn from the operation for appendicitis, in which we have adhesions, pus, and wide infection. Here new pathological factors are met with. The peritoneum throngs with polynuclear leucocytes which are engaged in destroying the bacteria. If time be given these faithful guards to mass themselves in the peritoneal lymph channels, they will prevent the extension of the peritonitis from this point. The surgeon, having evacuated the pus, removed the appendix, and inserted the drainage apparatus, is tempted, because of its bad smell, to wash out the wound. Such a measure would not only give the patient detrimental annoyance, but would inflict a new traumatism upon the tissues. “This traumatism calls out an unnecessary number of leucocytes, and an unnecessary degree of reactive inflammation ensues. If, on the other hand, the colon bacilli are allowed to increase, they will at first produce a very foul odor to the discharge, but in three or four days we will usually find streptococci abundant, and perhaps displacing all other bacteria.” In such cases, leave the drainage apparatus in place and “neglect” the wound. “Repair and destruction of bacteria will go on much better if we leave the wound alone, after having removed the principal mass—the contents of the abscess cavity.”

Another illustration is found in burns of the second degree. Here large blisters have formed and broken, and much skin is denuded of its cuticle. In such a case the author administers an anesthetic, opens the blebs, removes the detached skin, scrubs the parts with an antiseptic solution, covers the denuded surface with strips of gutta-percha tissue, and leaves the case to nature. When a change is made, it should be of the outer dressings only. And the reasons for this treatment are that in such burns “the serum which is thrown out is germicidal, and is destroying all the bacteria upon the skin very rapidly. This germicidal action will go on so long as the serous exudation is free, but when the coagulation of lymph begins on the surface, this action becomes very much diminished, and the bacteria are then liable to liquefy the lymph and grow very rapidly, as new portions of serum are thrown out. This leads to sepsis and sometimes to the formation of thrombi, with necrosis of the duodenum and perforating ulcer. The patient’s friends complain if the dressings are left long in place, and yet I know of no wounds which do so well when ‘neglected’ as burns.”

In the discussion that followed, the author, being asked what he would do with suppurating sinuses, said “he knew of sinuses that had been kept open week after week and month after month, and had proved veritable gold lodes to the surgeons. If the surgeon had been compelled to go away for a time, these sinuses would have healed long before they did. This might seem like a joke, but it was a fact with which he was brought face to face all the time. His rule was to leave sinuses alone, in the belief that the poorly fed granulations lining them would in time cause approximation of the walls, and healing would occur. It was true that exceptions would have to be made for some sinuses, but that did not affect the rule as given.”

Such considerations give accentuation to the dictum of Velpeau, that “nature is a good physician but a bad surgeon,” and dignify the _bon mot_ of Holmes, who, seeing the smoothly healed and finely cushioned stump which resulted in time after an amputation, exclaimed:

“There’s a divinity that shapes our ends,
Rough hew them how we will!”

For the surgeon’s far more than the physician’s successes depend upon the _vis medicatrix naturæ_, and he who is best versed in physiological and pathological processes, and administers the surgical art accordingly, will secure the best results.

They who neglect their surgical cases from ignorance, carelessness, or a wanton disregard of the great pathological dicta of the day, can find no justification in these teachings, for the truth, as embodied in the author’s closing words, puts all such to shame and confusion: “A good deal of skill is required in order to neglect wounds well. This ‘neglect’ of course implies a proper understanding of the processes with which one is dealing.”

Obituary.

DR. J. Q. A. STEWART.

On the 25th ultimo this accomplished physician and estimable gentleman died at his home in Farmdale, Ky. He had been in failing health for something more than a year. His ailment was Bright’s disease, and the end was precipitated by uremia.

Dr. Stewart was born near Louisville, Ky., in 1829. In 1849, having secured a good common school education, and graduating in law, he went to the gold fields of California, where he sojourned for seven or eight years. Returning to his native State, he entered upon the study of medicine, and graduated from the Kentucky School of Medicine in 1859. He began practice in Daviess County, Ky., but after a few years moved to Owensboro, where a larger field of usefulness and fuller success awaited him.

In 1878 Dr. Stewart was called by Governor John B. McCreary to the position of Medical Superintendent of the Kentucky Institution for the Training of Feeble-Minded Children. It was here that the chief work of his life was done. And it was here that he served humanity and the State with honor, with ability, with fidelity, and with an earnest, self-sacrificing devotion to the welfare of these rejected waifs of humanity which entitles him to place and rank among the higher philanthropists of our philanthropic profession.

In the care of the feeble-minded Dr. Stewart added to his executive work the habits of a careful student, and became one of the best known alienists of the land. His address as retiring President of the Kentucky State Medical Society in 1894 was an able and scholarly treatise upon the management of the feeble-minded. It was received with great favor by the Fellows, and has since been the subject of high encomiums from doctors, lawyers, and political economists.

