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difficult must be the diagnosis between ascites originating in alcoholic peritonitis and that occasioned by alcoholic cirrhosis. It is even probable that the cases in which a cure has occurred after a great number of tappings, more than 100 in certain cases, must be considered as cases of ascites due to chronic peritonitis. Besides chronic peritonitis of alcoholic origin, it must be remembered that, tuberculosis being a frequent complication of alcoholism, we may encounter cases with affusion of tuberculous origin.
While, then, it may be said that a relative cure may be obtained in patients suffering from cirrhosis in the hypertrophic stage, it must be remembered that the proverb, "Who has drunk, will drink, "never has a more apt application than in cases of alcoholic cirrhosis, and that the imperfect action of the liver in these cases renders these patients liable to many disturbances. The least cold or the least dietetic excess renews the congestion of the liver, and a return of the ascites.
As regards cirrhosis of the liver, I have nothing to say from an etiological point of view. It is a professional disease par excellence. In the experiments which I have undertaken in connection with Dr. Audigé in developing chronic alcoholism in hogs by the daily introduction of alcohol of different kinds by the stomach, in a series of experiments which continued during three years, we were never able to obtain hepatic cirrhosis, although we observed a great number of symptoms and lesions resulting from the alcohol. The failure to obtain hepatic cirrhosis in our experiments was due to the anatomical structure of the liver in hogs. The very resistant septæ which surround the hepatic globules protect the hepatic cells against the choking produced by sclerotic processes.
Nearly the same results have been reached by different authors who have experimented upon animals. Sabourin, Laffitte, Strauss, and Blocq have been able to produce disorders in the rabbit somewhat more pronounced, but still very far short of the cirrhosis of Laënnec.
We have now only to call attention to the means which may be employed to obtain a cure of cirrhosis when this is possible, and first, we will consider paracentesis. The physician is called, in a majority of cases of cirrhosis, only when the abdominal effusion has taken place,
and has developed to such a degree as to interfere with the functions of digestion and respiration. The pre-ascitic stage, as Chauffard calls the period which precedes that of abdominal effusion, usually passes unobserved. Accustomed to frequent attacks of hepatic congestion, the inebriate gives the matter little attention, and takes no greater notice of the passing disorders relating to the urine, nor even the increase in size of the abdomen. The last symptom is most generally regarded as due to an accumulation of flesh. The fact that in the first stage of the disease pain is not the conspicuous symptom of cirrhosis, is often the cause of failure on the part of patients to observe the first symptoms of the malady.
On being called to a case of cirrhosis, the first question, then, is, whether or not tapping should be at once performed, or whether it would be better to wait for a time. In the discussion of this question, we will first establish a primary fact, which is, that when the fluid has reached a quantity exceeding six or seven liters (13 to 15 lbs.), it is very difficult by other therapeutic means than tapping,
cause the fluid to disappear. The effusion hinders the digestive functions, and especially the urinary functions. It is then necessary to leave the patient where he is, or to interfere by withdrawing the fluid. ing the fluid. Is such interference dangerous? In the majority of cases, no. In speaking thus I refer, of course, to the operation, in which complications seldom arise. It is one of the most simple operations in minor surgery. During my service as a hospital physician, I have never seen the operation followed immediately by any accident. But there are secondary accidents which have been well presented in a thesis of one of my students, Dr. Ch. Ehrhardt. We see, in fact, in the course of cases of cirrhosis, that profuse hemorrhage from the stomach or intestines may occur either before puncture for ascites or afterward. These hemorrages result from varices of the portal veins, which are produced by obstruction to the circulation in the parenchyma of the liver.
Is there always in these cases ulceration?-No; and the investigation made by one of my students, Dr. CourtoisSuffit, with his master Debove, has shown us that these ulcerations are usually not present.
There also occurs in these cases, as in hemorrhoids, a veritable diapedesis of blood through the distended venous walls. Among the causes which favor these venous hemorrhages, should be placed all causes of irritation and congestion. Among the causes which produce irritation, must be especially mentioned alcohol, which irritates and inflames the gastro-intestinal mucous membrane. Exposure to cold, by congesting the abdomen, increases the venous engorgement. Causes which produce prolapse and displacement of the abdominal viscera, also produce hepatic congestion. When the amount of the ascitic fluid is very great, there is a mechanical compression of the portal veins. The effect is similar to that produced by elastic stockings upon varicose veins of the legs, and is, to a certain degree, a preventive of hemorrhage from the portal veins. If the fluidis suddenly withdrawn from the abdominal cavity, this condition of the circulation is rapidly changed, producing considerable venous distension, which may resultin hemorrhage.
that it is much more rational to withdraw not more than 5 liters (11 lbs.), and to repeat the tapping at frequent intervals, rather than to remove all the fluid at once. But all this depends upon many circumstances: the general state of the patient, the quantity of liquid, and the amount of interference with respiration. The condition that ascitic fluids should be withdrawn slowly or in small quantities, has led some physicians to think that we might utilize in these cases the proceeding which consists in maintaining a permanent opening into the abdominal cavity. This proceeding, however, gives in practice very mediocre results. Either the opening closes itself rapidly, or, if it persists, more or less serious inflammations arise from the incision as the result of the contact of the liquid with the skin. There may appear symptoms analogous to those which follow puncture for the relief of edema of the legs. In the last stages of cardiac affections, I believe that it is wiser to employ the simple proceeding of the partial withdrawal of the ascitic fluid.
