Society Proceedings

THE MISSOURI STATE MEDICAL ASSOCIATION AT SEDALIA.*

(CONTINUED.)

The report of the committee on Progress of Medicine was read by DR. W. H. EVANS, of Sedalia, and DR. T. C. BOULWARE, of Butler. Among the rapid and effective strides in medicine were mentioned the serum-therapy in tuberculosis and diphtheria, and organo-therapy, with special reference to the use of the thyroid body in myxedema. Diagnosis is rapidly being reduced to a science. The Widal reaction in typhoid fever, and the Röntgen ray were cited as fair examples of diagnostic aids recently put to practical Allusion was made to the germ theory of cancer as a probability.

use.

DR. J. W. ALLEN, of Liberty, commended especially the use of antitoxin, and referred to his satisfactory experience in diphtheria.

DR. H. SUMMA, of St. Louis, warned the profession that they lay not too much stress upon the use of antitoxin in consumption. Koch, one of the greatest bacteriologists of the age, had given much of his time and attention to this subject, but had not succeeded in finding a cure for consumption.

DR. J. S. MYER, of St. Louis, though a firm believer in the germ theory of disease, is not yet willing to accept the germ theory of cancer. The bacteria found in carcinomata are purely accidental. Bacteria gain entrance to the blood indirectly through the tonsils, intestines, etc., but are left in abeyance through the phagocytes and the resistance of the tissues. The carcinomata afford a splendid soil for the growth of germs. The true causes of cancer are to be found in a combination of the Cohnheim theory and the traumatic theory.

DR. GILMORE, of Adrian, read a paper on Typhoid Fever. Etiology, symptomatology, and treatment were taken up in turn and discussed at length. The observations of Keen, of Philadelphia, with reference to bone lesions were cited. The outlets through which the bacteria and toxins leave the system are not well understood.

DR. SUMMA, of St. Louis, maintained that the outlets for the bacteria in typhoid are well known, viz.: the bile, urine, and feces. In typhoid fever, ulcers are frequently found in the gall-bladder and are conducive to the formation of gall-stones. DRS. SEXTON, PEARSE, MATTHEWS, WOODSON, GROVE, LOGAN, and CLAUSEN discussed the paper, referring especially to the good results obtained through hydrotherapy, diet, and intestinal antiseptics.

*Reported by J. S. MYER, M.D., Assistant Recording Secretary.

DR. G. M. NICHOLS, of Higbee, read a paper on Spinal Meningitis, referring to the recent epidemics of cerebro-spinal meningitis.

DR. C. R. WOODSON, of St. Joseph, recommended venesection and hydrotherapy in the treatment of cerebro-spinal meningitis. Salicylate of sodium and mercury have yielded good results.

DR. SEXTON, of Kansas City, uses pilocarpine with good results.

DR. GROVES, of Kansas City, had seen cases in the Klondike resembling in every particular those cases observed in this community in the recent epidemics.

DR. CLAUSEN, of Kansas City, referred to the diagnostic value of the lumbar puncture, especially in suspected tubercular meningitis.

DR. J. E. LOGAN, of Kansas City, had seen many cases of otitis media complicating meningitis.

DR. T. E. POTTER, of St. Joseph, read a paper entitled Indications for Cholecystotomy and Review of Technique. The indications are (1) gall-stones; (2) pus or abnormal fluid in the gall-bladder; (3) cholecystitis (chronic jaundice); (4) stenosis of the duct.

DR. W. S. MCCANDLESS, of St. Louis, read a paper on Surgery of the Gall-Bladder. Pain, a slow pulse, emaciation, jaundice, etc., are indicative of gall-stones. The technique of the surgery of the gall-bladder was carefully reviewed, interesting specimens demonstrated, and cases reported.

DR. JABEZ JACKSON, of Kansas City: The size of the gall-bladder lends material aid in locating the stone. If in the cystic duct, the gall-bladder is usually small, in fact smaller than normal; if in the common duct, it is frequently larger and can be readily felt on palpation. He recommends cholecystenterostomy when adhesions will not admit of drainage through the abdominal wall.

DRS. J. F. BINNIE and A. H. CORDIER, of Kansas City, alluded to the points in the technique, agreeing, in the great part, with the views of the author.

DR. J. S. MYER, of St. Louis: Surgeons are too prone to slight the diagnostic means at their command, and depend upon an exploratory incision for the diagnosis of gall-stones. The demonstration of gall-stones in the feces "clinches" the diagnosis. Naunyn's theory as to their formation is undoubtedly the most rational.

