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He Has TWO GOOD LEGS One Made by Nature

The Other by Marks

ANSW

READ WHAT HE SAYS:

To A. A. MARKS, N. Y.: I wish you to know how many days the leg you made for me worked during the year. During the month of January I worked 407 hours; February, 292; March, 358; April, 253; May, 280; June, 316; July, 337; August, 376; September, 337; October, 391; November, 375; December, 337.

If you will add up the number of hours you will find it amounts to 4,131, or more than 413 days for the year, and you know there are only 313 working days in the year, so I have worked a year and one hundred days in the year wearing your artificial leg every hour of that time, and it has not cost me one cent for repairs. It is as good now as it ever was. The engine that I am firing is one of those big ones that

hauls coal from the mines to Pottsville, No. 148. I enclose a photograph of my engine, where you will see me at my post of duty. I get all over her with the same ease that I ever did. Sometimes I climb on top of the boiler when in motion. I can tell you more about what I am doing with my leg if you want it. The hard use I am giving your leg, and the excellent wear it is giving, proves it to be the best in the world. I am respectfully yours,

FRANK FAUST, Pottsville, Pa. This demonstrates that the loss of a leg does not debar a man from firing a locomotive.

Manual of Artificial Limbs and Measuring Sheet sent gratis. Address

A. A. MARKS, 696 to 702 Broadway, New York

- Incorporating
Kansas City Medical Index-Lancet

An Independent Monthly Magazine

Vol XXXIX.

FEBRUARY, 1918

No. 2

ine displacements may be attributed to too long Original Contributions

rest in bed upon the back, after confinement.

Therefore, early getting up after confinement, | EXCLUSIVELY FOR THE MEDICAL HERALD.1

with moderate exercise, is to be encouraged as a

prophylactic measure. RETROVERSION AND RETROFLEXION OF THE UTERUS

Pathology-In consequence of the usually H. J. BOLDT, M. D., F. A. C. S., New York.

present, and more or less marked descensus of

the uterus in cases of retroversio-flexio, the vaWe speak of the retroversion of the uterus ginal part of the cervix seems to be elongated. If when the uterine body, in the upright position,

the cervix is lacerated, the lips of the cervix does not lie in front of, but behind, the uterine

gape; which is a frequent causative factor of cervix. A retroflexion has a similarly faulty laceration ectropium. The gaping of the lips position, but shows more angle at the junction of may be the result of inflammatory and adenoid the cervix with the body. Most frequently flex

granulation processes when these estalish themion and versions are combined in the same pa- selves on the lower cervical portion the gaptient. In the case of a pure version there is al- ing becomes more marked. If the retroversioways more or less induration at the juncture of flexio is long present and in so marked a degree the body and cervix. An accurate diagnosis that at the point of flexion there is not a curve should never be attempted with a filled bladder, but an acute angle, the flexion area will continusince the position of the uterus necessarily varies ally become atrophied. And to this may be in accordance with the bladder contents. Fur- added a tissue fixation, so that to straighten the thermore, it should be remembered that usually, uterus it is practically impossible. in a case of retroversion, simple or with retro- Frequently there are inflammatory peritoneal flexion, there is more or less displacement of the adhesions, which vary in density, between the uterus downward.

posterior uterine wall and the pelvic peritoneal To enable us to treat intelligently patients surface, and often spreading to the adnexae. with retroflexio-versio, it is necessary to under It is not necessary to call attention in detail stand fully the etiological factors which bring to the complications that may be caused by coabout this form of posterior uterine displace- existing pelveo-peritonitis and bilateral salpingoments. We may mention, first, certain retarda- oophoritis, resulting from gonorrhea. The detion in development; second, fixation of the grees and extent of the inflammatory process vaginal part of the cervix to the anterior pelvic varies in different patients. While usually the wall; third, unilateral posterior fixaton of the inflammation of the adnexae is equally severe on cervix; fourth, a shriveled or shrunken condition both sides, still, exceptions are not infrequent. of the posterior uterine wall, or an elongation of We should bear in mind that if the pelveothe anterior uterine wall; and fifth, relaxation of peritonitis is of gonorrheal origin, it has ascended the uterine attachments.

from the uterus, and the uterus is therefore the According to Sellheim, who made an excep- seat of a gonorrheal infection. This is importtionally careful study of the causes of retrover- ant to keep in mind because of the treatment. sions, one-ninth of all patients were found to The endometrium-though no gonococci may have embryonal peculiarities of the vagina. still be present in a condition of interstitial en

