THE MEDICAL STANDARD. VOLUME VI. NUMBER 5. NOVEMBER, 1889. TREATMENT OF HIP DISEASE. It seems strange that people for whom we have the highest respect will sometimes make assertions equivalent to the proposition that black is not white, use considerable printed space to prove it, and thereon base a proceeding not otherwise excusable. Dr. Edwin Borck is quoted (MEDICAL STANDARD, October) as saying in an article on hip disease, that "extension and counter-extension employed upon the fanciful theory that thereby the head of the femur is separated from the acetabulum are useless." After describing the joint he says: "It cannot be pulled asunder." Then because these propositions are incontrovertibly true and the joint cannot be so relieved, he advocates what I consider a most B. Vertical section through hip joint of a child. A to B indicates the direction of extension necessary to relieve pressure in the socket. C to D indicates the direction in which the head of the femur is carried by extension in a line with the body, aided by the femoro-pelvic muscles. atrocious proceeding-an incision into the joint in the second stage. Of course, every ounce of extension and counter-extension with the aid of the large mass of femoro-pelvic muscles pulling the head of the femur directly inward, must add an ounce to the pressure of the head in the acetabulum, though from the time I first learned orthopraxy, twenty-five years ago, until the present, American textbooks have taught the mechanical impossibility of extension in a line with the body affording relief from pressure in the socket. CHICAGO: G. P. ENGELHARD & CO. If to direct extension and counter-extension there be added sufficient lateral extension directly outward to equal the extension in a line with the body, the mean force of extension will be seen to be in an axis with the neck of the femur, and every ounce of extension so exerted must relieve an ounce of pressure in the socket, even though there be no appreciable separation of the head from the acetabulum. This is just as certainly true as that ninetyfive pounds of lifting power will relieve that much pressure of a hundred pound body on the ground, even though there be no separation of the body from the earth. As the result of quite an accumulation of cases entirely recovered, with slight or no deformity to show that a diseased condition had ever existed, the following propositions which have been proved many A times over, are offered: First. With proper attention in a given case, improvement will generally be in proportion as movement and pressure, the two factors of friction are relieved, for it is friction that destroys the delicate new tissues of repair more rapidly than nature can provide them. Second. Extension in an axis with the neck of the femur relaxes the muscles by overcoming reflex spasm, relieves the pain of the second stage, D prevents jar and concussion in the socket and returns the adducted leg to its natural position. The orthopaedic surgeon, with a clear idea of what is to be accomplished, will usually find the means. I use a splint made as follows: An inflexible strip of iron, known as "binding," is bent to the form of the body and made to extend from the lower angle of the scapula to the heel on the affected side. This secures nearly complete immobility. Direct extension and counter-extension are made from bands riveted to the main upright at ankle and waist. A spring is made to reach from the outside of the knee to the crest of the ilium, to which is attached a soft padded band passing around inside the thigh, by means of which all the lateral extension is exerted, which the patient will tolerate. Both extensions being equal, the mean extension will be in an axis with the neck of the femur. Put a high shoe under the foot of the unaffected side, provide a pair of crutches and insist on plenty of outdoor exercise, the more the better, for the diseased joint is now fully protected from accident. Though the disease is generally of a tuberculous character, there is in my experience but slight danger that there will be any such special or general tendency to tubercular deposit as will influence a return to a diseased condition, either in the joint or other parts of the body. Relief from friction and outdoor exercise results in healthy appetites, red cheeks and rapid recoveries in the great majority of cases, while plaster of Paris, wire and other splints which only prevent movement, weight and pulley and other extensions in a line with the body that can only impinge the head still more disastrously into its socket, lead to incisions, excisions, pain, deformity, and often death. 34 E. MONROE STREET. THREE CASES OF TUBERCULAR MENINGITIS.' One of our principal writers on diseases of children has stated that bromide of potassium was the sheet anchor in the treatment of tubercular meningitis, and if this failed, then the case was hopeless. Many physicians and authors have said that if a case of tubercular meningitis recovered, the probability is that the doctor was mistaken in his diagnosis, and the case was non tubercular. In a clinical report in "Archives of Pediatrics," August, 1889, Dr. V. P. Gibney states, concerning a case of basilar meningitis, that so soon as the diagnosis was made the boy was placed under a treatment of bromide of potassium and mild laxatives, from which I should infer that the bromide was still the treatment in some hospitals. I will report three cases of tubercular meningitis, where the diagnosis seemed reasonably clear, to show that some cases in the first stage may recover, and also to add an additional mite of testimony to the efficacy of iodide of potassium, instead of the bromide, in this very fatal disease. Case I-Et 4. Had