After sixteen years of State service Dr. Stewart purchased the old Kentucky Military Institute near Frankfort, where he established the “Stewart Home for the Feeble-Minded.” The venture was successful beyond expectation, and here in the bosom of his family he passed serenely and blissfully the closing years of his gentle, useful, and beautiful life.

Notes and Queries.

THE SURGERY OF THE THYROID FROM A NEUROLOGIC STANDPOINT.—In a suggestively written paper in the January number of the American Journal of the Medical Sciences, Dr. J. J. Putnam uses the following words: “We are rather in the habit of assuming that the removal of large portions of the thyroid does no harm, provided it does not cause myxedema. But the probability is that we shall learn to recognize affections which lie between myxedema and health, as well as peculiarities of development and disorders of nutrition for which the thyroid is more or less responsible.” ... That this is a statement of fact will hardly be disputed by any neurologist, but that it expresses a truth that has as yet been insufficiently impressed on the profession generally is another fact the importance of which is not likely to be overestimated. It is only within a comparatively brief period that we have learned that the thyroid had any definite function and our knowledge of its physiology is still very far from being exhaustive. The dangers also of interference with it are as yet also only partially known, but it is certain that they are not confined to the operation itself. The cases of sudden fatal dyspnea occurring hours after an apparently prosperous operation in Graves’ disease, recently reported by Debove and others, are in evidence of this, and Dr. Putnam adduces other important facts and arguments against any too venturesome surgery of the thyroid gland. Among these are the experiments of Halsted, showing that excision of the gland in dogs had a serious and very evident disturbing effect upon their offspring, and that even very slight operative interference produced hypertrophic changes and apparent increase of secretion in the gland itself; and the observations of Kocher of goiter and cretinism inherited from parents with no disease other than impaired thyroid function are also cases in point. Still another fact brought forward by Putnam is the one that removal or atrophy of the thyroid in infancy checks the growth and function of the reproductive organs, and gives rise to the various disturbances of development that follow the suppression of this very important function. The close relations of the various internally secreting glands, the thyroid, the testicles and ovaries, the suprarenal glands, and the pituitary body, for this it seems probable must be included in this category, are revealed in many pathologic conditions, and the thyroid as the largest, and presumably the most important, has apparently a larger part in the disturbances than any of the others. It seems to be involved to some extent in many cases of acromegaly; its relations with the genital development have already been mentioned, and its implication in many pathologic conditions of organs is probable and is strongly suggested by the clinical history in certain cases of Graves’ disease. Seeligmann has indeed recently reported a case of this affection apparently closely associated with genital disorder in which he obtained decided benefit from the administration of ovarian extract, thus adding another suggestion to the therapeutics of the disorder.

When any organ is removed, as Putnam says, two factors are set in operation which may have more or less important effects upon the system generally. One of these is the action of toxins, the other is the effort of the organism to adapt itself to the new and changed conditions. The first of these is important enough in the case of removal of the thyroid gland, but the other, from what we are beginning to know of its physiology, must be even more important. Because the function of the organ is already deranged, it does not necessarily follow that matters will be remedied by its removal. The operation may only make a bad matter worse. The mortality of thyroidectomy, according to Poncet, is from fifteen to thirty per cent, which is alone enough to induce caution. When the facts brought forward by Dr. Putnam are also considered, the known and the possible and hinted though yet unknown effects of thyroid ablation, there is still more reason for prudence and hesitancy in this operation.

Of course when a goiter has become a dangerous mechanical embarrassment to important functions, or when a tumor exists in the thyroid that by its growth and situation has become a threatening danger, the case is clear, and operation may not only be justifiable but necessary. It is in such affections as Graves’ disease, in which thyroid operations are still somewhat popular, that we are likely to have not only useless but dangerous surgery, and the time seems to have come to emphasize the cautions implied in Dr. Putnam’s paper. The theory of hyperthyroidization in this disease, though it has apparently much in its favor, is not yet sufficiently demonstrated, and even were it so, would not form a justification for any indiscriminate or frequent practice of operative interference. Graves’ disease is not by any means a hopeless disorder under medical treatment, even in its advanced stages; it is therefore impossible to say when surgery is indicated as a last resort. When the facts of its absolute inefficiency in perhaps the larger proportion of instances in which it has been tried, the immediate dangers of the operation which are not slight, and the remote ones pointed out by Dr. Putnam, are all taken into consideration, it would seem that it ought to be relegated to innocuous desuetude.—_Journal of the American Medical Association._

THE TREATMENT AND PROGNOSIS IN GRAVES’ DISEASE.—This short article is prepared solely with the view of eliciting from medical men who have met with cases of exophthalmic goiter in their practice, the results of their observations regarding many points of interest in connection with this curious disease. I do not intend to give a systematic description of the affection in question. This can be found in any good modern text-book. Described many years ago by Parry, Basedow, and by others more recently, it is much better understood and more widely known than formerly.

