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than normal, while the postThese facts are not alone in
before death the cardiac area is decidedly less mortem reveals an empty or nearly empty heart. our clinical investigations, but are analogous in many infectious diseases, as tuberculosis, typhoid, etc., as well as non-infectious, such as nephritis, pseudoleukemia, etc., which led to a conviction that we have a vascular death ("Gefästodes"), or death due to an impaired condition of the vessels concerned and not at all contributable to heart failure. This condition would be better described as vasomotor paralysis.
This subject has been further demonstrated on animals by drugs by Pässler, who first paralyzed the vasomotor system and subsequently by vascular stimulants stimulated the tonus. The suprarenal extract has the same power.
The State of the Gastric Secretions in Organic Disease of the Heart. Murdoch (N. Y. Med. Jour., vol. 49, no. 24) has examined the gastric contents of twenty-three persons with organic heart disease.
An aortic systolic murmur was present in five. Free HCl was present in four of these cases and absent in one.
A mitral systolic murmur was found in eight cases. Free HCl was absent in one case, subnormal in one, and nearly normal in the others.
A mitral presystolic murmur was found in five cases.
Free HCl was absent
in one case, normal in one, and in excess in the other three.
An aortic and mitral systolic murmur was present in four cases. In one free HCI was present in excess, and absent in the others. Of the three cases in which HCl was present, in one the total acidity was ten, and rennet was absent, in the two others rennet was present; the total acidity in one was twenty, and in the others seventy-two.
Simple hypertrophy of the left ventricle, due to prolonged muscular exertion, was present in one case. HCI was absent, rennet was present, and the total acidity was four.
It will be seen, therefore, from the record of these sixty-seven cases, that there is no constant relation between the state of the gastric secretions and any one form of organic heart disease. Neither does the presence of heart disease seem in many cases to stand in the way of the recovery of patients suffering from the various forms of stomach trouble, for my records show that such patients get along just as well on the way to recovery as those whose hearts are in a normal condition.
Of the twenty-three patients examined, three came in only a few times, ten were seen but once, three were greatly improved, and seven made complete recoveries.
In those who recovered or were greatly improved, intragastic faradization was used in seven, lavage and faradization in one, and lavage alone in two. The patients were directed in regard to bathing, exercise, etc., and the diet in all cases was carefully regulated.
He lives long that lives well; and time misspent is not lived, but lost;
UNDER CHARGE OF W. B. ROGERS, M.D.
Professor of the Principles and Practice of Surgery and Clinical Surgery,
The Conditions of Successful Operation in Epilepsy.
Kocher, in a paper read before the Berlin Medical Society (Med. Press & Cir., vol. 67, no. 3129), thought pessimism in regard to operation for epilepsy had been carried too far. From recent experience he had concluded that the method of operation practiced had not been the right one. V. Bergmann had introduced an improvement by removing the cortical portion from which the epilepsy started. About 10 per cent. were cured in this way. Since the eighties the speaker had operated after a theory of his own, and had obtained six complete cures in traumatic epilepsy. He had collected 175 cases of operation, only calling those cures that remained well at the end of three years, although epilepsy sometimes returned even later than that. In this investigation he was able to determine that that treatment was successful that attacked the cause of the epilepsy direct. After extraction of foreign bodies from the skull, and especially from the brain, 88 per cent. of recoveries took place. In the latter cases, where the dura was incised, the results were the best. He assumed that an essential cause of the occurrence of attacks was tension, which was relieved by incision of the dura. Perhaps this reduction of tension was the factor in these cases that had been cured after incision of the cortical center, and also in those cures in which the center could not be determined by electricity.
In his successful cases the covering over the opening had remained soft, so that "giving" could take place on pressure, whilst in the unsuccessful ones, the covering had become bony or at least of tense connective tissue. If the principal factor of the attack was assumed to be a cicatrix or adhesions, operations should not be performed, as a cicatrix was always left by them. But these need not be feared. Aseptic soft cicatrices, even when they projected into the brain, almost never caused epilepsy. Guinea pigs could be made epileptic by a simple blow on the head, and in these cases blood pressure was increased four-fold. If the animals were then operated on and a lateral ventricle opened, the epilepsy ceased. An etiological connection between increased pressure and epilepsy had thus been experimentally proved. In this way cysts and collections of fluid of all kinds within the brain easily gave rise to epilepsy.
