diff options
Diffstat (limited to 'old/52983-0.txt')
| -rw-r--r-- | old/52983-0.txt | 2274 |
1 files changed, 0 insertions, 2274 deletions
diff --git a/old/52983-0.txt b/old/52983-0.txt deleted file mode 100644 index dd0d2bb..0000000 --- a/old/52983-0.txt +++ /dev/null @@ -1,2274 +0,0 @@ -The Project Gutenberg EBook of The Cleveland Medical Gazette, Vol. 1, No. -4, February 1886, by Various - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: The Cleveland Medical Gazette, Vol. 1, No. 4, February 1886 - -Author: Various - -Editor: A. R. Baker - S. W. Kelley - -Release Date: September 4, 2016 [EBook #52983] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK CLEVELAND MEDICAL GAZETTE, FEBRUARY 1886 *** - - - - -Produced by The Online Distributed Proofreading Team at -http://www.pgdp.net (This file was produced from images -generously made available by The Internet Archive) - - - - - - - - - -Transcriber Note - -Text emphasis denoted as _Italics_. - - - - - === THE === - - Cleveland Medical Gazette - - ---------------------------------------------------------------------- - _VOL. I._ _FEBRUARY, 1886._ _No. 4._ - ---------------------------------------------------------------------- - - - ORIGINAL LECTURES. - - ---------------------------------------------------------------------- - - - ULCER OF THE STOMACH. - - A LECTURE BY PROF. L. OSER OF VIENNA, AUSTRIA. - - [Translated for the Cleveland Medical Gazette by Dr. C. Rosenwasser]. - - -Gentlemen! The disease which we intend to study to-day is one, the -traces of which are found much oftener at post-mortems than the disease -itself in the clinic. A great many cases are overlooked and improperly -diagnosed for reasons which I shall state hereafter. - -It has been called by various names. Round ulcer, perforating ulcer, -chronic ulcer, corroding ulcer and simple ulcer are only different -designations for one and the same condition. I prefer to call it -_peptic ulcer_, as it is always the result of self-digestion of a part -of the walls of the stomach, but is not always round, nor perforating, -nor chronic, nor corroded; nor is it always simple, several ulcers -having occasionally been found in one and the same stomach. - -Pathologists have not yet come to a positive decision on the _modus -operandi_ of its origin, but several conditions are mentioned as -necessary for its development. - -1. The self-digestion of a part of the stomach by the gastric juice. - -2. Disturbances of the circulation of the blood in the walls of the -stomach. - -3. The alkalinity of the blood circulating in the walls of the stomach -prevents the digestion of the mucous membrane. If this action on the -walls of the stomach is prevented in any way, the development of an -ulcer is aided. This clause has been accepted until recently, when -it has been rendered somewhat doubtful by the results of certain -experiments. - -The first clause is sustained by the fact that the peptic ulcer is only -found in those parts which are brought into direct contact with the -gastric juice. It is further proven by the softening of the stomach so -frequently found at post-mortem. But as long as the circulation of the -blood in the walls of the stomach is normal, ulcers do not form. The -formation of an ulcer in the stomach presupposes a local disturbance -of the circulation. It is usual to find thrombi and diseases of -the bloodvessels in cases where ulcers of the stomach occur. For -this reason the latter is more common in anaemic persons where the -circulation is retarded and the bloodvessels frequently subject to -fatty degeneration. - -Virchow regards embolism of a small vessel as the origin of ulcer of -the stomach. Cohnheim disproved this beyond doubt by showing that there -is an abundant circulation in the walls of the stomach by which the -parts affected are again quickly supplied with blood. Klebs takes for -granted a spasmodic contraction of single bloodvessels as the cause -of the retardation of the circulation, while Rindfleich attributes -it to the poor anastomotic connection of the gastric veins. He calls -attention to the frequent coincidence of ulcer and hemorrhagic -infarct in the walls of the stomach. Cohnheim injected chromate of -lead into the gastric branch of the splenic artery in animals, and -when he succeeded in cutting off the arterial supply of the mucous -and submucous layers _only_, he found as a result large ulcers with -sharp, well-defined margins and a circular base. If the animals were -examined in the second week after the experiment, they showed several -small ulcers in place of the larger one. In the third week the ulcers -were found to have healed. From these experiments you can see that -the gastric ulcer has a natural tendency to heal when not interfered -with. By experiments such as these it has been proven beyond doubt that -disturbances of circulation of a small part of the stomach may lead to -ulcer. But the causes of these disturbances, and the reasons why some -ulcers do not heal, are still disputed questions. - -Pavy claims that the alkalinity of the blood prevents the gastric juice -from acting on the walls of the stomach. When he introduced acids into -the stomach and allowed the circulation of the blood to continue, -no ulcers resulted; if he impeded the circulation, the stomach was -digested by its acid contents. Samelson instituted experiments to -test the statement of Pavy. He introduced large quantities of various -acids into the stomach of his animals without observing ulceration as -a result; he also neutralized the blood by the injection of weakened -acids into the bloodvessels, but no ulceration followed. But he did -not impede the gastric circulation in his experiments, while Pavy did, -hence the difference in their results. Clinical experience, however, -favors Pavy's views. We can prevent the further progress of the gastric -ulcer by the use of alkalies, while acids only favor its growth. These -questions still need additional research before they are definitely -solved. - -Gastric ulcer may occur in any part of the digestive tract which is -exposed to the action of the gastric juice; hence it is found in the -lower part of the œsophagus, any part of the stomach and the upper part -of the duodenum. It is found most frequently in the pyloric end of the -stomach, because this part is most frequently subjected to mechanical -irritation and to the action of the gastric juice. - -The shape of the ulcer is usually conical or terraced, its diameter -being largest in the mucous membrane and smallest at its base, in the -deeper structures. - -The gastric ulcer must be very common. In about five per cent of all -cadavers we find ulcers in the stomach or else scars as traces of -former ulceration. Ulcer of the stomach is frequently passed over -without recognition, because most physicians do not decide upon this -diagnosis, unless hæmatemesis occurs. Gastric hemorrhage, however, is -not necessarily a concomitant feature of every gastric ulcer, and the -hemorrhage may occur without vomiting, the blood being either digested -and absorbed or passing on into the bowel and causing dark stools. -Thus occasionally the only symptom of hemorrhage of the stomach is the -appearance of darker stools, a symptom of doubtful value when taken -alone, but of some importance when in connection with others. - -A few years ago an elderly lady was admitted into the hospital on -account of severe pain in the stomach and the appearance of dark -stools. While in the hospital vomiting of blood set in, continuing -three days, and then the patient died. At the post-mortem we found -that an ulcer of the stomach had burrowed through the diaphragm and -pericardium into the wall of the left ventricle, perforating finally -with a small opening into the left ventricle. I can only explain the -length of the time between perforation and death (three days) by -assuming that part of the gastric fistula leading through the walls of -the heart was firmly closed during systole, and only allowed a small -quantity of blood to ooze through during each diastole. - -_Symptomatology._ If you were to rely upon the occurrence of gastric -hemorrhage in making your diagnosis, a great many blunders would -necessarily occur, as this symptom is present in but one quarter of -all the cases. I can give you an exact picture of the symptoms from -experience on myself, having repeatedly been a sufferer from gastric -ulcer and having studied every phase of the question carefully upon -myself, frequently experimenting to get at various truths. - -One of the most important and characteristic symptoms is the _localized -pain or soreness_ which is felt in a small, well defined area, and -either originates or is increased by chemical or mechanical irritation. -This spot always was sensitive both to warm and cold food. Salty food, -alcoholic or sour articles brought on pain. I could feel when the -food passed the spot. It was always more sensitive about an hour or -two after a meal, when the process of digestion was most active. My -ulcer was on the anterior wall of the stomach, so that I could greatly -ease the pain after meals by lying upon my back, while lying upon -the abdomen greatly aggravated it, as the food then came in contact -with the ulcer. I was a student yet when first suffering from this -trouble, and was treated by one of our prominent professors for heart -disease. He even gave me a certificate stating that I was suffering -from beginning hypertrophy of the left ventricle. I was not improving -under this treatment, and was taken one day with violent pain in the -stomach, followed by vomiting of a large quantity of blood. Now the -state of things was cleared up, and under the proper treatment (for -ulcer of the stomach) I soon regained my health. I remained well for -a long time, but in the course of the last twenty years have passed -through several relapses. One of these, I distinctly remember, occurred -while I was making a tour through the Alps. I had walked quite a -distance that day and being very thirsty drank three glasses of water -in quick succession. I immediately felt a pain in the stomach, and -could distinctly feel how one of the old scars was again rent asunder. - -During these repeated attacks I found that the painful sensation -was really divisible into three distinct periods, that of constant -increase, during which the ulcer is developing and extending, that of -remaining at one height, and that of gradual decrease during the period -of healing. I could distinctly tell from these various changes how my -ulcer was getting along. - -Two different kinds of pain are felt, the one constant and the other -occasional. The _constant pain_ is usually present where the ulcer has -extended deeper into the tissues or when the surrounding tissues are -implicated. This pain is increased during digestion or when pressure is -made on the parts from without. The _occasional pains_ are either of -a dyspeptic type, caused by the catarrh which usually accompanies the -ulcer, or of a cardialgic (neuralgic) type, the result of irritation -of the exposed nerve-endings with the ulcer. These cardialgias are -acute attacks of very severe, excruciating pain, which occur during -or between the periods of digestion and are felt in the epigastrium -and back mostly, but sometimes radiate over the entire abdomen, into -the chest and even into the limbs. These attacks differ in no respect -from those occurring in some diseases of the gall bladder, kidneys, -peritoneum or uterus, and are consequently not characteristic of -gastric ulcer. The dyspeptic pain partakes more of the character -of feeling of fullness, a sense of oppression in the epigastrium, -heartburn, etc., such sensations as occur in catarrh of the stomach and -are felt during digestion. - -_The characteristic pain in ulcer of the stomach is a localized feeling -of soreness._ It is not always prominent. Chemical or mechanical -irritation of the ulcer brings it on, or if already present, aggravates -it. Especially acids, both mineral and vegetable, have this effect, -while alkalies allay it. This pain only occurs during the process of -digestion, when the food or gastric juice comes in contact with the -ulcer, or when the stomach is distended with gas, and tension exerted -on the tender spot. During the periods when the stomach is at rest it -does not occur. - -_Vomiting_ occurs in about three-fourths of all cases of gastric ulcer; -vomiting of blood, however, only in about a quarter of all the cases. -The latter occurs oftener where the ulcer is deep. In cases where the -stomach is dilated, the amount vomited may be enormous, and contain -food which has been retained in the dilated portion for several days. - -As a result, also, of the accompanying catarrh of the stomach and the -consequent diminished absorption of fluids, we find _constipation_ and -_diminished secretion of urine_ in cases of ulcer of the stomach. - -Perforation of the stomach is most frequently caused by gastric -ulcer, and may be said to be a characteristic symptom; but it usually -occurs too late to be made use of in the treatment of the ulcer. It -is occasionally the first symptom which calls the patient's attention -to the fact that his stomach is and has been seriously diseased. By -the agglutinations of the base of the ulcer with neighboring organs, -through inflammatory processes, perforation can take place into these -organs. The most frequent forms of perforation under such conditions -are those into the liver, spleen or pancreas, but cases have occurred -where perforation into the colon or pleural cavity has taken place, -or even into the pericardium, the heart or lungs. Some time ago I saw -a case of gangrene of the lung, the result of the perforation of a -gastric ulcer into this organ. - -A few days ago I saw an interesting case, where an acute gastritis -culminated in the vomiting of a large quantity of pus. The patient had -been having high fever for a few days, with incessant vomiting and -great tenderness in the epigastrium. Evidently an abscess had formed in -the neighborhood of the stomach, and finally opened into this organ, -with the given result. - -_Diagnosis._ There are two classes of characteristic symptoms--those -originating from the exposure of nerve-endings, and those caused by -ulceration into bloodvessels. The first class includes the painful -sensations, the characteristic soreness, which occurs in about -four-fifths of all the cases; the second class, the hemorrhages, -occurring in only one-fourth of all the cases. You can readily see -why pain occurs more often than hemorrhage. Even a very superficial -abrasion may expose nerve-endings to the irritation of the food, while -it takes a deeper ulceration to lay open a larger bloodvessel. In order -to make a positive diagnosis, these two symptoms should be present. - -Vomiting of blood alone need not necessarily be caused by a gastric -ulcer. There are a great many other conditions which may cause it. It -should, however, put you on the guard, and can, in a great many cases, -justify a diagnosis of probable ulcer of the stomach. - -The localized pain occurs, according to my experience, only in cases -of ulceration of the stomach; that is, in gastric or peptic ulcer -and in cancer of this organ. In order to