Opinions differ radically as to its real nature. The best modern authorities regard it as a pure neurosis, and functional only in character, although organic changes often develop during its course in the heart, thyroid gland, and elsewhere. Some still speak of it as due to changes in the medulla oblongata; others again look upon functional and structural changes in the thyroid gland as the real cause of the malady. My own experience inclines me to view it as a neurosis pure and simple, although marked and characteristic structural changes supervene during its course, and may become permanent. Probably in the near future we shall learn more as to its exact nature. Already it is satisfactory to note that cases are far earlier and more frequently recognized, and that their treatment is more successful.

From their first appearance its special features attract attention. These are few in number, and easily borne in mind: 1. An unusual and more or less constant rapidity of the heart’s action; 2. The early presence of more or less protrusion of the eyeballs; 3. A marked enlargement of the thyroid gland; a tendency to tremors or tremblings under very little, and sometimes no excitement, although this always increases it. It is not surprising that these indications of exophthalmic goiter which develop more or less rapidly and become often most distressingly marked, should cause much anxiety to the patients and their friends, as well as to their medical attendants.

With regard to the duration of ordinary chronic cases (for acute ones are seldom met with), what has been the experience of those who may read this article? I have never met with an acute case, but have seen months and one or two years pass before there was more than a partial improvement.

One case, a very bad one, in which the patient’s circumstances were so poor that she worked on during her illness, when she should have had care and rest, recovered completely. But so serious was this case, that the sight of both eyes was entirely lost from the excessive protrusion of the eyeballs during the disease. When I first saw her, which was years after her recovery, the story of her case was intensely interesting, but most sad.

Then as to the frequency with which relapses occur in this disease, it would be interesting to get the experience of good men. Many speak of relapses being frequent, even after apparently complete recovery has taken place. Others think them not of so common occurrence.

There are also many points of great interest in connection with the prognosis. One of these is the probability of the recovery being perfect. My own experience has been that the lighter or milder the case the greater the probability of a perfect cure.

Another matter of interest is in connection with cases in which the symptoms greatly abate, the health indeed appearing to be perfectly restored, but in which the exophthalmos and thyroid enlargement continue noticeable; whether in such patients very slight causes may not lead to a return of the disease. From what I have seen, the conclusion appears correct, that provided the heart’s action is normal as to frequency, and not too easily disturbed, these cases are not specially likely to have a second attack, which is tantamount to saying that, provided the heart’s action has become normal, any other relic of the illness is comparatively unimportant.

I have observed, too, more or less scleroderma present when the attack has not been by any means of a serious character, and when afterward the general health became all but perfectly restored. This is an interesting concomitant. It would be desirable to have others give their experience as to its occurrence in cases they may have attended.

Then as to the effects of pregnancy during the course of the disease; some high authorities speak very strongly as to its great danger. Others remark that the affection has improved during gestation. This is another matter on which fuller information would be most useful.

As to the percentage of fatal cases, this is hardly as yet to be determined so as to be useful to the practitioner. My own cases have led me to the conclusion that every particular case has to be regarded _per se_, that is, if the symptoms are light and comparatively trifling, and show signs of abating, the prognosis is favorable, while under an opposite state of things it is the reverse.

As to treatment, what has succeeded best in my hands has been enjoining upon patients the necessity of a great deal of physical rest, at least ten or twelve hours a day if possible, and the avoidance of all mental worry. On this, great stress should be laid. These patients require abundant nourishment. Galvanism in my hands has been found most useful; employed twice a day and so applying the poles that the current may go from the back of the neck through the thyroid gland, and the heart, and even (the current being made very weak) through the eyeballs. This current has been continued for months, and in some cases for a year and a half, with good effects. Sometimes tincture of digitalis has been useful in moderate doses, ten or twelve minims three times in twenty-four hours, in some cases, and useless in others. Iron has been found of great value and persisted in for a long time. As a nerve-tonic, strychnine in small doses has been exceedingly beneficial. Quinine, if used, should, unless malaria complicates the case, be used in small doses only, such as 1½ grains three times a day, with the iron and strychnine.

