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you, not only study the letter of the code, but its spirit as well. Read carefully the article on consultations. In case of disagreement, a little tact, a little firmness, and kindliness of spirit, and expression, as well as a little giving way on both sides will often pave the way to harmony. I well remember a case, a desperate one of laryngeal diphtheria, where the consultant believed that the life of the patint depended upon the use of antitoxin, while the attending physician was equally strenuous in objecting to its use, declaring that he had never used it, and never intended to do so. So prejudiced was he against the "horse juice," as he styled it, that it required the greatest tact and kindly argument to induce him to give it a trial. The patient was operated upon with the understanding that he would give it a trial, and at the same time continuing his own medication. The result was so remarkably satisfactory, that he was convinced of its utility, and since has been one of its most earnest advocates..
Some of the sections of the code must be interpreted by each man for himself. You must remember that people sometimes become dissatisfied with their attending physician, sometimes very justly, more frequently very unjustly. You must be quick to see, and feel this dissatisfaction, and head it off by calling in council, but if you are unsuccessful you must remember that your patients have a perfect right to discharge you and to call in some one else, and it is far better to retire gracefully than to grumble about it. Above all things, harbor no ill feeling against your successor. It is often the lot of every physician to be unceremoniously discharged.
A word more regarding consultations. Should a physician who has seen a patient in consultation, take charge of the case, the attending physician having been discharged? There is nothing in the code of ethics to guide us; no clause of the code would be violated, and it would be a beautiful way of getting even, for some real, or fancied wrong; but would it be fair? Would it be right? Would it be a "square deal? That is the question each one must answer for himself. It might under certain circumstances and again it might be eminently improper. In the great majority of cases, it would appear to me, not to be the wise, the dignified, or the proper course to persue.
In conclusion, I would say to you young men and women, have great, have high ideals and live up to them. Be true to thyself, to thy neighbor, to thy profession, and to thy God, and you will not go far astray, or far overstep the rules of the strictest code of ethics.
BLACKWATER FEVER---REPORT OF A CASE
By James R. Arneill, M. D., Denver, Colo.
Colorado physicians occasionally have the opportunity of studying and treating cases of malaria. However, the disease is imported in every instance; to the best of my knowledge. The majority of these patients come from the Southern States, for the purpose of getting rid of their disease or its after effects.
J. H. Alpenfels, 42 years of age, a millwright by occupation and for many years a resident of Colorado, went to Port Leconde, on the west coast of Africa, in September, 1904. He was in excellent health on reaching Africa, and had never been sick a day in his life. Six weeks after his arrival he was seized with chills and fever. The paroxysms occurred twice a week at first, and his temperature reached 103. He felt badly between chills, had no appetite, sometimes went three days without food, was extremely thirsty, and lost 20 pounds in weight. He was bitten by small mosquitos. Blood examination for plasmodia was not made in Africa. His physician did not give him quinine during his chills, as he feared it would produce black water fever. Instead, the patient took 10 grains of phenacetin and hot drinks, to produce copious sweating. On the day following the chill, he took 10 grains of quinine and continued it daily except on chill days. In spite of this medication, had fever during his entire stay on the Gold coast. The patient left Africa, April 14th, 1905, for the United States, via. England, having spent between six and seven months on the dark continent. He continued to take 10 grains of quinine each morning, till April 20th, when he stopped it as he was feeling well. About April 24th, he was again seized with chills and fever. Immediately he began sweating himself by using hot water bottles, and drinking copiously of hot lemonade, and soon felt some better. He did not take quinine at this time, as friends on ship board on their way home from Africa, warned him against it, fearing that it would produce the dreaded black water fever. He now felt well till he left London about May 6th, when he again had chills and fever. Notwithstanding his fear of the effects of quinine, he began taking 10 grains each morning before breakfast. In spite of this medication, he was seized again in a few days with chills and fever. The chills now occurred daily and there was practically continuous fever. On the morning of May 13th he again took 10 grains of quinine, and not getting any better, consulted the ship's doctor.. He was advised to take immediately, 24 grains of quinine. Just before taking it, however, he passed what appeared to him to be pure blood. This fact was reported to the doctor who immediately administered the large dose of quinine. An African physician, who happened to be on shipboard, advised giving 30
grains of the above drug. The patient took a second dose of 24 grains of quinine in pill form in the afternoon. The next day, the second of the attack of black water, he took one dose of 24 grains. The urine coatinued to get blacker and blacker, till it looked like porter. He drank large quantities of water and passed as much as a gallon of this black urine daily. His temperature reached 103 1-2 and he was extremely sick. On the first day of the attack of blackwater fever, the patient noticed that he was intensely jaundiced, his sclera and skin being as yellow as a lemon. This jaundice continued till two days after the water cleared up.
During the attack he was constipated and very sick at the stomach, vomiting frequently. He was extremely restless, couldn't lie still in any one place; all the bones of the body ached, and he felt as if he had gone through a threshing machine.
An interesting phenomenon associated with the attack of malaria was the development of boils on either side of the calves of both legs, with every new chill. Brownish discolored spots can now be seen at the former site of the boils.
