where the patient's history was simply occasional attacks of "stomach trouble" until a short time before presenting herself at the hospital when she became jaundiced. Dr. W. E. Fischel said that there was a good deal to be said on this subject. The symptoms which Dr. Richardson spoke of as indicating the presence of gall stones in the bladder or ducts can often be accounted for by a disturbance of the alimentary tract. The doctor said that he had not yet learned to distinguish between the pains of a frequently recurring gastric indigestion from the pain of a stone in the gall-bladder. The fact that so frequenlty there is found recurrence of jaundice does not indicate that there is danger of the presence of stone in the gall-bladder. Who has not seen an oftrepeated attack of jaundice as a result of imperfect digestion? It might be argued that if we were not less bold, these cases might be sent to the surgeon and a stone would be found. The speaker said that it might sound like an expression of ignorance on his part, but as a matter of fact he was frequently in a dilemma when dealing with symptoms in the upper right quadrant of the abdomen. He emphasized the fact that it would be a dangerous practice indeed for the internist, after he has exhausted every means in his power to diagnosticate a condition in the upper right quarter of the abdomen to send, all such patients to the surgeon for operation. He said that it always depended upon "whose ox was gored." Dr. H. Tuholske said that it was indeed disease, especially the pain which the patient feels after the acute attack of colic over. There is a pecuilar feeling of discomfort two or three inches below the scapula, a feeling quite uncanny." The surgeon is handicapped by not seeing the patient during the acute attack. After the diagnosis is made, the surgeon should not hesitate to operate. The fact that many patients get over their attacks after going to Carlsbad does not mean that they have been cured of this disease. There has simply been a cessation of the catarrhal condition in the gall bladder. Some drinking the Carlsbad water that they are such patients are really helped so much by cured, passing their gall stone. The speaker said that he has made it a habit of examining the gall-bladder in all cases where he opens the abdomen. He remembered one case which he thought must have been cured by the Carlsbad treatment, because he said after opening her abdomen later for the extirpation of fibroids of the uterus, he passed his hand up to the gall bladder and found no stones. In this connection he mentioned the old saying, that "there have been enough stones passed in Carlsbad to pave its streets. Dr. W. G. Moore said that he did not know why he had been called upon to discuss this subject except to tell Dr. Tuholske how to cure gall stones without cutting them out. (Laughter.) If his patient was able to go to Carlsbad, he would send him there. He did not think that there was any remedy to cure gall stone except an operative procedure. He said he liked Dr. Carson's suggestion that the surgeon relies too much upon the medical man to make his diagnosis because the medsurgeon with which the surgeon agrees before ical man usually makes a diagnosis for the the operation and disagrees after the operation. Appendicitis and gall stone are especially pregnant fields for this state of affair. The cases of appendicitis which I have had danger from an operation," yet where the faoperated were all "particularly free from tality occurred, it was due to "technique." He said "technique" was a peculiar term which is quite convenient for the surgeon. true that most cases that are sent to the surgeon by the internist have the diagnosis already made, but that he questioned whether it was right to yield the palm of diagnostic skill to the internal man. He said that a great many people have gall stone disease without characteristic symptoms. This must be so, because it is a fact that a great major. ity of the people have gall stones, women more than men. The difficulty is in making a diagnosis of some change in the biliary passages requiring operative interference. The diagnosis of cholecystitis is just as imperative as if gall stone was added to it. The surgeon makes the mistake of thinking that Dr. Richardson, in closing the discussion, if when a case is referred to him he does not said that the medical profession, like conmake a diagnosis immediately, the case is liagress, need He an "opposition" party. ble to slip away from his hands to another pointed out his extreme conservatism in the surgeon. The speaker argued that the past in dealing both with appendicitis and surgeon should have plenty of time to have plenty of time to gall stone cases. He said he was the last one make his diagnosis, keeping the case under to say that there was no danger in opening his observation for weeks, if necessary. If the abdomen. He pointed out the fact that this could be done, the surgeon would make if the abdomen of perhaps every man in his a correct diagnosis in most instances. The audience opened, there would surely be but pain has certain characteristics in gall stone little mortality, but perhaps the same pro cedure on an equal number of others would have more mortality. There should always be a reasonable conservatism but no progress can be made unless the profession proceeds correctly. He said that it took him many years