Слике страница
PDF
ePub

!

the gaseous molecules. The instability of Radium, Thorium, Uranium and Helium are splendid examples of the subject in hand. We know that Radio-active substances are constantly undergoing a chemical change; that the Radium is being constantly given off; the little corpuscles which are disseminating into the surrounding atmosphere are quickly united into the nearest chemical combination available. We know a little of the nature of the Alpha rays; we know that these tiny bodies are charged with positive electricity, and that they are constantly flying off heated metals only to recombine with other substances. The heat acts as the cleavage product. We do not know how they combine nor why, we only know they do. The Beta rays of Radium are similar in their deflection to the force of a magnet from their course. The Gamma rays or X-ray is unlike the Alpha and Beta in that it is not subject to deflection. It will pass through opaque substances with ease and record its transit upon the sensitized plate from whence we obtain our skyagram. The physicist has taught us that the ultimate expression of matter is the electrical corpuscle of the Alpha, Beta and Gamma ray. The spectrum records the presence of these rays as they bring their messages from the ends of the universe. The most remote planet is studied by their aid but who is able to know the orderly sequence of their relationship to the substances with which they combine. For instance; the Beta corpuscle of Radium and its relationship, step by step up through its various combinations to that of the constant flow from the great electrodes at Niagara which are capable of crystalizing the sands of the desert into diamonds on the one hand or its storage in the electrical fish who has commercialized it for obtaining his food and bridled its power for his own defense. I do not wish to stray from the mark but I only wish to show you how difficult it is for the biological chemist to give us the pure chemistry of the toxins of substances whose combinations in the organic rings are far more complicated and as unstable as the example just cited. I believe that it will not be hard for any of you to realize that the Co2 index of the blood is not the most fundamental thing in this study. The giving of soda is an adjuvans to the combining of these substances into a non-irritating urea is good, but the primary study is left for the chemist. To accomplish this in the presence of terrific destruction of tissue which continually liberates more and more of these poisons is our problem. In the subject in hand, that of intestinal obstruction, we first call in the surgeon to repair the mechanical defects, after that the physiological chemist must come to the rescue of both surgeon and internalist and until he does I feel assured that little progress will be made in the treatment of this terrible malady. The analysis

of the toxic group of all the proteids in nature yields a common poison. How to combine these poisons is the problem for the chemist. This poison is not a ferment or at least most of the biological chemists of the day do not think so. The chemistry of ferments is little known. We feel that it is a proteid in construction but it is generally agreed that it is not the same poison as that found in proteid cleavage. They are labial chemical bodies resulting from the intermolecular rearrangement in the proteid molecule of the cell. The proof of this is the change in the character of the ferment liberated by the cell when attacked by toxic proteins of different chemical consistency. Upon this we build our system of sensitization of the cells of the body. These ferments are thrown out for the specific purpose of destroying the foreign proteid by absorption. Now in the cells that die in the bowel wall are broken down into cleavage products of Amino acid and without a doubt the ferments contained in them if liberated in the blood stream would naturally set up two forms of intoxication. The Amino acids must be combined into urea in the non-irritating form. In case they are not combined immediately because of a lack of combining elements they are thrown into the system in overwhelming quantities and we have set up what is known as acidosis.

This acidosis is accentuated by the cleavage from the bacterial infection which is also present. In this class of cases it is not hard for the imagination to conceive, that after the attempt of surgical interference that only fifty per cent. of our patients recover. When we consider the appalling loss in the hands of the very best. surgeons and after forty years of devoted efforts we have not changed our mortality rate, and upon seeking diligently we find this problem confronting us, we are not amazed that our past efforts have not been rewarded with the solution of the problem.

VESICAL CALCULUS FOLLOWING

HERNIOTOMY*

C. R. KENNEDY, M. D., Omaha, Neb. Professor of Urology, University of Nebraska College of Medicine.

I wish to report two cases of calculus formation in the urinary bladder as a result of injury to the bladder during herniotomy.

Case A. Male, aged 55. Previous history negative up to 2 years previous when he had an operation for the cure of a right inguinal hernia.

Convalescence was normal and he remained well for some months and then commenced to have pain in the bladder, frequent urination, passed pus and blood in the urine.