I know that many of the matters I have mooted in this paper have been quite recently discussed by Drs. Ord and McKenzie, of London, in an excellent article on exophthalmic goiter in the fourth volume of the new System of Medicine edited by Allbutt, but a still wider discussion on the matters alluded to, and on many others, by practitioners who have met with and treated such cases, will do much good, and tend to make the care of such cases more pleasant and the results of treatment more satisfactory. _Walter B. Geikie, M. D., C. M., D. C. L., in Philadelphia Medical Journal._

DANGERS OF THE NASAL DOUCHE.—Lichtwitz (_Sem. Med._, November 26, 1897,) deprecates the routine prescription of the nasal douche in all cases of hypersecretion of the nasal mucous membrane. Irrigation is called for only when the nasal fossæ require clearing of pus and crusts, for instance in idiopathic ozena. This affection is mainly limited to the nasal fossæ properly so called, and irrigation is in such a case the most fitting form of procedure. An ordinary syringe or enema syringe with suitable nozzle should be used. In all other nasal affections irrigation is inadequate or useless; it is even dangerous. Repeated flooding of the mucous membrane may give rise to olfactory lesions. Antiseptics are highly injurious and pure water is badly borne; the physiological solutions of sodium chloride, sod. bicarb. or sod. sulph. are the only harmless liquids. In numerous cases irrigation has caused the sense of smell to be temporarily or permanently diminished or lost. Distressing frontal or occipital headache may result owing to the liquid passing into the sinuses. The injection of irritating liquids may even set up inflammation of these cavities. The most skilful and careful irrigation is insufficient in many cases to prevent the resulting headache. A very grave complication is the penetration of the liquid into the middle ear, suppurating otitis media occasionally supervening. In acute coryza, especially in children, douching should never be practiced. In one such case known to the author mastoiditis followed irrigation of the nasal cavities. The predisposition to otitis is increased after retro-nasal operations, in particular after ablation of adenoid vegetations. For eight years the author has given up all irrigation after pharyngo-tonsillotomy, and during that period has met with no case of post-operative complication.—_British Medical Journal._

ANTIPYRIN.—In July of this year the antipyrin patent, held by the Hochst color-works, will expire by limitation, it having run its course of fifteen years—the span of life allowed to a German patent. During these fifteen years the monopolists have sold the drug at about $12.50 a pound, but it will, of course, fall considerably in price the moment the manufacture and sale are permitted competitors. It is anticipated that it will shortly fall to at least half its present price, when the usual convention of the principal competitors will be called and the inevitable trust formed, leading to a consequent rise in price. It is rumored that a number of chemical works are busy with the manufacture of antipyrin, so as to be prepared with it immediately upon the expiration of the patent.—_Philadelphia Medical Journal._

PROFESSOR ROBERT KOCH has been invited by the Indian Government to make another stay in India for the purpose of studying the epidemic and endemic diseases of man and beast so prevalent there. Koch is now engaged on work that will keep him in German East Africa for some time, probably about a year, and does not think of leaving until he has concluded it.

Special Notices.

RHEUMATOID ARTHRITIS.—Rheumatoid arthritis is a chronic progressive disease with an almost hopeless prognosis as regards a complete cure. The most that can be hoped for is to arrest its progress for a longer or shorter time, and to render the patient’s life more tolerable by improving his health and relieving the pains in the affected articulations. Galvanism, massage, baths, and an invigorating diet have been found of more or less value, as well as the administration of cod-liver oil, ferruginous preparations, and the iodides. A comparatively new remedy that seems to have a promising future before it in the treatment of this disease is Lycetol. Judging from the observations thus far published its use in rheumatoid arthritis is capable of effecting considerable improvement. One of its distinct advantages is that, owing to its pleasant taste and freedom from irritating effects, its administration can be kept up for a long time, a point of great importance in the treatment of chronic affections, in which remedies must be given for a prolonged period before beneficial results can be expected. In two cases recently reported by Dr. Paul Norwood (Times and Register, November 6, 1897), one being a very bad one of chronic rheumatoid arthritis, the results were very encouraging. A slow but steady improvement occurred in the second case, while in the first the patient provoked a recurrence by discontinuing the treatment. In view of the obstinate character of the affection and its resistance to the remedies heretofore in use, Lycetol should be certainly considered an eligible remedy in these cases.

MEETING OF AMERICAN MEDICAL PUBLISHERS’ ASSOCIATION.—The Fifth Annual Meeting of the American Medical Publishers’ Association will be held in Denver, on Monday, June 6, 1898 (the day preceding the meeting of the American Medical Association).

Editors and publishers, as well as every one interested in Medical Journalism, cordially invited to attend and participate in the deliberations. Several very excellent papers are already assured, but more are desired. In order to secure a place on the program, contributors should send titles of their papers at once to the Secretary.

CHAS. WOOD FASSETT, St. Joseph, Mo.

OBSTINATE CONSTIPATION.—I used Chionia, a teaspoonful three times a day and at bed times, in a case of long standing obstinate constipation. The first three nights I directed a hot water enema to be given every night. This treatment brought about regular and spontaneous evacuations, and resulted in a complete cure.

E. T. BAINBRIDGE, M. D.

Lickton, Tenn.