In four or five days the bloody urine began to clear up. On the second day of the attack, the ship reached New York and he was sent to a hospital. While in the hospital he was given 10 grains of quinine three times daily, in capsule. He could not take it in solution. The urine became clear May 17th, 1905, and has remained so ever since. He stoppped taking quinine on May 20th. The patient came to Colorado immediately and was examined by me on May 26th, 1905, through the courtesy of Dr. McGugan. He complained of being weak and of having swollen feet and ankles. He was passing 2 to 3 pints of urine in 21 hours.
The patient looks somewhat sallow and pale. There is fairly marked soft oedema-pitting on pressure-and extending half way to the knees. THE SPLEEN-is enlarged and is felt one inch below the edge of the ribs, on deep breathing.
HEART dullness extends to the left to within 3-4 inch of the nipple. No murmurs are heard.
BLOOD Hemoglobin:-Dare is 42 to 45 per cent.
Blood spread stained with Wright's stain and shows a slight poikilocytosis. No malarial organisms or pigmented leucocytes are found after a long search.
URINE.-Sp. gr. 1010-neutral.
ALBUMEN.-Boston ring test negative. Acetic acid and potassium ferrocyanide-shows the faintest cloudiness.
Microscopical examination of the sediment-negative.
He was given iron in the form of Blaud's pills-and began to improve promptly. The edema soon disappeared entirely and the blood con
dition improved markedly, the hemoglobin being 80 per cent on June 12th. His appetite is good, and his thirst tremendous. He says he could drink a pint of water every five minutes.
The patient picked up the following items, relative to blackwater fever, in the region of Port Leconde. It was the prevailing opinion among the men in camp, that the disease was very fatal. This belief was evidently due to the fact that several men had died in four or five hours after being attacked, rather than from an actual study of the statistics. In truth, Dr. Wilson of the camp, had treated thirty-six cases without a death (hearsay). He gave 10 grains of boric acid every four hours, and a teaspoonful of salt to the pint of water, very frequently, to flush out the kidneys
The workmen and natives all believe that if quinine is taken during the chill-blackwater fever will result.
The doctors of that section advise the men to take quinine daily—except when they have chills. On these occasions they give 10 grains of phenacetin. Our patient latterly took his quinine during his chills. and thinks that he thus brought on the attack of blackwater fever.
The cardinal symptoms of blackwater fever are fever, icterus, hemoglobinuria, and the presence of the malarial parasite. (Mannaberg).
In the present case these postulates are all clinically satisfied, though the criticism might be offered that we have not the exact chemical and microscopical proofs of the hemoglobinuria and the presence of the malarial organisms.
The following statements are taken from Mannaberg's article in Nothnagel's system:
The genesis of blackwater fever is not yet fully understood. Blackwater fever occurs almost exclusively in persons who have lived for a long time in severe malarial regions and have suffered several times from malaria.
It is a rarity to see a person attacked within the first half year of his residence in these districts.
The chief seat of blackwater fever is the west and east coasts of Africa. It occurs in many other tropial and sub-tropical countries, including the Southern United States.
Repeated infections with malaria, create an individual predisposition which acts as a ground work for the disease. Some authorities hold anaemia to be the most responsible factor in this predisposition.
Blood examinations of recent years have proven that black water fever is an expression of malarial infection (in most cases to the malignant tertian parasite).
Tropical climate is another cause of the individual predisposition. Alcoholism and cold are considered auxiliary causes. Syphilis has also been suggested; also physical hardship and psychic emotion.
Quinine plays a very important part. The lay inhabitants and physicians of these malarial regious, believe that this drug has the power of producing blackwater fever in predisposed individuals.
The role of quinine in the production of blackwater fever is a complicated one not yet fully understood.
Cartier mentions the fact that the female Creoles refuse quinine on account of their belief that it causes metrorrhagia and abortion.
According to Ponfick's experiments, about one-sixth of the entire number of red blood corpusles must be destroyed to produce hemoglobinuria. If a smaller number succumb the liver activity is sufficiently great to use them up in the elaboration of bile.
SOME METHODS USED IN THE BACTERIOLOGICAL EXAMINATION OF WATER
By Dr. Dessie B. Robertson, Boulder, Colo.
In making a bacteriological examination of water, we may have two purposes in view. First. The estimation of the number of bacteria present in a given volume of water.
Secondly. The identification of the several species, and in this we include the most important object, the recognition of disease germs.
The number of bacteria present in a given volume of water has not a great weight in determining hygienic conditions, but still it has some value in the final decision.
Some authorities state that in ordinary city hydrant water bacteria number two to fifty in a cubic centimeter.
In good pump water, one hundred to five hundred. In filtered river water fifty to one hundred. In unfiltered, six thousand to twenty thousand and according to pollution may reach as high as fifty million.
Some authorities state that not more than five hundred to a cubic centimeter is safe. Five hundred to a thousand suspicious and more than one thousand unfit for drinking.
It must be remembered, however, that the majority of water bacteria are not disease germs, and it is not the number but the character which is important. The number, however, serves as an indicator. Having some idea of the usual number found in ordinary drinking water, any sudden and marked increase should be looked upon with suspicion, since it shows that for some reason this water has become good culture medi
Bacteria, it is known, grow and multiply rapidly on organic matter, hence, the inference, that this unusual increase is due to the addition of some organic material, the most probable being sewerage contamin