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termination of the physiologic action of the proprietary remedy in question.
Primarily, one must study the nasal mucosa as a center for the discharge of reflexes. Some years ago in an article on, "Heretofore Undescribed Neuroses of the Lungs" (New York Medical Journal, June 13,1896), I stated the premises upon which my conclusions were formulated. The first proposition was, that there are conditions of nasal reflex genesis manifested by dilatation and contraction of the lungs. The second proposition was that the pulmonary neurosis of lung dilatation can be invoked in every healthy individual by any irritation of the nasal mucosa. At that time I maintained that the vagus contained fibres which could dilate or contract the bronchi. Auld of London, England (Lancet, October 17, 1903), referring to the epoch-making researches of Dixon and Brodie, says, "It undoubtedly belongs to the credit of Abrams, to have proved at least seven years since by a simple clinical observation, that the vagus must contain broncho-dilator as well as bronchoconstrictor fibres." Now, when the proprietary remedy is sponged into the nose even of a normal individual, it will be noted, that after a few minutes the normal lung resonance on percussion will be supplanted by dullness and, in some chest regions, a flat percussion note is elicited (Abrams' lung reflex of contraction). The same reflex phenomenon was observed in asthmatics. It may be noted parenthetically, that hypodermic injections of adrenalin possess the same action in translating lung resonance into dulness or flatness. Adrenalin subcutaneously only, is perhaps one of the most efficacious remedies for arresting a paroxysm of asthma. I employ the adrenalin chloride solution (1 in 1000) of Parke, Davis & Co., of which 8 to 15 minims are injected. It is rarely necessary to repeat the dose. I have found it equally serviceable in many forms of dyspnea even when morphin was without effect. It remains to be seen how far experi mental adrenalin atheroma will influence the clinical employment of the drug. We owe the hypodermic use of adrenalin chloride to Bullowa and Kaplan (Medical News, October 24, 1903).
Next I ran the gamut of all the recognized antispasmodics to determine their effect on lung resonance by nasal instillation. I concluded in brief, that employed alone, they induced lung dilatation (Abram's Lung Reflex of Dilatation) and only when combined with cocain was it possible to obtain the same percussional lung effects as from the proprie tary remedy previously referred to. Hence to the formula suggested by Bertram add 3%
of cocain. The formula thus constituted is the nearest approach in my opinion to the proprietary remedy in question. I contend that the theory of asthma must not be based alone on a spasm of the circular fibres of the bronchi, but on an inability of the weaker, longitudinal fibres of the bronchi being unable to expel residual air imprisoned by the circular fibres. The effect of the proprietary remedy, like other efficient antispasmodics in arresting the asthmatic attack, is caused in my opinion, by the contraction of the longi. tudinal fibres of the bronchial musculature which are no longer antagonized by the circular fibres. The action has its analogue in the bladder musculature when, in consequence of a spasm of the sphincter vesicae, the weak detensor vesicae, cannot expel the urine and ischuria spastica results. Everything speaks for the correctness of this theory. Thus, in asthmatics, owing to the feeble development of the longitudinal bronchial muscular fibres, or to the excessive development of the circu lar ones, it is impossible to elicit the lung reflex of contraction, or at any rate, it is but feebly expressed. My tracheal traction test is practically lung contraction induced by vagus stimulation when the head is thrown forcibly backward, during which time percussion of the chest is executed. It will be found that in health this test is positive, i.e., when the head is thrown back or forcibly to the right or left, percussion over the manubrium sterni and lungs contiguous thereto, will yield a dull or fat percussion sound, which is rather felt than heard (palpatory percussion).