always been a robust, healthy child, with rosy cheeks. Her family history was not good, aunts and uncles of both parents having died from phthisis, although her own parents were moderately strong and in good health. Two years previously I had attended her sister, who died from tubercular meningitis at the age of five, after an illness of three and a half weeks, all the peculiar symptoms and final lingering having been wellmarked. This illness of the second child was very similar in its prodromata to that of the deceased sister. Her appetite failed first; she became pale and languid, and moped around; continually lost in flesh and strength; became peevish and shy, and would not go near any one except the parents, although previously of a very happy, rollicking disposition; pulse was irregular. Finally she would allow no one to touch her but her parents, who told me of the continued irregularity of the pulse. The temperature was not high, ranging from 100 to 102°. The respiration was not especially 1 Read before the Miss. Valley Med. Asso., Sept. 10, 1889. changed. Vomiting occurred on several occasions, and the bowels were sluggish, though not constipated. She complained of pain, extending from the forehead back over the crown of the head. The nervous symptoms were well marked. She would awaken once or twice every night with a scream (hydrocephalic cry) and it was five to ten minutes before she could be relieved of her fright, and induced to relax her hold on her mother. Then she would not go to bed again without her mother. During these paroxysms she seemed to be unconscious and knew no one for a time. In the daytime, as well as at night, she was afraid to be left in a room by herself. At first I gave the child quinia very freely, supposing that there might be a malarial factor in the disease, but utterly failed to ameliorate the trouble. Purgatives gave no evidence of worms. Dr. Eustace Smith says that "in doubtful cases the fact that a previous child had fallen a victim to intracranial inflammation, becomes an important aid in arriving at a decision. The parents and I both remarked the similarity of the symptoms to those of the sister who had died two years before, and without further delay I began the use of iodide of potassium, five grains four times a day. Under this treatment alone the child began to improve, and gradually regained her usual health and strength. kept up the treatment for four or five months, lessening the iodide to three, then two, and then one dose a day before ceasing. I Case II. This child was a year older than the first, being five. The family history was similar to the first case; a history of consumption in the generation previous, although the mother and father were well. A sister had also died of tubercular meningitis. For over a month before I saw her the child had been failing in health and had become languid, and the appetite, at first capricious, had entirely failed. From a plump, little ruddy-cheeked girl she gradually dwindled away until the bones on the back of the hand were clearly outlined, and the cheeks hollow. She had the nocturnal hydroceph DOES HYDROPHOBIA EXIST AS AN INFECTIOUS DISEASE. This child was given five grains of potassium iodide, four times a day, and made a good recovery. The iodide was given at intervals for a year. Case III. Æt 6. Family history revealed no consumption, but on the mother's side there were marked scrofulous landmarks in several members of the family. The child was a precocious girl, did not look robust, but had not been a sickly child. She was seized with the characteristic symptoms of tubercular meningitis, diagnosed as such by Dr. Parvin, now of Jefferson Medical College, who informed the parents of the gravity of the disease, and that the result in all probability would be fatal. She was given the potassium iodide treatment, and bromide of potassium when restless, and to the surprise of all recovered, and is now about sixteen years old. A few years after, however, her younger sister, aged seven, was attacked with tubercular meningitis, and after the usual prodromata, the disease ran a typical course, and she died. I do not know the plan of treatment in this case, as I did not have charge of it, except that an ice bag was kept constantly on the back of the head to subdue the pain, and she was given bromide of potassium in the beginning. The typical course of the disease in this case rather substantiates Dr. Parvin's diagnosis in the sister, who recovered after so many of the prodromata had been present. In none of these cases was there any trace of hereditary syphilis. I have had under my care seven fatal cases, 137 of basilar meningitis, all children but one, and the points I wish to emphasize in this report are, first, that a few cases are curable if recognized early, and second, that our hope rests in the use of the potassium iodide, and possibly cold and counter-irritants. Dr. J. Lewis Smith says that "if the initial stages have passed without proper treatment, death may be considered inevitable." "M. Guersant believes that recovery from the first stage of tubercular meningitis is possible." Dr. Charles West, in his lectures on the Diseases of Childhood and Infancy, states that potassium iodide as a remedy is more encouraging than any other, and mentions one case in which recovery took place under its employment. In the Annual of the Universal Sciences for 1889 we find the remedies most recently recommended. Lemoine praises iodoform and gave it in doses up to eight grains a day for three months, with the happiest results and no toxic action. Garrison describes a doubtful case which recovered after the application to the shaven scalp of an ointment of iodoform and adeps, one to