differentiate between these -conditions, it becomes necessary to observe whether the patient is -cachectic or emaciated or not, and whether a tumor can be felt in -the region of the stomach. But even these symptoms can be deceptive, -as an abnormal hardness or resistance--the result of perigastritic -infiltration--may occur in cases of simple ulcer, making the diagnosis -almost impossible. This is true especially in cases of ulcer of the -pyloric regions, while ulcers of the anterior wall of the stomach are -rarely accompanied by such infiltrations. - -The pylorus is the most sensitive part of the stomach, and frequently -the seat of pain, when no lesion can be detected post-mortem. The other -parts of the stomach only become painful when attacked by ulcerative or -other pathological processes. Another point worthy of consideration -is that all forms of pain in the stomach are usually referred to the -pyloric region by the patient, even if they originate in other parts. - -From all this you can see that no positive diagnosis can be made where -any one of these symptoms is presented unaccompanied by the others. A -careful consideration of the symptoms present will frequently, however, -be of aid in making a diagnosis. Intelligent patients will tell you -that they have a feeling of oppression, a feeling of distress in -dyspepsia, but will describe their feeling as that of distinct pain in -ulcer. Pure neuralgic pain is not always localized, but radiates into -distant parts, is not constant, but sets in all at once and disappears -with equal celerity, sometimes intermitting for days and weeks, and -then again setting in on the slightest nervous excitement. Such pain is -not aggravated by local pressure, shows no relation to the digestive -functions, does not depend upon the quality or quantity of food taken, -and may as well occur during a fast as during a feast. Often such -patients will tell you that their pain does not cease until they have -taken a hearty meal. - -In cases of peptic ulcer, you will find that the pain is in direct -relation to the amount and quality of food taken; that the patient -has little or no pain when the stomach is at rest; that coarse foods -as well as acids cause or aggravate the pain, and that indifferent -foods, such as milk, do not bring it about, though they may sometimes -cause a sense of fullness or oppression. Some patients with ulcer will -tell you that the position of their body has an influence on their -pain. If they are so placed that the food, by its gravity, lies on the -ulcer, the pain is brought on or increased, while if the patient under -such circumstances then changes his position, he is relieved of his -pain partially, or even entirely. Yes, some such patients must assume -abnormal positions while their stomach is active, in order to avoid -this suffering. Some patients with gastric ulcer cannot digest _any_ -food without great pain, and frequently live on a very scanty diet, -rather than risk taking more food and enduring these excruciating pains -again. - -_Anomalous Cases._ Occasionally cases will occur in which the symptoms -presented do not justify the diagnosis of ulcer of the stomach, only -those of dyspepsia or else of gastric catarrh being present, while we -are still compelled to assume the diagnosis of ulcer from the result of -the treatment. Such cases resist all kinds of treatment based upon the -diagnosis of dyspepsia or catarrh, and can only be cured by a strict -"ulcer cure." - -Another class of cases only presents gastralgic pain without any other -symptom. Such are frequently patients who have had gastric ulcer -before. Others will come to you with intercostal neuralgia on the left -side. They have, perhaps, tried all the usual anti-neuralgic remedies, -have gone through a course of treatment by electricity, and spent a -large amount of time and money, without obtaining permanent relief, -until some physician puts them on a strict milk diet and cures them in -this way in a short time. - -Some cases of ulcer of the stomach present the queerest symptoms. -For instance: they complain of pain after drinking milk, or even -after taking a morphine powder, while they can eat the coarsest food -without any harm. Others run along without presenting any symptoms at -all, until they, as well as their physicians, are surprised by the -perforation of a gastric ulcer. - -All these abnormal cases, which form about one-fifth of all the cases -occurring, are so indistinct that they frequently remain unrecognized -throughout their entire course, and baffle the skill of the best -diagnosticians. - -In order to be able to make a sure diagnosis, there must be a localized -pain, together with tenderness on pressure from without on the -painful spot. A great many persons in good health are tender in the -epigastrium, so that you have to be on your guard in this direction, -too. From the occurrence of hæmatemesis in an otherwise healthy person -you can, with great probability, diagnose ulcer of the stomach. - -_Differential Diagnosis._ In order to differentiate _between catarrh -and ulcer_, it is simply necessary to keep in mind the difference in -the character of the pain, the fact that local pressure is more liable -to aggravate the pain in ulcer than in catarrh, and the occurrence of -hemorrhage in the former. The two conditions, however, frequently occur -in the same patient. - -The differentiation between _ulcer and neurosis_ has already been -discussed. The direct connection of the attacks of pain with the -introduction of food, and the character of the pain will soon clear up -the matter. Should you still be in doubt, a course of treatment, such -as an ulcer would demand, will soon clear up the matter. If the case is -one of ulcer, it will have been cured or materially benefited, if it -was a pure neurosis the patient will if anything feel worse than before. - -By far the most difficult question to decide in making a diagnosis is -whether the case is one of _ulcer or cancer_ of the stomach. Here close -attention to several points will usually clear up the diagnosis. Cancer -sufferers always have a sallow complexion, a worn, emaciated, cachectic -appearance, no matter what or how much they eat. Ulcer patients -frequently have a robust, healthy appearance, and are emaciated or run -down only after repeated hemorrhages, or when other grave diseases, -such as heart disease, chlorosis, tuberculosis, etc., are also present. - -The _presence or absence of a tumor_ is a very important aid to the -diagnosis, though as I have already stated, not always reliable. -Sometimes an ulcer may be covered with granulations, and its -surroundings so infiltrated and hardened, that even post-mortem the -naked eye can not tell whether it is cancer or simple ulcer, and the -question has to be decided by microscope. Such are likely the cases -which form the bases of cancer cures which are reported from time to -time to have been effected by the use of various remedies. - -_Vomiting of blood_ is a symptom common to both cancer and ulcer of -the stomach, but is usually more copious in the latter. If the absence -of acid in the gastric juice of cancerous stomachs proves to be as -reliable a symptom as has been recently asserted, this will be an -important feature in the differentiation from ulcer. - -You will frequently be astonished by the success of your treatment if -you think of ulcer in doubtful cases of stomach trouble, such as occurs -in young girls with chlorosis and institute a strict milk diet with -the measures adopted for the cure of ulcer. - -_Prognosis._ From what has been said you can see that in general the -prognosis of ulcer of the stomach is good, that with proper avoidance -of all irritation, the ulcer has a tendency to heal of itself. This -tendency has been observed even in large ulcers, where death was -perhaps the result of some intercurrent disease. - -Ulcers of the anterior wall of the stomach are more dangerous than such -as occur on the posterior wall, for the reason that in the latter case -adhesion with the neighboring structures are more easily formed, and -thus fatal perforation prevented. The anterior wall takes a much more -active part in the peristaltic movement of the stomach, and as a result -does not enter so easily into adhesion with its surroundings. Even -after an ulcer has healed it always remains a weak point, and cases of -rupture of the stomach in old cicatrices are described by Chiari. - -_Treatment._ The pain is the most important criterion as a guide -during the treatment. It is the signal by which I judge of the present -condition of the ulcer. According to the variation of its character -and intensity, I can judge whether the ulcer is healing, is remaining -stationary, or is spreading and increasing in size or depth in spite of -the treatment. If the pain has been removed permanently the ulcer has -been healed. From the relation of this symptom to different kinds of -food you can also judge of a progress or improvement of the ulcer. - -Theoretically considered, that form of treatment would seem the best -which gives the stomach absolute rest, entire abstinence from food, a -fast of several weeks. But this can not be carried out in practice. -The patient could be nourished per rectum, you might say, by means of -nutrient enemata. In my opinion this method of nourishment does not -amount to much. I believe that very little water is absorbed by the -rectum, the patient would suffer from thirst and you would then be -compelled to allow him to drink water at least. - -Luckily we do not need to resort to such extreme measures in the -majority of cases. With the exclusive use of the proper bland, liquid -food, we usually attain the same results. In the treatment of gastric -ulcer I lay the main stress on the restriction and regulation of the -diet, and put the patient on an exclusive milk diet. Milk contains all -the constituents necessary for the nourishment of the human body. - -I begin by giving every half hour to one hour a small quantity of -skimmed, boiled milk, which has been cooled on ice. The patient must -rest in bed or on a lounge, as he is weakened by the treatment, and can -not follow his usual avocation. I forbid all other articles of food. -With this diet a patient with ulcer should have no pain and usually -has none. Should there be pain it is necessary to find out whether the -feeling described as such be not simple oppression, or a feeling of -weight in the stomach. Some patients do not seem to digest milk well. -It ferments, forms gases and then they have this feeling of oppression. -Some drink the milk too fast and take too much at a time, swallowing a -lot of air with the milk, thus distending their stomachs unnecessarily. -The patient must be instructed to drink the milk slowly, and only take -a small quantity at a time (about one or two ounces). Some patients can -not stand iced milk but bear luke warm milk much better. Others seem to -prefer milk which has slightly soured. - -The patients should adhere to this strict diet as long as possible, -regulating the length of time according to the duration and intensity -of the disease. They have to observe the above rules one or two weeks -at least, several weeks if possible. - -Often you will meet with the reply: "I have already tried this diet, -I was put on milk diet once before by Dr. ---- and it did not help -me any, I even felt worse afterwards." If you inquire more closely, -however, you will find that they drank milk several times a day, -but ate bread with it, soaking this in the milk. This is what is -understood to be a milk cure. Gentlemen! I am sorry to say that this -misunderstanding is not confined to the general public, but that some -physicians even do not know better, and consider such a course of diet -a milk diet. I cannot impress it upon your minds any too strongly -not to allow yourselves to be diverted from your purpose by any such -assertions, but to order another course of milk diet, wherever you -find it indicated, and see to it that it is carried out properly this -time. You will thereby occasionally meet with excellent success where -a previous wrong attempt in the same direction failed. - -After the patient has been free from pain from eight to ten days, I -then add to his diet soft boiled eggs with a slight addition of salt, -beginning on the first day with one half of an egg. If this is well -borne I gradually allow more day by day, until he is able to digest -four or five a day without difficulty. Eggs do not agree with some -patients. In such cases I pass on the use of meat. I have beefsteak -chopped fine, roasted in little meat cakes of the size of a silver half -dollar. One of these is given to begin with, and if well borne repeated -every two or three hours as long as there is no pain. When eggs agree -I prefer to give them for a few days before beginning with the meat, -waiting until such patients can digest four or five eggs a day. After -the meat has been borne well in small quantities for a while, I -gradually increase the quantity taken per day until it reach a pound or -two. - -You cannot be too careful and should instruct the patient to return to -the strict milk diet as soon as any pain is felt, no matter how nicely -he may have been getting along up to the time. Not until the patient -has been entirely free from pain for several weeks is it advisable to -allow the use of cereals boiled in milk, such as rice or tapioca. Then -he can also be allowed to take a quarter of a biscuit (well baked) at -each meal. A full meal, however, in the sense in which it is ordinarily -understood, a large quantity of food taken at one time, is still to -be avoided. It is better to give small quantities of food oftener, in -order not to distend the stomach, and thus run the danger of too great -a strain upon the newly healed ulcer. - -These meat cakes made of beef can be taken for a week or so, and then -if well borne other kinds of meat may be occasionally substituted. - -_Wine and alcoholic liquors in general_ are to be avoided for several -months. - -_Beer_ should never be taken by one who has suffered from gastric -ulcer. In fact it is well for all who have stomach trouble to avoid the -use of beer, especially such as have had ulcer. Such patients have to -be on their guard in matters of diet through the remainder of their -lives, and must avoid excesses both in eating and drinking. You will -occasionally come across persons who can not stand a milk diet in any -form whatever. They frequently do not bear eggs well. In such cases I -proceed at once, but with great care, to the use of meat in very small -quantities, finally chopped and roasted, and have it taken several -times a day. You will frequently have to try one article of food and -then another, and experiment for awhile before you reach that form of -diet which suits the case best. - -There are a number of _substitutes_, some of which are really good, -while others are worthless. Of them all I prefer the fresh meat juice -_ext. carnis recent. pressum_, and have it prepared in the following -manner: The meat (beef should be used) is cut into thin slices, placed -between pieces of tissue paper, and pressed in a hydraulic press. The -juice thus obtained is given in teaspoon doses every half hour or so, -just as