So much for the first tapping. It now remains to give instruction respecting subsequent tappings. If the abdomen is completely emptied by the first tappings, the question of a new interference must be determined by the rapidity with which the fluid returns. In cirrhosis, the removal of the ascitic fluid is never more than palliative, and when the fluid returns rapidly, it is easy to understand that rapid wasting must occur as the result of the enormous amount of fluid, 20-25 liters (40-50 lbs.) which is furnished by the system. Consequently it is necessary to delay the intervention in these cases as long as possible, and to resort to it only when required by interference with respiration.
When, on the contrary, the reproduction of fluid is slow, so that four, five, or six weeks may intervene between the tappings, this measure may be employed with greater freedom. There are some patients, in fact, who have endured such tappings for years.
In cirrhosis, death results not simply from the circulatory disturbance produced by the affusion, from digestive disorders, or from hemorrhages, but from another cause which has not been sufficiently noticed. I wish to speak of the suppression of the hepatic functions.
This suppression gives rise to a group of symptoms which have been compared to uræmia, and the patient sometimes succumbs to a coma very analogous to that which is observed in patients afflicted with suppression of the renal functions.
After paracentesis, comes, in the order of importance from a therapeutic point of view, the use of milk. Here is a most happy application of the exclusive milk regimen, and indeed, in this respect, all authors are unanimous, from Chrestien, who in 1831 recommended the utility of milk in the treatment of abdominal dropsy. Until our own time, all cases of cirrhosis have been submitted to this regimen. But Semmola has appeared the warmest partizan of this method. Milk acts in two ways: 1st, as a diuretic, by virtue of the lactose or water which it contains; 2nd, by the small amount of toxines which it furnishes to the body. Let us not forget that the cirrhotic liver possesses no antiseptic properties, and that if left to itself, it allows the toxines manufactured within the intestinal canal or introduced into it, to pass through into the blood unchanged. Finally, it acts favorably upon the gastro-intestinal irritation, which is the most common condition in habitual inebriates.
There is not a single diuretic which has not been recommended for these cases. It should be remembered that diuretics often fail, and that when cirrhosis has reached the atrophic stage, it is impossible to increase the activity of the kidney sufficiently to combat the ascitic effusion. The cirrhotic patient, in fact, as has been said, urinates into his abdominal cavity, or at least the blood serum passes in such abundance into the peritoneal cavity that the urinary function is, so to speak, completely arrested. I will indicate only a few of the pure diuretics: I have employed the hippurate of lime recommended by Poulet, to combat hepatic congestion, and with the following formula :—
25 grams, q. 8. to neutralize, 500 grams, q. 8.
We know that since the work of Jendrassik in 1886 and since the researches of Germain Sée, calomel has been considered as able to render great service in the treatment of cardiac dropsies. Jendrassik recommended calomel in doses of 12 grains daily. Germain Sée advised 7 to 9 grains; Bouchard, 3 grains. It should be well understood that this medication can be continued at the farthest only two or three days. I never employ calomel in cirrhosis, for a reason which, I have already given, namely, I fear the appearance of mercurial salivation, which might still further increase the cachectic state of the patient without giving any of the curative results of the drug. There is another diuretic which has been greatly praised in England, and more recently in Russia. I refer to copaiba. It is not the balsam which is employed, but the resin, which is much better tolerated by the stomach than the balsam. The dose of this resin is 4 grams (I dram) daily.
I know that the balsam of copaiba is not a balsam in the pharmaceutical sense of the word, but a turpentine composed of an essence, a volatile principle which is eliminated through the lungs and gives a peculiar odor to the breath, and a resin which is eliminated by the urine. This is the acid copaivic. It is this acid of which we make use.
With these diuretics, purgatives have been associated; but here it is also necessary to make some reservations. The venous stasis in the portal veins produces an edema of the intestinal mucous membrane, from which result hemorrhages, hemorrhoids, and abdominal flux. If we employ drastic cathartics, the patient may be weakened without being benefited.
It is necessary to be very prudent as regards hydrotherapy and electrization. It is necessary to be very prudent, as Millard has remarked, in the employment of cold water in cirrhotic patients. The least congestion produced in the liver occasions the reappearance of the symptoms. As to electricity, it may cause the effusion to disappear and restore the urinary secretion. In spite of the observations cited in support of this view, the experiments which I have made have given me no result.
In conclusion, I will mention a medicament which has been very highly rec
ommended, particularly by Lancereaux ; I refer to iodide of potash. For a long time, iodine and iodide of potash have been very highly recommended for ascites recurring in syphilitic patients. It is well known that syphilis, and particularly hereditary syphilis gives rise to congestions of the liver and spleen which may be accompanied by ascites. In such cases we can easily understand the utility of the iodides. But Lancereaux has maintained that iodide of potash is capable of antagonizing the hepatic sclerous process. Large doses are required, from 2 to 4 grams (1 to 11⁄2 drams) daily. It is a good plan, in giving large doses of iodides, to employ in addition a milk regimen to favor diuresis and the elimination of iodine by the urine. Relying upon the same principle, Semmola required that the iodides should always be dissolved in a great quantity of water. He employed a liter of water as the vehicle for the daily dose.