DR. H. SUMMA, of St. Louis: The diagnosis of gallstones is to a great extent guess-work. Pain and jaundice, the chief symptoms, are often misleading. Icterus is not an essential factor. It remains for the surgeon to make an absolute diagnosis by means of the exploratory operation.

DR. J. L. WORDEN, of Pleasant Hill, read a paper on Psychiatry. The neuron theory has completely revolutionized all former ideas of the nervous system. The so-called functions of the cord are purely reflex.

Late developments prove that the corda tympani nerve is the special nerve of taste. There should be fourteen instead of twelve cranial nerves.

The Report of Progress in Neurology was read by DR. W. F. KUHN, of Kansas City. The histology of the nervous system has been revolutionized, necessitating a revision of all text-books. The changes in histology as a matter of fact produce changes in pathology.

DR. JNO. PUNTON, of Kansas City, believes that while the neuron theory is generally accepted, it is still nothing more than a theory. Efforts are being made to disprove it.

DR. KUHN: The so-called authorities who attempt to disprove the existence of the neuron are not authorities at all. The neuron is not a theory, but a matter of fact, as is easily demonstrable by the microscope.

DR. HARRIS, of Marshall, read a paper on Gynecology With the Country Doctor. Great stress is laid upon constipation and its treatment. "Woman is a constipated animal." The treatment of amenorrhea and dysmenorrhea in young girls should be purely constitutional, not local. Take care of the general constitution and menstruation will take care of itself.

DR. J. M. BALL, of St. Louis, reported a case of Brain Tumor Causing Chiefly Ocular Symptoms. Diagnosis was verified by the post-mortem. A large tumor was found involving the lower third of the right frontal lobe.

DR. F. B. TIFFANY, of Kansas City, reported a case of Embolism of the Central Artery of the Retina. The case was not an unusual one of its kind. The circulation was not re-established.

DR. PINCKNEY FRENCH, of St. Louis, reported an Original Method of Excision of the Rectum for Prolapsus. The method is made the same as that recommended by Miculicz, of Breslau. Its advantages lie in the fact that (1) the peritoneum is not

opened; (2) there are no mesenteric vessels to ligate; opened; (2) there are no mesenteric vessels to ligate;

(3) the sutures hold well.

DR. GEORGE R. HIGHSMITH, of Carrollton, the president of the Association, delivered the annual presidential address on Contributions of the Medical Profession to General Literature and the Allied Sciences. The history of medicine is synonymous with progress, advancement, and civilization. Knowledge was never more eagerly sought after by the profession than now. The literary lights of the medical profession from the sixteenth century up to the present time and their works were reviewed in detail.

DR. P. Y. TUPPER, of St. Louis, read a paper entitled What Can be Done in Operable Sarcoma.* DR. JAMES J. CLAUSEN made a report of Progress in Bacteriology, with special reference to practical. *See page 425, this number.

deductions. He reviewed the recent investigations concerning the use of antiseptics in surgery, the use of the mask for the head and face, etc.

The third day, May 18th, was devoted to business transactions, election of officers, etc.

ST. LOUIS MEDICAL SOCIETY.*

MEETING APRIL 22, 1899, DR. JOSEPH GRINDON,
PRESIDENT, IN THE CHAIR.

DR. J. ELLIS JENNINGS read a paper on
Eye Complications of Cerebro-Spinal Meningitis. †

DISCUSSION.

DR. J. K. BAUDUY said that the sequela which follow cerebro-spinal meningitis are not only multiple, but extremely intractable; that permanent deafness and blindness and epilepsy disturbances in mentality and various other disastrous consequences follow this disease. We have not yet arrived at that stage where we can positively state that the microbic origin of this disease is the diplococcus intracellularis, because according to the researches of Adenot other bacilli are found and are supposed to have caused the disease, such as the streptococcus pyogenes, the pneumococci, and other bacilli. It can be said that this disease, from a microbic standpoint, shows some difference from a primary and secondary microbic invasion, or the primary invasion of bacilli which are usually supposed to be associated with the development of the disease, and again secondary bacilli which do not necessarily have their habitat in the meninges at all, but on the contrary in other places. It is a well-established fact that in quite a fair number of cases cited in the literature, the bacillus of Eberth has been found to produce secondary

spinal meningitis. And we also know that a septic pericarditis has been produced by the gonococcus,

which of course has not its habitat in that region. So cerebro-spinal meningitis has been started by the bacillus of Eberth. He regards prognosis as grave and treatment as unavailing.

