Page images
PDF
EPUB

in many cases, and efficacious in preventing the paroxysms, though hyperesthesia of the nervous system may be a prominent symptom. Many objects, when found to be excitants, may be easily removed; but others cannot be, and it may be advisable to remove the patient from them, as in the asthma of autumnal catarrh or other less defined climatic or atmospheric conditions.

In other cases the slightest change in location will give relief. More patients get relief by going from the country to the city than from the city to the country. A curious feature of the immunity of location is that in time it often fails, and another change is necessary. In making any change consideration must, of course, be paid to the probable effect of the climate on other factors, for example, on the condition of the lungs and bronchi and on the nervous system.

Peripheral origin of reflex irritation is another important factor. The nasal polyp is easily recognized. Contact of a turbinate bone with the septum, chronic disease of the turbinates, tonsils, pharyngeal-adenoid, may be a source of great irritation. The whole naso-pharynx must be put in as healthy a condition as possible.

Digestive derangements have been far too little considered. Indigestible food, especially when taken at night, is often the cause of an attack; though other factors may be present, it is this added irritation which determines the paroxysm. It is important to regulate the quality and quantity of food and time of meals,

and perhaps also to treat some evident morbia condition. The intestinal tract must be investigated, especially for parasites. The sexual system and possible trauma must be considered.

Many morbid conditions may be concerned directly or indirectly in the production of bronchial asthma, which act singly or combined, and the treatment should be directed towards the removal of as many as possible of these conditions. The more of these factors we can diagnosticate the simpler may be our treatment. Grand combinations of many drugs for inhalation or internal use are to be avoided unless single remedies fail. Patent and proprietary medicines, and treatment of patients at a distance without examination for differential diagnosis, must be condemned; but when a physician can have his patient under observation this can often be avoided. The influence of climate is often very subtle, but proceeding on the same lines as have been suggested for medical treatment, the hay-fever patient may be removed from the direct irritant, a suitable climate may be found for the hyperesthetic, or for the patient with bronchial inflammation. If the bronchitis is moist, a dry, elevated region is preferable, but a warm, moist climate will probably be better if the bronchial mucous membrane is dry and irritable. The nearer we get to an exact diagnosis of the exciting and underlying causes of asthma, the more intelligently and successfully will we be able to advise in regard to treatment by change of climate.

APPENDICITIS AND TUBO-OVARIAN LESIONS. Dr. George R. Fowler presented an interesting and complete paper on the differential diagnosis of appendicitis and tubo-ovarian lesions before the American Medical Association (Journ. Am. Med. Assn.), of which the following is an abstract:

obscured in an unmarried woman by false statements made by the patient regarding the menstrual history, should not be lost sight of.

Frequency.-Based upon the study of a large number of cases, the proportion is as 1 to 4 (males 80 per cent, females 20 per cent).

History of the Attack.—In a large proportion of cases the history in appendicitis is that of an acute onset. In tubo-ovarian disease a previous history of infection, with endometritis, salpingitis, ovaritis and pelvic peritonitis, and coincident progressive menstrual disturbances, may generally be obtained. Further, in considering the possibility of ectopic gestation in a given case, the fact that the diagnosis may be

Pain. In appendicitis the pain is usually acute and radiating, while in adnexal disease it is more apt to be dull and localized. Three considerations having a bearing in this connection, should be borne in mind, however. The first relates to the fact that in subacute and chronic appendicitis the pain may be dull and localized. The second, that in acute appendicitis the pain may have been masked by the injudicious administration of opium; and the third, that the supervention of an acute exacerbation of a chronic pelvic inflammation may give rise to pain sufficiently acute and severe to simulate appendicitis...

Vomiting is exceedingly common

in ap

[ocr errors]

pendicitis, and of much less frequency, relatively, in adnexal disease.

Tenderness. In the great majority of cases the tenderness in appendicitis is located at the site of the appendix, and in tubo-ovarian disease it may be traced to the site of the adnexa. The maximum point of tenderness in appendicitis corresponds to or is above the level of the anterior superior spine of the ilium, while in adnexal disease it is located well below this level. Considerable force is required to elicit this point of tenderness by vaginal touch in appendicitis; but it is easily accomplished by this route in adnexal disease. On the other hand, the tenderness brought out by external pressure in the last named is nothing like as great as that by vaginal touch, while considerably less pressure in the region of the appendix will show the latter to be extremely sensitive in appendicitis. Movements of the uterus by the examining finger do not as a rule give rise to complaints of pain from the patient in appendicitis, while they are almost certain to do so in adnexal disease. The nearer proximity of the tenderness to the median line and bony anterior pelvic wall, examined either externally or by the vagina, the greater the chance of pelvic inflammation being present, and vice versa.