to concede the claims of the men such as they are held today regarding the operation for appendicitis, and when it should be performed. He said that the time is coming when the gall stone is to be taken out whether it offends or not. THE VAGINAL METHOD IN GYNECOLOGY. He Prof. Dr. Duehressen, of Berlin, gave a description of his method of performing gynecological operations through the vagina by his anterior incision method. He demonstrated the method by the aid of a number of excellent cuts made for him by one of his pupils, Zelle. He said that he had actually demonstrated it to a number of St. Louis physicians at the City Hospital on the morning of this day. He said that by separation of the bladder from its ligaments, it was possible to cure every case of cystocele by this method. He mentioned the use of this method in removing ovaries in case of policystic degeneration ovariae with excessive hemorrhage from the uterus which stops after the operation is performed. It is possible to perform all the operations upon the uterus and its appendages by this method. The uterus is easily pulled down. Pyosalpinx can be operated by this method. He has seen normal pregnancy following this method of operating for removal of an ovary. said the main objection raised against his method was that one cannot see the operative field, but he maintained that one can see everything, if the proper instruments are used. The mortality with this method. is strikingly low compared to that with the abdominal route. In 1600 cases he personally had a mortality less than 2%, and even this mortality was due to the fact these fatal cases were bad cases of extrauterine pregnancy, or cases of large fibroids of the uterus. He thought that the use of the method for operating upon large fibroids was attended with the worst results because of the large area exposed in the operation, especially when there is a following pregnancy; some months ago there was a sudden death of a woman in the eighth month of pregnancy where there had been a previous operation for uterine fibroids by the abdominal route, this death being due to rupture of the uterus at the site of the operation for the fibroids. After these operations by the vaginal there is not as much pain as there is after the abdominal method. Patients are walking four weeks after the operation. He mentioned the prejudice against this operation on the part of American surgeons who claim they cannot see what they are doing. Yet he called attention to the fact that the first vaginal hysterectomy was performed by an American, Thomas. He said that operating posteriorly through the cul-de-sac was bad surgery because asepsis is not so good and because forcible traction must be made with consequent danger of tearing the pedicle. In the anterior operation, there is no such traction. The uterus can be pulled out with the finger. The appendages are easily within reach through the anterior operation. DISCUSSION. He Dr. Geo. Gellhorn said that the operations performed at the City Hospital by Prof. Duehrssen demonstrated the fact that the most extensive operations can be performed through the vagina as well as by the abdominal route. We wished to make a few remarks upon the technique of the operations. said it was an established fact that there is less shock as a rule in operating by the vaginal route than by the abdominal. It is also an established fact that vaginal operations are followed by less danger of infection than are those performed by the abdominal route. Dr. Richardson had said in a previous paper that there is always an element of danger in opening the abdomen. Dr. Gellhorn said that he thought this danger was minimized if the approach to the pelvic organs is made, through the vagina. The objections that have been raised against vaginal operations in general are first insufficient view of the pelvic organs. Prof. Duehrssen has demonstrated that every step of the operation can be seen and that it is the result of either faulty technique or insufficient vaginal instruments that the operator does not see enough in doing vaginal operations. The instrument of the ordinary operator usually uses in vaginal work are those designed for abdominal surgery; the objection to these instruments is that they are not long enough to permit the operator to gain easy access. Another more important objection is that in vaginal operations one is not able to operate upon the appendix or upon the gall-bladder. Dr. Richardson has already dwelt upon the importance of making the diagnosis before operation. If this is done, there will be found many cases in which it will be found that there is no disease of the appendix or gall-bladder. If this is true, then the vaginal route can be used. If there are symptoms of appendicitis or gall stone, then the abdominal route can be used. Dr. Duehrssen, in closing, stated that one is able to operate upon the appendix through the vagina without any trouble. MEDICAL MISCELLANY A DISTINCTION of no mean degree has been conferred upon an American book, the joint authorship of Drs. J. Madison Taylor and William H. Wells. The revised second edition of their treatise on "Diseases of Children," published by P. Blakiston's Son & Co., of Philadelphia, has been translated into Italian by Dr. Mario Flamimi, of the Pediatric Clinic of Rome, with contributions by Prof. Concetti and Dr. Valagussa. The translation has proven very popular abroad, and the occasion is one of felicitation, not only to the authors but to Amercan medicine generally, inasmuch as the work was chosen as being especially adapted to clinical teaching in Italy. Few American books have attained such honor. Its success abroad is but a repetition of the favor which it enjoys here. SAFE LOCAL ANESTHETIC.