Part 3

Prof. H. Starck states that among 450 cases of Basedow’s disease observed in the last few years sixty-nine were operated on by prominent surgeons, nearly all of which had been seen by him before the operation. From his observations he concludes: 1. Operation effected a cure (_i. e._, complete physical and mental restoration) in approximately 30 per cent, improvement in 35 to 40 per cent, while in the other cases it proved ineffective or was followed by a change for the worse. 2. The operative mortality was 9 per cent (6 deaths in sixty-nine cases). Kocher had a mortality of only 3.1 per cent; according to others, however, it is 12 per cent. 3. If the surgeon accepts the view that a persistent thymus is responsible for a fatal outcome, although no positive evidence is at hand, he must determine whether this gland be present before resorting to resection of the struma; if it is, ligation of the vessels or resection of the thymus is to be considered. 4. The choice of the anesthetic is of great importance as to the outcome of the operation. The Basedow’s type with predominating nervous, myasthenic and psychic symptoms is best operated on under general anesthesia, the other cases under local anesthesia. 5. Operation is contraindicated in status lymphaticus; if it can not be avoided, a local anesthetic should be employed. 6. In many cases the operation only lays the foundation for successful internal treatment. 7. The most unfavorable time for operation is that of increasing intensity of the disease; the most favorable, the stage of latency, or arrest. 8. The most suitable cases for operation are those in which there is a “goiter heart;” also some cases with classical Basedow’s symptoms. Only slight success is to be expected in the presence of a nervous-myasthenic-psychic symptom complex with but moderate cardiovascular symptoms. 9. The size of the goiter as determined by palpation is no criterion as regards the question of operation. Small, soft goiters are often of greater significance than large, firm ones. 10. The blood picture also is of no importance in considering the operative treatment, since it is not materially influenced by operation.—_The International Journal of Surgery._

ACUTE APPENDICITIS.

John B. Deaver says the important points that have to be learned about this disease are that it is the most common intra-abdominal inflammation; that indigestion is often a forerunner, preparing the soil for the infection; that being an infectious disease and the most common infectious disease of the abdominal cavity, the appendix constitutes the avenue by way of which infection most commonly invades the upper abdomen. He considers acute appendicitis from the anatomical, etiological, bacteriological, and pathological standpoints: the points of the latter touched upon chiefly are in connection with peritonitis and abscess. The portions of the peritoneum most susceptible to infection are the diaphragmatic and enteronic. The differential points between a diffuse and a localized peritonitis are that in the former the pain is greater, the abdominal breathing more restricted and the rigidity and tenderness embrace a greater area of the overlying abdominal wall; upon auscultation the peristaltic waves are heard over a greater area and the abdominal breathing is less marked in the diffuse than in the localizing variety. In the early stages the tenderness and rigidity are best elicited by slight pressure. If the symptoms and signs, namely, pain, vomiting, fever, tenderness, and rigidity are interrupted, the diagnosis of acute appendicitis may be considered doubtful. Leucocytosis is of value as a confirmatory symptom when the patient reacts well to the infection. The most important point in the differential diagnosis is the distinction between acute cholecystitis and acute appendicitis. Acute pancreatitis, perforated ulcer, or perforated gall bladder, present symptoms so much more intense than those of acute appendicitis that they should not give rise to confusion. As to the treatment, the writer states most emphatically that in all cases of acute abdominal pain nothing in the shape of a purgative or aperient medicine should be given until the cause of the pain is understood. In his experience purgatives play the greatest amount of havoc in acute abdominal conditions; 90 per cent of cases of perforating peritonitis have been purged. In the presence of peritonitis and in the absence of operation the patient should be set up in bed, given nothing by mouth, not even cracked ice; he should be given enteroclysis by the Murphy method and have an icebag over the site of rigidity and tenderness; the icebag is useful to prevent the doctor from making too many examinations and for its local anesthetic affect. The idea that it has any effect in controlling inflammation is fallacious. In diffuse peritonitis, in the absence of peristalsis and of a definite point of localization, it is the writer’s practice to defer operation until the peritonitis becomes a localized or localizing one. The principles of anatomical and physiological rest, assisting the functions of the peritoneum, absorption and exudation, are defeated by any treatment other than the foregoing.—_Medical Record._

EFFECT OF PHLORIDZIN ON TUMORS.