The remarks concerning the possibility of masking the pain by opium apply with equal force to the symptoms of tenderness.

[blocks in formation]

the severity of the attack, particularly in cases in which the temperature is but slightly elevated and the pulse not markedly accelerated. It may be absent, or nearly so, in chronic adnexal disease, until a spread of previously existing infection, or the introduction of fresh infectious agents, is announced by its presence.

Muscular Tension.-While rigidity of the right rectus muscle is occasionally absent in appendicitis, it is almost invariably wanting in adnexal lesions, unless the latter are complicated with considerable peritonitis. This sign is so marked as to be almost pathognomonic in the differentiation of these two diseases. It may be masked by opium.

Tumor.-Tumor may be present after the second or third day in appendicitis. In tuboovarian disease it is usually present when the surgeon is called in. In appendicitis its usual location is beneath the right rectus muscle, and opposite the anterior superior spine of the ilium, or to the outer side of this area, where it is easily made out by abdominal palpation. In tubo ovarian disease it is easily made out by vaginal touch, while abdominal palpation may altogether fail to reach it. It is rare that a tumor of appendical origin can be felt per vagina.

Course. Appendicitis usually follows an acute course, while adnexal disease is usually subacute or chronic in its course. In chronic appendicitis there is usually at least a history of one acute attack, and recurrent attacks are common. In adnexal disease, while the chronicity of the course may be disturbed by acute exacerbation, it is rare to have in the history a statement of a well defined and sudden onset.

ABSORPTION AND ELIMINATION OF DRUGS.

H. A. Hare (Therap. Gaz.) writes in a very entertaining way of the rapidity of absorption of some of the more commonly employed drugs as a guide to their elimination. He says that we too often study the effect of the drug upon the different organs upon which we wish it to exercise a particular influence, and ignore its influence upon the organs of absorption and elimination, although the speed and manner of absorption and elimination should govern dosage as to size and frequency.

Of the mineral drugs which are rapidly absorbed and eliminated, the iodide of potassium is absorbed and eliminated so rapidly when taken by the empty stomach as to appear in the

saliva and urine in ten to twenty-five minutes. It does not tend to accumulate in the human system to any great extent. The rapidity of total elimination may be thirty-six hours. The larger part is eliminated in the urine. It is evident, therefore, says the writer, that in the use of the iodide of potassium we should give it freely and frequently at first until the residual amount has reached its limit, when smaller doses may be given and given less frequently for the purpose of maintaining the iodine influence; that is to say, the drug should be given up to the point of tolerance, whatever that may be, and then a smaller dose will be sufficient to maintain its influence by replacing

the albuminoid compounds as they are slowly periods of time, and is found deposited in all eliminated. If this is not done the drug accumthe organs. In other words, the doses of ulates and causes chronic iodine cachexia. mercury ordinarily given are always large enough to produce cumulative effects. It is evident that after a full mercurial effect is produced, it is well to decrease the dose of mercury, and only give enough to maintain the effect. It is also evident that it is advisable to use iodide of potassium occasionally to aid in the elimination of residual mercury.

Bromide of potassium is absorbed rapidly, and exceeding slowly eliminated. It has been found in the urine two weeks after the drug was stopped. The same rule which governs the use of the iodides holds good here; namely, after the drug has once manifested its full effect, smaller doses will maintain this effect. Iodides and bromides given in frequent and small doses possess no advantages and are apt to disorder digestion and overload the organism. They should be given twice or thrice daily in full doses, rather than frequently in small doses.

The rapidity of absorption and elimination of mercury depends largely upon the variety given. All theories as to the form of its absorption are open to grave criticism. Mercury is known to be eliminated by every avenue of exit from the body-the urine, feces, sweat, tears, milk and saliva. After a single dose the drug begins to be eliminated in about two hours, and is entirely gotten rid of in about twenty-four hours, according to Byasson. If, however, the doses are persisted in, it gradually accumulates in the body, and is so slowly eliminated as to remain for almost indefinite

Antipyrin is rapidly absorbed from the stomach, in from fifteen minutes to half an hour, and begins to appear in the urine at this time; but Reihlen asserts that its elimination continues for from thirty-three to fifty-six hours after the last dose. It should, therefore, not be given in too frequent deses.

Acetanilid is absorbed in thirty minutes, and eliminated in twenty-four hours.

Atropine and belladonna are absorbed and eliminated with extraordinary rapidity. Harley asserts that the elimination is complete in two hours.