seven, applied every eight hours under oiled skin. "Bystrow saved two of three cases in which the symptoms pointed clearly to tubercular meningitis, by the use of ice and counter-irritants to the head, and the administration of iodide of potassium." "Bristowe reiterates his belief in the possibility of recovery from the disease." Lemoine reports a case of recovery in a girl fifteen years old, to whom he gave four grains of iodoform twice a day, dissolved in ether and put in a capsule. I will not, however, multiply cases of reported cures or failures, but conclude by urging a free and early trial of the potassium iodide, as recommended by most authorities at the present time. DOES HYDROPHOBIA EXIST AS AN INFECTIOUS DISEASE? My answer to the question "whether hydrophobia exists as an infectious disease" is a decided negative. The more I examine the subject of lyssa the more am I convinced that this bete noir of human pathology does not exist in the race as a pathological entity; that persons bitten by dogs, rabid, or alleged to be rabid, exhibit a combination of grave symptoms, there can be no doubt; but that these symptoms are the result of an infection derived from the teeth and salivary secretion of the animal, admits of serious question. Of course an assertion can not have any weight unless it be substantiated by a reasonable amount of proof. I thirk that the following facts summarize the position taken by the writer at the outset of this article: First. All infectious diseases known to man have a distinctive set of symptoms, follow a certain course, and exhibit a fixed pathological basis. Can the same be said of lyssa? Whoever has examined cases of this alleged disease during life, and the organs of the affected individual after death, will be compelled to say: The symptoms of my cases corresponded in no particular except, perhaps, in the dread which all, or nearly all, my cases presented. The postmortem record of all these cases presented absolutely no data on which to assume that an infection had performed its deadly work. Four different varieties of bacteria have been described as being the cause of this disease. If observers were more numerous there would be no limit to the varieties of bacilli and micrococci which would be found in the blood and secretions of an individual alleged to be suffering from lyssa. Dowdesdale found a micrococcus, Motte and Protopopoff a bacillus, while Solles found a bacillus differing in shape from the former. When the number of varieties will cease is a question which, in the present state of bacteriological science, will not permit of an an swer. Secondly. All infectious diseases known to us have a constant period of incubation. Lyssa certainly has not. Numerous cases attest that the alleged period of incubation extends between a few hours and seventeen years. It may be said that syphilis shows this tendency; but who will say that the initial symptom of the latter disease can always be detected? Thirdly. There are no constant and invariable signs of this disease. Neither is its course uniform nor is its clinical history. If these criteria, which would make a nosological entity of lyssa, were the fact, it would have a recognized stable pathological basis. The converse of this proposition is likewise true. For example, have the clinical and pathological histories of typhoid, small pox and anthrax changed? Are they inconstant? And can the same be said of lyssa? What must we then infer? The only inference which can be drawn is that no infectious agency can be the ultimate cause of this disease. And yet the bite of a rabid dog (and for that matter of a dog that is not rabid) is oft followed by fatal results. If there be no infection in the bite, what has caused death? Laying aside the numerous diseases which have been mistaken for lyssa, and which Dulles, of Philadelphia, so ably portrays, it is my opinion that the fatal results in all cases of lyssa may be relegated to one of the following categories: Either septicæmia, tetanus, acute delirium (grave delirium, typhomania). The presence of either the first or second of these classes may be readily explained. That of the third is not so readily. However, it is my purpose to show the chain of thought which induced me to place this third category in this classification. It is a fact known to alienists that grave delirium more frequently follows intense emotional shocks than any other form of mental disease. Fear and dread, the result of the superstitious traditions which are attached to dog bites, are the predominant factors, to which must also be added expectant attention, in the production of the mental disturbance of lyssa. These disturbances correspond in all particulars to the clinical history of acute delirium. My belief is therefore that in the great majority of cases lyssa is but this form of insanity—an insanity which is known to be very fatal. It is not the infection of the bite which produces this form of lyssa, but the fear and expectant attention which the bite has engendered. 