In the experiments cited by Wood and McLean the animals were injected with phloridzin in suspension in olive oil. Treatment was begun, as a rule, seventeen days after inoculation. All treated animals were kept rigidly on a diet of meat and lard, while the control animals were given the regular laboratory diet of dry bread and vegetable. From time to time, at the end of the second or third day period following injections of the phloridzin, the collected urines were examined for sugar with Fehling’s solution and were found to give a positive reaction in the case of the treated animals on the carbohydrate-free diet, while the urine of the untreated animals as well as a phloridzin solution gave a negative reaction. The animals under treatment rapidly became emaciated, the fur roughened, and they appeared to be very ill; a great many died soon after beginning of the treatment. For the experiments with the Buffalo rat sarcoma, 324 animals were inoculated, with 90.4 per cent of “takes.” For the experiments with mouse sarcoma No. 396 mice were inoculated, with 97.7 per cent positive. Among the mice bearing spontaneous tumors and Crocker Fund mouse sarcoma No. 180, there were no cases of absorption of the tumor under treatment. The Buffalo rat sarcoma showed a much smaller percentage of absorption among the treated animals than among the controls, 37 per cent as compared with 58.4 per cent. In the majority of the experiments the growth among the treated animals was much more vigorous than that among the controls. Considering the very great variability of growth of the Buffalo rat sarcoma, as well as the high percentage of cases of spontaneous absorption occurring constantly, but with a great irregularity in different series of animals, the futility of using this tumor for therapeutic experiments or of basing conclusions on such investigations, is at once evident. Any “cures” obtained in work with the Buffalo rat sarcoma must be ascribed to spontaneous absorption rather than to the effect of the therapeutic agent.—_The Journal of the Amer. Med. Asso._

DIAGNOSIS OF EXTENT OF INJURY IN CASES OF ABDOMINAL WOUNDS.

Kausch has found that it is impossible to determine whether or not the intestines or other viscera have been injured, by the discovery of free air in the abdominal cavity. This is an almost certain sign of perforation, according to his experience, which has been wide and varied. The army corps to which he is consulting surgeon has served in turn in Belgium and France, Alsac, Galicia, Russian Poland and Serbia. A very small incision will reveal whether there is free air in the abdominal cavity. He makes the exploratory buttonhole for the purpose in the epigastrium under local or general anesthesia. The thicker the abdominal wall, the longer the incision, from 1 to 3 cm. The peritoneum need be only punctured; a pinhead hole is enough. If air streams out, he proceeds at once to a regular laparotomy. If not, the patient is spared a major operation for the time being at least. He has had cases in which a bullet passed through the abdomen, front and rear, without perforating the gastro-intestinal tract. When there was perforation, death was inevitable without operative relief, and he is convinced that his prompt operating saved a certain proportion of such cases. No one was ever harmed by the operation after an abdominal wound. Kausch was kept informed by telephone where fighting was under way, so that he was on the spot, ready to operate, before the wounded began to come in.—_The Journal of the Amer. Med. Asso._

MEDICAL

DIPHTHERIA CARRIERS.

A recent investigation of diphtheria carriers in Detroit is reported by Goldberger, Williams and Hachtel, in Bulletin No. 101, of the Hygienic Laboratories, of the United States Public Health Service. The problem of diphtheria carriers has become one of considerable importance and has been given special prominence of recent years by the studies of von Scholly, Moss, and Nuttall and Graham Smith. The writers of the report mentioned above studied 4,093 people in the city of Detroit, and found that 0.928 per cent harbored bacilli identical morphologically with the Klebs-Loeffler bacillus. This figure is rather lower than those of some other investigators, but would indicate, as stated by the writers, that there were from 5,000 to 6,000 diphtheria carriers in the city of Detroit.

