481 type of fever are characteristic. The patient for a day or two is not wellhe has loss of appetite; his trouble is often preceded by a slight diarrhea, or he may be constipated; complains of a slight headache; nearly every case complains of a dull or heavy backache; the urine is scanty and high colored; you obtain history of slight repeated chilly sensations--at times a distinct chill. These symptoms send him to your office; you find his countenance has a pinched, dusky, sallow hue; his tongue is covered with an evenly distributed, dingy, yellowish white coat, often complains of nausea on taking water-the nausea is often especially marked after beginning the use of quinine that you prescribe; you find his pulse small, hard, rapid, 108 and 120. Temperature 100.5 to 103.5. Now the proper treatment is a bath, rest in bed, no food, a mercurial purge and large doses of quinine. Under such treatment your patient will be about in from three to ten days. On your next visit if in the A.M., you will find the patient improved, temperature possibly normal or 99 to 99.5, but about noon it begins to rise, runs up until about 5 P.M., or up to 11 P.M., when it subsides, and usually in the early morning hours the patient will be free from fever. The case unattended or improperly treated very much resembles typhoid fever in some respects, but can be differentiated by the more sudden advent of indisposition and fever, by absence of any distinct iliac tenderness, history of distinct chills or chilly sensations, persistent nausea-in many cases in fever, by the yellowish white, evenly distributed coat on the tongue, by the absence of rose-colored spots, the early appearance of nose bleed, by the absence of the characteristic ochre colored stools, and finally and most of all by the specific influence of quinine. I select from my note book four cases: Oct. 21st, 1890, I was called at 10 P.M., to see C. F., male, age 9 years. He had been complaining for a week or more, with head-ache, nose bleed, limbs and back-ache, chilly sensations, tongue coated yellowish white, some nausea, abdomen slightly tympanitic, no tenderness in iliac region, pulse 120, temperature 103. Órdered mercurial purge and two grains of quinine every three hours. Oct. 22nd, 10 A.M., rested fairly well during the night, pulse 90, temperature 100. Continued the quinine, to have all the milk he would take; saw him again at 8 P.M., pulse and temperature same as the evening before. This case ran on until the tenth day with very little change, when the temperature at 8 P.M. was 991⁄2, pulse 85. On the morning of the eleventh day pulse 80, temperature normal. Case II. This case occurred in the same family. Female, age 12 years, complains of head-ache, back-ache, chilly sensations, loss of appetite, bowels constipated, tongue coated yellowish white, pulse 90, temperature 100. Gave a mercurial purge, ordered four grains of quinine every three hours. The next day, Nov. 2nd, felt some better, nose bled during the night, some tympanitis, pulse 94, temperature 100.5. Continued quinine. Nov. 3rd, feeling much better, temperature normal. Ordered three grains quinine every four hours. Nov. 4th, ate some breakfast, temperature normal, to continue quinine during the day and then stop it. Case III also occurred in the same family a few days later, John, aged 24 years, complained of head-ache, nausea, nose bleed, loss of appe 482 tite, bowels constipated, tongue heavily coated, pulse 96, temperature 102. Ordered a mercurial purge and five grains of quinine every three hours. The next day feeling some better, nose bled during the night, pulse 90, temperature 100.5; continued the quinine. On the third day, temperature normal, had some appetite, tongue clean and moist; quinine continued. On the fourth day he called at my office, and was directed to take three grains of quinine four times a day for three days. This was the last I saw of him. Case IV. T. P., male, aged 38; was called to see him Sept. 29th; had been under the treatment of a physician since Aug. 25th; during this time was up and down, some days better, then not so well, complained of head-ache, nausea, nose bleed, a great amount of lassitude, bowels open, a disgust for food of all kinds, abdomen slightly tympanitic, no tenderness in iliac region, pulse 100, temperature 102.5, tongue evenly coated. Ordered three quinine grains every three hours, and five minims aromatic sulphuric acid every three hours. Sept. 30th, 8 A.M., pulse 96, temperature 101. Same treatment continued; small glass of milk ordered every two hours. 8 P.M., pulse 100, temperature 102.5. Oct. 1st, 8 A.M., condition about the same. Same treatment continued up to Oct. 8th, when tympanitis began to increase, nose bled some almost every day. Oct. 9th, 8 A.M., pulse 110, temperature 102. Continued quinine, ordered turpentine plaster over abdomen. 8 P.M., pulse 115, temperature 103. Oct. 1oth, 8 A.M., pulse IIO, temperature 102. 8 P.M, pulse 105, temperature 103.5. Oct. 11th, about the same as day before. Oct. 12th, 8 A.M., tympanitis increasing, nose bled during the night, and slight hemorrhage from bowels, was somewhat delirious during the night, pulse 115, temperature 102.5. 