Ziegenspeck considers anterior fixation of the dometritis—is usually markedly thickened, simicervix the most frequent cause of retroversio- larly to the myometrium. The entire organ is, in flexio. This is not, however, in accord with my fact, hypertrophied (i. e., thickened and enown observations.

larged) the walls are rigid, and the passive flexI have seen a number of such displacements ibility at the corporal cervical junction is dicaused, I believe, by septic infections, producing minished or entirely lost. an atrophy of the uterine musculature and sub- Inasmuch as with this injection sometimes sequently retroversio-flexio.

the tubes are more involved, and sometimes the Unquestionably, not a small number of uter- ovaries, it may be that occasionally the ovaries

are but slightly affected; whereas, in other in- uterus fills the cavity of the true pelvis, and then stances, the infection may be of such a nature pressure of the bony pelvis give cause for irrithat abscess formation in the ovaries is present. tation to the growing uterus, thus causing con

Varying degrees of ovaritis, however, occur tractions and expulsion of the fetus. Abortion more frequently than abscess formation.

at an earlier period of gestation, however, is not Hyperaemia and congestion lead to chronic excluded. In such instances pressure may not ovaritis; and any factor that may cause such be considered a cause. The most probable inhyperaemia—as sexual irritation, exposure to ducing factor is a pathologic condition of the cold during menstration, circulatory disturb- uterus, following circulatory disturbances ances, etc.—is of significance for the picture of brought about by the displacement. Sometimes a posterior displacement. A retroflexion, of small hemorrhages into the decidua may be held itself, causes, in most instances, a downward accountable for the accident. displacement of the ovary. As a consequence of Leucorrhoea is of such frequent occurrence the consecutive torsion which the broad liga- that we set this down as one of the symptoms ments then undergo, the circulation in the uterus caused by the displacement, though no logical and ovaries is affected. These inflammatory reason for it can be given. conditions of the ovaries then not infrequently Bladder disturbances may be ascribed to the cause adhesions of the glands to the surround- change in the contour of the bladder due to the ing structure. And when the adhesions are not displacement. Indeed, during pregnancy they very firm, they are more likely to be the result may become so serious as to endanger life, unless of uterine displacement than of infection. Fur- the uterus is emptied. thermore, following ovarian inflammation we Constipation is attributable entirely to memay see ovarian growths. Thus we have an eti- chanical reasons: The pressure on the lower ological factor for some ovarian tumors.

bowel. This, too, is not an infrequent cause for It is readily conceivable that retro-uterine hemorrhoids. inflammations may be considered as an etiologi Whether backache is caused by the displacecal factor leading to retroflexion. Take, for in- ment is an open question. It is certain, howstance, a retro-uterine haematocele. During the ever, that the backache often ceases when the process of absorption it will cause a shrinking organ is replaced. And for that reason one may which will draw the uterus into a posterior posi- not be wrong in giving it as one of the symption.

toms. The most frequent adhesions between uterus. Headache is quite often a result of the disadnexa and the surrounding structures are due placement. Likewise a variety of other nervous to inflammation of the organs themselves; and symptoms. These may be called border-line the most usual cause is some form of infection. disorders, between gynecologic and neurologic. The firmest adhesions of the tubes and ovaries It is to be regarded as an exception when a are found as a rule at their lowest border. retroversion, simple or combined with retro

There is a difference in the infections that flexion, exists during the entire period of a attack the tubes and ovaries. If of puerperal. woman's genital life without causing symptoms. origin, the inflammation, if it heals spontan- The reflex nervous, or local pains may only eously, does not leave its ear-marks, as does one become manifest shortly before the onset of of gonorrheal infection, with salpingitis nodo- menstruation. We must remember that with sum.

perfectly normal genital conditions there is no When an organ lies inactive in a serous cav- dysmenorrhea. ity, the opposing visceral and parietal serous sur- Occasionally sterility may be caused by the faces must as a consequence of pressure, be displacement considered. The best proof for denuded of their endothelium and then become the correctness of this assertion is: That someadherent to each other. The length of time for times a sterility covering a number of years in this to occur, of course, varies. This shows the cases of retroflexion is cured by its correction reason for adherent retroversio-flexio.

and the adjustment of a proper pessary. It may

be that this is due to the relief of complications Symptoms—These may be local and general. existing in connection with the displacement, as Again those arising from mobile, and adherent metritis or metro-endometritis, which undoubtretroflexion.

edly are a factor in the pathology. Among local symptoms, meno or metrorrhagia is the most constant, particularly among Diagnosis—This must always be based on the girls.

palpatory findings. Symptomatology is worthAs the result of the displacement abortion is less for the purpose of making a diagnosis, since often seen. This takes place usually about the all the symptoms mentioned may be present in fourth month, since at this period the size of the connection with other disorders.