Of nineteen cultures isolated from nineteen of the carriers, only two were virulent, which would indicate that only 0.097 per cent of the people examined carried organisms capable of producing disease. An interesting further point is that the bacillus Hoffmanii was present in at least 41.9 per cent of over 2,000 individuals examined, and that the forty-nine cultures morphologically identified as bacillus Hoffmanii were avirulent. This would confirm the impression gained, we believe, by most experienced laboratory workers, that a true Hoffmanii can be distinguished with considerable certainty from a Klebs-Loeffler bacillus by morphological examination alone, and that its significance is probably that of a frequently present saprophyte of the throat and pharynx. The studies of Goldberger, Williams and Hatchtel also indicate that in examining for diphtheria carriers, it is best not to confine oneself either to the nose or throat, but that cultures should be taken from both places in every case.—_The Journal of Laboratory and Clinical Medicine._

INJURIES FROM HOT WATER BOTTLE.

In an action against a sanatorium and its superintendent it appeared that the plaintiff had employed the superintendent to perform an operation for hernia. After the operation was performed the doctor carried the plaintiff to the room assigned to him and placed him in bed while still under the influence of an anesthetic. A rubber bottle, filled with very hot water, had been placed in the bed, and the unconscious man was laid upon it, and was burned on his back severely. The witnesses described the wound as being 15 to 18 inches in diameter. He also received a smaller burn on his side; the attendants, believing that his struggles on becoming conscious were due to delirium, having held him down on the bed for a time and then turned him on his side. He was under treatment from the burns for a number of months and suffered excruciating pain. The jury found the doctor, but not the sanatorium, guilty, and rendered a verdict for $5,000, which the trial court reduced to $2,500. On appeal, the court said that it did not mean to condemn the doctor, nor even to say that he was in fact negligent; but, taking the situation as it found it, and as the jury observed it, there was evidence to justify them in finding that the doctor had not exercised proper care; and, having so found, the court had no right to dispute the verdict. It also held that the damages awarded were not excessive.—Grosshart v. Shaffer, Oklahoma Supreme Court, 152 Pac. 441.—_Medical Record._

HEART INHIBITION DURING VOMITING.

Gam says that while experimenting on intrathoracic and intra-abdominal pressures, the blood pressure was observed to fall during vomiting. A series of experiments were performed to determine the cause of this fall. In all experiments the blood pressure, the intrathoracic pressure and the movements of the abdominal wall were recorded. Vomiting was induced in some cases by means of apomorphin; in others by filling the stomach with hot salt solution, hot soap suds, copper sulphate solution, etc. In every case a high negative pressure was observed in the thorax during the act. The pressure would fluctuate rapidly from zero to twenty-five or thirty centimeters (water) of negative pressure. The blood pressure, however, always fell, sometimes to less than half its former level. The fall in blood pressure was found to be due to a vagus inhibition of the heart, for on cutting the vagi while the vomiting was taking place, and while the blood pressure was at its lowest, there was an immediate increase in heart rate and rise to above the normal in blood pressure. Furthermore, when the vomiting was induced after the vagi had been cut, there was a rise instead of a fall in blood pressure.—_The Journal of the Amer. Med. Asso._

HOME TREATMENT OF SCIATICA.

Pœppelmann suggests the following method for the home treatment of sciatica. A pail of boiling water is placed in a tub large enough to permit an old chair to be set in it. A tablespoonful of ol. pini sylvestris is poured into the boiling water, the patient seated on the chair with his feet outside the tub, and two sheets pinned around his neck, so that they reach the floor on all sides, covering him completely but leaving the head free. In this steam bath the patient is allowed to remain for twenty minutes. He is then rubbed briskly with a cold wet cloth, dried and put to bed for an hour. If necessary, especially with elderly people, cold applications may be made to the head during the process of steaming. Internally, iodides are given, preferably iodine-vasogen, 7–8 drops three times daily. The bowels must be kept freely open. The baths are given every other day, and five to fifteen sittings are required for a cure. In the author’s hands a successful outcome has been practically uniform.—_Critic and Guide._

USE OF CAFFEINE IN DIGITALIS ARRHYTHMIAS.