Cystoscopic examination revealed a high grade cystitis and a calculus the size of a hickory

*Read before the Medical Society of the Missouri Valley at Lincoln, Neb., Sept. 21, 1917.

nut lying in the bladder. A supra pubic cystotomy was done and one stone was found free in the bladder and a smaller one hanging from a silk ligature in the fundus.

Case B. Female, aged 72. Admitted to the Methodist hospital, complaining of pain in the bladder and supra-pubic region, frequent urination, urine contained large quantity of pus and blood.

Vaginal examination revealed a mass in the bladder region and the cystoscope disclosed a calculus lying free in the bladder. This was removed by vaginal section and on sawing the stone in two, a silk ligature was found in the

center.

She gave a history of operation for a right inguinal hernia 21⁄2 years before. The hernia has recurred.

There is no doubt that these patients had vesical hernias which were not recognized until the bladder was injured and the defect was closed with silk which acted as a nucleus for the deposit of urinary solids.

As to the frequency of this condition we can draw no conclusions as there is little reference to it in the literature, but we do think it is a condition which should never occur, as it can be prevented by correct technique in herniotomy.

Vesical hernia in itself is a rather frequent occurrence. Brunner collected 180 cases up to 1890, only 13 being diagnosed before operation, and Heineck in a recent article reviewing the literature from 1896 to 1914 and including German, French and English journals, has collected 164 cases of vesical hernia in 159 patients, and I do not think half of the cases have been reported. According to his analysis, it occurs at all ages, but is uncommon up to 16 years. It occurs in women, as well as men, in direct, indirect, femoral and ventral hernias, as intraperitoneal and extraperitoneal and may be reducible, incarcerated or strangulated. From this we must conclude that the bladder must be thought of in every herniotomy.

The diagnosis of vesical hernia is possible in a large number of cases and if we find a patient with a hernia has any urinary disturbance such as frequent urination, decrease in the size of the hernial swelling during urination or we find that pressure on the hernia causes a desire to urinate we suspect the presence of the bladder in the sac.

If we find on cystoscopic examination that there is a diverticulum in the region of the hernia or if we can introduce the cystoscope into this cavity and tranilluminate the hernia, or if the hernia enlarges as we fill the bladder we are positive of it.

Still there remain a large number of cases in which we find none of these signs and still the bladder is present in the sac.

To prevent injury to the bladder in these cases there is only one method, that is care in operating.

In a herniotomy we should give just as much thought to injury to the bladder as the intestine. or any other organ, and if the operator will take time to identify every structure and to cut or clamp nothing till he is sure what he has, he will never cut into a bladder.

There are a few points, though, which will aid us in avoiding injury to the bladder.

First, if there is more than one sac, be very careful, and if necessary, pass sound into the bladder and outline its limits.

Second, if there is an extra amount of fat around the sac, isolate it carefully as it is likely to come from the pre vesical space and may contain the bladder.

Third, do not pull too strongly on the sac, and be sure the neck is isolated from everything before ligating, as you may ligate a portion of the bladder and get a slough later.

If the bladder is present in the sac it should be carefully isolated, reduced and the usual closure of the canal made.

In case of injury to the bladder before it is recognized, it is still possible to prevent serious

consequences.

The bladder should be carefully isolated and closed with chromic catgut sutures, the first row passing through all coats but the mucosa, the second row going through the muscle and burying the first. Some authorities advise a third row of Pagenstecher or silk but this should be avoided by all means as it is an established principle that unabsorbable sutures in a hollow viscera always find their way to the lumen of the viscera, so if the third row is used make it chromic catgut.

The herniotomy should be finishel in the regular way and it is preferable to use no drain. If one is used it should be gutta percha folded up or rolled into a tube as a gauze drain is apt to cause a fistula.

The bladder should be kept empty either by frequent catheterization or an indwelling cathe

ter.

Recovery is usually prompt, and if no permanent sutures are used there is no danger of calculus formation later.

page 592.

BIBLIOGRAPHY

Heinech, Aime Paul-Hernias of the Bladder. Surgery Gynecology and Obstetrics-Vol. XXII, No. 5. Moschowitz, A. V.-Johnson's Operative Therapeusis, Vol. IV, pages 31-38.