According to these views, we had first of all in our operation to remove all local irritation, such as foreign bodies, and then take measures for reducing local and general blood pressure within the calvarium. The dura when incised should not be sutured, but should rather be excised, and the defect should not be covered by bone. In penetrating wounds of the head, the damage was not caused by the opening, but by the firm closure of the skull.
Hr. V. Bergmann said it was yet to be determined what was the nature of epilepsy, and then there was the proposition that there was no epilepsy without spasmodic changes in the brain. This condition was congenital, and it would not be too much to say that in nine-tenths of the cases of epilepsy, whether traumatic or not, there was a hereditary tendency. If we took from the
remaining tenth all the cases in which infective diseases were the cause, the remainder would be very small. Hereditary disposition could not be assumed when the attacks began after the 20th year. As to the cases operated on it was very difficult to determine whether they had a hereditary predisposition or not. There were two categories of causes of epilepsy-1st, the supposed epileptic change in the brain, which could be treated by operation, bromides, and section of the sympathetic, and 2nd, those where the disease was caused by localized peripheral injury, and here we must satisfy the indicatio causalis. If excision of the cortex did not always succeed, it was because general epileptic changes had already set up in the brain. For fulfillment of the indicatio causalis operation should not be too long delayed. A definite judgment as to results of operation could only be given years after they had been performed.
Laparotomy for Intussusception.
Clubbe (Pediatrics, vol. 7, no. 8) reports eight cases of laparotomy for intussusception in children, with six recoveries. These are to be added to nineteen cases already reported. Of the total of twenty-seven cases fifteen recovered. This is a most excellent showing. In discussing the expediency of using injections in intussusception, this being commonly opposed, the author states that he has been successful in reducing the intussusception in this way in six cases. He maintains that whether we see the cases early or late we should always inject. His reasons are these:
In early cases the intussusception is occasionally completely reduced. In every case, no matter how long standing, the mass is always reduced to a certain extent and in the gentlest and best possible manner. And so at the coming operation there is less manipulation of the bowels, and therefore less shock. It is common to find an elongated tumor extending say from the middle of the transverse colon to the sigmoid flexure. After the injection we probably find the tumor greatly reduced in size and now on the right side, at the first part of the ascending colon.
In operating now we can open the abdomen to the right of the middle line just over the tumor. This means making a much smaller opening. There is not now any difficulty in reaching the tumor and there is much less trouble in keeping the intestines from getting outside. All this tends toward a favorable result.
In advocating the use of injections the author does not wish to be misunderstood. He is quite alive to the importance of not wasting valuable time in these The injection should always be given while the child is under an anesthetic. Before the anesthetic is given the child should be prepared for operation. If, after the injection has been given the tumor can still be felt, the abdomen should at once be opened. If, on the other hand, the tumor seems to have entirely disappeared, the child may well be put to bed; but it must be carefully watched, and should be examined again by the surgeon in a few hours.
is any return of the tumor operate without further delay.
The use of injections has been brought into disrepute by the neglect of these simple precautions.
UNDER CHARGE OF A. G. SINCLAIR, M.D.
Professor of Ophthalmology, Otology and Laryngology, Memphis Hospital Medical College; Ophthalmic, Aural and Laryngeal Surgeon to St. Joseph's Hospital; Ophthalmic and Aural Surgeon to the City Hospital.
Nervous Defects as Factors in Strabismus.
De Micas, Toulouse (Annales d'Oculistique), bases his paper on his own observations in twenty-one cases and upon the works of Valude, Borel, Parinaud, and Charcot. His conclusions are:
1. Hysteria gives rise to a particular form of strabismus that has been studied by Borel and which has its own characteristics that consist above all in transient ocular spasms.
When a permanent strabismus becomes temporarily augmented through emotion it is considered as an hysterical exacerbation of the concomitant variety.