805 LEXINGTON AVENUE. CIRCUMCISION.' BY A. U. WILLIAMS, M. D., HOT SPRINGS, ARK. In performing circumcision the simplest method is the best. I use Henry's phimosis forceps, as I consider them superior to any other. I draw the loose integument forward, clasp the forceps firmly over it, and with a large bladed knife, cut away the surplus tissue at one stroke, and quickly pour a solution of cocaine (I usually use a four per cent. solution) over the cut, which stops all pain in a few seconds. The application of cocaine is repeated at intervals of a few minutes over the inner skin. Then with a pair of strong scissors I slit up the dorsal surface back to the corona; trim the sides with scissors to suit the first cut; if the first cut has been a little short I leave more of the under skin, but if too much is left it may become ten 1 Read before Miss. Valley Med. Assn der and furnish room for herpes. I then use a fine silk thread, about number eleven, to unite the cut edges. They should be nicely adapted, as in a majority of cases union by first intention can be secured over a large portion of the cut. I sometimes use the interrupted and sometimes the continuous suture, but as a rule I prefer the continuous suture. As a dressing I use a small piece of absorbent cotton saturated with balsam Peru; apply a roller bandage with a wide strip of muslin drawn between the legs, fastened in front and back to a strip around the waist for the purpose of retaining the dressings and to hold the penis erect. It is not necessary to put the patient to bed; he can go about his usual business unless it is manual labor. On the second or third day POST-DIARRHEAL CONSTIPATION OF CHILDHOOD. I direct him to take a bath, when I remove the stitches and apply a dressing of vaseline. In a few days he is well; a circumcised Gentile. I have made over 400 circumcisions, and fully fifty per cent. of these were for the cure of herpes. Many men who have herpes imagine they have syphilis, and with or without the ad 139 vice of a physician take constitutional treatment. Many come to Hot Springs thinking they have "blood disease." It is for this reason and for cleanliness that I advocate circumcision. I would follow in the footsteps of Moses and circumcise all male children. The operation is simple and free from danger. POST-DIARRHEAL CONSTIPATION OF CHILDHOOD.1 The constipation of childhood is important because of the great diversity of its causes, the innumerable remedies recommended for its relief or cure, and the great tendency on the part of both parents and physicians to neglect it until it begins to make visible inroads on the health of the child, at which time organic changes have resulted in the bowel, disordered functions in other organs, chronic focal poisoning, and in some cases fatal complications. The worry, trouble and grave anxiety concerning the present health of the child is not of as great moment as the effect constipation will have on the future development and working condition of the intestinal tract during its after life; which may so affect the general health as to make the prognosis more doubtful in any disease which may subsequently attack the child. Diarrhoea is by no means an infrequent cause of constipation. The constant and continuous irritation of both the muscles and nerves of the bowel in a prolonged diarrhoea is followed by exhaustion and diminution of irritability. The muscles are overworked and lose their inherent irritability and tonicity; while one of the most important agencies in the restoration of the normal condition of the muscle—the blood— is interfered with. Not only is there anæmia; the muscle not receiving sufficient nourishment, but there is a sluggish circulation which retards the removal of waste products, caused by contraction, which is exhaustion. Next to the left ventricle the muscles of the bowels lose their contractibility, soonest after death. Reasoning from analogy it may be assumed that the muscles of the bowels lose their tonicity during life more readily than any other except the left ventricle. The same causes which produce loss of tonicity in the muscles of the bowels affect equally the loss of irritability in the nerves which so abundantly supply them. The effect on the ganglia of Auerbach and Meisner's plexuses, and reflected through the solar plexus accounts for a great number of reflex phenomena. Mississippi Valley Med. Assoc. Trans. Condensed. In a number of cases a not infrequent symptom has been the retention of urine; at first this was attributed to direct pressure of the distended bowel on the bladder causing vesical irritation and spasm of the neck, but at the suggestion of Dr. W. H. Thomas of Indianapolis, I looked to another source for its explanation. The ano-spinal center and the vesico-spinal center are situated near each other in the lumbar region of the cord. May not a connection exist between these two centers through which reflex impulses are transmitted? In cases of prolonged constipation there is no stimulation to the anal sphincter, no impulse is conveyed to the ano-spinal center, and none can be reflected to the vesico spinal center. This deprives the latter of a stimulus which normally it receives at least once every twenty-four hours. Constipation results from atony or paresis of the bowels, caused by the excessive irritation of a diarrhœa, in which there is diminished peristalsis, accumulation of fæces, dilatation of parts, or the entire bowel, oftentimes displacement of distended portions, reflex symptoms, and interference with the proper performance of other functions from lack of reflex stimulation. Tonic treatment naturally suggests itself. Thoroughly evacuate the bowels, by enema and saline laxative--avoid drastic cathartics-assist in forming habits of daily evacuation by glycerin suppository. Correct defects in diet, hygiene and clothing. The systematic application of massage and electricity and the internal use of strychnine, ergot, iron, and quinine, either singly or in variable combination, are indicated. As preventive measures do not dismiss your cases of diarrhoea as soon as the bowels check, but see that the proper functions are established. 126 N. MERIDIAN STREET. ENGLISH workhouses do not seem to be much better officered medically, if as well, as the best American. A pauper druggist in the Birmingham workhouse nearly killed three women recently by giving them zine sulphate in lieu of Epsom salts. |