Chetwood-Urology, Second Edition, page 418. De Quervain-Clinical Surg. Diagnosis, 391. Guiteras, Raymon-Urology, Vol. II, page 26. Keyes, Edward L.-Diseases of the Genito-Urinary Organs, page 518.

Greene and Brooks-Diseases of the Genito-Urinary Organs and Kidneys.

Binney-Operative Surgery.

Coley, Wm. B.-Keen's Surgery, Vol. IV, page 80.

[blocks in formation]

ASSOCIATE EDITORS

P. I. LEONARD, St. Joseph.
J. M. BELL, St. Joseph.
JNO. E. SUMMERS, Omaha.

CONTRIBUTING EDITORS

H. ELLIOTT BATES, New York.
JOE BECTON, Greenville, Texas.
HERMAN J. BOLDT, New York.
A. L. BLESH, Oklahoma City.
G. HENRI BOGART, Paris, Ill.

ST. CLOUD COOPER, Fort Smith, Ark.
W. T. ELAM, St. Joseph.
JACOB GEIGER, St. Joseph.

S. S. GLASSCOCK, Kansas City, Kan.
H. R. HARROWER, Los Angeles, Cal.
JAS. W. HEDDENS, St. Joseph.
VIRGINIA B. LE ROY, Streator, Ill.
DONALD MACRAE, Council Bluffs.
L. HARRISON METTLER, Chicago.
DANIEL MORTON, St. Joseph.
D. A. MYERS, Lawton, Okla.
JOHN PUNTON, Kansas City.

W. T. WOOTTON, Hot Springs, Ark.
HUGH H. YOUNG, Baltimore.

The Editors' Forum

War Deafness and Its Prevention

War deafness is important from several standpoints, but particularly that of prevention. It incapacitates trained men for shorter or longer periods and they must frequently quit the service, the victims are handicapped when they return to civil life, and the government may have to pay them a pension.

The present war has enormously increased those cases compared to former wars on account of the great use of high explosive shells and hand grenades. Much has been written on this subject. An editorial writer in the British Medical Journal on March 24, 1917, states that "at a recent meeting in Germany, at which concussion wounds of the tympanum were discussed, it was authoritatively stated that no satisfactory device has yet been found to prevent this and allied injuries."

Detonation effects on the ear are rupture of the tympanic membrane, organic disturbances of the labyrinth and functional disorders of the central nervous system. These may occur alone or in combination. Rupture of the membrane. may bring about infection of the middle ear. Pathologic changes occur simultaneously in all parts of the organ of corti as a result of deton

ation. Of "functional deafness" due to nervous disturbance very little is known.

Shell shock is also due to the high air pressure in the vicinity of the exploding shell and in the most severe form the result is instantaneous death, with no external lesion at all. Examination of the tissues from these cases has shown the existence of microscopic hemorrhages, especially in the nervous system and the kidneys, and bloody urine in non-fatal cases. There may be secondary suppression of the adrenal secre

tion.

Men handling large guns have had as common practice during the discharge the opening. of the mouth. It permits pressure on both sides of the tympanic membrane. For troops under fire this is useless, because they can not anticipate the time of the explosion.

Of little avail is the placing of the finger tips in the ears. Plugging the meatus with cotton is the most common procedure. Dry, air containing cotton is of little use, but if used with various oils it fills the spaces. Solid obturators of many shapes and materials have been made. Lizzati raised two objections. The hardness of the material irritates the skin and causes inflammations and eczema, while they project and become the source of severe injury. The Elliott "ear drum protector" used by many naval and artillery officers, is based on the principle of a double diaphragm with a tube in the center passing through and supporting both diaphragms, with a narrow air passage in the tube that has openings between the spaced diaphragms and at the inner end, designed to permit slow changes of the air pressure. It interferes with the hearing, but little is known about its efficiency. There are many kinds of obturators, some made of various wax mixtures and they are probably the most satisfactory. A plug conforms exactly to the shape of the meatus. Guild of Ann Arbor, in the Journal of Laboratory and Clinical Medicine in a long article summarizes as follows: "In the first place, the issuance and compulsory use of some preventive, even if it be nothing more than cotton with vaseline, is in the interest of efficiency in the army, and it is of economic importance. Protectors should be issued like clothing, rations, etc., to all troops alike, and their use made compulsory." Some such method lies in the direction of the prevention of war deafness. P. I. L.