(To be continued.)
EXPERIMENTS ON BREAD AND BISCUIT.
BY M. BALLAND.
Translated from the Revue Internationale des Falsifications 1. ACCORDING to our experiments, the interior temperature of bread coming from the oven is always between 97° and 100° C. (207°-212° F.) It never exceeds 100° C. (212° F.), even when the baking is continued for 40 minutes, the time of baking usually being 30 minutes. This temperature lowers progressively, and it is only after five to six hours that a loaf weighing about two pounds acquires the temperature of the surrounding atmosphere.
2. The interior of the loaf contains, ordinarily, from 35 per cent to 49 per cent, and the crust from 16 per cent to 25 per cent, from which it results that 100 parts of crust represent in nutritive value exactly 135 parts of the soft portion of the loaf.
3. There is no relation between the quantity of water in the soft portion of the loaf and the crust. Of loaves of the same weight and the same form, the proportion of water contained in the soft portion of the loaf and in the crust is independent of the weight of the loaf and of its form. The difference in the two cases may be as great as 9 per cent or 10
per cent. For the soft portion of the loaf, the difference comes from the variable quantity of water taken up by the flour during the working of the dough. Some minutes more or less in an oven more or less heated, are a matter of small consequence as regards the soft portion of the loaf, but in reference to the crust it is different.
4. It is not indifferent what portion of the loaf is taken in determining the proportion of water. In round loaves it is proper, as Millon advised, to employ a circuit of bread weighing 150 grams running with an acute angle from the center to the circumference; but it is preferable, for loaves of all sorts, to divide the loaf into two or four parts, as symmetrically as possible, and to dry a half or a quarter. It is without doubt a different process that has led many authors to find in certain parts as much as 48 to 50 per cent of water. That is the maximum amount found in the soft portion of the loaf.
5. The amount of water which a loaf contains is in direct relation to the form of the loaf. A round loaf of 1500 grams (375 drams) contained 39 per cent water, while a round loaf of 750 grams made from the same dough contained only 35 per cent, and a long loaf of the same weight contained about 33 to 34 per cent.
For equal weights there is, then, an advantage in having loaves rich in crust. 6. The water contained in army biscuit, according to numerous observations, was found to vary with the season between 11 per cent and 14 per cent.
7. Bread coming from the oven, placed in a dry place and sufficiently aerated, dries slowly, until it contains about 12 per cent to 14 per cent of water; that is to say, only the amount of water normally contained in wheat and flour.
The time of desiccation, which is thirty or forty days for loaves of 750 grams, is no more than eight to ten days for small, long loaves of 70 to 100 grams. The latter, after spontaneous desiccation in free air, contained no more water than the ordinary military biscuit, and can be preserved equally well. They are moistened in water, tea, coffee, milk, and soup, better than the ordinary soup-bread of the soldier, and preserve this property during many years. They take up instantly, so to speak, five or six times their weight in water, when biscuit take scarcely their own weight.
Dunham's Test for Cholera.- In an article in a recent number of La Semaine Medicale, Prof. Koch approves of Dunham's test for cholera, known as the "Red Cholera Reaction," which, according to Prof. Koch, is conclusive, provided the following rules are regarded:
"In the first instance care should be taken to select a good preparation of peptone, for all peptones are not equally well adapted for this test. The variations observed are probably due, as was pointed out by Bleisch, to a difference in the quantity of nitrates present. The delicacy of the reaction can therefore be increased by raising or lowering the proportion of nitrates in the peptone solution, as was suggested by Bleisch. It is also essential that the sulphuric acid used should be free from all trace of nitric acid. Moreover, success depends on a third condition, viz., the cultures of cholera bacilli employed should be absolutely pure, for with mixed cultures the results remain open to the objection that the indol and nitrous acid which gave the characteristic red coloration were the products of the secretion of other organisms than those of cholera.
"Cholera cultures in broth never give, even in the presence of peptone, a very distinct and uniform reaction. Hence, the test should only be performed with pure cultures of the bacilli in sterilized peptone solution."
Intestinal Digestion. - Mc Fadgen, Mencki, and Sieber have recently reported the results of their observations upon an interesting case in the clinic of Prof. Kocher, of Berne. The patient, 62 years of age, had been obliged to undergo an operation for strangulated hernia, which required the removal of several inches of the small intestine at its point of junction with the cæcum, and also a portion of the cæcum. The intestine was attached to the skin, forming an artificial anus and excluding the large intestine. The following conclusions were reached by the observations:
The time required for food to reach the large intestine after being taken into the stomach, is from two to five hours.
2. From 14 to 23 hours are required for foods not the most easily digested, such as green peas, to pass the entire length of the small intestine.
3. Fermentation of the carbo-hydrates