-Every physician who has employed cocaine as a local anesthetic for any length of time has encountered occasional cases of collapse following its use. Some of these may be due to subjective influences but not all. Some time ago we advised the addition to the cocaine solution of brucine, or 2 per cent, adding if necessary a drop of hydrochloric acid to insure solution. We have now had reports from a sufficient number of cases to satisfy us as to the value of the addition. Brucine gives the support and stimulation of strychnine and is at the same time itself a local anesthetic of no small value. The effect of the cocaine is increased and prolonged by the brucine. Up to the present every reported case bas been successful. The importance of this suggestion does not need demonstration. THE July issue of The Century is announced as a fiction number, with the second instalment of Anne Warner's very funny "Seeing France with Uncle John," and short stories by Alice Hegan Rice, Anthony Hope, Harry Stillwell Edwards, Lawrence Mott, Annie C. Muirhead and other popular writers. Mrs. Rice's story is called "The Wild Oats of a Spinster," and is said to be quite as good as its title. Harry Stillwell Edwards's "The Funeral of Rat Brooks" is in the vein of the inimitable "Two Runaways, " and Lawrence Mctt's "Wilkinson's Chance" will carry the reader back to his "Jules of the Great Heart." "Overproof," the humorous account of an astonishing incident, will introduce a new and promising writer, W. Albert Hickman. Anthony Hope's story, "What Was Expected of Miss Constantine" is a tale of the unexpected. "Love Laughs at Lions" is said to be one of Miss Kenton's best stories. The list of titles and writers promises an unusually rich and varied number. A CASE OF GENERAL FATAL INFECTION WITH GONOCOCCUS AND STAPYLOCOCCUS.Messrs. Courtos-Suffit and Beaufume report the history of a patient, who after a simple interference with his urethra and many catheterizations, presented a grave infectious condition with multiple suppurations which had a fatal termination. Staphylococci were found in all the abscesses and in the blood. Most of the gonococci were found with all their classic characters in the abscesses at the level of the brachial triceps and the sural triceps (gastrocnemius and soleus) of the right side, on the posterior face of the sternum, in the left thigh, also at the level of the left testicles and epididymus. This is a very rare and exceptional case of a general gonococcic infection to end fatally. It will be noticed, that the gonococci had a predilection for the muscles, and that the patient presented two intramuscular abscesses, like in the cases of O. Bujwid, and that of Johns Hopkins.— Gazette des Hopitaux, No. 45, 95, p. 537— From Am. Jour. of Clinical Medicine. It is with reluctance that I call attention to what might be an injustice to a great work and one much needed in St. Louis. The following correspondence has reference to statements published in the reports of the City Hospital Alumni Society in a recent number of the FORTNIGHTLY. May 27th, 1906. DR. HORACE W. SOPER, St. Louis. Dear Doctor:-In the MEDICAL FORTNIGHTLY of May 25th, you are reported as saying, "At Mount St. Rose the patients sent there in the incipient stage become so depressed by seeing patients in the later stages that they soon left the hospital in many instances." Kindly let me know if you are reported correctly? Very truly yours, WM. PORTER. To this Dr. Soper promptly replied: May 29th, 1906. WILLIAM PORTER, M. D., St. Louis. Dear Doctor.-Yours of the 27th inst. duly received. The quotation that you refer to is not correct. I wished to emphasize the desirability of having sanatoria for incipient cases only, and said, "that in several instances patients who had been in Mount St. Rose stated to me that they had been depressed by the sight of patients in the late stages of the disease." I regret that I did not notice the manner in which I was reported, as I certainly meant no reflection on Mount St. Rose, as I have the highest regard for the institution and its management. Very truly yours, HORACE W. SOPER. Dr. Soper's honorable reply leaves little. room for criticism, but it gives the opportunity for some statements of facts suggested by a further reading of the discussion: Ist. While all stages of tuberculosis are admitted at Mt. St. Rose, care is taken to keep the incipient cases separated from the others. They are forbidden to enter the rooms of the advanced cases, and are given the "out-door treatment," which cannot well be applied to the others. When the new wings are added, separation will be still more definite. 2d. All cases have their meals in their rooms, have individual drinking cups, covered cups for sputum, and are protected as far as possible. Each room is disinfected as soon as vacant, and the floors repeatedly varnished during the year. Those of us who are acquainted with the care taken to prevent in fection have no fear. Every week there are applications from non-tubercular cases who, knowing the conditions and the attractiveness of the surroundings, want to come fcr rest and recuperation. 