though it were medicine. In the majority of cases I have the -meat juice made by the druggist, so that a large number of the patients -think it is medicine. It has a rather pleasant taste and is well borne -by the stomach. There are a great many _peptones_ in the market, a -large number of which ought not to be used, as they are not fresh and -more likely to do harm than good. Of them all the English make is the -best, as it is usually well preserved, being packed dry. - -Patients who can only take a small quantity of nourishment by the -stomach can be materially aided by the use of nutritious enemata given -luke warm once or twice a day. When the rectum is very irritable a -suppository containing one-half to one grain of ext. opii given a half -hour before the enema is very serviceable. There are a great many -_other remedies_ recommended in the text books, but I would advise you -not to rely too much on them. Lay your main stress on the dietetic -part of the treatment, and use remedies only where they are absolutely -necessary to support this. Among the remedies used the alkalies are the -most valuable. Bicarbonate of soda alone, or in combination with ext. -belladonna when the stomach is very irritable. - - ℞ Sod. Bicarb., ʒiss. - Ext. Belladon., gr ii. Misce et div. in pulv. XVI. - Sig. One in the morning and one in the evening. - -Or I sometimes substitute atropia sulph. (1/120 gr. pro dosi) for the -belladonna. At any rate the use of alkalies is the most plausible -treatment. But the permanent alkalization of the contents of the -stomach by the frequent use of large doses of alkalies, as has been -recommended in Paris by Debove is not plausible, as by this the process -of digestion would be checked entirely. - -It is also good to give a dose of Carlsbad salts in the morning every -two or three days, in order to correct the constipation usually -attendant upon such a course of diet. These salts also aid in rendering -the contents of the stomach more alkaline, and in this way aid the plan -spoken of before. - -I do not think it advisable to send patients with gastric ulcers to -_health resorts_ or watering places. They can only regain their health -by a strict enforcement of dietetic measures, and these can be carried -out just as well at the patient's home as at the health resort. For -the treatment of such cases _after the ulcer_ has healed, these health -resorts can be of great benefit, but the patient must be cautioned not -to commit excesses in eating or drinking, especially to the latter must -their attention be called, as it is customary in most resorts adapted -to such cases, to drink large quantities of the medicated waters in the -morning. It is also well to caution the patients with regard to their -diet before sending them away. This should be unirritating, bland and -easily digestible. Among the European health resorts, Carlsbad is the -most suitable for such cases. - -There are unfortunately some patients who are not benefited by any -method of treatment hitherto thought of, but luckily they are few, and -if you will follow the rules I have laid down you will in a great many -cases meet with splendid results. - -One important question still remains to be answered, namely: "What -should be done in case of hemorrhage of the stomach?" Here the patient -must be left quiet just where he happens to be--placed in a horizontal -position on his back if possible. Ice bags should be applied to the -region of the stomach, small pieces of ice swallowed, and hypodermic -injections of ergotin given. This is all that can be done with benefit -in such cases. The patient should not be transported for several hours. -Monsel's solution can be of no service, as it cannot be introduced into -the stomach in a sufficient concentration to be of benefit. - -In cases of perforation of an ulcer all that can be done is to -give anodynes to ease the pain and make the patient's condition as -comfortable as possible. Schlipp recommends that when perforation is -threatened on account of gaseous distention of the stomach, the stomach -tube should be used to evacuate the organ. - -The mechanical treatment, washing out the stomach with the stomach tube -or stomach pump is contraindicated in cases of ulcer, as more damage -can be done by such procedure than good. - - ---------- - - - ORIGINAL ARTICLES - - THE RECOGNITION OF MORTIFIED BOWEL IN - OPERATIONS FOR THE RELIEF OF - STRANGULATED HERNIA. - - By REUBEN A. VANCE, M. D., CLEVELAND, OHIO. - -The medical practitioner who has been hastily summoned to operate -upon a patient with strangulated hernia finds himself confronted with -problems, the gravity of which can alone be appreciated by those who -have frequently met them. The medical treatment to be adopted, the -extent to which taxis should be employed, and the time it is prudent to -delay operative interference when other measures have proved fruitless, -are grave questions upon the solution of which the life of the patient -depends. The operation decided upon, the particular method to be -employed and the manner of dealing with the stricture--with or without -opening the sac--are matters of minor consequence, and affairs that -should be settled in the mind of every practitioner by a reference to -sound surgical principles and the teachings of experience. There are -questions connected with the condition of the parts strangulated that -must be solved by the surgeon during the progress of the operation, -about which much less is said in works on surgery than their importance -warrants. These pertain to the vitality of the part that has been -strangulated, and the duty of the surgeon in the premises. If the -part is still living, it matters not how much damaged by compression, -it should be returned at once into the abdomen; upon this step the -patient's life depends. If the part is mortified and dead, to return it -within the cavity of the belly is to insure the patient's destruction; -if he is to have a chance for life, other measures must be adopted. - -Again, the decision of the operator can but rarely be guided or aided -by aught but the conditions revealed by his knife during the operation. -The state of the patient and the history of the case may indicate the -imminence of mortification of the bowel; in the end the appeal is to -the senses of the surgeon, and upon the conclusion at which he then -arrives will depend the fate of the patient. - -Under these circumstances it behooves every man who may be placed in -position to make such a momentous decision to at least go to the task, -sustained by every aid that can be derived from the experience of -those who themselves have been placed in this dilemma and compelled to -act with such lights as they then possessed--whose records, next to -personal experience, become the best guide for those forced to follow -in their footsteps. - -The history of the case may throw some light upon the state of the -intestine. This is especially so in those cases in which the severity -of the symptoms suddenly subsides without the rupture having been -reduced. The pain is violent, the abdomen distended and singultus -and stercoracious vomiting present; suddenly the patient's suffering -cease, and were it not for the cold extremities, flickering pulse and -persistent tumor--but above all, the teachings of experience--the -surgeon could not but acknowledge that all tangible appearances -portended a change for the better. Yet, almost invariably gangrene of -the gut has taken place, and the fallacious evidences of improvement -above noted are in reality its best clinical exponent. Certain almost -as these signs are, when present, yet it comparatively seldom happens -that the surgeon has their aid in guiding him in the measures he -must adopt; they form, but infrequently, a part of the history of -cases submitted to operation. If present, the surgeon is reasonably -sure of what he will find when he operates; they may be absent and -mortification yet exist. The patient's chance of life depends upon the -surgeon's ability to recognize mortification of the bowel when he sees -it, and his promptitude and skill in dealing with it when present. - -It scarcely need be said that mere darkening in color of the bowel, -effusion of fluid into the sac, or exudation of lymph about the -stricture are of no special significance in this connection, and bear -in no way upon the presence or absence of mortification. It has been -again and again repeated in manuals treating of hernia operations -that a deep, purplish discoloration of the bowel and absence of -circulation indicate mortification; that when these physical signs -are present the surgeon should press upon the strictured part, and -if the color remains unchanged when the finger is removed, the bowel -is dead. It requires but little practical experience in dealing with -these cases to appreciate the fallacious character of these signs; the -gut may be fairly black from congestion and yet alive; the color may -remain unchanged under pressure and still that fact have no bearing -on the question of mortification, for a band of stricture, as yet -unappreciated, may be the sole cause of the persistent hyperæmia. - -It is quite different as regards certain other signs, especially when -two or more of them are seen in conjunction. _If the bowel be dark and -mottled with grayish spots, of contracted and shrivelled aspect, with a -slight amount of discolored fluid surrounding the gut, and a cadaveric -odor apparent when the sac is opened_, mortification is certainly -present, and the return of the strictured part within the abdominal -cavity dooms the patient to certain death. The surgeon's duty is to -open the sphacelated gut, apply a poultice and favor the relief of the -obstructed bowel by a free discharge of the intestinal contents through -the outlet thus formed. An artificial anus is thus established, and the -patient, for a time, must be content with this deformity; fortunately -it is a condition susceptible of relief, and the surgeon may ultimately -free his patient of even this defect. - - ---------- - - - JABORANDI AS A GALACTAGOGUE. - - JOHN H. LOWMAN, M. D. - - Professor of Materia Medica in the Medical Department of the Western - Reserve University. - -There is a decided difference of opinion among therapeutics as to the -effect of jaborandi on the mammary gland. Some claim that it has no -effect upon the gland. Some claim that it assists in increasing the -secretion of milk. - -This note is made to show the action of jaborandi as a galactagogue in -the recent puerperal state. The preparation used was the fluid extract -obtained from Squibb & Co. - -M. S., age thirty-five years, a multipara, of fair health, not well -nourished. The babe was two weeks old at the time of this observation, -and in good condition. The secretion of milk by the mother began -gradually to fail until not one-third the average quantity was -produced. The child was then nourished artificially. The fluid extract -of jaborandi was given to the mother. The dose was eight minims every -three hours. About fifty minims were taken in twenty-four hours. On -the second day of the administration of the drug the milk increased -in quantity. By the third day it had increased still more, so that -the child had nourishment from the mother sufficient to satisfy it. -Increased salivary and cutaneous secretions led to a discontinuance -of the drug. The milk flowed in good quantities for eight days, -and then rapidly diminished. Jaborandi was again used. The plan of -administration was the same. Increase of the milk was again noted. The -renewed activity of the mammary glands continued for five or six days -only. For a third time the drug was used, and its use followed by good -effects. In the meantime the nourishment of the mother had been pushed. -Iron, quinine and mineral acids were also given. The general health of -the patient improved. After the last increased activity the secretion -of the gland remained normal for three weeks, after which the patient -passed from observation. During the last two weeks no jaborandi was -used. - -Whereas in this case the improved condition of the individual was -responsible for the permanent increase in the supply of milk, the use -of the jaborandi and the temporary increase were apparently more than -coincidental. During the first two stimulations the quality of the milk -deteriorated; the quantity of cream diminished; the specific gravity -fell; no microscopic examination of the milk was made. After the last -increase in the activity of the glands the quality of the milk was good. - -Two similar cases were noted. B., aged nineteen years, primipara, had -a tedious labor. She recovered slowly. She was well nourished and has -previously been well. At the end of the second week of convalescence -the milk began to fail. Jaborandi was used as in the case just cited. -Marked improvement in the milk was noticed the second day the drug was -given. On the fourth day the medicine was omitted. The milk continued -to flow in sufficient quantities for ten days. The quantity then -gradually and rapidly diminished. The medicine was again given for four -days with the desired effect, which remained for the following ten days -that the patient was under observation. - -D., age twenty-five years, a multipara, was a poorly nourished person, -the mother of two children. The confinement was normal. The milk -failed soon after its appearance. Following the use of jaborandi the -milk increased rapidly in quantity, but diminished in three days on -withdrawing the drug. The milk continued to respond to the jaborandi -for the four weeks that the patient was under observation, but no -permanent result was obtained. - -On three other cases the jaborandi was used with scarcely perceptible -effect or no effect at all. From a few cases it is impossible to -generalize with expectation of a truthful conclusion. We can, however, -know that the jaborandi has an effect on the mammary gland, and causes -an increase of the milk in puerperal women. This effect is by no means -a constant sequel to the administration of the drug. As far as my -observation is concerned the effect of jaborandi is temporary, and -can be useful only where there is a tendency in the gland to assume -its normal function. This tendency may at times be subordinated to -general influences and even entirely subdued. In such conditions a -timely stimulation of the gland may tide over the threatening arrest of -function. Variation in the activity of the mammary gland, especially -in the early puerperal state, is not unusual. The close relation of -the increase of milk and the use of jaborandi justifies, however, the -assumption of effect and cause. - -No effect was observed on the children. Jaborandi is excreted by -the mammary glands, and it was consequently withheld as soon as -practicable, lest the child should feel its presence. - - ---------- - - - INDICATIONS FOR OPENING THE MASTOID - PROCESS. - - BY A. R. BAKER, M. D., CLEVELAND, OHIO. - -The operation of opening the mastoid process is said by some to have -been first performed by Riolan in 1649; according to others, by Petit -in 1750, and later by Jasser, in 1776. During the latter part of the -eighteenth century the operation was performed frequently without -definite