Arsenious acid is absorbed with fair rapidity, but is eliminated very slowly. Elimination begins after fourteen hours, and continues for sixty hours. This drug ought, therefore, to be. given at long intervals rather than in frequent small doses.

APPENDICITIS.

Dr. John B. Deaver read before the American Association of Obstetricians and Gynecologists an interesting paper on appendicitis in relation to disease of the uterine adnexa and pregnancy (Buffalo Med. and Surg. Journ.), in which he maintains the position he has always heldnamely to operate as soon as the diagnosis is made. His experience embraces many hundred cases, and of this number no death has occurred where the operation was done immediately after the onset.

The ultimate results of inflammation of this organ more than justify operative interference. The large mortality in appendicitis is the result of too conservative measures in the early stage of the disease. He has yet to see a human life lost where, in an acute attack of appendicitis the appendix has been removed within six to eight hours after the onset of the disease, while, on the other hand, he has seen many lives lost by adopting the so-called conservative methods —namely, opium to relieve pain, allowing the bowels to remain confined, leeches, fly blisters,

turpentine stupes applied-any or all of which are not only useless but harmful.

He then details the differential diagnosis of appendicitis from acute salpingitis, pyosalpinx and ovarian abscess, extra-uterine pregnancy, suppurating ovarian cyst, ovarian cyst with twisted pedicle, fibroid tumor, varicose veins of broad ligament, painful menstruation and the

menopause.

Pregnancy complicating appendicitis forms. one of the most serious conditions which may come under the consideration of the surgeon. The life of both mother and child must come under consideration. When we consider that the gravid uterus with its contents occupies the abdomen to a large extent, and that there is a likelihood of the uterus forming a part of the abscess wall, involving the risk of miscarriage and subsequent shrinking in size of the uterus, the consequent likelihood of adhesions being torn and the escape of the contents of the abscess into the general peritoneal cavity, it is easy to imagine the risk in allowing such a

condition of affairs to occur. Women who present a history of previous attacks of appendicitis and complain of local pains and distress in the right iliac fossa, with all the symptoms of chronic appendicitis conjointly with pregnancy, should, in the author's opinion, be relieved of a chronically diseased appendix. Although many of the conditions above stated may not go to the formation of pus, still the great uncertainty which hangs over chronic disease of the appendix and the indefinite outlook as to the ultimate outcome when combined with pregnancy makes it imperative that we should not be conservative enough to endanger the life of the patient.

The following summary is appended: The many difficulties of diagnosis between diseases of the uterine adnexa, pregnancy and appendicitis, and the probability of their co-existence in the same case, brings us face to face with the general rule that he who opens an abdominal cavity must be prepared to meet any or all the complications which may arise in this most complex portion of the human anatomy.

The first and most important point is the necessity for an early diagnosis because the

good results for operation in appendicitis depend upon the time of operation. The danger increases in direct ratio with the progress of the disease.

In women who are liable to become pregnant, and who have had an attack or attacks of appendicitis, the appendix should be taken out in order that the dangerous complication of pregnancy and appendicitis may be avoided. This is particularly true if an attack of appendicitis supervenes upon pregnancy. The latter condition does not contraindicate operation under the circumstances, but rather, on the other hand, makes operation more advisable and even imperative.

Another point is one based upon a rich personal experience, covering both operative cases and those in which the so-called conservative treatment was practiced. It is that the number of cases of appendicitis that become perfectly well, cases that do not suffer during the interval between attacks, and that are not subject to the certainty of future attacks, are so extremely rare that the question of curative treatment resolves itself to the time of operation.

DIAGNOSIS OF DIPHTHERIA.

Dr. W. K. Jaques, chief of the antitoxin staff of the Chicago Department of Health, in an interesting and exceedingly practical article on this subject, says that the diagnosis of diphtheria is one of the most important functions a family physician is called upon to perform. Upon that diagnosis depends the safety of his patient, of all the susceptible persons with whom the patient has come in contact while developing the disease, as well as those who still care for him; and, what is most important to the physician, his own reputation. If the physician's duty ended with curing his patient, he might be justified in using antitoxin in all cases without reference to the bacteria causing the inflammation; but the safety of the public and the interests of the city demand that the doctor make a correct diagnosis.

He cites a case in which he was called to intubate the child of a milkman. A week previous one of his drivers had a sore throat. He consulted a physician, and was given a dose of antitoxin, resuming work the next day. A culture from both patients showed the bacilli still present. No one knows how many families the driver infected besides that of his employer. The doctor who did not make a

proper diagnosis and warn the man of his danger to others is responsible for every death that may have ensued.