3d. In less than four years 875 cases of tuberculosis have been admitted, and so far as known to the management, there has been complaint in only a few exceptional instances. One of the cases to which I am sure Dr. Soper refers was a case of bone tuberculosis and was unhappy from the beginning. The records show that a large percentage of our discharged cases if there is evidence of new infcetion, make application for readmission. 4th. Only those physicians who have personally visited Mt. St. Rose can fairly estiSisters of St. Mary. mate the magnitude of the work done by the The beauty of the exbuilding and the care taken with the very tensive grounds, the adaptation of the large reasonable rates, suffice to keep the Sanatorium full, with a large waiting list. Dr. S. A. Knopf, the well known sanatorium expert, spent a day at Mt. St. Rose, and said, that for the purposes intended he could suggest no improvement. 5th. As to the individual care, it is the best that the resources of the institution can afford. The public has been very generous in its support, but the actual expense for each patient for the necessities of living even with the strictest economy has been 99 cents per diem. This means about $50 each day not including interest on building, repairs, improvements, attendance, etc. 6th. I can earnestly appeal for the honest support of the profession for Mt. St. Rose, as there is not a dollar accruing to any one connected with the management, the very ample return being the experience and the satisfaction of helping the tubercular and protecting their families. Whatever is paid by those who are able is more than offset by the equally worthy who are unable to pay. The very requirements mentioned by the gentlemen who took part in the discussion are emphasized, viz., psychical aids, sanitary care, fresh air, best of food as far as possible, and control of individual symptoms as far as they can be met. Those in charge find it "pretty heavy going" at times, but the work progresses just the same, and each year it becomes more attractive. WM. PORTER. IN light narcosis the pupils may dilate reflexly from operative manipulations. This, of course, is not to be confused with the sudden extreme dilatation that occurs when the narcosis has been carried too far. THE MEDICAL FORTNIGHTLY A'Cosmopolitan Biweekly for the General Practitioner The Medical Fortnightly is devoted to the progress of the Practice and Science of Medicine and Surgery. Its aim is to present topics of interest and importance to physicians, and to this end, in addition to a well-selected corps of Department Editors, it has secured correspondents in the leading medical centers of Europe and America. Contributions of a scientific nature, and original in character, solicited. News of Societies, and of interesting medical topics, cordially invited. Advertising forms close on the first and fifteenth of each month. Time should be allowed to submit proof for correction Advertising rates on application. Remittances and business communications should be addressed to the Fortnightly Press Co. Subscription, $2.00 a year, in advance, including postage to any part of the United States, Mexico and Canada. Postage to foreign countries in the Universal Postal Union, including Newfoundland, $1.00 a year additional. Entered at the St. Joseph post-office as second-class matter. The Medical Fortnightly will not be discontinued at expiration of subscription, as many of our readers prefer not to have their files broken on account of failure to remit. Unless we receive a distinct request to discontinue, and payment for all arrearages, this magazine will not be discontinued. Subscriptions may begin at any time; volumes end with June and December. Contributors should understand that corrected typewritten copy is essential to clean proof and prompt publication, and is much more satisfactory than manuscript. Original articles should be as condensed as justice to the subject will allow. Editorial offices in St. Louis, Jacksonville, and St. Joseph, where specimen copies may be obtained, and subscriptions will be received. Contributions and books for review should be addressed to the editors, 319 and 320 Century Building, St. Louis, Mo. M. Sig. One-half teaspoonful every three hours. The relief of the immediate symptoms is best assured by local treatment. The fol. lowing is a favorite prescription: R Menthol... Campho.. Petralati liquid............ : aa gr. j M. Sig. One drop in each nostril several times a day. The menthol and camphor increase the roominess of the meatus and usually afford prompt relief. The oil may be introduced by a small cotton tampon or preferably a bit of cotton on an applicator. BRONCHITIS. Dr. Burnett, of Cecil, Ark., advises the following course of treatment in bronchitis when the cough is harsh, dry, and unable to expectorate: B Fluid extract of amphiachyris.. 3ij 3iss 3iij or two Sig. Dose, one dram every one hours until expectoration is free, and then give: R Fluid extract of prunus virg.... Simple elixir, q. s.. Sig. Teaspoonful when needed. 3ss 3iij 3iij If there is irritable laryngitis with an expulsive sensation in the larynx, the following can be given: R Fluid extract of sanguinaria... 3ss Fluid extract of collinsonia..aa 3ij Simple elixir, q. s.... : 3iv 3iij Sig. Dose, one dram every two hours.Medical World. |