To illustrate definite drug action: Many times have I seen a certain. medicine (a vegetable drug), well known in all schools, to be a liver specific, taken for weeks, one-tenth of a grain doses each night, remove undoubted accumulations of gall-stones. In this case gall-stones had been diagnosed by competent physicians and the patient made ready for operation. Again, in chronic cases, I have seen small doses of arsenic palliate for a brief interval, while smaller doses lengthened that interval, and doses commonly called infinitesimal make dying an easy matter. We know that belladonna will relieve congestive headaches if given in minute doses. We believe because it induces congestive headaches; and we know that some belladonna in a dose almost infinitesimal cures still other similar cases when the first dose will not. These facts go to show, to our minds, that the smaller dose is the better one, provided the remedy is the right one. And, to confirm this, the Herter lectures at the Johns Hopkins this fall (given by Sir A. E. Wright), fully corroborate by definite experiments the efficacy of small doses. It was shown that, after a reasonable dose, there was considerable reaction and a little elevation of opsonic index, whereas, with smaller doses up into what would be ordinarily considered infinitesimal, the reaction and the opsonic index was higher. This is exactly in accordance with what homeopathists have believed since Hahnemann's time, merely using different terms. What he calls reaction we call aggravation; his opsonic index is Hahnemann's "active vital energy," or dynamics. Terms are nothing, but the facts are what we are after. We claim that the proper use of all medicaments is based upon the fact that they have caused similar conditions in health. All is a broad term, but we claim that all real cures can be accounted for in that way, and while physiological and palliative measures are often necessary, and the only expedient means, the cure must come along these lines. We have all read of the case of Dr. W., in whom cancer was produced by the longcontinued use of the X-ray machine in treating this disease among his patients. Homeopathists have always invited free criticism and use of their drugs along the lines of proper practice. "Try for yourself and be convinced" has been our motto, and the longer a man practices homeopathic medicine the greater is his faith in drug efficacy. We deplore greatly the unbelief of the profession as to the efficacy of drugs, especially in pneumonia. With few exceptions, it is a positive disgrace for a homeopathist to lose a case of that disease, because we have at least half a dozen drugs which specifically cause and cure pneumonia. And other diseases might be given as similar illustrations. It is our belief that the salvation of the profession as therapeutists lies in recovering their faith in the efficacy of specific medication. 819 Andrus Building. LUPUS EXEDENS-REPORT OF CASE. BY STERLING B. TAYLOR, M. D., Columbus, Ohio. Professor of Anatomy and Lecturer on Rectal Diseases, Rectal Surgeon in Grant Hospital, Columbus, Ohio. [Written for the MEDICAL BRIEF.] N. J., a girl twenty-one years old, was referred to me by Dr. E. T. Tidd. Previous history: Father and mother dead; cause of death unknown. The girl, very early in life, began to lead vicious habits, and at nineteen years of age was operated on at the Protestant Hospital by another surgeon for hemorrhoids. A few weeks after this operation an ulcer appeared around the anus, which absolutely refused to yield to treatment. The girl was transferred from this hospital to the county infirmary some two months after the original operation. I saw the case some months after she had been taken to the county infirmary. At that time the ulcer extended for an inch and a half from the anus in all directions, making a diameter of about three inches. The base of the ulcer was tough, fibrous; the edges were slightly undermined, showing that there had been somewhat of a tendency to cicatrization, and yet cicatrization was imperfect. The edges resembled those of a tuberculous ulcer. There had been a history of pain primarily, but in the later days of the trouble there was very little, if any, pain. The ulcer bled freely if the patient used hard or coarse paper as a detergent. There was a strip of ulcer running up along the labia on one side to the width of one inch, with the same peculiar characteristics as the larger ulcerated area. I made a diagnosis of lupus exedens, and had the patient prepared for operation. I thoroughly curetted the wound down to the thick, heavy, fibrous