Society Reports. ACADEMY OF MEDICINE OF CINCINNATI. OFFICIAL REPORT. Meeting of May 10, 1897. days previous to operation. In this case the bowel was black but still intact, and after relieving the constriction the bowel Iwas allowed to lie in the wound over night and hot applications made. In the morning, the bowel having regained its color, was returned to the abdominal cavity. The woman made an uninterrupted recovery. In each case the dis The President, W. E. KIELY, M.D., in position of the omentum was such as to the Chair. W. EDWARDS SCHENCK, M.D., Secretary. Intestinal Obstruction. DR. J. C. OLIVER presented a portion of the small intestine showing a Murphy-button anastomosis. The specimen was from a boy, fourteen years of age, who had been suffering from intestinal obstruction for two weeks. When the boy entered the hospital (Christ's) he was moribund; the temperature was subnormal (96.6°), pulse rapid and thready, mind wandering, semi-comatose except when aroused. There was regurgitation of fecal matter through the mouth. Examination revealed an undescended testicle on the right side and a small obscure swelling in the region of the inguinal canal; this swelling was not appreciable to the sense of sight, but could be made out by palpation. There was no impulse in this lump when the patient coughed, nor could I determine whether the swelling was inside or outside the cavity. An incision showed the mass to be an entero-epiplocele above the undescended testicle. The omentum was gangrenous and the bowel had been cut through by the constriction. A Murphy-button anastomosis was made, but the patient died six hours. later. An interesting point is the wellmarked adhesions between the two sections of the bowel. It is very evident that repair is very rapid in operations of this sort. The unfortunate result in this case must be ascribed to the prolonged obstruction, the death being due to exhaustion. On post-mortem examination there was no evidence of peritonitis. In the past three weeks I have seen two cases of hernia which should be classed as neglected cases. The other was a woman who had suffered with a strangulated femoral hernia for seven receive the brunt of the constriction, thus saving the bowel to a great extent. Specimens. DR. H. W. BETTMANN exhibited specimens: Stomach from a tubercular woman, who, during the last few weeks of life, was annoyed with persistent vomiting. It was bound down by peritoneal adhesions. Epitheliomatous nodules in the bladder, also involving the connective tissue between the rectum and bladder. Metastasis in the liver. Kidneys and brain from a case, aged sixty. A few hours before death had convulsions. Kidneys, granular nephritis. Especial attention was called to the rigid arteries and arterioles in the kidneys. Brain, rupture of a vein on right side posterior to Sylvian fissure, at which point was a clot the size of a dollar, which probably occurred during convulsion. DR. T. W. HAYS exhibited specimen: Brain from a male, aged twenty-five years. Syphilitic meningitis. DR. H. C. WENDEL read a paper entitled Thirty-Five Cases of Diphtheria Treated With Antitoxine (see p. 627). DR. R. C. HILL read a paper on Antitoxine (see p. 629). DISCUSSION. DR. R. C. JONES: Doctor, was there any albumen or indication of nephritis in any of your cases following the injection of antitoxine? DR. H. W. BETTMANN: The Academy should be thankful for so interesting a report. It would be especially inter esting to know the indications for re- | instances. The case was a boy, aged peating the injections. Some informa- six years, who lived in a tenementtion about the quantity of antitoxine house, and had malignant diphtheria. indicated in a given case would also be A thick membrane covered the uvula desirable. The early statistics seem as and pharynx; the former was so thick favorable as the more recent ones for and gangrenous that I thought I would cases treated early in the disease, and a have to clip it off. With the old treatfew years ago more than 1,000 units ment he recovered, but had a post-diphwas rarely given. Personally I have theritic paralysis later that was not conhad perfect success with a single dose fined to the muscles of deglutition, but of 1,000 units. was so severe that he would fall to his The Academy would like to hear knees when standing erect. This confrom the the newly appointed Health-dition lasted for three months. The other Officer of the city what steps he is going children could not be sent away. The to take to place the means of scientific mother developed a follicular tonsillitis, diagnosis within the reach of the prac- as likewise did the children, which was ticing physicians. coincident with the condition of the boy. DR. J. L. CLEVELAND: I would rather listen than speak upon this subject, but I desire to express my