Page images

are particularly apt to occur at or near the menstrual period in woman -a time at which arterial turgescence seems to occur in the most diverse parts of the body. Brain tumors exhibit the singular feature that, while the tumor is always present and slowly growing, the frightful headache is intermittent and recurs in paroxysms. These paroxysms must be due to some cause acting in addition to the mere presence of the tumor. That cause seems to be a changing degree of cerebral congestion. Tumor plus congestion and we have unbearable headaches. The congestion relieved, the pain abates.

Doctor William Browning, of Brooklyn, publishes an excellent article in the Journal of Nervous and Mental Disease on “Relief of Pain in Tumors of the Brain.” The following extract gives the gist of the article:

One unquestionable advantage of the use, which, as you know, I have so strongly advocated for a number of years, of the vascular agents (whether to increase or depress the blood-pressure), is that they act in an intelligible way and not in some presumed or speculative manner. Their influence can be pretty definitely foretold and its effect controlled; hence the remedy can be fitted to the case. In other words, they are rational remedies and meet the demand for both honesty and exactness in practice.

The method in the present instance is very simple. It consists in the administration of such depressants as aconitia, veratrum or gelsemium in doses sufficient to soften and control the pulse. The amounts required are not far from those which were recommended in the abortive treatment of apoplexy (New York Medical Journal, February 15, 1902). The remedy can be continued as required, though the condition of the circulation should be frequently observed and the amount of the drug regulated according to the necessity of the case and the way it is borne. The dosage in any particular case is kept where it does not dangerously reduce the pulse on the one hand, and yet controls the pain on the other.

This plan may not at any and every instant completely stop pain, but it holds it within bearable limits, and may be all that is required even when the course of the trouble extends over many months. It appears to accomplish quite as much as the method of symptomatic trephining, which was proposed for a similar purpose, and to do this without any of the operative drawbacks.

Doubtless the thoroughness with which pain can be controlled in any given case will depend somewhat upon the manner in which it is produced. Clinically we have, besides those relatively fortunate cases without pain, certain types, and we can trace the source of the pain to at least three factors: (1) There is the local and more or less general increase of intracranial pressure, as occurs most typically in intrasubstantial growths. Where the pain is thus directly due to pressure, it is less intense, but may be more continuous, like a deep ache. In this form marked relief may be expected. (2) Then there is the paroxysmal augmentation of arterial pressure in certain cases, to which reference will be made more fully. It is in these attacks doubtless that the terrific pain-seizures occur, and correspondingly this form should be relieved most of all by depressants. It is really here that we most need analgesics, and that opiates fail except to stupefy. (3) But when on the contrary the pain is the result of direct implication or stretching of external structures, as the meninges or outgrowing nerves, and we get instead neuralgias and localized pains, then the good to be realized from depressants may be only proportionate to the degree in which pressure is a factor. And in fact it is supposed that in this last type of cases pain is especially likely to be felt.

It is fair to ask whether this plan has any injurious effect on the course of the trouble itself. Nothing of the sort has been apparent in any case, nor is there any theoretical reason for suspecting harm. So far as one can decide, life has if anything been prolonged. On paralysis, if present, it can hardly have much effect either way.

Browning has in mind the pain of brain tumors, but it is at once evident that the therapeutic application of the idea is a wide one. Congestiye neuralgia of the ovaries, often is used as reason for their removal. It would, I suspect, save some useful ovaries if arterial depressants were used more generally. The use of gelsemium or aconitia in trigeminal neuralgia is fairly common, but there are other visceral neuralgias which would seem equally adapted to such treatment.

The trouble is, we are afraid of arterial depressants just as we seem frightened to bleed or give emetics. As a matter of fact the heart will stand a tremendous amount of depression safely, provided it be not too suddenly induced. We all know it, yet we give arterial depressants reluctantly. It is a mistake. Browning's suggestion is an excellent one.




CONTROL OF HEMORRHAGE. Doctor HOMER DUPUY (The Therapeutic Gazette for October, 1903) says he is desirous of giving his experience with adrenalin, given for the control of hemorrhage, for the reason that everyone should contribute to the profession whatever information he may have gained concerning a drug as important, now and prospectively, as is adrenalin.

In the first place he calls attention to the fact that adrenalin is derived from suprarenal extract, and may be regarded as the active principle of this substance. Adrenalin, he says, is a vasomotor constrictor of the most powerful type. It may be administered by the stomach or hypodermically. The effect is the same whichever mode is chosen. Doctor Dupuy seems to favor the stomach route.

Two cases are reported, in both of which recurring and persistent hemorrhage from the nose was controlled by the administration per orem of twenty-drop doses of a one to one thousand solution of adrenalin. In one of these cases the drug was given every hour for twelve hours, then every two or three hours for two days, then three times a day for a day or two. In the other case it was given in the same form and dose every hour during one night, then at increasing intervals for four days.

Doctor Dupuy says the points claiming attention are:

(1) Large and frequent dosage, twenty drops every hour or two for the first twelve hour

(2) The absence of any toxic or untoward effect. (3) The absolute control of hemorrhage.

The doctor reports also most satisfactory results from the use of adrenalin in hemoptysis and other forms of bleeding, such as typhoid intestinal hemorrhages, and those occurring among hemophilia.

As the effect of the drug is due to its constricting action on the blood-vessels, Doctor Dupuy argues that the blood vessels should be allowed to assume their natural size gradually, if return of the hemorrhage is to be avoided. It is this principle that causes him to discontinue the use of the remedy in a gradual rather than in an abrupt manner.