In the _American Journal of the Medical Sciences_ for September, 1915, Barton asserts that all the irregularities of the heart-beat which are brought about by digitalis tend to be removed by caffeine. Although in many cases digitalis arrhythmia will spontaneously disappear when the drug is stopped, instances arise, unfortunately too common, in which after prolonged digitalis administration the conductive system is so depressed that serious results may arise. Under these circumstances the administration of caffeine will be of service and is therefore strongly indicated. The action appears to be due to the increase in irritability of the conduction system produced by the caffeine, which antagonizes and finally overcomes the depressing effects which digitalis exerts upon the auriculo-ventricular bundle.—_The Therapeutic Gazette._

THE EFFECT OF CAFFEINE UPON THE BLOOD-FLOW IN NORMAL HUMAN SUBJECTS.

The _Journal of Pharmacology and Experimental Therapeutics_, for November, 1915, contains a report of a research by Means and Newburgh in which they report experiments upon the blood-flow of two normal subjects during rest, and of one subject during muscular work.

The action of caffeine on the blood-flow was studied in both subjects while at rest, and in one during work.

The average blood-flow of the two subjects at rest was 4.5 and 4.0 liters per minute; the systolic outputs were 61 and 57 cc.; the coefficients of utilization of the oxygen-carrying capacity of the blood were 31 per cent and 41 per cent.

With increasing work a steady rise in blood-flow, oxygen absorption, and pulmonary ventilation was found. The increase in blood-flow was produced first by an increase in systolic output until a maximum of 118 cc. was reached, beyond that by an increase in pulse-rate. This suggested that the supply of venous blood in this subject becomes “adequate” at about 640 kg. meters of work per minute. The coefficient of utilization showed a slight rise during work, indicating a slightly greater economy of the circulation.

After giving caffeine during rest, or when the supply of venous blood is “inadequate,” evidence of drug action was found with both subjects. This action consisted in an increase in total blood-flow without a corresponding increase in oxygen absorption, and hence a decreased coefficient of utilization of the oxygen-carrying capacity of the blood. The pulse-rate was unchanged. Consequently the systolic output was increased.

During work probably no other action was obtained from caffeine than possibly an increase in pulse-rate, and consequently slight diminution in systolic output.

It is suggested that during rest when the supply of blood to the right heart is “inadequate”, caffeine increases the blood-flow by increasing the venous supply through an action upon some mechanism outside the heart. When the supply becomes “adequate” or approaches adequacy, no such action is obtained.—_The Therapeutic Gazette._

OBSTETRICAL

DIURESIS AND MILK FLOW.

There are observations on record which indicate that the secretion of milk may be influenced by a contemporaneous diuresis. Precisely what changes in the composition of the milk may be initiated in this way had not been determined until recently, when the question of the influence of specific diuretics on milk flow was investigated by Steenbock at the University of Wisconsin. He remarks that in view of the importance which heretofore unknown constituents of diets and rations have lately assumed, it is of the greatest interest to dissect the various factors normally operative in the body under ordinary conditions of diet. Steenbock found that urea, for example, administered in a diuretic dose, is able to decrease temporarily the flow of milk. On repeated administration, however, the increased intake of water which follows the impoverishment of the tissues with respect to water content balances the draft for water imposed by the diuretic, and the milk secretion comes back to normal. Other diuretic salts, like sodium chloride, may be entirely unable to depress the milk secretion under normal circumstances, because they call forth a compensating thirst which simultaneously increases the water intake. In cases in which diuresis does lead to temporarily decreased flow of milk, the percentage of solids in the secretion is ordinarily increased, the fat being the principal variable. In ordinary experience, however, the composition of the milk may be regarded as essentially unaltered by slight variations in renal activity.—_The Journal of the American Med. Asso._

INDICATIONS AND CONTRAINDICATIONS FOR ABDOMINAL SECTION.