thanks to the reporters for their excellent contribution, which is in line with that from others. My own experience has been limited, though I have found it a useful remedy. While listening to the reports it shows a mortality of about 10 per cent., which is far better than any other method has shown. In reference to the result obtained in the treatment of diphtheria, it depends upon the character of the epidemic. There are many among us who may treat a number of cases for several seasons and not lose a case, and yet at another time, in spite of all efforts, lose many. I have never had occasion to use more than one injection with recovery, but those cases that did not recover I am confident could not with another. Further use of the remedy, I fear, will demonstrate to us that we will still lose some cases, and it will not furnish the results we had hoped it would. It is only of service in the pure form of diphtheria; in the mixed form, where we have pyemia, we cannot expect much. DR. C. E. CALDWELL: It is not with a spirit for controversy that I enter the discussion, but simply a desire to relate a case that occurred in my practice, that I reported to the S. W. Medical Society, at which time I had a tilt with Dr. Whittaker, because I took the stand that it was almost impossible to differentiate between a membranous pharyngitis and a true diphtheria, in certain We have Klebs-Loeffler and other pathogenic organisms in the mouth, so is it not possible that we have not a positive diagnosis by the bacteriological examination? So that at present we are not in a position to tell positively which is and which is not diphtheria. Recently I had a case of a child that developed a membrane upon the tonsils, which did not extend to the pharynx or nose, but the latter discharged some. The child apparently did well, but on the twelfth day it died. Not arrogating too much to myself, I think I could distinguish diphtheria, and there was every reason to believe that the child would recover. The question arises, had I given antitoxine to the other children in the first case would I not have falsely attributed their protection to the use of antitoxine? DR. J. M. WITHROW: A word as to what the Health Department intends doing. It is proposed in some of the out-door districts to establish stations, at which will be left tubes containing a brush-the tubes in a wooden casewhich will be at the disposal of any physician to use, and after it is returned to the station the Health Office will be notified and a sanitary officer will be sent to bring the tube to the office. To expedite the examination a laboratory will be established in the City Hall. Antitoxine will later be placed at these stations, and the results from the experience of the District Physicians will be noted upon a card that will accom pany it and thus establish the worth of but we should endeavor to prevent it, the remedy. but better than that is to try to stop it with antitoxine. DR. J. C. OLIVER: If the Health Officer is open to suggestions, I would suggest that in addition he have noted the hygienic conditions surrounding the patients, which is of especial interest, in that many of these cases occur among the poor. In reference to the protective influence of antitoxine we must not fail to remember that all persons exposed do not develop diphtheria, and therefore the statements as as to the protective powers of antitoxine must be very cautiously received. DR. G. B. TWITCHELL: I have treated a large number of these cases with antitoxine, but have never been so unfortunate as to have one of the gangrenous kind. I have made a number of intubations, and since the last six months, with the use of antitoxine, it was only necessary to leave the tube in two days, where formerly, without antitoxine, it was necessary to leave the tube in from six to twelve days, and I lost many of these cases, which did not appear more severe than similar cases that we treat to-day with antitoxine that recover. If there is anything to speak in favor of antitoxine it is the less number of days required to leave the tube in the larynx, in cases that need it; perhaps this may later be reduced to hours instead of two days. If we save life, surely it is in these cases. This may be a rash statement, but with the exception of the gangrenous form I do not expect to lose one in ten cases. I do not know that the hygienic conditions have much to do with it; of course, many of these cases occur in the tenements, yet there is something peculiar in the immunity under some conditions. One instance occurred in a family where all lived in one room, but no other member of that family had the disease, yet in other cases the disease has gone through the entire family. It seems to me to depend upon the character of the epidemic. It has been remarked in the country