BOOK REVIEWS. Syllabus of Lectures on the Practice of Surgery, Arranged in Conformity with the American Text Book of Surgery. By N. SENN, M.D., PH.D., LL.D., Chicago. Unfortunately, like all other works of its kind which sacrifice truth for space, the syllabus is full of statements likely to misinform the student. For example, on page 199 the author states that gonorrhœa in the female is not “as serious in its results as in the male." The fallacy of this statement, viewed in the light of modern pelvic surgery, needs no comment. Again, on page 143. puncturing the intestine is mentioned as a method of treatment in intestinal obstruction "when great distension is a marked feature." To refer to this plan of treatment in writing a review of the history of surgery is eminently proper, but to place it among the recognized methods of modern surgical practice is not only misleading to the student, but danger. ous to his future patients. The author tells us, in the preface, that “ "every teacher of surgery must have felt the need of some short guide to aid him in the lecture-room," and suggests that the syllabus may fill this longfelt want. Granting, for the sake of argument, that there is a "teacher of surgery" in any of our leading medical colleges so wanting in originality as to need such a guide, we are of the opinion that it would be less of a strain upon his brain to devise a classification of his own than to separate the obsolete from the modern or to add what has been omitted in this syllabus. We had hoped that the mania for condensations had reached bottom rock when the manual and compend made their appearance in medical literature, but our hopes were evidently in vain, as the syllabus before us has condensed away even what little good they contained. A Manual for Boards of Health and Health Officers. By LEWIS BALCH, M.D., Pн D., Secretary State Board of Health of New York, etc. Banks & Bros., Albany, 1893. This manual should be very useful, particularly to those who are engaged in the service of State or local boards of health. It is also capable of proving serviceable to every physician in the course of his practice. The book is concise and practical. It is divided into chapters treating of the State Board of Health, its powers and duties; the functions of local boards; the duties of the health officer; how to deal with nuisances; the duty of the physician regarding contagious and infectious diseases, etc. Each chapter is subdivided into a number of sections, in which information upon the various points is clearly but concisely given. CURRENT MEDICAL LITERATURE. A New Holder for the Sims Speculum. By B. How Shall We Make Our Homes Healthy? By Benjamin J. Portugaloff, M.D. Translated from the Russian. An Economical System of Sanitary Drainage for City and Country. By M. Nadiein, Captain of the Russian army. Ventral Hernia following Abdominal Operations. A New Pathology and Treatment of Nervous Catarrh. By Seth Scott Bishop, M.D., Chicago. The Use of Nitro Glycerin in Arterio Sclerosis. Read before the Section of Therapeutics, PanAmerican Congress, at Washington, September, 1893. By Thomas G. Ashton, M.D., Demonstrator of Clinical Medicine in the Jefferson Medical College, etc. Fifteenth Annual Report of the Sunday-Breakfast Association, of Philadelphia. Vaginal Extirpation of the Uterus. Forty Consecutive Cases. By Joseph Eastman, M.D., LL.D., Indianapolis, Ind., Professor of Diseases of Women and Abdominal Surgery, and late Professor of Anatomy, College of Physicians and Surgeons. A Few Points of Interest to the Family Phy sician. By Joseph Eastman, M.D., LL.D., Indianapolis, Ind. Abdominal Surgery and its Evolution and Involution. By Joseph Eastman, M.D, LL.D., Indianapolis, Ind. COMMERCIAL NEWS. CONSUMPTION CONTAGIOUS. Dr. Herman M. Biggs, Chief Inspector of the Division of Pathology and Bacteriology of the New York City Health Department, officially declares consumption to be a contagious disease. Six thousand deaths from this dread disease were reported in that city alone during 1892. State and municipal boards of health in all parts of the country agree that consumption is at least an infectious and communicable dis ease, and that every tubercular person is a source of actual danger. The disease is transmitted from the sick to the well usually by means of the dried and pulverized sputum floating as dust in the air, and it is estimated that at least one-seventh of the persons who die from phthysis acquire it from breathing the air so tainted. This being the case it can in a great measure be restricted by the use of proper and unobjectionable disinfectants. Platt's Chlorides, I part to 10 of water, frequently sprinkled about the room, and the same disinfectant, I part to 4 of water, in the cuspidor or vessel receiving the poisonous and offensive expectorations is especially applicable, as it is a liquid without odor or color, and its frequent use is not attended with any annoying features. Certainly it is time that more strict surveil lance of this destructive disease were assumed by physician and