pathological indications. But after the unfortunate death -of the Danish physician Berger (1791) the operation was very seldom -or never performed until 1864, by Mayer, following the suggestions -made by Tröltsch some years previous. Berger, for chronic deafness -without suppuration of the middle ear, had the operation performed upon -himself, and died on the twelfth day from meningitis. During the past -twenty years the operation has taken its place as one of the recognized -surgical proceedings owing to the work of the German physicians Moos, -Jacobi, Hartman, Bezold, Schwartz and others, who have laid down the -real indications for the operation from their extensive clinical -observations and pathological researches. The American otologists, -Roosa, Agnew, Buck and others were among the very first to perform the -operation, and have done much to establish its claim to recognition. -And yet it is somewhat remarkable that some of our text books barely -mention the operation; and as short a time ago as 1883, Strawbridge, at -the meeting of the American Otological Society, said that he had seen -over four thousand cases of purulent middle ear disease within twelve -years, and yet had not trephined in a single case; and several other -authorities looked upon the operation as a questionable one. Knapp -took decided grounds in favor of the operation, and cited three fatal -cases in which he believed an operation would have saved life. Kipp had -seen quite a number of fatal cases in which the post-mortem had shown -the mastoid cells filled with pus, which had given rise to cerebral -abscess. Dr. C. H. Burnett reported a fatal case which died from -pyemia, and he thought if his patient had been operated a year before -his life would have been saved. - -Gruening said surgery has established that wherever there is a focus of -purulent discharge it should be removed. This, (removal of the focus) -is a life-saving operation and should be done under all circumstances. -Dr. Roosa said that he believed the revival of this operation of -opening the mastoid process has saved many lives. Since his first -operation not a year has passed that he has not found it necessary to -repeat it several times. He says further that "it is true that we shall -seldom need to open the mastoid if an experienced practitioner sees a -case of acute aural disease early in its course. It is an operation for -neglected cases, where suppuration has been allowed to advance from the -tympanic cavity in consequence of not having a free outlet through the -drum-head. But purulent inflammation of the mastoid may occur in acute -cases that have been thoroughly treated by leeching, poultices, rest, -etc., from the start." - -The most recently stated indications for opening the mastoid process -are: - -1. Purulent inflammation in the mastoid process appearing in the course -of suppuration of the middle ear when persistent severe pain in the -bone cannot be subdued by the application of the ice-bag, leeches, or -by Wilds' incision. (Schwartz). - -2. Painful inflammation in the mastoid process occurring in acute -and chronic suppuration of the middle ear, in consequence of growths -filling up the external meatus or the tympanic cavity. When attempts -to remove the obstacle to the free escape of pus have failed, the -operation is imperative. (Grüning). The operation is indicated even -though the soft parts over the mastoid are not swollen or infiltrated. -(Politzer). - -3. When the posterior superior wall of the meatus is bulging, and when -after incision the abscess is not emptied and the symptoms of retention -of pus continue. (Toynbee, Duplay). - -4. Persistent pain and tenderness in the mastoid process lasting for -days or weeks, in which there is probably an osseous abscess not -communicating with the tympanic cavity. (Politzer). - -5. In every suppuration of the middle ear combined with inflammation of -the mastoid process in which fever, vertigo and headache are developed -during the course of the affection, which may indicate a dangerous -complication. In such cases the indication for the operation is vital. -(Politzer, Roosa, Buck.) - -As to the time when the operation should be performed, writers do not -agree. While one proposes that the operation should be done as soon -as there are symptoms of inflammation of the mastoid process, another -defers it till the dangerous symptoms (fever, headache, vertigo, etc.,) -set in. The latter proposal must not be followed, as in many cases it -would be too late; on the other hand, many cases will recover without -an operation. As far as it can be formulated, I would say that in a -given case of acute purulent inflammation of the mastoid process I -would first apply leeches, poultices, cathartics, antiflogistics. -If the inflammation is not promptly subdued, I would make a Wilds' -incision, including the periosteum, if the bone is found softened; or -if a fistulous opening is found, this should be enlarged at once. If -the bone is found healthy and not roughened, if there is no fever, -vertigo, headache, etc., I would wait a few days; if the symptoms, -pain, tenderness, etc., do not subside, I would then perforate the -mastoid process. - -For the performance of the operation trepans were formerly used, which -were replaced by drills which are still used by Buck, Jacobi, Lucae -and others, but by most operators they have been set aside, owing to -their uncertain and dangerous advance in the deep parts, and on account -of their soiling the wound with splinters. The most rational and safe -method is by means of the chisel, as recommended by Schwartz, and is -performed as follows: The patient being anæsthetized, a perpendicular -incision beginning a little above the linea temporalis, extending an -inch and a half in length immediately behind the attachment of the -auricle. Formerly I employed a straight incision, but recently have -followed the suggestion of Politzer, and from the superior end of the -perpendicular incision a second one is made backward at right angles, -thus forming a flap, which I have found to simplify the operation very -much, as it affords a better view of the locality and extent of any -pathological changes which may have taken place, and gives more room -for operative procedures, and the periosteum can readily be removed -to any desired extent. The linea temporalis and the more or less -strongly developed protuberance on the posterior superior orifice of -the osseous meatus, so strongly urged by authors, are very nice guides -theoretically or to point out on an exceptional skull in the class -room, but practically are seldom well enough developed to be of any use -to the operator. The best guide to go by is to take the superior wall -of the meatus as the upper boundary, and the angle formed by the plane -of the mastoid with the posterior wall of the external meatus for the -anterior boundary when opening the mastoid. This is best determined by -pressing the finger into the meatus. Often in children, and when the -bone is diseased in adults, the cortical plate of bone can be removed -with the hand chisel, and we come at once upon the pus cavity, or -diplœ, or cholesteatomatous epidermic masses, or a sequestrum of dead -bone, or bleeding granulation tissue, or whatever the case may present. -Sometimes the external plate is very thick and we have to chisel our -way carefully for almost half an inch before reaching the diplœ, or -may find the entire mastoid process sclerossed. No absolute rule can -be given as to the depth it is safe to penetrate. Schwartz says "never -to go deeper than 25 mm." Buck says "it is better to place the extreme -limit at 20 mm," about three-fourths of an inch. - -Although I do not consider the operation a particularly dangerous -one, especially with the chisel where we can watch each step of the -operation; and even though we opened into the lateral sinus or the -duramater, the injury would not be necessarily fatal. Yet I would not -advise any one to attempt it (unless the indications are imperative) -who has not performed the operation on the dead subject. Politzer -says "no one should operate on the living before having performed the -operation at least forty or fifty times on the dead." I cannot close -this article better than in the words of Dr. St. John Roosa, to whose -admirable work I am indebted for a large portion of this article. - -"Yet, hesitation, when the way is plain, or when the chances are -largely on the side of the necessity of the removal of pus, cannot be -too sternly condemned. No drug has yet been discovered which can be -substituted for the scalpel or trephine when pus has actually formed in -the mastoid cells. I wish, however, to repeat what I have said before -on the subject of surgical operations. I am in full accord with the -great English surgeon, Sir James Paget, who, in his admirable lectures, -expresses many times his hesitation to perform any surgical operation, -however trivial, that is not absolutely required. We have no right, -I think, to perform operations to clear up doubtful diagnosis. If in -case the operation proves to have been unnecessary, the patient will -be decidedly the worse for it. If we put ourselves in the place of our -patients, what we may regard as a trifling thing--"a mere cut"--will -not be so esteemed. A mere cut, when unnecessary, may have the most -serious consequences, and all the history and symptoms should be -carefully weighed before even that is undertaken. Such care will never -prevent prompt, rapid and thorough surgical interference when demanded. - -In teaching medical students, I have always found them, when fully -awakened to the dangers of neglecting certain diseases, to be more apt -to do too much than too little, especially with the knife and active -drugs. It is possible, also, that the crying ignorance and neglect of -the previous decades in regard to the treatment of aural disease has -had a tendency to cause us, who see many of the afflictions of the ear, -to lean toward the side of surgical operations upon the drum, head and -mastoid. This is a leaning no less dangerous to the cure of some cases -than was the steering toward Scylla or Charybdis to the safe navigation -of ancient mariners." - - ---------- - - - A CASE OF ANOMALOUS DEVELOPMENT OF THE - ANTERIOR PILLARS OF THE SOFT PALATE. - - BY B. L. MILLIKIN, M. D., - - Oculist and Aurist to Charity Hospital, Cleveland, O. - -Some time since, Mrs. G. D., age about 23, applied to me on account of -deafness and tinnitus of both ears. In pursuing my examination I found -the following unusual anatomical relations of the anterior pillars of -the soft palate, which I deem not unworthy of record. - -The uvula and posterior border of the soft palate are normal in -appearance and formation; but, beginning about the middle of the -anterior pillars, these gradually widen out into thick, heavy, broad, -muscular folds, which attach themselves firmly to the sides and dorsum -of the tongue, extending two or three lines upon the dorsum. They seem -to be intimately connected with the muscle of the tongue itself, making -them very firm. The posterior pillars are much less well developed than -the anterior, and do not control or prevent the drawing forward of the -soft palate when the tongue is protruded. The tonsils are small in size -but normally located. - -The attachments of these bands give a peculiar appearance to the -throat. When the tongue is in a state of rest, in the bottom of the -mouth, or, better still, when the tongue is depressed, these bands hang -like two large curtains, narrowing very much the faucial opening. When -the tongue is protruded they are put upon the stretch, and narrow very -greatly the faucial opening by drawing forward and downward the whole -of the soft palate, so that the posterior border of the soft palate and -uvula rest firmly upon the dorsum of the tongue. When the tongue is -thus protruded the attachments of these membranes are brought forward -almost to the teeth. - -In a state of relaxation there is formed back of these folds, on -either side, quite a deep cavity, which often collects quantities of -solid food, to the great annoyance of the patient. She even sometimes -is obliged to remove these obstructions with the fingers, or, by -gulping or swallowing frequently, is able to dislodge them. She has no -difficulty in swallowing liquids. - -There is some impediment in her speech, a peculiar lisping as if -she did not have good control of her tongue, which she has always -attributed to the fact that she is of German parentage. Her English is, -however, very good, other than as above indicated. - -In looking up what anatomical literature is at my command, I find -no reference to any anomalies of this kind, although I have been -able to consult the standard French, German and English works on -general anatomy. I myself have never seen a case with an anatomical -construction approaching this, so I, therefore, present it for record. - - ---------- - - - HINTS ON VOCAL TRAINING--THE BREATH. - - By BERNARD W. FISHER, A. M. - -The prevalence of throat troubles is so marked in America, and by no -means least so in this city, that if one hundred individuals, collected -at random, had their throats examined, it is probable that four out of -every five would be found to have these delicate organs more or less -affected. Whatever cause may be assigned by the medical expert in each -particular case, the importance of a thorough mastery of the art of -correct breathing can hardly be insisted upon too strongly. If it be -urged that the widely distributed works of Behnke and others must have -put an end to any general ignorance of the importance of this branch of -vocal training, I can only reply that a defective style of breathing is -by no means uncommon even in public singers, while among amateurs it is -so rare that a perfect management of the breath excites in a critical -observer a feeling of gratified surprise. The name and works of Behnke -have, of course, been known in this country for a considerable time, -but some of his statements are too striking to be omitted in an article -on this subject. When lecturing at the Tonic Sol-fa College, London, -he took ten students and measured their lung capacity in cubic inches, -by means of the spirometer, with wrong or "collar-bone" breathing. He -then showed them how to breathe correctly, that is, midriff and rib -breathing. The average increase among the ten was twenty-five cubic -inches of air; the least increase twelve inches, and the greatest -forty-five. He adds: "I imagine that these figures are more eloquent -than any words, and I think it superfluous to make any further comment -on them."