This test is positive in health and in all cardio-pulmonary affections, but it is not present in all instances of idiopathic asthma. I have already shown that inhalations of amyl nitrit (American Medicine, January 3, 1903), which often succeed in arresting asth matic paroxysms, induce the lung reflex of contraction. This remedy recently so highly vaunted for the arrest of hemoptysis, owes its efficacy in my opinion, not to any alteration in blood pressure, but to the production of a veritable lung reflex of contraction. Amyl nitrit in hemoptysis may justly be regarded as a specific. In individuals who suffer from asthma of presumable nasal genesis, I have frequently found, that stuffing both nostrils with cotton will precipitate a typic asthmatic attack. Even though a par. oxysm may not be induced, one may bear on lung auscultation, after the cotton test, the rales peculiar to asthma. Two factors, psychic and reflex, operate in this test. chic stimulus sets up directly an altered visceral condition. Thus the firm impaction of cotton in the nasal cavities creates the con
POSTMORTEM REPORT OF A CASE OF
J. A. HARTMANN, M. D.
ST. LOUIS, MO.
THE following case is of considerable interest because of its rarity, and because of its etiology which is unusual. I regret that the records are far from complete; the examination was made under most unfavorable auspices, in the home of the deceased, on the undertaker's cooling board, and with such limited facilities as were at hand. The stomach only was removed for demonstration to the coroner and for chemical analysis.
cept of air hunger which is followed by the automatic employment of agencies which tend to combat it. The reflex factor is undoubtedly predominant, insomuch as previous cocainization of the nasal mucosa, will with the cotton test in most instances inhibit auy tendency toward a paroxysm. In the employment of agents by the nasal route for the arrest of an asthmatic attack, I cannot deny the possibility of absorption. Thus in experimenting with various antispasmodics, I often induced physiologio and even toxic action of the drugs in question. In several instances intractable emesis followed the insufflation of apomorphin. These observations taught me the very important fact, that the nasal mucosa is a suitable channel for the introduction of medicaments into the body. Thus with On July 22d, 1906, the case was reported apomorphin, nausea and emesis in several to the coroner, and early in the day I was orinstances were induced by less of the drug dered to make a post-mortem, as death octhrough the nose than by the stomach. The curred suddenly and without medical attendeventual mastery of asthma will be accom- ance, and the cause of death as given by plished along the lines of least resistance. It the family (heat-stroke), did not seem tenawill not be a subjugation of spasm, but of ble as the night previous had been but conditions which can antagonize spasm. In In moderately warm, and the death had occurred other words, spasm in the presence of circu- in the early morning. The police evidently lar and longitudinal fibres is an expression of inclined to the theory of self-destruction, as enfeeblement contending with strength, and did the reporters for the daily press who to annihilate this anomaly, we must direct our were present. The residence was remote efforts toward toning up the longitudinal from my office, and I arrived at 5 p.m. and fibres of the bronchial musculature. This immediately proceeded with the examination. is not an impossible task, if we but appreciate the fact, that the lung reflex of contraction can be evoked.
COEDUCATION was roundly condemned by President G. Stanley Hall, of Clark University, in his paper recently read before the American Academy of Medicine, in Boston. From his profound studies of adolescence, Dr. Hall is entitled to consideration and his opinions will have great weight in the present tendency to separate the sexes in the public schools after 12 years of age. It is quite likely that the vast majority of the medical profession already agree with Dr. Hall though from different motives. His opinion is based upon the fact that the life role of men requires a set of mental characteristics, the opposite of those of women, and that to modify either sex by training it in the atmosphere of the other, is to unfit it for its struggle for existence. A compromise of methods is unsuitable for either. Boys must be trained to greater manliness and girls to greater womanliness, so that each will be able to supplement the other. Coeducation may nct produce long haired men and short haired women, but its tendency is that in that direction. Am. Med.
The body was that of a young woman of 25 years, Jewish, a native of Hungary, and for six years a resident of St. Louis. A very incomplete family history could be elicited; her mother died at the age of about 50 of heart disease; her father lived to the age of 78, the cause of his death was said to have been senile debility. Three brothers living, all in good health; one dead, his death at 37 having been due to brain fever. A brother stated that the deceased had never been really sick in her life; she had had the hardy rosy cheeks, and such color as is the picture of health and is found in many foreigners on their arrival in America. Her occupation had consisted in general housework and care of her brothers' home. She first complained of indisposition three years ago, when she attributed her trouble to her heart. She had taken on flesh rapidly, a matter which disturbed her considerably, and which seemed a contributory cause for periods of depression and melancholia, her imagination centered on the point that she was getting too stout. This was aggravated by members of the family twitting her of being fat. To counteract this tendency to superfluous flesh, she had begun at a time about two years previous to her death, to limit her diet as closely as pos
* Read before the Macoupin County (Ill.) Medical Association at Carlinville, October 16, 1906.
sible to acid foods; eating pickles and drinking vinegar and other acids for their supposed therapeutic effect, and avoiding all fat producing foods. This had been continued up to the time of her death.