Dr. Ross McPherson (_Provid. Med. Jour._) summarizes his views in the following conclusions: First. Cesarean section is a very useful operation for removing the child from a pregnant woman at or near term in cases: (a) where there is a relative disproportion between the birth canal and the fetus, sufficiently large to make the birth difficult or impossible; (b) in cases of serious obstruction due to tumors, or deformities congential or acquired; (c) a certain number of cases of placenta previa, convulsive toxemia, or occasionally organic disease. Second. The operation should not be decided upon except by a person whose training and experience in pelvic and abdominal examination is sufficiently large to warrant the acceptance of his judgment. Third. The operation should not be performed by anyone unless he be a skillful abdominal surgeon, preferably one who has given particular thought and attention to this subject. Fourth. A long labor, much handling and manipulation, especially in the presence of ruptured membranes, predispose the patient to infection of the peritoneal cavity, and fifth, therefore, intraperitoneal abdominal Cesarean section should not be undertaken under those conditions, with one exception, namely when the religious prejudices of the family demand the saving of the child at the expense of the mother, and then only in the presence of and with the advice of a consultant and a clergyman, after carefully explaining the situation to the family and obtaining their written consent to the procedure. Sixth. If the above demands and conditions are fulfilled the maternal mortality should be practically nothing, the morbidity negligible, the end result perfect, and with the exception of those cases undertaken solely in the interest of the mother, every child should be born alive.—_Medical Progress._

TREATMENT OF OPHTHALMIA NEONATORUM.

G. A. Neuffer, in the _Journal of the South Carolina Medical Association_ for February, 1915, states that he has met with universal success in this condition by means of the following treatment: A sixty-grain (4 gram) to the ounce (30 c.c.) solution of silver nitrate is at once applied to the conjunctiva and immediately precipitated with a solution of sodium chloride made by dissolving one teaspoonful of the salt in a glassful of water. This application is repeated once every twenty-four hours, until one is satisfied that the disease has been controlled. Only in extreme cases are more than two applications necessary, and often one proves sufficient. In addition, an ounce (30 grams) of boric acid is ordered dissolved in a quart (litre) of hot water and the solution kept constantly warm. With this the nurse or mother is instructed to wash out the eyes as often as any pus collects, even if this is required a hundred times a day. One drop of a one per cent solution of an organic silver preparation is dropped into each eye three times a day as long as there is any pus; after this an astringent lotion is substituted. The author also has squares of lint kept on a block of ice and applied constantly, with frequent renewals, for forty minutes in each hour. The treatment described should be applied both day and night until the condition has been mastered.—_New York Medical Journal._

Editorial

PUBLISHER’S NOTICE—The Journal is published in monthly numbers of 48 pages at $1.00 a year, to be always paid in advance.

All bills for advertisements to be paid quarterly, after the first insertion of the quarter.

Business communications, remittances by mail, either by money order, draft, or registered letter, should be addressed to the Business manager, C. S. Briggs, M. D. corner Summer and Union Streets, Nashville, Tenn.

All communications for the Journal, books for review, exchanges, etc., should be addressed to the Editor.

SLOW DISSEMINATION OF KNOWLEDGE.

Charles Darwin, in his “Descent of Man,” published in 1871, writes thus of the appendix: “It is occasionally quite absent, or again is largely developed. The passage is sometimes completely closed for half or two-thirds of its length, with the terminal part consisting of a flattened solid expansion. In the orang this appendage is long and convoluted: in man it arises from the end of the short cecum, and is commonly from four to five inches in length, being only about the third of an inch in diameter. Not only is it useless, but it is sometimes the cause of death, of which fact I have lately heard two instances: this is due to small, hard bodies, such as seeds, entering the passage, and causing inflammation.”