Red Cross Seal Campaign
in Kansas City

The sale of Red Cross seals during Christmas holidays in Kansas City brought a total of $14,400 to the Kansas City Anti-Tuberculosis Society. The local organization turned over to the state and national Red Cross societies combined, $2,187, of which two-thirds goes to the national

organization and one-third to the state society. The local society has $10,157 net. It had remaining in bank $4,426, a total of $14,583 for use by the Kansas City Anti-Tuberculosis Society during this year.

"The society is now maintaining about 175 tubercular and anemic children in open air schools," said Mr. W. C. Root, president, "and soon expects to add at least fifty more."

Two nurses are maintained in the schools who look after the condition of the children while there and follow them into their homes and arrange for their diet and proper hygienic care there. Four physicians also watch over the children of the open air schools, advising as to treatment, diet and living conditions.

Aside from these, two other nurses are employed to visit in the homes where persons are suffering from tuberculosis and give instructions as to the proper care of patients.

It has just come to the notice of the society that many men summoned in the draft were rejected because of tuberculosis. Many of them never even suspected they were so afflicted. Thirty soldiers also have been sent home from Camp Funston, it having been discovered in reexamination there that they are victims of the white plague. The names of all of these have been furnished the society and these cases will be followed up and an effort made to benefit these sufferers.

Atlantic City

a Rendezvous

There can be no question as to the therapeutic value obtainable from a change of scene and a modification of environment. In fact, there are numerous cases in which much more may be obtained by such means than by the use of drugs. Unfortunately, however, in many instances, mere change of this sort does not prove beneficial, because the patient is not placed amid surroundings that are congenial and is made to feel more or less as if he or she had been transplanted into an uncongenial soil. On the other hand, there are places where such a feeling cannot exist and an excellent example of such a place may be found at the Hotel Chalfonte, in Atlantic City, N. J.

The first impression made upon the writer when entering the hotel is the homelike character of the place. The hostelry is large and thoroughly equipped in every way to cater to the wish or whim of the tourist or pleasureseeker. But at the same time, there is an entire absence of what might be called "hotel atmosphere."

The service is of the best, but at the same time is not obtrusive or insistent.

Perhaps the most striking feature of the Chalfonte is the space devoted for lounging purposes. Long halls and large rooms, differently furnished and fitted out invite the restless guest to tarry for a time here and then to move to some other part of the hotel, thus giving a sense of hominess and privacy that is lacking in so many modern caravansaries.

The Chalfonte is an ideal place in which to rest. Noise, glitter, glare are all noticeable by their absence. The table leaves nothing to be desired; there is employed variety and the quality of the food is above criticism.

One does not have to remain long at the Chalfonte before one realizes that it is a place much favored and frequented by medical men and a little inquiry discloses the fact that hundreds of doctors send certain patients to the Chalfonte for rest and recuperation.

There seems to be an idea in the minds of many people that Atlantic City, being the great pleasure resort that it is, must necessarily be noisy and not adapted for those who require quiet, peace, and restful surroundings.

A visit to the Chalfonte will dispel such illusions and not only this, will probably result in a return from time to time for a repetition of the benefit to be secured within its walls. H. E .B.

Death of

Dr. Herbert Lee

Dr. Herbert Lee of St. Joseph, died Thursday, March 21, at his home, 1022 North Nineteenth street. The doctor had been sick for six months or more, had spent several months in Texas, his former home, and returned to the city a month. ago, not much improved. He was born in Bristol, England, and before coming to America had been a buyer of Italian marble for his brother. He spoke Italian fluently. After coming to America he spent several years in Dallas, Texas. Later he came to St. Joseph and graduated in medicine at the Central Medical College. After fifteen years of general practice, he became house physician at the Woodson Sanitarium. He continued there until his health began to fail a year ago, when he resigned. Dr. Lee was of a highly cultured, studious, esthetic tendency, ill adapted to the harsh commercialism of medical practice of the day. He was both gentle and loving, a man to be trusted with responsibility of duty as well as the intimacy of friendship. As a student, a lover of books and an investigator, Dr. Lee has left a name and an individuality the loss of which will be felt by a large coterie of friends in the Buchanan County Medical Society and among the public. The body was put to rest by the Masonic fraternity Saturday the 23rd.