On the evening of July 21st, she had seemed in usually good health, she had spent the evening with a brother and his family in a distant part of the city; he states that they noticed that she was in unusually good spirits. On her return home she retired without complaining of feeling ill. In the morning she arose at supposedly the usual time (about 6 a.m.) and walked to the bath-room, a distance of about ten feet, and in the bath-room fell forward striking her forehead on the edge of the tub causing a contusion described below. The family, on hearing the fall, hastened to the room and found her lying on her face on the floor. A physician was hastily summoned and pronounced life extinct. The case was reported to the police, and they in turn reported to the coroner, who ordered the post-mortem examination.
The body was that of a white female, height 5 feet 3 inches and weight about 140 pounds; well nourished, but very anemic, having the waxy color, indicative of possible internal hemorrhage. There were no external evidences of violence, except a small superficial circular contusion about three-fourths of an inch in diameter, situated on the forehead, above the left eyebrow, close to the margin of the hair, and which was so insignificant that it could have played no part as a cause of death. There were no burns about the lips, tongue, or mouth and no odor was discerned.
A median incision was made from the supra-sternal notch to the symphysis pubis, exposing the abdominal viscera; the left side of the abdominal cavity was filled with altered blood clots, and pure blood, much of which had to be removed before the viscera could be examined; the blood clots covered both the anterior and posterior walls of the stomach at the fundus, completely surrounded the spleen, and a considerable quantity was found anterior to the left kidney. The space between the diaphragm and the left lobe of the liver and between the left lobe of the liver and the stomach was filled. The hemorrhage area being the left side of epigastrium, left hypochondrium and the left lumbar regions.
The peritoneum was found normal, the stomach collapsed empty, and markedly congested, its mucous coat was dark brown, there was an entire absence of rugae; this even extending to its pylorus; its walls were very thin and slimy and were translucent when held to the light, showing an evident atrophy of the muscular coat. There were no evi
dences of gastric ulcers, past or present, but there was an irregular tear along the fundus, following the greater curvature and situated anterior to the gastro-splenic omentum; this was about four inches in length, the peritoneum was retracted from its edge, and at the edge the stomach wall was of the thickness of thin paper, and over the rest of the stomach was but slightly thicker. The examination of the other viscera showed the liver and gallbladder normal, the common duct patulous; the intestines were empty, a chronic catarrhal duodenitis was discovered, but there was no other pathological lesion of the intestines. The pancreas was normal; the left kidney was movable, but the kidneys were otherwise normal as were the ureters. The bladder showed a mild cystitis at the trigone, it contained about two drams of clear, light colored urine. The uterus showed a subserous fibroid, about one inch in diameter, situated on the posterior wall, near the fundus, it was otherwise normal. Both ovaries were cystic.
The sternum was then removed, and the thoracic organs were found in normal position; the pericardial cavity contained about an ounce of citron colored fluid, the heart was normal in size and showed a slight degree of fatty degeneration. The semi-lunar valves of the aorta were slightly thickened. The arteries were markedly atheromatous. The plural cavity showed pleuritic adhesion on both sides, but no effusion. The lungs were normal. The mucous membrane of the esophagus was silver white in color, very thin and easily torn.
The scalp and skull were normal, the coverings of the brain and the brain itself were normal. This narrowed the examination down to a consideration of the conditions presented by the stomach.
Owing to the extreme thinness of the walls of the stomach and the congestion and dark color of the mucous membrane of that organ, a chemical analysis was made of the stomach substance, there being no contents, for the following poisons with results noted; the regulation tests being used.