2. The establishment of true strabismus requires two things—a disturbed disposition of the organs concerned in binocular vision and a nervous defect. This nervous affection may be found to exist, generally, if not always, in some of the progenitors of the patient, as proven by the author's observations; it not being necessary that this should be found in the direct ancestors. Frequently the patient himself shows transmitted nerve stigmata. The faults most frequently found in the direct ancestors are idiocy, mental disturbance, and epilepsy.
3. Strabismus is a sign of complex degeneration, since its development, outside of nervous imperfection, requires an association of conditions. This explains why it is that such subjects, although degenerate in type, may be themselves exempt from grave nervous manifestations, such as epilepsy, alienation, etc., and as a rule procreate healthy children.
4. Direct hereditary strabismus is rare. When a subject with strabismus is born of a parent with strabismus the nervous defect should always be searched for on the side of the faulty transmitter.
5. It would be interesting to trace the connection which exists between the different manifestations of alienation of the progenitors and the forms of strabismus of the descendants. The author has found that esophoric patients in asylums are gloomy, while the exophoric ones are loquacious.
6. If an ametropic subject is born of parents having some nervous imperfection, it would be well to examine the refractive condition carefully and to employ all possible means to develop binocular vision.
7. The results from operations for the cure of strabismus should be better in proportion as the hereditary traces are farther removed and as the patient is freer from taint.
8. In order to maintain the good results that have been obtained by operation it is well to insist upon a prolonged course of treatment such as baths, douches, the bromides, etc., which are to be directed toward the nervous condition of the patient.
9. The operator should at first do as little as possible, especially if the subject be young, in order that he may avoid the risk of causing a convergent eye to diverge.
The author believes that it is impossible to grade the operation with exactitude and says that the nervous factors may create very disagreeable surprises.
He states that successive operations are exempt from danger, and moreover he has found that the parents will readily consent to such a method of procedure if the matter is explained to them in advance.-[Annals of Ophth.
The Visual Acuity of the Dahomey Negroes.
Prof. Dr. Hermann Cohn (Wochenschrift für Ther. und Hieg. des Auges) has recently had an opportunity of examining the eyes of quite a number of native Africans. It was found they had somewhat over double the normal sight, and as compared to the school children of Breslau, somewhat better sight than the latter. Annals of Ophth.
NOSE, THROAT AND EAR.
UNDER CHARGE OF RICHMOND MCKINNEY, M.D., MEMPHIS.
Laryngologist to the East End Dispensary.
Deflections of the Nasal Septum.
At a recent meeting of the Section of Laryngology of the New York Academy of Medicine a series of papers on deflective nasal septum and its treatment, was read. These papers are all published in the Laryngoscope for June, 1899. In the first paper of the series Bosworth contended in favor of his original suggestion, made in a paper published in 1886, in which he advocated the complete removal of the projecting portion of a deflected septum.
Asch, the next essayist, plead in favor of his excellent method of making a bisecting incision through the cartilage, forcing the convex over to the concave side, and putting in hard rubber tubular splints. Asch stated that in over 350 operations coming under his personal knowledge within the past ten years, not a single death occurred, and in only a few badly nourished cachectic patients were perforations observed.
Roe, who followed, dwelt upon the necessity for bringing the osseo-cartilaginous portion of the septum into line, which is done by breaking this portion of the septum thoroughly up with a special forceps, and forcing it over to where desired. Roe's treatment of the cartilaginous septum is to make a vertical and horizontal incision in the shape of a Greek cross through the most curved portion of the septum, with a knife. The septum is then placed in position and supported by either a cotton dressing or, if for a length of time, hard rubber tubes, pins, or other method.
Watson described his method, which consists of a beveled incision which permits of the sliding of the redundancy of the septum over its base.
Gleason considered his idea of making a U-shaped incision and thrusting the tongue-shaped flap over into the concavity.
Douglas also gave the technique of his operation which, briefly, consists of four steps: 1. Buttonhole the septum at the point of greatest obstruction, and incise obstructing ridges or convexities in the line of convexity. 2. Break with forceps all fibrous bands and separate cartilage from the superior maxillary spine