A. SO

For the purpose of making an examination SERUM TREATMENT OF PNEUMONIA it is essential that all clothing be loosened, the

A. SOPHIAN, M. D., Kansas City, Mo. bladder emptied and the abdominal walls relaxed. If any one of these requirements is not

Lobar pneumonia is an acute infectious discomplied with an exact bimanual examination

ease, generally caused by the pneumococcus, is impossible.

characterized by general systemic infection as

well as inflammation of the lungs. The most important error-one that is not sel

The pneumococcus causing pneumonia has dom made—is to confound a retro-uterine tumor

been classified into four groups, namely, Groups of small size for a retroflexed uterus. One who is accustomed to examine frequently can usually I, II, III, IV, the division being determined differentiate such uterine tumor-whether it be by serum tests, viz., the serum of animals ima myoma or tubal swelling the size of a uterus- munized against pneumococcus of one group from a retro-flexed uterus, without resorting to shows the presence of specific immune bodies a sound; but one who is not accustomed to ex only for that group pneumococcus, and little or amine bimanually many gynecologic patients, no specific antibodies for the organism belongmay sometimes be helped by using a sound. ing to the other groups. Group III pneumococ

Utmost care should be used in making a cor- cus (pneumococcus mucosus) has distinctive rect diagnosis before attempting to replace a

cultural characteristics. supposed retroflexed uterus, since a number of The bacteriological study of many cases of such instances are on record of deaths caused pneumonia has shown that about 30 per cent of by mistaken diagnosis, in instances when the all cases are caused respectively by pneumococretrouterine mass was a pus sac. Therefore, not cus Groups I and II, with an average mortality only the uterus but also the adnexa should be of about 30 per cent; 12 per cent by Group III palpated in all instances. One must determine with an average mortality of 45 per cent; with whether the displacement is fixed or mobile. In Group IV, 24 per cent with an average mortalsome cases an anesthetic may be necessary to ity of 16 per cent. make a diagnosis.

The pneumococcus in pneumonia can be isoThe therapy may be divided into mechanical Tated iro

lated from the sputum, blood, urine and from and surgical. Personally, I always elect mechan- aspiration puncture of the involved lobe. The ical therapy if the uterus can be held in proper organism can be most quickly isolated from the position by such means; reserving surgical in

sputum. The method found most practicable is tervention for those patients in whom one cannot

to inject some carefully collected and washed retain the uterus in position with a pessary; for

sputum into the peritoneal cavity of a white those who do not want to have a pessary applied,

mouse, which sickens generally within 24 hours. and lastly, for instances of fixed displacement

The peritoneal exudate of the animal contains when it is impossible to reduce the dislocation.

the organism in large numbers. This culture It is understood that a pessary should never be

tested seriologically against Groups I, II and III adjusted until the uterus has been replaced in

serum by the agglutinin or precipitin test, enproper position. We must not lose sight of the

ables a rapid, accurate diagnosis of the pneufact that there are a goodly number of women mococcus as to group. with marked displacement who have no symp

The most important principle of specific imtoms whatever. In the case of such women, un mune serum therapy is to use a specific serum less they consult the doctor because of sterility of high titre. The importance therefore, of it is best to let them alone.

prompt classification of the type pneumococcus It would carry me too far were I to consider

causing pneumonia is obvious; one can deterin detail the therapy of dealing with this class

mine as to the probable gravity of the disease, of patients. I have but briefly alluded to the

and if serum treatment is used one can select fundamental methods. There are so many sur

a serum containing many immune bodies against gical interventions that this is proof enough that

the Special Group pneumococcus indicated. Anwe not yet have anyone that is ideal in the opin

other principle is to inject an immune serum in ion of all gynecologic surgeons.

ample dosage, directly into the infected region.

In pneumonia the infection is present in the blood 39 East 61st St.

and in the lung. It is dangerous as well as im- .

practicable to inject serum in the lung. Serum, Eclampsia: Sedation, venesection, elimina- therefore, should be injected into the blood by tion and prompt delivery-venesection during direct intravenous injection, thereby meeting attack most potent of all.

the general infection and to a lesser degree, the

local infection in the lung. The dosage used Overfeeding is now quite universally ac varies with the individual cases; an average corded a foremost place in the etiology of gastro dose is 100 c.c., repeated every 8 hours if necesintestinal disorders in infancy.