districts that whole communities are affected, then again we have epidemics that are milder. I do not know how the disease is carried, My experience has been limited to the laryngeal type, in which we do not get all the symptoms, but we recognize it as such, and it occurs along side of the typical form. One dose of antitoxine will do more to prevent the spread of the disease than all the cards. Dr. WendeL: In answer to Dr. Jones, there was albumen in the urine in a few cases following the injection of antitoxine, but slight in amount. In several of the cases hydrogen dioxide was used in addition to the antitoxine, and other remedies when required. DR. HILL: I am thankful to the gentlemen for this very liberal discussion, which involves many points of interest. While it is very true that epidemics vary, and that there are cases which are severe and others which are mild, yet antitoxine has now been before the profession long enough to have demonstrated its value in all kinds of cases and in all parts of the country, provided only that it be used sufficiently early. The exact rate of mortality is still an unknown quantity, which must be fixed by future results obtained in private practice, but that it is very far below that following any other line of treatment in diphtheria has now been abundantly demonstrated. Undoubtedly the plan outlined to be pursued by the Health Department will result in valuable contributions to exist. ing statistics. Post-diphtheritic paralysis is not prevented to any appreciable extent by the use of antitoxine; indeed, it has even been asserted that paralysis more frequently follows in those cases treated with antitoxine than in other cases, which is explained by Tirard by saying that as there are more who recover under the use of antitoxine, so the number to be later affected by paralysis is just that much greater than it is under other forms of treatment. In reference to the indications for subsequent injections, it is my rule to give a second injection in from eight or ten to twenty hours after the first if the membrane does not begin to fade. I consider the indications for a second injection constantly present unless an amelioration of all the symptoms follows in a few hours after the first has been given, and any subsequent rise in temperature or other unfavorable symptom should be promptly followed by another injection. An Addition to the Treatment of Pruritus is so frequent a disorder, and is attended with so much suffering, both physical and psychical, that although but a symptom, it often assumes the importance of a disease. It is, therefore, of interest to note that Dr. Wannemaeker, of Ghent (Belgique Medicale), who has recently written an instructive article on the pathology and treatment of pruritus, has suggested a new remedy for obstinate cases of this affection. Starting out with the idea that carbolic acid taken internally seems to act directly upon the phenomena of pruritus, he has, in addition to the appropriate local and dietetic treatment, for some time made use of salophen, which is a combination of salicylic acid and acetylparamidophenol. Aside from a few failures, this drug has yielded some results which, in the author's opinion are very encouraging, and some which are very suggestive. Whether the favorable influence of salophen is attributable to the anti-arthritic action of its salicylic component, or to a sedative effect upon the nerve terminals, or to that of an antitoxine, remains questionable. The cases cited as illustrations of its efficacy as an anti-pruritic, comprise prurigo, psoriasis in a gouty subject, pruritus in diabetes, eczema in a gouty person, and chronic urticaria occurring in attacks. The dose was usually large, ranging from four to five grammes daily. In summing up his results the author concludes that in certain conditions which can not as yet be defined with precision, salophen offers a resource which should not be neglected by the physician who is anxious to relieve these unfortunates.— Col. and Clin. Record. OBSTETRICAL SOCIETY OF CINCINNATI. OFFICIAL REPORT. Meeting of December 10, 1896. The President, RUFUS B. HALL, M.D., in the Chair. E. S. MCKEE, M.D., Secretary. Report of Cases. Dr. BYRON STANTON: At the last meeting we considered the subject of occipito-posterior positions, and in that discussion I expressed the belief that many of these cases could be relieved by internal rotation—that is, by placing the patient under an anesthetic, lifting up the fetus in utero and turning it on its long axis. Within forty-eight hours after our last meeting I had an opportunity to do that. I was called by Mrs. Hart, a midwife, to a patient who had had five still-born children, and I recognized an occipito-posterior position. The pelvis was small. The membranes had not been ruptured very