Part 4

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

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

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

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

THE AMERICAN PRACTITIONER AND NEWS.

“_NEC TENUI PENNÂ._”

══════════════════════════════════════════════════════════════════════ Vol. 25. FEBRUARY 1, 1898. No. 3. ══════════════════════════════════════════════════════════════════════

H. A. COTTELL, M. D., Editor.

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THE ART OF NEGLECTING WOUNDS.

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

Footnote 2:

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

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

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

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

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

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

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

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

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

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

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

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

Obituary.

DR. J. Q. A. STEWART.

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

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

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

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

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

Notes and Queries.

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

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

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

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