--('Mechanism of the Human Voice,' page 20.) Now, putting -aside the extreme increase of forty-five inches, let anyone consider -what an increase in lung capacity of twenty-five cubic inches of air -must mean to the vocalist in the execution of difficult passages, to -the speaker using his voice by the hour, and, lastly, to the running -athlete. It will surprise a young man commencing vocal training to -inform him that, at the same time, he will become a better man in the -gymnasium and the race; but unless good lungs are an advantage to -the athlete in name only, the above figures tell their own tale. I -may add that, in teaching young men and boys, I always put this view -of the subject before them, knowing that it will be an incentive to -their acquiring a thorough mastery over the interesting art of "taking -breath." - -Correct breathing cannot _cure_ disease. The medical expert must do -that. But it will _prevent_ disease; and when the throat, under proper -treatment, has been brought to a healthy state, it will assuredly be -the chief means of keeping it in that condition. The following is a -striking instance to the same effect: - -Some years since, an English clergyman had to give up all ministerial -duty from "Clerical Sore Throat." Acting under the absurd advice of -a London teacher of elocution, he resided in Spain for five years -without the slightest benefit. He then returned, and at the house of -the elocutionist who had made him an exile saw a copy of Behnke's -celebrated work. Coming to the conclusion that the author must be -rather clever, he at once consulted him. Following his advice he had -his throat made medically sound by Lennox Browne, and then took the -usual course in breathing and voice production under Behnke. A short -time after I was with Herr Behnke, when a post card arrived from the -clergyman: "I preached yesterday in Chichester cathedral, and was -congratulated on the strength of my voice and the ease with which I -filled the building." - -A few weeks since I heard a sermon in a Cleveland church. The preacher -took short "collar-bone" breathings, using twice the power necessary -for the building, and towards the conclusion was in evident distress -(which naturally communicated itself to his hearers), a failing voice -and perspiring face. If before entering the ministry he had learned -to breathe and use his voice properly, such troubles could never have -existed. - -There is yet another unpleasant affliction which correct breathing will -rarely fail to cure, a high-pitched and effeminate voice in a man. I -quote again a case from the same work: - -Mr. M----, a tall, thin young man, engaged in evangelistic work, -suffered from "weakness of voice." He spoke chiefly in a "child voice," -over which he had very little control. His breathing power increased -by sixty cubic inches in two lessons. "In one week more," adds Herr -Behnke, "I could dismiss him with a full, sonorous man's voice in place -of the uncertain child's squeak with which he had come to me." - -I must lastly point out that the cure of stammering often entirely -depends on the management of the breath, and in all cases it must be an -important agent. - -The limits of this paper allow but a brief notice of the best course -for a breathing instructor to follow. Let the pupil lie down on his -back, place the hand lightly on the lower part of the lungs, and tell -him to inhale easily through the nostrils, allowing the air to fill -the lower part of the lungs, avoiding all motion of the shoulders and -heaving up of the chest. When the lungs are fully inflated count four -with deliberation, and let the pupil inhale all the air as suddenly as -possible. Gradually increase the counting week by week up to twelve, -which marks a real control over the unused muscles. The next course is -for the pupil to inhale suddenly and exhale slowly. The instruction -given is of necessity meagre, but it need hardly be pointed out, no -written directions can take the place of personal teaching. From four -to six weeks is usually sufficient for the young and vigorous to gain -command over the breathing apparatus; older pupils have sometimes great -difficulty in mastering the muscles, unruly through disuse. - -Herr Behnke allows no use of the voice beyond ordinary speaking while -the breathing exercises are going on. I have followed this rule much -modified, and do not find the results unsatisfactory. - -The total neglect of this important subject in both American and -English schools is to me perfectly astounding. Half an hour a week for -three months would be ample for the purpose. These few hours would -confer a benefit of the highest value, and lasting a lifetime. - - - - - The Cleveland Medical Gazette. - - _A MONTHLY JOURNAL OF MEDICINE AND SURGERY._ - - ---------- - - One Dollar per Annum in Advance. - - ---------- - -All letters and communications should be addressed to the Cleveland Medical - Gazette, No. 5 Euclid Avenue, Cleveland, Ohio. - -A. R. BAKER, M. D., _Editor_. S. W. KELLEY, M. D., _Associate Editor_. - - ==================================================================== - - - EDITORIAL. - - -------------------------------------------------------------------- - -We have mailed the Gazette regularly to a number of our -friends who have not remitted their dollar. We hope they will do so -soon. - - ---------- - - - MEDICAL DEFENSE ASSOCIATION. - -Last month we urged the necessity of the profession organizing a -medical defense association. We publish this month the proceedings of -the Chicago Medical Society, in which the same question is discussed -very fully. - - ---------- - - - STATE SOCIETY REORGANIZATION. - -The editor of the Cincinnati Medical Journal asks the secretaries -of local societies to bring the matter before their respective -organizations, and suggests that they invite expression upon the -following propositions: - -1. To so change the constitution of the State Society as to make the -members of county societies members of the State Society simply by -virtue of their local membership. - -2. Present members of the State Society to remain members without -reference to membership in local societies. - -3. All members to stand upon an equal footing, thus doing away with the -delegate system. - -4. All papers to be presented to the State Society must first be -presented to the local society, by which it may be referred to the -State Society. - - ---------- - - - MEDICAL PRACTICE BILL. - -A bill to establish a medical board of examiners and licenses, and to -regulate the practice of medicine and surgery in the State of Ohio, and -to define the duties and powers of such board, will be presented to the -Legislature of Ohio. It provides for: - -1. A mixed board so far as schools are concerned. - -2. No attache of a medical college is eligible to a place on the board. - -3. All candidates for the practice of medicine in Ohio shall submit to -an examination by this board. - -4. None but graduates in medicine and surgery shall be eligible to -examination. - -5. Licenses may be refused or revoked for criminal or dishonorable -conduct. - -6. Graduates at present practicing in the State may continue without -submitting to an examination, but must register in the office of the -probate judge. - -These are the essential features of the bill, and on the whole good. -It does not interfere with physicians already in practice, which -has caused the failure of nearly every bill presented to the Ohio -Legislature becoming a law. Excluding college professors from becoming -members of the board is fair to the profession, and saves the bill from -being the tool of the medical colleges, unlike the Pennsylvania law, -and yet it does not ignore the medical schools entirely as educational -and graduating bodies, like the Illinois and West Virginia laws. It is -impracticable, even if desirable, to ignore denominational lines in -medical legislation. - - ---------- - - - PHYSICAL EXAMINATION OF YOUNG GIRLS. - -The following remarks were made by the president of the Royal College -of Physicians, December 28, and were the result of an inquiry into the -conduct of Dr. Haywood Smith, by the college, for having physically -examined the girl, Eliza Armstrong, without the consent of parent or -guardian: - -"It is, in the opinion of this college, a grave professional and moral -offence for any physician to examine physically a young girl, _even_ -at the request of a parent, without having first satisfied himself -that some decided medical good is likely to accrue to the patient -from the examination, and, also, without having first explained to -the parent or legal guardian of the girl the advisability of such -examination in general and the special objections that exist to their -being made. Moreover, the college feels that a young girl should on -no consideration be examined, excepting in the presence of a matron -of mature age, and, so far as the physician knows, of good moral -character...." The rest of the remarks were put direct to Dr. Smith, -and are of no general interest. - -The decision of the college was favorable to Dr. Smith; his name was -_not_ erased from the roll. - - ---------- - - - SUET BANDAGES. - -"These are admirable for dressing. You can make them by melting mutton -tallow over a slow fire. Have your bandages of close cloth, ready cut -the proper length and breadth, dip them into the suet; when saturated, -hold them so as to let them drip off, or the grease may be spread upon -the cloth. Hang them over a line where they may be protected from -dust; let them cool, fold them, put away for use. These bandages are -especially adapted to dress old ulcers and wounds. They are smooth -and adapt themselves perfectly to the surface; are agreeable to -the patient, and can be medicated with any therapeutical agent you -wish."--_American Medical Digest_, quoting Dr. Edwin Brock in _New -England Medical Monthly_. - -A disadvantage of the tallow bandage is its becoming rancid. Vaseline, -not becoming rancid, has been tried, but melts too easily. For most -purposes the wax bandage is as good as the tallow, perfectly smooth and -does not become rancid, but cannot very well be medicated. A useful -material for a bandage of this kind is the paraffine, as recommended by -Tait. - -The tallow bandage can be put to another use by those who do not live -convenient to an instrument dealer. When made wide the tallow bandage -can be rolled into a very good rectal bougie, large or smaller as you -wish by a few more or less thicknesses of the cloth. By the same means -a very good vaginal dilator can be extemporized for cases of stricture -or vaginismus. But where it is to remain long _in situ_ for these -cases beeswax or a mixture of beeswax and tallow, which are generally -available in the country, make a better substitute. "Cere cloth" was -formerly much used by gynecologists. - - ---------- - -We observe that Dr. Piffard has retired from his editorial connection -with the Journal of Cutaneous and Venereal Diseases. The Journal -will be continued under the sole editorial charge of Dr. P. A. -Morrow. We may remind our readers that this is the only publication -in the English language devoted to Skin and Venereal Diseases, and -during the three years of its existence it has won for itself a high -reputation for scientific excellence as well as practical utility. In -addition to presenting all that is new and valuable in these special -departments, the colored lithographs and wood engravings with which -the original articles are illustrated are worth more than the price -of subscriptions. Judging from the handsome appearance of the January -number, which is enriched by an admirable chromo-lithograph and a -number of well-executed woodcuts, and the eminently practical character -of its contents, this high standard will be maintained in the future. - - - - - SOCIETY PROCEEDINGS. - - -------------------------------------------------------------------- - - CHICAGO MEDICAL SOCIETY. - - OFFICIAL REPORT. - - _Stated Meeting, January 18th, 1886._ - - President pro. tem., D. W. Graham, M. D., in the chair. - - -Dr. E. J. Doering read a paper entitled - - MUTUAL PROTECTION AGAINST BLACKMAIL. - -The author stated that among the many trials which physicians have to -encounter in the practice of their profession is the ever-existing -liability of being blackmailed. This may either assume the more -frequent form of a so-called malpractice suit, or the relatively less -frequent charge of a criminal assault, according to the viciousness -of the complainant. Such suits against physicians are increasing. -One reason quoted was the fact that every city is overrun with petty -lawyers, who have little or nothing to do, and are always willing -to encourage any suit whatever, if there be the least prospect of -getting something out of the defendant. The author stated that since -investigating the matter he became convinced that many of these -blackmail schemes were settled before being made public. Many a -physician preferred being robbed of one or two hundred dollars, rather -than incur the publicity, the loss of time and the endless expense -of a lawsuit. Again, the average jury, composed of the ignorant and -illiterate, will always have a strong leaning toward the complainant -and against the defendant in a malpractice suit, as physicians are -popularly supposed to be capitalists. The author stated that personally -he had never been sued or even threatened with a suit, and it was -therefore from no motive of selfish interest, but from a sincere regard -for the welfare of the profession, that he advocated the formation -of an association for the mutual protection of physicians against -blackmailing suits of all kinds. His plan is to organize a society -composed of two or three hundred members of the regular profession, -all of whom shall be of acknowledged ability, possessing a good moral -character and standing in the community. Said association to employ the -best legal talent attainable, by the year, to furnish the members such -legal advice as they may desire at any time and defend any suit against -the members arising in the discharge of their professional duties. It -was stated that the expense to each member of an association composed -of about two hundred would not exceed five dollars per annum, and that -an initiation fee of five dollars would create a sufficient fund for -court expenses. Such an association would be a power in preventing -suits. Let it be known that the individual physician is backed by the -financial and moral support of a few hundred of the best physicians, -and aided by the best legal talent obtainable, and he will be let -severely alone by the offscouring and dregs of society who constitute, -almost without exception, the blackmailing element in our professional -life. The author stated that he was not aware of the existence of -such an association as the one proposed in any other city, but the -principle at least has been carried out recently by the New York County -Medical Society, in voting $500 to assist in the defense of the Drs. -Purdy, members of the Society, in the case of Brown _vs._ Purdy. After -reading a number of letters from prominent physicians in favor of -forming a protective association, and presenting several legal opinions -sustaining the advisability, practicability and legal status of such a -society, the author concluded by stating his firm belief that such an -association for mutual protection was needed, that it would be a power -for good, that it would draw the profession closer together, that, in -short, it would be based on the principles of a common brotherhood, -viz.: equality, harmony, justice and unity. - -Dr. F. C. Hotz said that the extract of his letter to Dr. -Doering, which was incorporated in the paper, indicated that at the -time it was written he did not think favorably of the project. And, -after