Hydrochloric acid could be detected, though not in abnormal quantity. A digest of portions of the stomach was made which showed acetic acid very definitely. Test was made for acetic acid by digesting the stomach substance with distilled water and filtering, the color of the filtrate was light straw with de
cided acid reaction; the odor of acetic acid was marked. Neutralizing with ammonia
water and ferric chloride test solution added a blood red color proved the presence of acetic acid, this was confirmed by the color being dispelled on the addition of sulphuric acid.
The examination left us with a confirma
tion of the opinion that death was due to the development of the condition by violence of diet. We were told that the deceased has not only used an acid diet, and that for a long time, but that she had been known to drink pure vinegar, and that at frequent intervals.
The chemical analysis of the stomach confirms these statements and demonstrates the morbid effect thereof. Whether or not the rupture of the stomach occurred before, at or after death, is a matter which we cannot definitely determine; its cause may have been hemorrhage in the stomach, or an accumulation of gases, the presence of either may have occasioned her arising and going to the bath-room where in falling the stomach was ruptured or the rupture might have occurred from the same cause even before she arose from her bed. It would seem that spontaneous rupture of the stomach
rarely takes place, then only a post-mortem condition, or in the agony just preceding death (Stengel).* In this case we have absolute cause for the malacia by chemical examination and the previous history of the case. The fact that the deceased retired
in what was considered by her family normal health, in conjunction with the fact that there was no terminal edema in either lung, proved conclusively that death was sudden. It seems possible that there may have been a tear in the mucous membrane, or that an artery ruptured in the stomach wall (the arteries is being atheromatous) causing hemorrhage into the stomach, and that the weight of this blood and the effort of the stomach to get rid of it could have resulted in a rupture at the thinnest part, which in this case was at the fundus. Had gases sufficient to cause the tear been generated in the stomach, one would have expected to find distention of the abdomen, which was not present. Such a condition would in all probability have occasioned great distress and caused the deceased to gain relief, either by changes of position or by direct pressure. In either or both attempts, the stomach could have been torn. Another interesting fact brought out
in this case was the marked atheroma of the arteries in one so young, which no doubt was occasioned by the peculiar acid diet, bearing out the theory that the condition was produced by dietetic causes.
Alfred Stengel's Pathology, 1903 edition, page 529.
In looking over the literature on this subject, I find according to Cattell, that when the contents of the stomach are found in the peritoneal cavity, care must be taken to determine whether the escape was due to (a) post-mortem digestion, or autopepsia; (b) to trauma; (c) to perforation from a gastric ulcer, or from chemical erosion by poison, etc.; (d) to the presence of (b) and (c) with the factor (a) as the real cause. In the first case, the ingesta are usually widely distributed throughout the abdominal cavity, though more plentifully in the immediate neighborhood of the perforation; the rent is large and irregular and the walls are soft and slimy, while in disease the opening is apt to be small and circular and surrounded by evidences of hemorrhage and peritonitis, undigested food enters the peritoneal cavity through a breach in the gastric wall.
Auto-digestion is especially frequent in cachectic children. I think while there is a possibility of there having been a certain amount of post-mortem auto-digestion, after a part of the stomach had ruptured, the previous history of acetic acid poisoning which we found so clearly before and after death, would correspond to the cause of rupture by Cattell under (c) chemical erosion, and the positive evidence of recent hemorrhage.
Unfortunately the specimen passed out of my control before I made a microscopic examination, but the fact of such extremely thin walls is in itself proof of atrophy of the muscular and the mucous coats which was undoubtedly the result of the diet.
My thanks are due to Mr. H. P. Leftwich for his painstaking chemical analysis, and also to Dr. Jules Baron, coroner, for allowing me the privilege of reporting this case.
1228 South Broadway.
REST CURE.-Six weeks in bed was the old treatment for acute articular rheumatism. Six weeks in typhoid, six weeks in iritis, six weeks in gonorrhea at its best, and six weeks in so many other infections, all suggest that perhaps here there is the basis for some kind of a generalization. Perhaps the organism really requires six weeks to gather its forces and manufacture its supplies to defeat an army of invading parasites of certain species and repair the damage they inflict. thought well worth following up. there is no such general law possible, it is a good rule to impress upon patients even in the most trivial complaints—a cold-an influenza-a depression from overwork.-Am. Med.