8 P.M., nose bled during the day two or three times, blood in passage from bowels. Gave opium and plumbi acetate every four hours. Oct. 13th, patient was very restless during the night, took but little nourishment, pulse 120, temperature 103. 4 P.M., some hemorrhage from the bowels, patient restless and flighty, pulse rapid, temperature 103.5. Patient died at 10 P.M. from exhaustion. I select these cases for the reason that cases II and III were seen early, and with large doses of quinine were aborted. Case I had been ill one week before I saw it, with no treatment, yet in eleven days was convalescent. Case No. IV had been under treatment for thirty-four days when I first saw it, had never had to exceed sixteen grains of quinine daily. It was a true continued malarial fever of an adynamic type. There is no question in my mind if this patient had been given 40 grains of quinine daily, early in the attack, he would have recovered. Gentlemen, there is no such thing as mountain fever. The so-called mountain fever is either an intermittent, remittent, or typhoid fever. It is differentiated from typhoid by the character of the tongue which is coated with a dingy yellowish white, evenly distributed coat, the suddenness of the attack, nausea early in the fever, pulse small, hard and rapid, dull, heavy back-ache, repeated chilly sensations, the early appearance of nose bleed, and last and most of all by the specific influence of quinine. With these cases it will not do to temporize. At least 40 grains of quinine must be given daily. 483 Some Thoughts on Appendicitis as a Purely BY DONALD MACRAE, M. D., COUNCIL BLuffs, Ia. READ BEFORE THE MEETING OF THE MISSOURI VALLEY MEDICAL SOCIETY, HOT SPRINGS. 8. D., SEPT. 21, 1895. THE evolution from "peritonitis" and "inflammation of the bowels" to typhitis and perityphitis, and then to the original and earlier origin of the affection, disease of the appendix, is familiar to you all. Until two years ago I was a firm and fixed opponent of operation for appendicitis, unless definite symptoms were present to require such a grave proceeding. I publicly and emphatically, both before this society and elsewhere, gave my preference for the temporizing methods recommended in our medical text-books, declaring that of a certain number of cases, a large percentage would recover without operation. Painful experience since then has given me a complete change of heart. So many cases have come under my notice where I have resorted to surgery as a forlorn hope, where I have seen so many useful and promising lives lost through this same dilatory proceeding; and only operated on when they and their friends had made up their minds that the end was near; so that now from being an extremist in one direction, possibly I may be an extremist in the other. The history of appendicitis in Western Iowa among healthy adults is short and quite apt to be fulminant in character. It seems to me that more of our cases are acute and their progress and termination more rapid than in the regions farther East. At least my experience with the one and my reading and study of described cases in the other would lead me to that conclusion. The quite common condition is that on the third, and sometimes even on the second day of the affection, not only is pus and necrosis of the appendix present, but there are also gangrenous spots on the caecum and on separating the intestines numerous foci of pus, with the peritoneum generally hyperemic, eroded and desquamating. These cases are practically beyond hope, but the condition generally cannot be foretold until an exploratory incision reveals the true state of matters. Acute cases, such as I have outlined, are described by specialists, but I am firm in the belief, and every day experience renders me still more emphatic in that belief, that our proportion of fulminating cases of appendicitis is much greater than the statistics of specialists in the large cities would lead us to expect. Nothing can be more disheartening to the conscientious surgeon than to find that a few hours ago a case might have been saved which now is lost, a life allowed to run along the edge of the precipice and not intercepted before the tragic fall. Those of us who have learned this disastrous lesson in the bitter school of experience cannot understand the frivolous statements of otherwise distinguished surgeons who counsel waiting until the acute symptoms have subsided. They speak of the proceeding as a "fad" and 484 characterize the earnest surgeon, whose aim is to save life when he is sure of doing so, as a "visionary enthusiast." It is true that from sixty to seventy-five per cent of cases of appendicitis will recover, to a certain extent, if left to nature, but what of the thirty per cent who must otherwise die? Are their chances for life to be imperilled because the edict has gone forth that some definite symptom must be present before operation is insisted on? Must they die because some cases get well without operation? The idea seems to me to be preposterous. Rather, I say, operate on all of them, early, obviate the tendency to death as we do in other ailments, remove the appendix and thereby prevent secondary complications in the one and death in the other. In the aged our cases of appendicitis are slower in progress, a limiting wall has time