listening with much interest to the doctor's arguments, he saw no -reason for changing his opinion. Professional reputation and honor is -the most personal of all personal property; if he lost it, it does not -hurt anybody but himself, and therefore if any attack be made on it he -should certainly wish to employ among the able lawyers the one in whose -ability he had the greatest confidence. But he was not sure whether the -lawyer retained by this protective union would be the one to whom he -should like to trust the defense of his reputation. The attorney might -be able, or abler, than the lawyer of his own choice; but should the -case go against him, he should never feel satisfied that the lawyer -had done all that could be done for him unless he had full confidence -in him. It is with the lawyer as with the physician, a question of -confidence, and his patrons find no fault with his treatment as long as -they have implicit faith in his ability. - -An objection of greater weight, however, has been urged by several of -the doctor's correspondents in asking what possible effect it might -have if the fact was brought out in court that the defendant belonged -to such a union? The lawyers whose opinions were obtained and read by -the doctor, say it cannot legally affect the case. There is no doubt -but what this is true. But the verdict of a jury in malpractice suits -is not determined by the legal aspect of the case; and circumstances -which cannot have any legal effect upon the case have often made a deep -impression upon a jury and decided the case against the physician. -To illustrate: In Dr. Bettman's first trial, the experts of the -prosecution testified so unreservedly in the doctor's favor that had -the case been submitted to the jury without arguments, the doctor -would have been acquitted at once. To fortify his cause Dr. Bettman's -lawyer called a number of experts, whose testimony was of course only -cumulative. Now what did the prosecuting lawyer do? Did he make an -effort to break down the expert evidence by scientific arguments? No, -sir; but he wiped out its effect upon the jury by the mere waving of -his hand, speaking thus: "The defense has piled up a mountain of expert -evidence. But, gentlemen of the jury, what does it all amount to? These -doctors are working together in the same hospital. Don't you see they -have a common interest to sustain each other, because every one of them -may be in the same fix some day? Don't you know they are clannish? -They wont admit that one of them can make a mistake. O, no!" One could -fairly see the impression this harangue made upon the jury, and they -rendered a verdict against the doctor, though it is certain the lawyers -will say the fact of his being associated with the experts in the -same hospital should and could legally not prejudice the jury. But it -evidently did, all the same. And after such experience, can you for one -moment believe it would not damage the physician's cause if he and his -experts belonged to a society formed for the express purpose of mutual -assistance in malpractice suits. A mighty poor lawyer he would be who -could not make a great deal out of it before a jury. - -Very interesting was that part of the paper in which the doctor evolved -his idea how his new society could prevent, ward off, malpractice -suits. He believes the shysters would not be so eager to engage in this -business if they knew they had to fight a corporation with plenty of -means to employ the best legal talent. Why this should discourage those -fellows it is hard to understand. They do not sue poverty-stricken -doctors. Whom they select for their victims they suppose to be rich, -and consequently able to employ a good lawyer. They do not expect to -have all easy game, but why should they not try it? They don't risk -anything by it. The blackmailer's stake is only two dollars and a -half for filing his application, and his lawyer's stake is his time, -which is not worth much anyhow. So you see they have nothing to lose, -but much to gain. What difference should it make to them whether the -opposing counsel is engaged by one physician or by one hundred? If -you wish to devise means by which this blackmailing nuisance can be -stopped, or at least reduced to a minimum, you must try to get to the -roots of the evil; that is, you must find the causes which usually -bring it forth. And you will not go far to find them, for you find -them right at your door, in your own profession, in the shape of -_indiscriminate dispensation of gratuitous services and of unkind -remarks of one physician about another_. Physicians are altogether too -quick to give their services gratis to almost any body at any time. But -you know very well people do not value very much what they can get for -the mere asking; they do not think much of what they get for nothing. -And it is also a widespread notion (especially among the lower educated -people) that the quality of service is regulated by the amount of money -they pay for it; that the treatment at a free dispensary, because -gratuitous, is not the same, not as good as at a physician's office -where they have to pay for it. These people cannot persuade themselves -that a physician will take the same interest in a case whether or not -he is paid for his services. The poor, therefore, are always suspicious -that they do not get their full share of attention. They are quickly -ready to charge their physician with carelessness if the case goes -wrong. And with a patient in this frame of mind, it takes but very -little encouragement to begin a suit for damages. And in nine out of -ten cases, doubtless, this encouragement is furnished by the members -of our own profession. He did not mean to charge physicians with -purposely, wilfully, instigating a lawsuit against a brother. Though -this has been done, such extraordinary baseness is a rare exception. - -What Dr. Hotz had reference to is the inconsiderate careless, -thoughtless habit of expressing an opinion about a case, or a -colleague. To illustrate: A physician at a dispensary shows a bad case -to professional friends, and without thinking of the possible evil -consequences, makes in the presence of the patient some remark like -this: "Well, perhaps I ought to have done this or that." The patient, -already laboring under the impression that he was not fairly treated -because he could not pay, sees in the doctor's remark the strongest -confirmation of his suspicion, goes to a shyster and begins a suit -for damages. And doubtless, in a similar way the mind of a patient is -often poisoned and set against his physician by a careless or unkind -remark of another physician. So many physicians are always ready -to express their opinion about their colleagues in the presence of -anybody, or to criticise their professional acts upon the information -received from a patient or some old woman. Now you all know how these -people misconstrue the words of a doctor; how they pervert the facts -inadvertently. You must admit you cannot rely on what patients tell -you, and you cannot form an opinion that is worth anything of a case -you have not seen or been informed about by the attending physician. -Why, then, don't you say so when somebody asks you what you think about -the case of Dr. H.? Or if you know the physician, say he is competent -to attend to his own business; if you don't know him, change the -subject. But at all events, unless he be a notorious quack, refrain -from uttering any words which even only insinuate the possibility of a -mistake or want of skill of your colleague. - -Stop running each other down; stand by each other; sustain each other, -"stick together and be clannish;" let it be understood in public that -no reputable physician will prostitute himself by going to court as -expert for a blackmailer. If all the reputable physicians of this city -adopt and act on this principle, blackmailing the medical profession -would soon be a thing of the past, and malpractice suits more -effectually prevented than by the organization of a protective union. - -Dr. P. S. Hayes said that, from his costly experience in a -malpractice suit, he felt that an association such as suggested by -Dr. Doering would be of great service. The lawyer employed by such an -association would speedily acquire such a fund of medical knowledge -that he would be considered an expert in malpractice cases. He would -not require an amount of coaching necessary to prepare for any given -case, as would be requisite in the case of a lawyer who had no -experience in such cases. His opportunity for obtaining information -in a given case would be largely extended, for each member of the -association to whom he might apply would be interested in giving him -the desired knowledge. He would soon become acquainted with medical -witnesses and know which would give the best testimony in any case. - -An association of the character suggested by the paper might be a means -of educating its members in regard to laws bearing on the rights of -physicians and their patients, now not generally understood. For one -he is heartily in favor of such an association, and should give it his -hearty support. - -Dr. G. C. Paoli said Dr. Doering's paper is not only a -valuable one, but contains such a high, noble, charitable feeling that -the Society ought to be grateful to him. He wondered that such steps -had not been taken before, because so many of our professional brethren -have not only suffered annoyance, but pecuniary loss as well. How -can we expect, from an ignorant jury, a decision based on scientific -knowledge and justice? - -Dr. F. M. Weller said that the subject of the paper was -worthy of consideration; that the discussion of the formation of an -association with an object so widely different from the Medical Society -seemed out of place; the one essentially scientific, the other in the -nature of an insurance. The right to form such an organization was -unquestioned; the policy should be considered by each individual. -That while any one might be made the object of blackmail, he believed -that charges of malpractice more frequently arose from the ignorance -of physicians of the statutes affecting the practice of medicine, -especially those of the criminal code, and of the rulings of the courts -in cases. - - ---------- - - - PROCEEDINGS OF THE CUYAHOGA COUNTY MEDICAL - SOCIETY, NOVEMBER 5, 1885. - -[Reported for the Gazette by L. B. Tuckerman, M. D., Cor. Sec.] - - COMPULSORY VACCINATION. - -Dr. Himes presiding. - -Dr. Hart said that thirty years ago, in a country region of -western Pennsylvania, he met an epidemic of smallpox. Over thirty years -earlier, under a State law, the whole community had been vaccinated. -Out of about fifty persons exposed to the disease the most were adults -who had been vaccinated at the time referred to, or earlier. Referring -to an article on the epidemic prepared at the time, he finds that -fully half had the disease in some form, from the mildest varioloid to -confluent smallpox, one case of secondary smallpox occurring. While -he believed that fifty per cent. of those vaccinated in infancy are -protected for a lifetime, still he regards the presence of the most -distinct cicatrix as no criterion by which to determine who are thus -secure. From twelve to twenty years of age, probably, fully one-half -will have a more or less perfect result from revaccination, and will -in most cases be thenceforth protected from all ordinary exposure -to smallpox. But in the presence of the varilous atmosphere of an -epidemic of the disease, revaccination is the only absolute safety. -He has always revaccinated himself as often as exposed, and advised -the same course for others. While smallpox prevailed here, say from -1865 to 1873, where patients were not removed to a pest house, and the -only precaution enforced was the notice on the house, he attended a -considerable number of cases. He always insisted on vaccinating every -exposed person, and although there were often unvaccinated children and -adults who had a thorough effect from revaccination, he never had a -second crop of calls in the same house. - -He referred to the complete revaccination of the Forty-first Regiment, -O. V. I., before going South. Many of the men with a fair cicatrix had -a perfect revaccination, while two hundred or three hundred had more or -less result. Humanized virus was used. During their term of service, -while repeatedly exposed to smallpox, and where other regiments about -them suffered severely from the disease, they entirely escaped. This -immunity could only be referred to their revaccination, and certainly -affords the strongest proof of its prophylactic power. - -While frequent renewals of the humanized virus is desirable, he -regarded it, when selected with the care which ought to be observed, as -milder in its effects and much more certain than cowpox. In vaccinating -with cowpox he has had severe effects follow much more frequently than -when he made use of the humanized virus. - -Dr. Dutton did not believe that the profession should insist -on compulsory revaccination, at least until it was proven that -revaccination was absolutely necessary. A second vaccination often -produces a serious inflammatory sore, quite unlike the true vaccine -pustule, and an ulcer sometimes follows. - -Dr. Preston stated that, as he had observed, a large -percentage of those who were not revaccinated were liable to have -varioloid. - -Dr. Scott stated that we must either vaccinate or inoculate. -He was vaccinated by his mother fifty years ago, and was protected -yet. He had been revaccinated many times without effect. He regarded -the humanized scab the best. He believed that the proportion that take -again is less than Dr. Hart is inclined to suppose. Every community -has a right to compel vaccination, and the question here is not of -revaccination. Bovine virus removes the danger of the communication -of syphilis, but the cultivation of the virus should be under State -control. Much of the trouble had come from scabs or points from -pustules where the lymph had been drawn off and the pustules allowed to -refill. A refilled pustule can communicate almost anything. - -Dr. Smith said he had seen some of the worst arms he ever saw -from revaccination. He would rather have a mild case of varioloid than -such a case. It is not certain that a second sore is evidence that the -patient will not have varioloid. - -Dr. Corlett stated that in the London Smallpox Hospital they -had for twenty years made it a rule to vaccinate every attendant, -and for twenty years there had been no case of smallpox among the -attendants. There is more attention paid to instruction in vaccination -there than here. Each student must go at least six times to one of -the dozen government stations and receive instruction. Vaccination is -done from arm to arm. As soon as the vesicle is formed, and before -pustulation, a capillary tube is inserted and a portion of the lymph -withdrawn. They do not believe that there is danger of scrofula or -syphilis if there be no admixture of blood cells, either white or red, -with the lymph. He believes that the cases of eczema and scrofula so -often attributed to vaccination are really due to a dyscrasia of the -patient. - -Dr. Millikin inquired