base, and I was able to confirm my diagnosis. After curetting the wound, I applied the thermo-cautery, being careful not to burn too deeply ---burning the entire field. Put on a dressing of ten per cent methylene blue, keeping the gauze soaked with this solution throughout the stage of convalescence. In addition to this I prescribed increasing doses of iodide of potash, going up to sixty to one hundred grains at a dose. The girl left the institution at the end of five weeks, the wound was. entirely healed, and the surface was perfectly smooth. In my mind there can be no doubt as to the diagnosis. In connection with this I would say that methylene blue, ten per cent solution, applied to small ulcers, keeping the wounds moist with this solution continuously, will effect a cure in the majority of cases. Occasionally it is necessary to freshen up the ulcerated edges before applying this dressing. This is also an excellent dressing in chancres, and in primary specific ulcers. 70 S. Grant Avenue. NORMAL FIXATION OF THE UTERUS. BY BYRON ROBINSON, B. S., M. D., Chicago. [Written for the MEDICAL BRIEF.] We have discussed the structure of the pelvic floor-muscularis, fascia— as separate factors, and compared it to the abdominal wall in other regions. In fact, the pelvic floor, though complicated by apertures-urethra, vagina and rectum is comparable to the other portions of the abdominal wall, as the distal and ventral abdominal wall complicated by the hernial, inguinal operations, canals, which, though they do not transmit excreta or other factors of commerce, yet transmit structures maintaining patent canals. We have discussed the normal position of the uterus as that of mobility, similar to that of the testicle, wrist joint, enteron. In short, a uterus is in its normal position when perfectly mobile. A uterus is in a pathologic position when fixed-abnormally fixed by disease-peritoneal exudation, sacro-pubic hernia, neoplasm. Here we will discuss theoretically, practically and, especially, clinically, the normal fixation apparatus of the uterus. We wish to remark on the rational utility of uterine supports as to gynecologic surgical procedures. At this point I wish to refer the reader to an excellent and valuable book, recently published (1907), by Dr. Josef Halban, "Privat Docent fuer Geburtshilfe und Gynakologie in Wien, and Dr. Julius Tandler, Prosektor der I Anatomischen Lehr-Kanzel in Wien." The title of the book is "Anatomie und Aetiologie der Genital Prolapse beim Weibe." The first reason the book is valuable is that an able philosophical, conservative gynecologist-Dr. Josef Halban—has composed the gynecologic portion. Second, an excellent, practical anatomist has added his labors combined-gynecologist and anatomist. The third reason the book is valuable is because it completely agrees with my anatomic and gynecologic teachings for the past fifteen years, as it teaches as irrational visceropexy (hysteropexy) and Alexander operation. The combined knowledge of anatomy, physiology and pathology is required. to comprehend the utility and rationale of any and all surgical procedures. At the present time it is my opinion that numerous, unnecessary, harmful operations are frequently performed. These unnecessary and harmful operations are based on irrational views of initial symptoms previous to operations and symptoms subsequent to operations. In short, neurology is mistaken for gynecology. Nervous symptoms are mistaken for uterine symptoms; e. g., an uncomplicated so-called retroversion requires neither surgical nor medical aid. In general, it may be said that the uterus is suspended, supported and fixed. The uterus possesses no single dominating support. The uterus is supported by every structure with which it is connected. The fixation apparatus of the uterus consists of every fibrous thread that binds it to adjacent structures-viscera and abdominal walls. No single fiber or combination of threads that fixes the uterus predominates-as elastic fiber, musculo- or ligamentous fiber (connective tissue). Every fibrous support of the uterus is distensible, yields, and nowhere in the body is the distensibility of different forms of fiberselastic, muscular, ligamentous-so evident as in uterine prolapse or sacropubic hernia. We may note the common observation of the distensibility of fibers in splanchnoptosia. The vessels, nerves, muscles and ligaments may be doubly elongated. An artery will elongate several inches, however, compromising the parietes and lumen of the vessel, and, consequently, blood supply, which is the life of tissue, and its diminution