to form and a circumscribed abscess is generally the result. In these cases possibly a few days of delay may not be so disastrous, but I see no reason why they should not also be operated on at once. Their danger is rupture of the abscess and extravasation of its contents. I would, therefore, earnestly and with due regard for the lives that depend on us, insist that the profession generally and the public as well, be educated and seriously impressed with the necessity of immediate operation and the tremendous danger of delay in all cases of appendicitis. The Woman's Medical Journal. All women and all students of the progress and history of medicine will be interested in the August issue of The Woman's Medical Journal. There is begun in this number a series of illustrated biographical sketches of the leading women of the medical profession. Those included in the August issue are Dr. Marie Zakrzewska, of Boston, who was one of the earliest graduates. Dr. Eliza Burnside, of Philadelphia, another pioneer woman, and Dr. Mary Spink, of Indianapolis, an admirable representative of the younger women of the profession. The series will include portraits and notes of all the women now prominent. This being the first attempt in making a history of the individuals who have made up the women in medicine, it will be of great value to all and will, no doubt, meet with a generous reception. There are also timely articles on various topics by able contributors, all of whom are women, besides valuable information and pertinent suggestions for all. This being the only woman's medical journal in the world, its utterances are of value. It is published in Toledo, Ohio. While New York is trying to get its saloons open, Paris is trying to get some of hers shut. New York has about 9,000 saloons. Paris had, in 1890, 29,583 wine shops. Eminent physicians, such as Laquean and Lancereaux, consider that the abuse of alcohol is increasing the amount of phthisis in Paris. In 1893 there were 10,680 deaths from this disease, about two-thirds being in men. In New York the total number of deaths from this disease were, in 1893, only 2,128. It is evident that phthisis, like the wine shops, is two or three times more prevalent in Paris. 485 Blepharitis. BY H. S. McGARVEN, M. D., OMAHA, NEB. READ BEFORE THE MEETING OF THE MISSOURI VALLEY MEDICAL SOCIETY, COUNCIL BLUFFS, IA., SEPT. 19, 1895. CHOOSE this subject, not because I have anything new to suggest in regard to it, but from the fact that it is so simple, and common, it does not get the serious consideration it deserves. It is not at all uncommon to meet with cases which have gone on unattended for years, and in some of these cases the result is a condition, in a degree at least, incurable. By producing this short article I hope to create enough of interest in regard to it to demonstrate that it deserves as much attention, at least, as some subjects which are much more written about. Definition: It may be defined as an inflammation of the border of the eye-lid, sub-acute or chronic. It is most frequently found among the children of the poor in our large cities, but may be found among people who are otherwise healthy and whose surroundings are in accordance with the rules of good health. Symptoms: The patient will complain of weak eyes and of difficulty in separating the lids on awakening in the morning, of itching of the eyes. after work, etc. On making an examination the lids, in mild cases, appear to be sprinkled with bran, or look red and swollen. In the more severe cases the edges of the lids may be covered with scabs intensely swollen and ulcerated. I will not attempt to give a classical division of the disease for the reason that scarcely any two authors give the same classification, and none of them pay any particular attention to their classification in subsequent remarks. Sooner or later, from extension of the inflammatory condition to the sebaceous and Meibomian glands, the secretion becomes abundant and thick, coating over the edge of the lids, under which is a raw, swollen or ulcerated surface. At this stage an attempt to use the eyes, even for a short time will produce marked irritation. This swollen condition removes puncta from immediate contact with the ball, allowing tears to flow over the cheek and to accumulate in the lacus lachrymalis where their presence will cause a chronic conjunctivitis. The ulcerative form leads to permanent destruction of the cilia and will, if the case be not attended to, end only when all the cilia are gone. The hypertrophy at the border of the upper lid will cause it to drop or more or less by its own weight, and ectropion may be produced in the lower lid by the contraction of cicatricial tissue drawing the conjunctiva forward over the border of the lid, causing it to look as though. bounded by a red streak or rim, destroying the well marked posterior border of the lid, preventing close coaptation of lid and ball as well as complete closure of lids. These conditions prevent the escape of tears through the proper channel, and this in its turn, produces excoriations and often eczema of the skin, causing it to contract and draw the lids farther and farther away from the ball until finally we have an ectropion of the entire lid. We |