how long the lymph retained its activity -after being withdrawn into the capillary tube. Dr. Corlett -stated that it could be used for six weeks or two months. - -Dr. Vance stated that the Germans of Cincinnati, irrespective -of creed, preferred inoculation to vaccination. Hence there was always -smallpox in Cincinnati. In spite of the stringent laws against it, -inoculation was systematically carried on. The parent would take the -infant to a neighboring hillside and leave it with a dollar-bill -beside it, and go away. In a few minutes he would return, the -dollar-bill would be gone, and the child was inoculated. The law -against it cannot be enforced. - - - - - ==================================================================== - - - CORRESPONDENCE. - - - -------------------------------------------------------------------- - - - NEW YORK LETTER. - - THE USES OF COCAINE IN SURGERY. - -It is not the object of this communication to speak of the discovery of -this drug and the experiments which were necessary to bring it before -the profession as a reliable and trustworthy agent. That cocaine is a -valuable addition to the armamentarium of the surgeon, I think no one -will doubt, but how beneficial, I think but few fully realize. - -Cocaine is constantly growing in favor with the surgeons here in New -York. New fields of usefulness are opening, and in nearly all of the -minor and many of the major operations it is taking the place of ether -and chloroform. These older anæsthetics, although so useful, were -accompanied by danger, and many deaths are attributed to their use, -while so far, I know of no well authenticated case where death or -serious symptoms have resulted from the use of this new anæsthetic. -Its first use was restricted almost exclusively to the eye and mucous -membrane, but the hypodermic syringe has made it as useful to the -general surgeon as to the oculist. - -There is not a day passes but that we see operations of more or less -magnitude performed under its influence at some of the clinics or -hospitals of New York. Circumcision, hemmorrhoids, fistula in ano, -felon, ingrowing toe-nails, hydrocele, cutting for foreign bodies, -removal of small tumors, etc., are some of the operations for which we -very seldom see an anæsthetic given. - -At St. Luke's hospital an operation for ventral hernia was performed by -the use of cocaine alone, where it was necessary to open the abdominal -cavity for three inches and reach into the abdomen with the fingers to -draw up the peritoneum, and all done with perfect success. Amputations -of the fingers and toes are not uncommon, and amputation of the leg and -fore-arm have been successfully performed by its use. - -External and internal urethrotomy and cleft palate are usually -performed by its aid. I have seen large stones removed from the urethra -in this way without any expression of pain from the patient, he talking -with the surgeon about the case while it was in progress. - -Dr. Corning, of New York, has devised a method by which the local -effect of the drug may be indefinitely prolonged. His theory was that -the drug was washed from the tissues of the blood and its effects thus -lost. To prevent this he applies elastic ligatures around the part, -between the injection and the heart, about two or three minutes after -the injection is made. When the injection is on the body or face where -the ligature can not be used, he uses large rings to surround the part, -so arranged that firm pressure can be made upon them, and thus cut off -the active circulation. He claims for this that a weaker solution can -be used and the effects continued for a much longer time. - -The mode of proceeding is usually to inject from ten to fifty drops -of a 4 per cent. solution around the part to be operated upon, using -an ordinary hypodermic syringe. From three to five drops of this -solution are injected at short intervals in a zone surrounding the -part to be operated; or a larger quantity is injected near the body -of the nerve supplying the part. If this is reached the anæsthesis is -complete. In two or three minutes the knife can be freely used, and the -patient feels no pain, although they look at the knife as it divides -the tissues. In the throat clinic a solution of cocaine is used with -an atomizer to allay the irritability of sensitive parts, that a more -thorough examination may be made. At the eye clinic cocaine is used as -a mydriatic, atropia being seldom used for the purpose of examinations. - -Patients usually dread the action of an anæsthetic; the nausea, -headache, and lassitude following its administration are things not -pleasant to contemplate, but with this new drug none of these are -encountered. - -The conclusions are, then, from our present experience, that cocaine is -a pleasant, safe and efficient local anæsthetic. - - O. T. Maynard. - ---------- - - - BALTIMORE LETTER. - -At the last meeting of one of the city medical societies one of the -members reported a case of typhoid fever in which the pulse had -remained quite low for over a week. Several questions were asked -concerning the _normal_ pulse of the man. The doctor insisted that he -knew the normal pulse was higher, as he had examined it many times in -health. This was strange and so many members plied the doctor with -questions that he finally confessed that the young man was a member -of the family when he (the doctor) was courting his (the doctor's, -not the patient's) wife. Of course the entire society understood -at once that the doctor felt the pulse of the entire family during -this love-sickness. There are many ways of courting--Josh Billings -had a very good way. Some fellows buy the old gentleman a cane (very -appropriate and often _useful_); the small brother a box of candy, so -that he will vacate the parlor--and for the baby sister a wax doll with -long flaxen hair--which she invariably informs the neighborhood was -given to her "by Sallie's beau." - -We once knew a nice young man who had been told that the best plan was -to court the mother for a while. He heeded the advice and was getting -along very finely, when one day he received an invitation to attend the -marriage of his girl to the fellow who had been courting _her_ and not -her _mother_. - -This little occurrence turned our minds to the humorous things of our -experiences, and after adjournment of the society a number of "funny" -things were related as we walked homeward. - -The following is interesting to the gynæcologists: - -A young married woman (without children, or she would have other things -to require her attention) had been for some time afflicted with -uterine trouble. She had been treated by several physicians. Various -pessaries had been worn. The last attendant discovered that it mattered -not what kind of pessary was used, nor in what position it was placed -in order to afford satisfactory relief. Finally an abdominal supporter, -with cup and stem attachment was wanted and obtained. This by far -surpassed any other, until one day it "hurt a little." The patient at -once thought of an improvement. She removed the cup and stem, detached -the cup and reintroduced the stem. It gave perfect satisfaction and -has been worn with comfort for about three months. We sincerely -hope this simple instrument will be able to permanently retain the -displaced--mind--in proper position. We offered it to the profession -as the finest instrument yet discovered for such cases. It is not -patented, no royalty is received by the discoverer, and no extra charge -is made for the thread on the internal end of the stem. - -The medical colleges have resumed their regular lectures, the students -having returned from their Christmas visit to their--mothers. - -One of the societies inaugurated the new year by a banquet, which was -a most delightful affair. It was given at the Eutaw House, was well -attended, substantial, and well served. The toasts formed no small -part of the enjoyment. Some of the reminiscences of the older members -afforded much merriment. - -A very interesting case of the heart displaced to the left side was -exhibited to the Clinical Society by Dr. McSherry at the meeting of -January 8. It is rare, and only a few cases are reported. Displacement -to right side is not of unfrequent occurrence, and a number of cases -are recorded. The apex beat in this case is heard two inches to the -left of a perpendicular line through the left nipple. The first line -of dullness is one inch and a half to the left of the center of the -sternum. Attachment to a contracted lung due to phthisis is the -probable cause of the displacement. At the same meeting there were -reported two cases of laparotomy for intestinal obstruction. Both -terminated in recovery. - -A somewhat novel, but said to be successful, treatment for cases of -"wry neck" due to neuralgia or "cold" was mentioned at the Medical and -Surgical Society on the 14th. It is to sit for one half hour or more -near a very hot stove, placing the affected side opposite an open door. -A screen should be placed beyond the patient so as to confine the heat -as much as possible to his immediate locality. - -It was suggested by the mention of a case, in a child eleven years old, -which had continued four weeks, in spite of treatment. One physician -thought the Faradic current a specific in such cases. - -I have read with pleasure a little work which, if I mistake not, will -be most welcome to the profession. It is a book of nearly seventy -pages, entitled 'Practical Notes on the Treatment of Skin Diseases.' I -am glad to say also, that it is written and published by a Baltimore -physician, Professor Rohé, whose 'Text Book of Hygiene' I took occasion -to mention in my last communication. - -I suppose all country practitioners, if not those of the city also, -who are busy from morning till night with hardly two hours a day -for reading, have felt as I have on many occasions, the need of -some concise practical text books not given to speculations and -generalizations! Especially is this needed in "Skin Diseases," because -of the meager knowledge that we common practitioners have of the -subject. There has seemed to me to be a tendency to call most skin -diseases "eczema," just as it undoubtedly is to call all vague pains -throughout the body "rheumatism." - -Dr. Rohé very truly remarks that "most text books on dermatology have -as their besetting sins complicated classifications or 'systems,' an -awkward nomenclature, great prolixity and a lack of definiteness in -the description of typical diseases, and an undue multiplication of -morbid processes." No one better understands this than a practical -physician who has spent half an hour hunting through one or two large -text books for light on a case in hand and finally "falls back on" his -'Dunglison.' It seems quite clear that without a fine atlas most of the -large works on dermatology are for the most part unintelligible. - -Dr. Rohé's book is one of a series, the others to follow shortly if -this is accorded a hearty reception. This first series is devoted to -the diseases of the perspiratory and sebaceous glands. Their anatomy -and physiology are briefly stated, then follows the descriptions of -the diseases commonly met with, as well as the rarer forms, in terse, -plain language. The last few pages contain formulæ which experience -has shown to be of value. The subjects of "prickly heat" and "acne" -are especially well treated, and either of them is more than worth the -price of the book. - -I have dwelt at much length on this subject because I feel that this -little work ought to be in the hands of every busy practitioner who is -not well acquainted with diseases of the skin. It can be had by sending -twenty-five (25) cents to the author, Dr. George H. Rohé, 139 North -Calvert street, Baltimore, Md. - - F. - - - - - - - - -End of the Project Gutenberg EBook of The Cleveland Medical Gazette, Vol. 1, -No. 4, February 1886, by Various - -*** END OF THIS PROJECT GUTENBERG EBOOK CLEVELAND MEDICAL GAZETTE, FEBRUARY 1886 *** - -***** This file should be named 52983-0.txt or 52983-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/2/9/8/52983/ - -Produced by The Online Distributed Proofreading Team at -http://www.pgdp.net (This file was produced from images -generously made available by The Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. Special rules, set forth in the General Terms of Use part -of this license, apply to copying and distributing Project -Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm -concept and trademark. Project Gutenberg is a registered trademark, -and may not be used if you charge for the eBooks, unless you receive -specific permission. If you do not charge anything for copies of this -eBook, complying with the rules is very easy. You may use this eBook -for nearly any purpose such as creation of derivative works, reports, -performances and research. They may be modified and printed and given -away--you may do practically ANYTHING in the United States with eBooks -not protected by U.S. copyright law. Redistribution is subject to the -trademark license, especially commercial redistribution. - -START: FULL LICENSE - -THE FULL PROJECT GUTENBERG LICENSE -PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK - -To protect the Project Gutenberg-tm mission of promoting the free -distribution of electronic works, by using or distributing this work -(or any other work associated in any way with the phrase "Project -Gutenberg"), you agree to comply with all the terms of the Full -Project Gutenberg-tm License available with this file or online at -www.gutenberg.org/license. - -Section 1. General Terms of Use and Redistributing Project -Gutenberg-tm electronic works - -1.A. By reading or using any part of this Project Gutenberg-tm -electronic work, you indicate that you have read, understand, agree to -and accept all the terms of this license and intellectual property -(trademark/copyright) agreement. If you do not agree to abide by all -the terms of this agreement, you must cease using and return or -destroy all copies of Project Gutenberg-tm electronic works in your -possession. If you paid a fee for obtaining a copy of or access to a -Project Gutenberg-tm electronic work and you do not agree to be bound -by the terms of this agreement, you may obtain a refund from the -person or entity to whom you paid the fee as set forth in paragraph -1.E.8. - -1.B. "Project Gutenberg" is a registered trademark. It may only be -used on or associated in any way with an electronic work by people who -agree to be bound by the terms of this agreement. There are a few -things that you can do with most Project Gutenberg-tm electronic works -even without complying with the full terms of this agreement. See -paragraph 1.C below. There are a lot of things you can do with Project -Gutenberg-tm electronic works if you follow the terms of this -agreement and help preserve free future access to Project Gutenberg-tm -electronic works. See paragraph 1.E below. - -1.C. The Project Gutenberg Literary Archive Foundation ("the -Foundation" or PGLAF), owns a compilation copyright in the collection -of Project Gutenberg-tm electronic works. Nearly all the individual -works in the collection are in the public domain in the United -States. If