sary till about 250 c.c. is injected. An evidence

of favorable reaction, is improvement in the non-specific protein reaction, which would be general condition, clearing up of cyanosis, fall in sharpest after intravenous injection. It must be pulse rate, fall in temperature and a shortening remembered, however, that the reaction, if very of the disease. The local extension of the dis- severe, may be decidedly harmful or dangerous. ease is stopped and bacterial invasion of the There are a few points in the general therapy blood stream prevented. There is no appreci- of pneumonia which may be emphasized here. able change in the local pulmonary signs, and The abdomen should be kept flat, and if necesno effect on resolution. Of 107 cases of Type I sary, milk avoided. Water should be taken pneumonia treated in the Rockefeller Institute freely, diet very light. Sugar and alkali should Hospital ony 7.5 per cent died.

be administered to prevent acidosis. Digitalis Injection of serum or any foreign protein, is favored by many for use throughout the disespecially intravenously is frequently followed ease. Plenty of fresh air, not necessarily freezby a sharp reaction, consisting of chill, hyper- ing air, is important. Absolute quiet is imperapyrexia, sweating, hyperleucocytosis with high tive. Camphor and quinine have been recompolynucleosis. This reaction is to a large ex- mended by some as having specific properties; tent a non-specific reaction following the in- the writer questions any special virtue, except jection of any foreign protein, specific or non- when especially indicated. specific. The therapeutic value of this reaction A word about prophylaxis: Pneumonia is a is often considerable. The specific therapeutic contagious disease; the germ is transmitted by action of serum is the destruction of the pneu- healthy carriers. The same precautions, theremococcus, as well as the stimulation of a specific fore, should be used to prevent the spread of this leucocytosis and phagocytosis.

disease as for epidemic meningitis, poliomyelitis The injection of foreign protein may also or other carrier disseminated diseases. be attended by the reaction of anaphylaxis, specific or non-specific. The symptoms may be “JEJUNOSTOMY IN ACUTE OBSTRUCthose of true anaphylactic shock, with convul

TION OF THE BOWELS”. sions, respiratory paralysis and death; fortun

New York City, December 13th, 1917. ately a very rare occurrance; or those of serum My Dear Dr. Fassett: I have read with much sickness, occurring at once, in four days, or ten interest Dr. McKinnon's article on jejunostomy, days following the injection of serum. It is im- but thus far I have had no experience with that portant to test patients before the therapeutic technic. It seems to me to be not quite clear injection of serum to determine whether or not regarding the element of risk when the bowel is they are susceptible or sensitive to the serum to dropped back into the peritoneal cavity with a be injected. This is done by the intracutaneous tube in it. It would occur to me that when the injection of 0.02 c.c. of sterile diluted horse serum tube became loosened we would be likely to get (normal or immune) diluted with salt solution leakage. If there be no risk in Dr. McKinnon's 1.10; a positive reaction consisting in the al- operation, the procedure would be ideal. I wish most immediate appearance of an urticarial to congratulate the doctor on his excellent rewheal at the site of injection reaching its maxi- sults and would be much pleased to get a little mum size in about an hour, then fading rapidly. more information regarding same. After the completion of the intracutaneous test, Faithfully yours, HERMAN J. BOLDI. a desensitizing subcutaneous injection of .5 to

Lincoln, Neb., December 29th, 1917. 1 c.c. of horse serum (normal or immune) should Dear Dr. Fassett: Replying to your letter of be injected even if the test reaction be negative. recent date with enclosure from Dr. Boldt comIf the skin test be positive, more thorough de- menting on my article on jejunostomy. sensitization must be employed. This consists in There are many methods of doing an enterinjecting small doses of serum subcutaneously ostomy. The method recommended in my paper at half hour intervals, beginning with 0.025 c.c. seems to me to be the simplest, and with an exof serum and doubling each succeeding dose. perience of over fifty cases now, without a fistula After 25 c.c. of serum have been given in these following, seems to show that if properly persmall doses, after a lapse of four hours, 50 c.c. formed it is the ideal operation. may be given, followed by the regular dose 6 to The technic as described in my paper explains 8 hours later.

how the tube with the intestinal wall is invaginThe reaction of anaphylaxis may also be ated into the lumen in the form of a cone. When modified or prevented by preliminary adminis the tube drops out the invaginated cone acts on tration of alkali to a patient for about 24 hours. the same principle as a safety ink well and pre

Vaccine has been used in the treatment of vents leaking until the peritoneal surfaces adpneumonia as in the treatment of other infec- here. If you use a small tube-less than 20 tions. The favorable results from the adminis- French-the question of leakage need not be tration of vaccine in an acute disease like pneu- taken into consideration, as there will be none. monia, may be expected principally from the Yours very truly, A. I. MCKINNON.

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