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Pneumonia of the Aged.
Babcock (Jour. Amer. Med. Assn., vol. 33, no. 8) says:
1. It is his conviction that aged pneumonic patients bear well and require large doses of strychnine.
2. Stimulants, as alcohol, in small or moderate doses, and ammonia in frequently repeated doses, are usually highly beneficial.
3. As little medicine as will meet the indications should be given, for fear of upsetting the stomach and thereby destroying what few chances the patients have at the best.
4. Because of the tendency to renal insufficiency, the nourishment should be largely fluid, and nothing is so suitable as milk and properly-prepared beef juice.
UNDER CHARGE OF W. B. ROGERS, M.D.
Professor of the Principles and Practice of Surgery and Clinical Surgery,
Operations in Gastric Ulcer.
Bidwell (Amer. Jour. Med. Sc., vol. 118, no. 3) contributes a study of the surgical treatment of gastric ulcer. In concluding his article the author briefly recapitulates the class of cases of gastric ulcer in which an operation should be done. These are:
1. In all cases of perforation at the very earliest possible moment; also in sub-phrenic abscess.
2. In all cases of hemorrhage (a) where there is continued oozing of blood, especially if the stomach be dilated, and (b), in cases of repeated severe hemorrhage.
3. In cases where there is severe pain and vomiting unaffected by treatment, and which is producing progressive emaciation.
4. In cases of dilatation of the stomach from contraction within or from adhesion outside the stomach.
The operations to be performed are: in class 1, laparotomy and suture of the ulcer; in class 2, gastrostomy and suture of the ulcer, with a purse-string suture, combined with gastro-enterostomy; in class 3, gastro-enterostomy, in order to give physiologic rest to the ulcer; and in class 4, either gastro-enterostomy, or, if the pylorus be affected, pyloroplasty or pylorectomy.
Surgical Cases of Disease of the Bladder and Urethra.
Fischer (Cleveland Jour. of Med., vol. 4, no. 8), from observation of various cases and from personal experience formulates the following conclusions: 1. The surgeon's duty is not done when he gains an entrance into the bladder, but it should be supplemented by proper after-treatment.
2. A small perineal incision is preferable, but if large, the excess should be sutured.
3. Without a proper drain, chills, fever and uremia, with closure of the cut surfaces, will cause a fatal issue.
4. When a proper drain is employed nature will usually render cut surfaces impervious to the absorption of urine.
5. As an aid, gauze should be packed around the catheter till this is effected. 6. In packing, be careful that the compression does not create an adhesive inflammation, uniting the distal end of the urethra and necessitating a second operation.
7. To prevent this cohesion of raw surfaces, begin instrumentation on the third day unless contraindicated.
8. The bladder should be flushed daily with mild antiseptic solutions, and when toxic symptoms develop, the whole tract, often.
9. An impermeable coarctation of the deep urethra resisting perineal section demands a suprapubic cystotomy.
10. In the combined method, the prevesical space should be opened and the bladder incision should be made of but sufficient length to admit the passage of a small sound.
11. When collapse of the bladder prevents immediate suturing, the through and through drain should be used for four to eight days, followed by the perineal drain. By this method a fistula is prevented.
12. In obstructive cases operate immediately, thereby preventing destructive changes that militate against recovery.
13. In retention from stricture, if instrumentation, baths, opium, belladonna, enemata and aspirations fail, do not delay operation beyond the third day.
14. After an operation, the urethra should be kept pervious by daily instrumentation, gradually lessening the same to once a month.
Electrolysis and Cataphoresis in the Treatment of Inoperable and Recurrent Malignant Disease.
Fraser (Canadian Practitioner, vol. 24, no. 9), from personal experience in treating a case of scrotal sarcoma with electrolysis and cataphoresis, draws the following conclusions:
1. Electrolysis and cataphoresis, together with the internal administration of arsenic, are worthy of further trial.
2. Not being incompatible with operative or any other plan of treatment, cataphoresis may be judiciously combined with any other method in the treatment of a case in which success is not assured by that other method.
3. No case, either of sarcoma or of carcinoma, should be abandoned as hopeless until the effect of this method has been tried.