attendant, and if physicians. will do with consumption as they have done with other dangerous diseases much suffering and loss of life can be prevented. DYSMENORRHEA D. M. Bloom, M. D., New Waterford, Ohio, says: "I have prescribed Aletris Cordial in the case of a young lady who had suffered from severe dysmenorrhea for a number of years. During this time she had been treated by a number of physicians, using almost every known remedy, without receiving any benefit. I prescribed Aletris Cordial, teaspoonful doses three times a day, with the most satisfactory results. She now passes over her monthly periods entirely free from pain. I have used it since in different cases of dysmenorrhea with the same pleasing results. I have also prescribed it in a case of prolapsus uteri, where there were present hysterical manifestations. Gave Aletris Cordial and Celerina, equal parts, dessertspoonful three times a day, with excellent results. I can heartily recommend it to the profession as one of our most efficient uterine tonics." EMPLOYMENT. Doctor, do you know of a young student who would like pleasant and profitable empløyment, something to help him along in his college course? If you do, and can recommend such a one to us, we will not ask that the service you thereby render us should be without compensation. For every successful man you recommend to us we will give you your choice of some very desirable and practical literature, payable when the cash sales of such agent will have reached the sum of $25 00. As we shall have some accounts to collect, we will have to have a small bond from each representative. See advertisement in reference to this matter on page 22. IMPROVEMENTS. The Galvano Faradic Mfg. Co., 300 Fourth Avenue, New York City, have just completed important improvements to their well-known. establishment at the above location. They have double the size of their showrooms and have re arranged it in such a manner as to make this the most attractive store of any in their line of business in this country. It is almost an education to walk through. their well-arranged establishment examining the complete line of batteries on exhibition, every one made throughout by this enterprising firm. Their catalogue "F" will be sent free to any of our readers on application, provided they mention this journal. MANY THANKS. Many thanks have been expressed to us by hundreds of physicians for calling their attention to Rudisch's Beef-Peptone (Sarcc-Peptones). It has helped them to solve that perplexing problem how to save the life of a patient whose stomach is disabled by acute or chronic disease, and will not retain or absorb food. Rudisch's Beef Peptone contains the greatest amount of genuine food in the smallest possible volume, is predigested and will be retained by the most irritable, inflamed, or diseased stomach, and will be quickly assimilated by the weakest system. For literature and samples address the Ru disch Company, 317 and 319 Greenwich Street, New York. 26 OCTOBER, 1893. METCALF'S COCAWEIN verdankt seine ausgedehnte Verbreitung, sowie überall_geteilte Anerkennung verschiedenen Umständen, von denen die nachstehenden die bemerkenswertesten sind. Vor allem zunächst dem zur Herstellung (Continued on advertising page 18.) CLINICAL LECTURE. SEQUELA OF No. 3. circumference was found to be fourteen inches. Over the right shoulder the measure was fifteen inches, a difference of one inch between the RHEUMATISM- two sides. Four inches below the acromion there was a difference of one-half inch. Four inches above the tip of the olecranon there was a variation of one-quarter inch. The right arm EMPHYSEMA AND CARDIAC ARHYTHMIA.* By J. M. ANDERS, M.D., PH.D., Professor of Practice of Medicine and Clinical Medicine at the is apparently normal. We might expect to find Medico-Chirurgical College of Philadelphia. G ENTLEMEN: The first patient was before us at the last clinic hour, when the history of the symptoms for which he sought admission was given, but kindly permit me to restate a few leading points to day. He is 37 years of age, and was born in England. He came into the hospital October 13, 1893. Three years ago he suffered from slight attacks of rheumatism. They did not, however, cause him to betake himself to bed, and he soon recovered from them. Two weeks before admission he was seized with pain, followed by slight swelling of the joints of the lower extremities; and subsequently the upper limbs became involved similarly. The clinical history, diagnosis, and pathological anatomy were fully described on last Friday, but since that day two complications or sequelæ have been noted. Yesterday, when the cotton which had surrounded the affected joints was removed, he noticed a difficulty in raising his left arm. It felt weak and numb. Examining his two shoulders I found that they differed considerably, as you can see. Measurement of the shoulders and arms above the elbowjoint also disclosed inequalities. In passing the tape through the left axilla and over the shoulder across the tip of the acromion, the Delivered at