J. M. B.

Dr. Heinrich Stern of New York City Dead

Dr. Heinrich Stern of New York City is dead. He was a Missouri product; we were proud of him. A very lovable man, a genial companion; ambitious, energetic; a good mixer; gifted with a fondness for detail and organization; he was an ideal medical secretary. A lover of books and study; a seeker after truth. His ideals were lofty and he maintained them. In his journal Archives of Diagnosis, he never carried any advertisement.

He refused to commercialize medical journalism. He will be missed by many friends and societies. The last time I met him in New York he was pale and gaunt. The report was current he had cancer of the stomach, yet he was active and genial and courageous. He was a brilliant man; he crowded a long life into 49 years. He graduated from St. Louis College of Physicians and Surgeons, 1899; aged 49; a Fellow of the American Medical Association, and at one time chairman of the Section on Pharmacology and Therapeutics; a member of the American Public Health Association, American Urological Association, and New York Academy of Medicine; secretary of the American College of Physicians; visiting physician St. Mark's Hospital and the Methodist Episcopal Home; gold medalist of the Medical Society of the State of New York; founder and editor of the Archives of Diagnosis; writer on biologic chemistry, diagnosis and diseases of nutrition; died at his home January 30, from cirrhosis of the liver. J. M. B.

Oleomargarine

a Popular Food?

Statistics show the sale of oleomargarine to have reached, during the past year, to 235,000,000 pounds. Manufacturers wonder why the old time prejudice should still exist, and why laws. should still discriminate in favor of butter. The question is a fair one, and the fact that oleomargarine is clean and nutritious cannot be disputed. But prejudices are slow to die, unless all arguments are overwhelmingly against them. From a purely economic standpoint there is no reason why oleomargarine should not come into general use, since it is clean, nutritious, made of pure fats, and has high caloric value as a food stuff. It is cheaper than well made butter. But the prejudice against it has some well founded scientific, as well as esthetic reasons for living. Oleomargarine lacks that perfection of food value in vitamines which makes for robustness, specially in children. However near the mark it comes, it is still a substitute, and as long as butter fat exists it will hold its own as to preference. The esthetic phase of the question will be slow to disappear. Butter is associated in thought with

green fields, rich cream, fresh clean hay, and the happy, if poetic, childhood days on the farm in the open air; the running brook, the cow calmly standing in the water or leisurely chewing her cud of fresh green grass. This view may be ideal and poetic and unreal in many cases, but the associated thoughts of the mental picture and butter are too deeply rooted in the public mind to be easily dissipated. Oleomargarine is twin in thought to the grime and dust; the offal and odor, the toil and oppressiveness of the packing house. Clean sweet fats though they may be, they have acquired an atmosphere discordant to the esthetic taste. From a standpoint of political economy, butter is entitled to protecting laws, originating as it does from the small farm universally. It would be manifestly less harsh to curtail the enormous income of the packer, than to deprive the army of small farmers of an avenue of income justly due them. J. M. B.

Medical Mobilization

The size of the undertaking confronting the general war-winning program will require a mobiliation of the entire medical and surgical resources of the country.

Every competent medical man in the country should put himself at the disposal of the Surgeon General of the United States.

The medical profession is composed of men whose patriotism is unquestioned and who are eager to serve their country in every way. The formation of the Senior Military Medical Association in Philadelphia is a society which now has 271 members. It is spreading all over the country. It is intended that this new corps shall be an instrument able directly to meet such civil and military needs as are not already provided for. It holds that the health of the people at home must be maintained as efficiently as before.

Hospitals, medical colleges and laboratories dent to examination of drafted soldiers, includmust be up to the standard; the demands inciing the reclamation of men rejected because of comparatively slight physical defects. Conditions of membership are not onerous and are such as any qualified practitioner can readily meet.

Write a letter to the secretary, Dr. W. F. Snow of the Central Governing Board, Council of National Defense, if you wish to join, and he will send the applicant a printed form. appropriate button will be adopted as official insignia.

An

The Ohio State Journal says: "What makes us madder than anything else is the person who stands by his country in this crisis all right, but acts as if he were making a great concession.

P. I. L.

« ПретходнаНастави »