4. Removal of even a portion of the diseased tissue by the knife is indicated in any case in which rapid healing of the wound can be expected, thus lessening the work to be accomplished by electricity, and thereby hastening the cure.
5. In such operations the greatest precautions should be observed in order to minimize the process of granulation and secure rapid healing, ligatures being avoided if possible.
6. By early recourse to cataphoresis recurrences may be prevented in many operable cases.
7. If good results have been secured in cases otherwise hopeless, and in which this treatment has been adopted only after several months trial and failure by other methods, surely much more may be expected if given a fair trial in a wider field and in cases in which the system has not already been injuriously affected.
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.
Acute Epidemic Ophthalmia.
Greef (Berl. Klin. Wochenschr.) says hardly a year passes without an outbreak of acute Egyptian ophthalmia. No district is quite free, and each year acute ophthalmia makes its presence felt in or about Berlin. In the early Napoleonic time Egyptian ophthalmia is said to have destroyed the sight of many hundreds in a few days. In pursuance of orders from the government, Greef has had good opportunities to carefully study true trachoma in the regions where it is most common, and also one such epidemic in a district hitherto free. He discusses the features of certain epidemic ophthalmias which, though often confounded with trachoma or Egyptian ophthalmia, are really distinct. The mode of outbreak is not like that of trachoma, which does not spread so rapidly; trachoma is no doubt contagious, but every contagious ophthalmia is not trachoma. The contagious character of trachoma shows itself rather in the slow invasion of the other members of the household or family, of whom one or more has been affected for years, and this usually in a country or district where the disease has been epidemic for a century, or it may be for ten centuries. He contrasts certain forms of conjunctivitis with another and with trachoma.
1. In pneumococcus conjunctivitis the pneumococcus (Fränkel-Weichselbaum) occurs as an occasional inhabitant of the normal conjunctiva, and it may increase so as to bring about an epidemic. It is generally children it attacks; adults are but rarely affected. It is a transient malady, running a benign course somewhat quickly.
2. Morax and Axenfeld's diplo - bacillary conjunctivitis is a more chronic variety, in which the lids participate largely. In coverglass preparations the germs are very numerous, lying for the most part in pairs, less frequently in chains. Implantation upon normal conjunctiva produces typical conjunctivitis. It is not certain that any epidemic of this has actually occurred.
3. The conjunctivitis of the Koch-Weeks bacillus seems to be the most frequent of the contagious forms. When in Egypt, Koch found the germ in cases of the slightest form of so-called Egyptian ophthalmia. It is the cause of acute contagious conjunctivitis. It sets in very rapidly; both eyes are usually affected; pain, lachrymation, photophobia and a sense of burning are complained of. The inflammation lasts about two weeks, and the prognosis is uniformly good. As regards the bacterial origin of trachoma there is nothing settled; whether a diplobacillus or bacillus septatus is the cause is not certain. In case of an epidemic of conjunctivitis arising, it is possible to make a diagnosis of its true nature by examination for microorganisms. Sometimes it happens that the medical officer of a school makes the alarming discovery that a great number of students are suffering from follicular enlargement, and he may find it necessary to close the institution. He must be careful not to be misled by an epidemic of
follicular catarrh, or to be more accurate, follicular swelling. Schmidt-Rimpler, while engaged in the study of the cause of the frequency of shortsightedness in schools, noticed that many children suffered from some affection of the conjunctiva, and decided to make inquiries as to the frequency of catarrh, etc., at the time when there was no epidemic; he found a percentage of 34. On investigation Greef finds follicles in 27 per cent. of the children. He believes them to be due, not to contagion, but to a general pathologic condition; they are quite common in anemic girls whose conjunctivæ are not in the least influenced. Prolonged fomentation of the eye, as in the treatment of iritis, etc., will also produce them. The difference between them and trachoma granules is essential.
Annals of Oph.
NOSE, THROAT AND EAR.
UNDER CHARGE OF RICHMOND MCKINNEY, M.D., MEMPHIS.
Treatment of Chronic Croup.