It is a
Hy. W. Cattell's Post-Mortem Pathology, 1905 edition, page 87.
THE MAN WITH WHOM YOU MUST LIVE.
A. L. BENEDICT, M. D.
III. TALKS TO RECENT GRADUATES.
SOME one has said that everyone should try to live in the society of his superiors and, some one else has asked what would happen if the said superiors should, themselves, adopt the same rule. In a broad sense, however, every man is, at one time or another and in cne respect or another, the supericr of every other man. It does not seem a wise, certainly not a generous policy, always to seek the society of those who can help us and yet, in the long run, it is both wise and just to select associates who will draw us upward rather than downward. Every man has one associate whose society he cannot avoid, with whom he must spend more time than with anyone else himself.
Right here, we wish to state that this article is not exactly a sermon, although it might be prefaced with one of a number of Bible texts, and that it is not a report of one's own case. The physician who reports his own case, does not always have the proper perspective and, besides, we dislike to report a case which has turned out not altogether successfully, and in which we are not even sure that the diagnosis is accurate.
It is scarcely necessary to state that this man with whom we must spend the greater portion of our lives, ought to be decent and honorable. We do not want to be tied down to the society of an abortionist, for example. Very early in your professional career, you will be asked to do an abortion. The request may come from a prostitute or a woman who, without mercenary motives, leads a rather promiscuous sexual life. Such a woman has already had so many abortions that she thinks nothing of them, if she cannot induce you to perform the necessary operation, she will go to this or that other physician, perhaps naming one of good standing and repute. At any rate, as the abortion is going to be brought about anyway, you might as well perform it. Or, the case may be the one of the melodrama or of the sexual morality lecturer or of the novelist: the innocent girl betrayed and struggling to maintain her reputation. argument is still more cogent and eloquent. There is nothing that you can say to her that she does not know and realize to be correct on general principles but, in regard to her particular case, there is not an argument or an appeal to conscience or a coldblooded statement of practical danger that she cannot meet with a better, stronger and
more eloquent plea. Or the request may come from some respectable married lady, of wealth and influence, who has nothing to fear as to reputation but who, as a matter of health, or convenience, or economics, or The whim, wishes to limit her offspring. request may come from some male acquaintance, perhaps your former chum, who is up against it-it may be his fiancee is involved or some other girl, when his wedding day is already set. Perhaps the request comes from some older man or woman, to whom you have looked up for years, as an adviser, a model of good morals, an active church worker, a professional colleague.
From whatever source the request comes, bear in mind two important facts: You do not need to explain the iniquity of an abortion nor its serious risk; everyone who has any sense at all, realizes these points. Neither can you summon any logic nor eloquence that can equal the need and the earnestness of the person who wants the abortion performed. One more fact may be stated: an abortionist who is aseptic and not too clumsy, can enjoy a lucrative practice, with very few deaths and the man who refuses to perform abortions will lose a good deal of practice and will make enemies of many influential persons.
Now, having these facts clearly in mind, make up your mind that you will not perform your first abortion, refuse to discuss the matter with applicants, and stick to your principle, which is simply a corollary of the sixth commandment, regardless of financial losses. It isn't pleasant to live with a murderer, however successful his practice; and, besides, the professional murderer is bound, sooner or later, to be found out.
Abortion is about the only out and out crime, to which the physician is particularly tempted. You will read in detective stories of physicians who administer poison to assist in securing life insurance, who run slender needles into the medulla oblongata in order to hasten the execution of wills, who chloroform disagreeable relatives, or who prepare cultures of cholera spirilla to bring about a change of political regime. But, whereas any physician, however good his standing, will be importuned to perform an abortion, every few months, the average physician will never in his life, be asked to perform postnatal murder. Neither will he, more than any other man, be sought to perform other gross crimes.
You will, however, probably be tempted to do many acts that, while not strictly criminal nor in gross violation of divine law are unethical and dishonorable. If you are a relig ¡ous man, don't imagine that you can live