In another case a physician was called to see the child of a milkman suffering from throat inflammation. He pronounced it diphtheria without taking a culture. The milkman had lost a child with this disease the year previous, and realizing his danger to others he closed his depot and asked another milkman to supply his families. The second day the child was so much better that doubt arose as to the diagnosis. Another doctor was called who took a culture, found no Klebs-Loeffler bacilli present and pronounced the case not diphtheria. The milkman's business was ruined and the first doctor threatened with suit for damages. Doctors have paid many judgments far less just than the one this milkman may get!

A child takes cold, the secretions are locked up and the most tender portions of the fauces and respiratory passages become congested. If on the mucous membrane of such a child is inoculated the three most common germs which produce diphtheria, and equal predisposition to each exists, the staphylococci will produce temperature, the streptococci pain, and the

Klebs-Loeffler ptomaine poisoning. Temperature and pain are present at the beginning of the invasion, but it may be some time before the ptomaine is produced. If the staphylococcus is the only associate germ present, its symptoms will have almost entirely subsided before the symptoms of ptomaine poisoning appear. This is why a patient sometimes seems to improve the second or third day, and the doctor is dismissed, only to be called back to find a typical case of Klebs-Loeffler diphtheria or laryngeal stenosis. When the Klebs-Loeffler bacillus is associated with other germs in its invasion, the symptoms of these germs so obscure the symptoms of the Klebs-Loeffler bacillus that its presence cannot be detected by clinical symptoms until ptomaine poisoning

occurs.

If the principal invading germ and its characteristics are known, an intelligent prognosis can be given. If the Klebs-Loeffler bacillus is the invading germ, antitoxin will bring the crisis of the disease within twenty-four hours. If it is the streptococcus, there will be a long, hard fight.

Looking at the subject of throat inflammations in the light of their bacteriology, it is possible to understand why past treatment in this line has been so unsatisfactory. To treat an angina intelligently, the invading germ should be known and the treatment adjusted accordingly. Diphtheria antitoxin can do no good in most, and is positively harmful in some cases of streptococcus angina. The toxin developed by the streptococcus is usually of small importance. The indication to be met is by a soothing application which will relieve the pain and destroy the germ.

RELATION OF SYPHILIS TO LIFE
INSURANCE.

Dr. T. Colcott Fox, who read a paper before the life assurance medical examiners' association (Med. Examiner), came to the following conclusions:

In estimating the value of the life of a man who has become syphilitic, it is difficult to formulate hard and fast rules, but there are certain principles by which we may be guided.

1. It is important to obtain as full an account as possible as to the date of infection, the history of the symptoms and the character of the treatment. The longer the interval from the date of infection the less liability there is to a relapse of specific lesions. The history of the symptoms will disclose in some measure the

degree of severity of the disease, as revealed by the character of the lesions with regard to form and aspect, and the occurrence of precocious so-called tertiaries, the incidence of the disease on the several organs, and the liability to relapses. These symptoms will permit the estimation of the quality of the soil on which the syphilitic poison has fallen. The character of the treatment is all important, since a judiciously carried out mercurial treatment signifies an immense reduction in the liability to further disease, directly or indirectly syphilitic.

2. It is advisable to pay special attention to the family history, and to the personal history and predisposition to disease in the individual, because on the one hand inherited and acquired conditions, such as alcoholism, malaria, scrofula-tuberculosis, neuropathic tendencies, etc., and on the other malhygiene, poverty, over-indulgence, mental anxiety and brain-stress, etc., have an influence in affecting the type of the disease and its incidence on various organs.

3. During the actual existence of any syphilitic disorder, the proposal for insurance should be postponed until a suitable treatment has been carried out and an adequate interval of probation has elapsed.

4. A man who has exhibited only the ordinary benign cutaneous symptoms without any marked tendency to relapses, and has undergone an adequate mercurial treatment, and is in good health, may be accepted (after an interval) with a slight addition. In such a case the extra risk is probably very slight, as the great majority of cases are then at an end. As the blood retains contagions for perhaps two or three years, and as the greatest liability to tertiary symptoms is during the second, third and fourth years after infection, it is advisable not to accept the applicant until the interval of at least a year has elapsed since the last treatment and of four years since infection. As tertiary accidents declare themselves in the vast majority of cases before forty years of age, the life is more valuable after that age, unless the disease has been contracted late.

5. Applicants giving a history of more severe relapsing eruptions, or of inadequate mercurial treatment, or in whom the disease has been contracted after fifty years of age, should be accepted only after a longer probation, and either at increased rates, or for a limited period. 6. Applicants with a history of recurrences in the tertiary period, affecting the skin or subcutaneous tissue, muscles, bones or joints or

« PreviousContinue »