the Medico-Chirurgical Hospital, October 27, 1393. some discrepancy, especially in a right-handed man, but there ought not to be so much difference above and so little below. In many cases of acute articular rheumatism we observe atrophy of the muscles near to the joints affected, especially in those instances in which the trouble persisted. This is the case in the patient present. Do not mistake this condition for something else; do not rest satisfied with mere inspection, although that might suffice in this instance. The muscles above the scapula are thin, the depressions above and below the spine of the bone are marked, and the deltoid is comparatively thin. On the other shoulder we see more rotundity. As the bones are the same upon each side there must be a wasting of the muscles of the left shoulder joint. In cases where nutritive disturbances of muscles persist, atrophy is apt to follow. Asking the patient to raise his arm, he tells us that it feels weak and has what he calls a "dead numbness.” There is no ankylosis. To be as brief as possible, What might produce this condition? In the first place, the muscles near a joint may atrophy even when the arthritic trouble is not rheumatic, this fact pointing to some trophic disturbance. We know that there is a nutritive relationship between the joints and the muscles by which they are surrounded. Char cot ascribes the difficulty to a reflex disturb. ance of the trophic centre by an influence which starts from the joint. Again, inflamma- | fever, which is almost always, if not invariably, present. It is not high, but ranges from 100° to 103° F. Often there is headache, with a tendency to faintness; sometimes mild delirium, especially at night. Cough, dyspnoea, cardiac distress, palpitation, nausea, epigastric tender cases. tion may extend from the joint directly to the muscles. This, however, will not explain all Neither is the condition the result of disease. The deltoid is the muscle most often affected, and shows the change more decidedly than any other in the body. Next to the del-ness to palpation, diarrhoea, and jaundice are toid, in frequency, the muscles of the arm and forearm are attacked. The prognosis is good when the condition is recognized and the proper treatment applied. The muscles in question respond to the faradic current, and daily applications of this agent, together with massage, restore the natural outline. There is no reaction of degeneration, or ten derness over nerve-trunks; hence no neuritis. The reaction is good. other symptoms which may be encountered. But fever must always be present, or we may not diagnosticate acute endocarditis when it follows rheumatism. We are not justified in basing a positive diagnosis in this instance, solely upon the occurrence of a murmur. If there is no accentuation of the impulse or increased area, no excited pulse, no fever, nervous symptoms or local symptoms referable to the chest or stomach, we must hesitate in forming an opinion. Could we have had here an acute endocar ditis without a murmur, the latter only developing after the fever declined? If the exudation were soft and limited to a certain part of the valve, there might not be sufficient anatomical change or its soft character might be unable to produce a murmur. Such an occurrence may have happened in this case. After the soft exudation has been absorbed in these instances and interstitial changes are beginning, the surface of the valve may become rough and a murmur develop. If this is the case, the sound will not disappear under treatment, but Another complication is a matter of interest, viz., a cardiac murmur which appeared after the temperature had remained at normal for several days. It is very important that the heart should be carefully and repeatedly examined throughout the febrile stage. Heart trouble is just as liable to occur early as late, and vice versa. The heart should be examined at each visit. After the temperature has descended to normal a cardiac murmur may or may not be due to acute endocarditis. The history and attendant symptoms of the case must be thoroughly studied. We must be acquainted, as a matter of course, with the usual clinical history, as well as the physical signs of acute endocar-will grow harsher and secondary changes in ditis. the structure of the heart will follow. But such a condition is rare and is not likely to have taken place in this case. We must, then, inquire, How may we otherwise account for the sound? A functional murmur may arise during or after the course of any infectious disorder, especially after those which cause anæmia and alter the composition of the blood. It may also, I verily believe, be due to nervous causes. It is apt to follow acute rheumatism. It may be marked one day and almost imperceptible the next. We cannot differentiate between functional murmurs occasioned by nervous disturbances and those dependent upon alterations of the blood, more particularly when, as in the present case, the patient is pale. We may regard it as functional if it improve rapidly under treatment. Inflammation