Rosenthal (Jour. Amer. Med. Assn., vol. 33, no. 12) discusses that form of croup in which the symptoms of stenosis are very persistent. Cases are met that are not bad enough to require intubation, yet require treatment by reason of that symptom-stenosis remaining or appearing at certain intervals. Cases are sometimes pronounced cured where the symptom-stenosis would return in a week or ten days and require a reintubation if the tube had previously been used. Rosenthal believes this condition to be due to the presence of the streptococcus pyogenes, and has frequently observed the presence of this bacillus when no Loeffler bacilli could be found.
Rosenthal always uses antitoxin in treating croup, and if he finds the streptococcus present immediately makes a further injection of antistreptococcic serum, and continues with the antitoxin, as the case may require. If there is a negative result as regards diphtheria, and a positive result as regards the streptococci, he drops the antitoxin and continues the treatment only with the antistreptococcic serum.
The method of its use is precisely similar to the antitoxin, with this exception. Where in the antitoxin treatment a smaller dose is begun, and a gradual increasing dose the rule, with the serum a large initial dose is the beginning, and the same or a smaller dose follows. The time to give the injection is also different. In the antitoxin, any time is of value; with the serum, the early morning or when the temperature begins to rise. The parts chosen are the loins or side of the chest. The parts are cleansed with alcohol soaked on corrosive cotton or gauze, and after injection the aperture is closed with iodoform collodion. The commencing dose is 10 c. c., or even a larger quantity, and this is repeated on the same day or the day following, and is continued until its influence is shown by a decline in the temperature and pulse rate, and an amelioration of all symptoms. The duration of the treatment is the same as with the antitoxin, and on the third day we may note evidence of a cure. The serum can be used to any quantity, and is as free from danger as is the antitoxin; the same sequelæ as noted with the antitoxin, as eruption, albuminuria and the like, are found here,
and in all the manifestations the results are equal. In all cases where the bacteriologic examination shows the specific germ, the serum should be used, and in those cases of chronic croup, or where the diphtheria bacilli are absent, it is always in order to use this serum.
Acute Tonsillitis in an Infant of Five Months A Second Attack Eleven Months Later.
Brownson (Pediatrics, vol. 16, no. 8) reports this rather unusual case:
The infant was a little more than 5 months old. It was breast-fed and had been previously well. On March 14, 1898, it suddenly became feverish and refused to nurse. Brownson was summoned and found the child hot and flushed. It cried frequently and the voice seemed a little husky. There were no other symptoms. There was no cough nor vomiting, nor any signs of indigestion. The child made attempts at nursing, but would immediately stop, as if swallowing caused pain. Examination revealed no disease in the chest or digestive organs. Examination of the throat showed typical signs of tonsillitis, namely: tonsils red and swollen, and on each several round, white spots. The child seemed very sick and on the next day was more so. The attack ran the ordinary course and subsided.
The child rapidly became pale during the attack and was left very anemic. Its color had not been particularly good before. It was fretful and did not nurse as well as usual. After several days, as the color did not improve, syrup of iodide of iron was prescribed, but the child vomited it. Brownson then prescribed pepto-mangan in 5-drop doses four times a day. This the child took without trouble and soon seemed to feel better. The color began to improve, and after three weeks the child was in better condition than before the sickness. The child continued to be quite well until February 6, 1899, when it was again seized with the same symptoms and passed through another attack of tonsillitis. This attack was also followed by anemia, and the same treatment was given, under which the color and general health soon improved. While cases equally young have been reported, two attacks of tonsillitis in a child so young are certainly rare.
In the last two sanitary reports issued by the Imperial Office the kingdom of Galatia has been represented as only using the anti-diphtheritic serum in 16 per cent. of the cases, which was given as a reason for the high death rate in that country (Vienna Cor. Med. Press & Cir., vol. 68, no. 3147).
Latest reports prove that the serum has been more widely used than in other places, and are pointed to as examples of "heilserum." The complaint now is that the serum has been indiscriminately used, which accounts for the high death rate. These revelations have all been disclosed since the Kassowitz discussion in the Gesellschaft, when this country was jubilantly pointed to as conclusive proof of the efficacy of the serum.
Raczynski, who is an authority on diphtheria, contributes an article to the Przeglad Lekarski to show how difficult it is to diagnose a truly diphtheritic case from an ulcerous process in the pharynx, and relates how every clinical feature was so well marked in this case, that every expert declared it to be a genuine