long, the uterus was quite relaxed, the waters not all discharged, and I thought it was a favorable case for internal manipulation. I brought the patient down to the edge of the bed, gave her chloroform and then introduced my hand. Getting my hand upon the chest of the fetus, I lifted it up and rotated it completely, and then applied the axis-traction forceps and delivered a living child. The manipulation was done with so much ease that I think very often it may be done in cases of this presentation. I have done it in three cases I can recall, and I have been surprised at the facility with which it can be done. Of course, if the membranes have been ruptured for some time, the procedure would be more hazardous, but where it can be done it is one of the easiest ways of managing cases of this kind. Of course, the entire body must be rotated. It would not do to only turn the head around, making a complete revolution of the head; but by getting hold of the shoulders of the child it is an easy matter to make complete rotation. Another case that I want to report is one of induced labor by injection of glycerine, attended with very unpleasant symptoms. I feel more in honor bound to report this case because I reported several cases of introduction of labor by this method, attended with the best of results, in which labor was induced quite speedily. I have used it a number of times without any unusual symptoms, but last March I induced labor in a case and had very unpleasant symptoms. When the injection was thrown into the uterus the woman at once complained of extreme pain in the head, and said she was dying, and, when I felt the pulse, I feared she might die. For some time after the pulse-rate was but 30 or 40 per minute. It was some hours before it was anything near normal. The labor, however, was very promptly induced; the pains came on in three or four hours, and the child was delivered alive. Not very long after the occurrence of this case I met Dr. Landy, who said he had a case in which he attempted to induce labor or abortion (I forget which it was), in which he had the same results as those I have just mentioned. I have since read of a number of cases of very unpleasant symptoms, following sometimes immediately after the injection, and in some cases there occurred a nephritis, which was believed to be the result of the injection of glycerine into the uterus. So I have come to regard this as not a safe method to resort to, and I think I have resorted to it for the last time. DISCUSSION. DR. C. D. PALMER: How soon after the injection did these symptoms occur? DR. STANTON: Immediately. DR. C. A. L. REED: How much glycerine did you use, Doctor? DR. STANTON: About two ounces. The syringe was filled and then a catheter passed over the beak of the syringe and all the air expelled, and then it was introduced, through a speculum, high up in the uterus. DR. PALMER: Was there any discharge of blood or separation of placenta? DR. STANTON: None at all. DR. PALMER: And there was no suspicion that there was any air injected? DR. STANTON: None at all. The instrument and the catheter were both full of glycerine. The glycerine was forced up into the catheter until it was completely filled, and then it was kept in that condition until it was used. There was no difficulty whatever in the introduction of the catheter; it was passed along the posterior wall of the uterus and almost the entire length of the cavity, and the injection made high up. DR. A. W. JOHNSTONE: Where did she complain of pain? DR. STANTON: In the head. DR. E. G. ZINKE: condition of the os! What was the DR. STANTON: Patulous. DR. ZINKE: And what evidence was there that you did not introduce the catheter between the placenta and the uterine wall? DR. STANTON: Only that there was no blood on the catheter when it was removed. DR. ZINKE: Does not usually the glycerine escape after the withdrawal of the catheter? DR. STANTON: No; where you can get the glycerine five or six inches in the uterus there is no danger of it escaping, if the patient is kept in the recumbent posture. DR. ZINKE: Where abouts in the head did the patient complain of pain? DR. STANTON: Principally the top of the head. DR. REED: How long did these symptoms continue? DR. STANTON: I gave her a stimulant right away, some camphor and whisky, and the symptoms gradually subsided. After half an hour I gave her some morphia, because of the continuance of the pains. I did not give morphia before because I did not want anything to interfere with the labor pains, but on account of the pain continuing so long I gave the patient a quarter of a grain of morphia, and it did not prevent the coming on of labor pains. DR. JOHNSTONE: How long did this condition of shock last, Doctor? DR. STANTON: Probably after two and a half or three hours it was all gone. |