of the endocardium is apt to occur on the leaflets, preferably of the mitral valve. Following an exudation there is roughening and interference with the functions of the valve,-conditions which produce a murmur. Therefore, we say that a cardiac murmur, under these circumstances, is the best sign of endocarditis. But alone it does not warrant the diagnosis. Other signs and symptoms must likewise be present. There is invariably an excited circulation, with an increased force and area of the impulse, the augmented force being quite a distinctive sign. The pulse, at first, feels soft and full, is rapid, but later a feeble, rapid, and irregular pulse is associated with an apparently strong impulse of the heart. There is a lack of correspondence. In addition to the pulse and enlarged area of the apexbeats there are general and local symptoms caused by the excited circulation. There is another possibility which should be discussed. In chronic valvular disease, complicated with acute rheumatism and endocarAmong the rational symptoms the first is ditis, the murmur may be entirely muffled and re-appear after recovery. In such an event, | almost immediately, as well as the pain and however, we almost invariably have the general swelling. An alkali lessens, or is supposed to and local symptoms which I have pointed out, lessen, the liability to cardiac complication, and invariably find more or less enlargement and, consequently, often shortens the stay in due to the chronic lesion. This enlargement hospital or bedroom. A combination meets, does not exist in our patient's case. What is perhaps, every indication. As the articular the prognosis of this case? Last week it was manifestations subside the temperature falls thought to be good on account of the absence of correspondingly. When the temperature has cardiac complication. Remember that when a reached the normal it is well to continue the murmur appears and we cannot positively salicylate in reduced doses. Do not stop it detect any organic cause, the prognosis is until several days after all swelling has disfavorable. If it is occasioned by an endocar- appeared. Then follow it up with iodide of ditis which escaped recognition it will not be potassium, which also has a direct antirheulikely to disappear. matic action. The treatment of acute articular rheumatism was described last week. Toward the close of the hour, however, I was obliged to curtail my remarks; and it will, therefore, be not inappropriate if I reiterate my statements and, perhaps, call your attention to some additional points. First, an almost infallible remedy is salicylic acid or salicylate of sodium. It matters little which form is given. As regards dose and mode of administration I would state that 10 grains of salicylate of sodium should be administered every two hours; that is, 2 drachms in twenty-four hours. Less is seldom beneficial and more is rarely needed. If the acid is employed it is best given in the form of capsules, as it is not well tolerated in a mixture. Again, if the urine become highly acid in the course of a few days, it is well to give enough citrate or bitartrate of potassium to render it and the saliva alkaline. 40 grains of the citrate exhibited four times daily will usually suffice. The mixed treatment was not adopted in this case because the urine was not highly acid. The salicylate of sodium was given, and, from the first, was well tolerated. If the stomach will bear large doses of the salt we may make use of a double dose every second hour till six doses have been given, and replace it during the night by citrate of potassium well diluted. In some cases the acid or the salicylate disorders the stomach, giving rise to slight toxic symptoms. In these cases oil of gaultheria is nearly as good and may be given in doses of 10, 15, or 20 minims every two hours. It also may be combined with an alkali, when the saliva and urine are acid. After the fever has abated and the urine and saliva have been alkaline for a number of days, the treatment may be changed. Salicylic acid diminishes the fever A capsule to be taken after each meal. Such a combination is especially indicated in this case on account of the presence of the murmur. Locally we shall use ichthyol ointment, and as there is considerable pain we may mix it with belladonna ointment, as :— B Ungt. ichthyol. (3j ad 3j), . 3ss. Ungt. belladonnæ, q. s. ad 3j. M. ft. unguent. Apply lightly upon the surface and afterward surround the joint with cotton batting. When the acute symptoms have vanished, withdraw the belladonna. As soon as the joints will tolerate the procedure I never omit having massage performed. It should be practiced daily, but not too long at a time. Electricity is also recommended by good authorities, especially in the subacute form, but I have not found it as valuable as massage. Electricity is best employed in the form of galvanism. Much more might be said in reference to local and general treatment, but other patients await us and I have pointed out the principles which should be your guide. |