an individual work is unprotected by copyright law in the -United States and you are located in the United States, we do not -claim a right to prevent you from copying, distributing, performing, -displaying or creating derivative works based on the work as long as -all references to Project Gutenberg are removed. Of course, we hope -that you will support the Project Gutenberg-tm mission of promoting -free access to electronic works by freely sharing Project Gutenberg-tm -works in compliance with the terms of this agreement for keeping the -Project Gutenberg-tm name associated with the work. You can easily -comply with the terms of this agreement by keeping this work in the -same format with its attached full Project Gutenberg-tm License when -you share it without charge with others. - -1.D. The copyright laws of the place where you are located also govern -what you can do with this work. Copyright laws in most countries are -in a constant state of change. If you are outside the United States, -check the laws of your country in addition to the terms of this -agreement before downloading, copying, displaying, performing, -distributing or creating derivative works based on this work or any -other Project Gutenberg-tm work. The Foundation makes no -representations concerning the copyright status of any work in any -country outside the United States. - -1.E. Unless you have removed all references to Project Gutenberg: - -1.E.1. The following sentence, with active links to, or other -immediate access to, the full Project Gutenberg-tm License must appear -prominently whenever any copy of a Project Gutenberg-tm work (any work -on which the phrase "Project Gutenberg" appears, or with which the -phrase "Project Gutenberg" is associated) is accessed, displayed, -performed, viewed, copied or distributed: - - This eBook is for the use of anyone anywhere in the United States and - most other parts of the world at no cost and with almost no - restrictions whatsoever. You may copy it, give it away or re-use it - under the terms of the Project Gutenberg License included with this - eBook or online at www.gutenberg.org. If you are not located in the - United States, you'll have to check the laws of the country where you - are located before using this ebook. - -1.E.2. If an individual Project Gutenberg-tm electronic work is -derived from texts not protected by U.S. copyright law (does not -contain a notice indicating that it is posted with permission of the -copyright holder), the work can be copied and distributed to anyone in -the United States without paying any fees or charges. If you are -redistributing or providing access to a work with the phrase "Project -Gutenberg" associated with or appearing on the work, you must comply -either with the requirements of paragraphs 1.E.1 through 1.E.7 or -obtain permission for the use of the work and the Project Gutenberg-tm -trademark as set forth in paragraphs 1.E.8 or 1.E.9. - -1.E.3. If an individual Project Gutenberg-tm electronic work is posted -with the permission of the copyright holder, your use and distribution -must comply with both paragraphs 1.E.1 through 1.E.7 and any -additional terms imposed by the copyright holder. Additional terms -will be linked to the Project Gutenberg-tm License for all works -posted with the permission of the copyright holder found at the -beginning of this work. - -1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm -License terms from this work, or any files containing a part of this -work or any other work associated with Project Gutenberg-tm. - -1.E.5. Do not copy, display, perform, distribute or redistribute this -electronic work, or any part of this electronic work, without -prominently displaying the sentence set forth in paragraph 1.E.1 with -active links or immediate access to the full terms of the Project -Gutenberg-tm License. - -1.E.6. You may convert to and distribute this work in any binary, -compressed, marked up, nonproprietary or proprietary form, including -any word processing or hypertext form. However, if you provide access -to or distribute copies of a Project Gutenberg-tm work in a format -other than "Plain Vanilla ASCII" or other format used in the official -version posted on the official Project Gutenberg-tm web site -(www.gutenberg.org), you must, at no additional cost, fee or expense -to the user, provide a copy, a means of exporting a copy, or a means -of obtaining a copy upon request, of the work in its original "Plain -Vanilla ASCII" or other form. Any alternate format must include the -full Project Gutenberg-tm License as specified in paragraph 1.E.1. - -1.E.7. Do not charge a fee for access to, viewing, displaying, -performing, copying or distributing any Project Gutenberg-tm works -unless you comply with paragraph 1.E.8 or 1.E.9. - -1.E.8. You may charge a reasonable fee for copies of or providing -access to or distributing Project Gutenberg-tm electronic works -provided that - -* You pay a royalty fee of 20% of the gross profits you derive from - the use of Project Gutenberg-tm works calculated using the method - you already use to calculate your applicable taxes. The fee is owed - to the owner of the Project Gutenberg-tm trademark, but he has - agreed to donate royalties under this paragraph to the Project - Gutenberg Literary Archive Foundation. Royalty payments must be paid - within 60 days following each date on which you prepare (or are - legally required to prepare) your periodic tax returns. Royalty - payments should be clearly marked as such and sent to the Project - Gutenberg Literary Archive Foundation at the address specified in - Section 4, "Information about donations to the Project Gutenberg - Literary Archive Foundation." - -* You provide a full refund of any money paid by a user who notifies - you in writing (or by e-mail) within 30 days of receipt that s/he - does not agree to the terms of the full Project Gutenberg-tm - License. You must require such a user to return or destroy all - copies of the works possessed in a physical medium and discontinue - all use of and all access to other copies of Project Gutenberg-tm - works. - -* You provide, in accordance with paragraph 1.F.3, a full refund of - any money paid for a work or a replacement copy, if a defect in the - electronic work is discovered and reported to you within 90 days of - receipt of the work. - -* You comply with all other terms of this agreement for free - distribution of Project Gutenberg-tm works. - -1.E.9. If you wish to charge a fee or distribute a Project -Gutenberg-tm electronic work or group of works on different terms than -are set forth in this agreement, you must obtain permission in writing -from both the Project Gutenberg Literary Archive Foundation and The -Project Gutenberg Trademark LLC, the owner of the Project Gutenberg-tm -trademark. Contact the Foundation as set forth in Section 3 below. - -1.F. - -1.F.1. Project Gutenberg volunteers and employees expend considerable -effort to identify, do copyright research on, transcribe and proofread -works not protected by U.S. copyright law in creating the Project -Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm -electronic works, and the medium on which they may be stored, may -contain "Defects," such as, but not limited to, incomplete, inaccurate -or corrupt data, transcription errors, a copyright or other -intellectual property infringement, a defective or damaged disk or -other medium, a computer virus, or computer codes that damage or -cannot be read by your equipment. - -1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right -of Replacement or Refund" described in paragraph 1.F.3, the Project -Gutenberg Literary Archive Foundation, the owner of the Project -Gutenberg-tm trademark, and any other party distributing a Project -Gutenberg-tm electronic work under this agreement, disclaim all -liability to you for damages, costs and expenses, including legal -fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT -LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE -PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE -TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE -LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR -INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH -DAMAGE. - -1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a -defect in this electronic work within 90 days of receiving it, you can -receive a refund of the money (if any) you paid for it by sending a -written explanation to the person you received the work from. If you -received the work on a physical medium, you must return the medium -with your written explanation. The person or entity that provided you -with the defective work may elect to provide a replacement copy in -lieu of a refund. If you received the work electronically, the person -or entity providing it to you may choose to give you a second -opportunity to receive the work electronically in lieu of a refund. If -the second copy is also defective, you may demand a refund in writing -without further opportunities to fix the problem. - -1.F.4. Except for the limited right of replacement or refund set forth -in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO -OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT -LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE. - -1.F.5. Some states do not allow disclaimers of certain implied -warranties or the exclusion or limitation of certain types of -damages. If any disclaimer or limitation set forth in this agreement -violates the law of the state applicable to this agreement, the -agreement shall be interpreted to make the maximum disclaimer or -limitation permitted by the applicable state law. The invalidity or -unenforceability of any provision of this agreement shall not void the -remaining provisions. - -1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the -trademark owner, any agent or employee of the Foundation, anyone -providing copies of Project Gutenberg-tm electronic works in -accordance with this agreement, and any volunteers associated with the -production, promotion and distribution of Project Gutenberg-tm -electronic works, harmless from all liability, costs and expenses, -including legal fees, that arise directly or indirectly from any of -the following which you do or cause to occur: (a) distribution of this -or any Project Gutenberg-tm work, (b) alteration, modification, or -additions or deletions to any Project Gutenberg-tm work, and (c) any -Defect you cause. - -Section 2. Information about the Mission of Project Gutenberg-tm - -Project Gutenberg-tm is synonymous with the free distribution of -electronic works in formats readable by the widest variety of -computers including obsolete, old, middle-aged and new computers. It -exists because of the efforts of hundreds of volunteers and donations -from people in all walks of life. - -Volunteers and financial support to provide volunteers with the -assistance they need are critical to reaching Project Gutenberg-tm's -goals and ensuring that the Project Gutenberg-tm collection will -remain freely available for generations to come. In 2001, the Project -Gutenberg Literary Archive Foundation was created to provide a secure -and permanent future for Project Gutenberg-tm and future -generations. To learn more about the Project Gutenberg Literary -Archive Foundation and how your efforts and donations can help, see -Sections 3 and 4 and the Foundation information page at -www.gutenberg.org - - - -Section 3. Information about the Project Gutenberg Literary Archive Foundation - -The Project Gutenberg Literary Archive Foundation is a non profit -501(c)(3) educational corporation organized under the laws of the -state of Mississippi and granted tax exempt status by the Internal -Revenue Service. The Foundation's EIN or federal tax identification -number is 64-6221541. Contributions to the Project Gutenberg Literary -Archive Foundation are tax deductible to the full extent permitted by -U.S. federal laws and your state's laws. - -The Foundation's principal office is in Fairbanks, Alaska, with the -mailing address: PO Box 750175, Fairbanks, AK 99775, but its -volunteers and employees are scattered throughout numerous -locations. Its business office is located at 809 North 1500 West, Salt -Lake City, UT 84116, (801) 596-1887. Email contact links and up to -date contact information can be found at the Foundation's web site and -official page at www.gutenberg.org/contact - -For additional contact information: - - Dr. Gregory B. Newby - Chief Executive and Director - gbnewby@pglaf.org - -Section 4. Information about Donations to the Project Gutenberg -Literary Archive Foundation - -Project Gutenberg-tm depends upon and cannot survive without wide -spread public support and donations to carry out its mission of -increasing the number of public domain and licensed works that can be -freely distributed in machine readable form accessible by the widest -array of equipment including outdated equipment. Many small donations -($1 to $5,000) are particularly important to maintaining tax exempt -status with the IRS. - -The Foundation is committed to complying with the laws regulating -charities and charitable donations in all 50 states of the United -States. Compliance requirements are not uniform and it takes a -considerable effort, much paperwork and many fees to meet and keep up -with these requirements. We do not solicit donations in locations -where we have not received written confirmation of compliance. To SEND -DONATIONS or determine the status of compliance for any particular -state visit www.gutenberg.org/donate - -While we cannot and do not solicit contributions from states where we -have not met the solicitation requirements, we know of no prohibition -against accepting unsolicited donations from donors in such states who -approach us with offers to donate. - -International donations are gratefully accepted, but we cannot make -any statements concerning tax treatment of donations received from -outside the United States. U.S. laws alone swamp our small staff. - -Please check the Project Gutenberg Web pages for current donation -methods and addresses. Donations are accepted in a number of other -ways including checks, online payments and credit card donations. To -donate, please visit: www.gutenberg.org/donate - -Section 5. General Information About Project Gutenberg-tm electronic works. - -Professor Michael S. Hart was the originator of the Project -Gutenberg-tm concept of a library of electronic works that could be -freely shared with anyone. For forty years, he produced and -distributed Project Gutenberg-tm eBooks with only a loose network of -volunteer support. - -Project Gutenberg-tm eBooks are often created from several printed -editions, all of which are confirmed as not protected by copyright in -the U.S. unless a copyright notice is included. Thus, we do not -necessarily keep eBooks in compliance with any particular paper -edition. - -Most people start at our Web site which has the main PG search -facility: www.gutenberg.org - -This Web site includes information about Project Gutenberg-tm, -including how to make donations to the Project Gutenberg Literary -Archive Foundation, how to help produce our new eBooks, and how to -subscribe to our email newsletter to hear about new eBooks. - |