DICTION AMONG DOCTORS The selection of precise and polished language for the expression of thought is apparently regarded of little consequence by many physicians. This declaration will undoubtedly enjoy the concurrence of discriminating medical journalists who have occupied the editorial tripod for even an inconsiderable period. The faulty diction is infinitely more deplorable because of the fact that a great majority of doctors are proficient in the art of rhetoric but seem content to blindly pursue the trail of colloquial style. The practice undoubtedly became vogue through carelessness which had its inception in medical society impromptu discussion, a cant word or phrase being employed by the speaker because of inability to command the proper one when siezed with the temptation to score a point quickly, and hence a crosscut through awkward English instead of pursuing the circuitous route required to couch the sentence in exact terms. A perusal of medical periodic literature reveals many glaring inaccuracies and inelegancies of expression. Author and editor are equally responsible for the syntactic discrepancies, and when the writer displays negligence in the preparation of a paper the editor should evince sufficient interest in faultless phraseology and the reputation of the journal over which he presides to rectify improper words or ambiguous sentences. The citation of a few examples will serve to elucidate the subject under consideration.

"In the first place” is a bugbear which is often more conveniently than consistently employed. The phrase is utilized to introduce a proposition but is scarcely ever followed by its natural sequent; in other words, the entire article is made subordinate to the initial phrase, which is often forced to cover half a dozen distinct propositions. Another abused introductory is the adverbial “first” or “firstly." Either word is often brought into requisition when a number of facts are cited to substantiate an argument, but here, again, the natural sequent is frequently overlooked, and succeeding sentences appear without a numeral antecedent. An article on electrocution contains the expression that consciousness was "blotted out instantly," but the author fails to state how consciousness, or anything else for that matter, can be “blotted out.” A proper regard for the sensibilities of the reader might possibly have suggested the expression that consciousness was obliterated. One writer “keeps the patients in bed,” but inasmuch as he refrains from enlightening the reader as to the amount of energy expended in performing the task upon the average patient the lightweight doctor will be somewhat loath to exercise power other than to request or require the patient to remain in bed. A dispenser of medicolegal lore informs the reader that the United States Supreme Court “handed down a decision.” This statement is calculated to invest some with the idea that “the most learned judicial tribunal in the world" is dealing in shelf goods, although the author probably intended to convey the information that the Court simply rendered a decision. One physician declared that the "lungs were all right," another that the "kidneys were all right," but a scientific examination would probably reveal the fact that in both instances the organs were normal. An operator who spent much time delving in a mass of pelvic adhesions for the womb, writes that “the uterus could not be made out,” whereas if ordinary tact had been exercised he might have distinguished the organ with comparative ease. Another writer who has probably been dabbling in the stock market announces that "respiration went down," whereas polite parlance would inform the reader that respiration decreased. An advanced therapist writes that certain hydriatic treatments should be "carried out," but unfortunately fails to disclose the technique of the new-fangled method, and under the circumstances the progressive doctor will regret that he can only pursue such treatment as heretofore.

“The title of my paper forms, I think, the most common complaint among those patients who consult us for throat trouble," is the introductory sentence of a contribution to an esteemed contemporary,

but little credence will be reposed in the statement that the "title" forms the "complaint." Possibly the author means that the title constitutes the name of the most common complaint. One writer who is offering testimony to defend a premise concludes by saying that when the proof is “sifted down” the evidence will be apparent. Inasmuch as one rarely hears of anything being sifted up, it would seem that brevity of language would be better subserved by simply employing sifted. Another exhibits a mania for employing the personal pronoun you, and in discussing a subject almost invariably begins by saying "You have a case," although as much heed in the selection of words as is observed in the selection of drugs would probably have suggested to the author that it is a physician who has a case. One hustling country doctor insists that "a physician's armamentarium should be up-to-date," while another entertains the reader with "a classification of certain cases that have been treated down to the present time," notwithstanding a happy mean that would doubtless suffice to all intents and purposes might find expression in the words to date. A close observer says that in consequence of certain treatment his patient "is putting on flesh," but whether this feat is being performed by skingrafting or otherwise is not specified, and possibly a more thorough knowledge of the case would demonstrate that the patient is only naturally acquiring flesh. An investigator says that "our views on the pathogenesis of cholelithiasis have become' radically revised during the past few years," but some might question such a change without the aid of human volition. In concluding a paper the author says "that death took place instantaneously is not doubted,” although he fails to adduce evidence in support of the declaration. The shortsightedness of this writer will invest some with the impression that death simply occurred. A neurologist conveys the information that "in paretic dementia 'we have demonstrable brain lesions," whereas elegance of diction would be greatly improved by saying there are such changes. One doctor writes that "a patient comes to you,” when in reality a person seeks medical service and thereby becomes a patient. A common blunder is that made by the writer who positively declared that "the case died," when everybody else interested knows that it was the patient who succumbed.

“The whole business" is the manner in which an enthusiastic writer refers to a certain system of therapeutics. A dermatologist announces that he “has almost done away with skin infection” by a certain procedure, although the drift of the sentence would indicate that the innovation had precluded skin infection. Another says that "the early symptoms of the disease have been carefully worked out," which, however, merely implies that they have been studied. An anxious doctor greatly exerted himself to “keep up the elimination," although it would have been much easier to continue the process. An abdominal surgeon declares that "an eminent operator ‘draws' comparison between the gall-bladder and appendix,” notwithstanding

« PreviousContinue »