decreases tissue vitality. Nerve fibers are enormously elongated in splanchnoptosia; this traumatizes the periphery, cord and center of the nerve, inducing neurosis. In splanchnoptosia the muscular fibers elongate, disturbing peristalsis. In short, in splanchnoptosia the muscle tissue, the connective tissue, elastic tissue and nerve tissue is elongated, distended, damaged, and consequently the parenchyma of the viscera functionate under difficulty. In splanchnoptosia of the genitals and pelvic floor, which is identical with sacro-pubic hernia or so-called uterine prolapse, the muscular tissue, elastic tissue, connective tissue (ligamentous), nervous tissue is elongated, distended, and the tractus genitalis (with pelvic floor) functionates under difficulties. For example, the vessels being elongated, distended, their lumen is compromised and conducts a minimum quantity of blood-nourishment is impaired, for it is blood that maintains healthy tissue and cures its disease. The nervous tissue is elongated, distended, and the nerves (periphery, cords and center) are traumatized-neurosis results. The muscle tissue is elongated, distended, and peristalsis is disturbed, and it is peristalsis that is the manifest life of an organ; it includes its secretion and absorption, as well as it governs, the blood supply. Defective peristalsis means defective secretion, absorption, blood and lymph circulation. With defective peristalsis, venous congestion occurs with consequent hypertrophy and pain. The distensibility of smooth muscle may be observed in gastric, cardiac vesical dilatation. The enteron may dilate similar to a stovepipe. Another example is the distention of the peritoneum in hernia, uterine gestation, ascites, colon distention in obstruction. As to the fixation apparatus of the uterus-suspension, support or intra-abdominal pressure. Numerous subjects must be borne in mind for a rational philosophy of sacro-pubic hernia and repair. As to the weight of the uterus, disregarding the gestating and puerperal, I think we may omit it as non-important. We must distinctly consider the uterus. as suspended by organic connections, as supported by a number of indulging structures as fixed by intra-abdominal pressure. It is curious, yes, unaccountable, how various writers dignify, in various views, certain factors into dominating supports of the uterus. As a student of practical visceral anatomy for a score of years, and as a practical gynecologist for the same two decades, I wish here to express some practical views as to the uterine supports and their rational application. I shall consider the subjects according to the following table: This table presents at a single comprehensive view the fixation apparatus of the uterus. The uterus is: I, suspended; II, supported ; III, fixed. FIXATION APPARATUS OF THE UTERUS. 1. Peritoneum. I. SUSPENSION 2. Ligaments. II. SUPPORT OF III. FIXATION OF UTERUS 3. 4. (a) Ligamentum rotunda. (b) Ligamentum sacro-uterina. (d) Ligamentum cardinale (Kock's). (e) Ligamentum transversum (Mackenrodt). (f) Ligimentum pubo-vesico-uterina(Hyrtl). Vessels and nerves. Connective and elastic tissue. 5. Connection of uterus to adjacent organs. (g) Levator ani. 6. Diaphragma (h) Coccygeus. pelvis rectale (i) Pyraformis. (rectal group) Sphincter ani externus (each with its proximal and distal fascia). Hiatus rectalis. 7. Diaphragma (k) Sphincter vaginæ. 18. itale or Liga mentum uro (m) Transversus perinei profundus. genitale (pu (n) Transversum perinei superficialis liga dental group -sphincter urogenitale). mentum. Hiatus urogenitalis. Intra-abdominal pressure accentuates We will discuss first the suspension of the uterus. I. UTERINE SUSPENSION. I think the majority of writers consider the suspension of the uterus its chief support. As a student of anatomy and gynecology, I wish to deny this emphatically, and to place the maximum support of the uterus on the pelvic floor. The view that the uterus is supported mainly by the combined pelvic floor discards, as an irrational operation, abdominal hysteropexy. In general, visceropexy is irrational, as it substitutes one pathologic state (excessive mobility) for another (visceral fixation). For the retention or maintenance of the uterus in its normal position, we must view the mechanical and architectural structure of the pelvic floor. That the pelvic floor supports the uterus can not be too frequently reiterated. The general structure from which the uterus is suspended are: (a), peritoneum; (b), ligaments; (c), vessels and nerves; (d), connective tissue; (e), connections with adjacent organs. |