DR. E. C. GEHRUNG reported favorable results from the applications of hot sand-bags to the spine. He was of the opinion that it promoted cerebro-spinal circulation and thereby helped to carry off and destroy the bacilli present.

The PRESIDENT said that Osler praises the application of the ice-bags to the spine.

DR. T. A. MARTIN: At an early period of my professional career I had considerable experience in the

*Edited by C. R. DUDLEY, M.D., Secretary. +See page 426, this number.

treatment of this disease, passing through a very severe epidemic of cerebro-spinal meningitis which prevailed in the locality at which I then lived. I found that in the more violent or fulminant cases treatment was of little avail, for the reason that the patient died before remedies could act. I gave calomel in nearly all of the cases, in repeated doses; in several of the cases a mild salivation was produced, and I found that in every case when ptyalism occurred early in the disease the patient made a prompt and early recovery. For the severe pain in rachialgia, etc., I gave opium in large doses, which I am sure was beneficial. I also gave ergot, potass. brom., tinct. gelsem., but from these remedies I have not seen any results, at least of a beneficial character, and were I to treat a case now would not make use of

any of them. I have used the salicylates with bene

ficial results.

DR. ROBERT FUNKHOUSER had had very little experience with this disease, but as the pneumococcus and the streptococcus has been found in many cases, he would use the antistreptococcus serum if the opportunity presented itself.

MEDICAL SOCIETY OF CITY HOSPITAL ALUMNI.

MEETING FEBRUARY 2, 1899, DR. GEORGE Homan, PRESIDENT, IN THE CHAIR.

DR. J. P. BRYSON read a paper on

Report of Two Cases of Prostatectomy Following Electrical Incision of the Vesical Outlet After the BottiniFreudenberg Method, with Remarks.*

DISCUSSION.

DR. E. S. SMITH said he thought the important question to be considered was, which operation would probably give the best results with the least mortality. Unfortunately, as Dr. Bryson has said, this was just the question which was at present sub judice, and he felt totally unable to answer it. The operator should keep in mind the condition of these patients at the time of operation-their ability to resist operative interference. All of these patients become prostatic along in the later stages of life-somewhere about fifty or sixty. This is about the stage when degenerative changes begin in all the organs of the body, sclerotic and especially in the vascular system

In

DR. R. B. MURPHY had used antistreptococcus serum in one case without result; the patient died. another case he applied unguentum Credé; the patient was alive, but he expected him to die.

DR. C. R. DUDLEY mentioned a case in which it was used with appreciable benefit.

DR. E. W. SAUNDERS has had experience in two epidemics of cerebro-spinal meningitis. Many mild cases that do not present typical symptoms are overlooked. The occurrence of cerebro-spinal meningitis. in infants is far from being rare, the statement in text-books to the contrary notwithstanding. Nursing infants are not immune. In the case of whooping. cough, erysipelas and cerebro-spinal meningitis, the mother's milk does not confer immunity. Infants frequently die a few hours after the onset, and the reason for the statement that the disease is rare in them is because the diagnosis is not made before death. If cerebro-spinal meningitis breaks out in a family, the infant is almost certain to take it. The humane treatment is morphine hypodermically and chloral by the mouth. Credé's ointment in his hands Credé's ointment in his hands has been entirely without effect, though he has not used it in the doses recommended by Shirmer, of Chicago, who uses an ounce for one inunction.

DR. M. GOLLAND had used antistreptococcus serum in two cases, without effect.

DR. L. BREMER has noted rapid improvement in some cases of poliomyelitis anterior acuta under the use of Crede's ointment, but whether it is due to the curative properties of the remedy or not, he was unable to determine.

which involve the entire vascular system and eventually the heart. As a result of this change we are apt to have sclerosis of the coronary arteries along with the others, and consequent disturbance of the nutrition of the heart muscle, which is one of the serious conditions to be found in attacking prostatic conditions. Anyone with a damaged heart or blood-vessels is not a safe subject for surgical interference for several reasons, but principally on account of the dangers of anesthesia on the circulation and on the heart. He was inclined to believe there must be some who succumb to what is called surgical shock following an operation, and which are doubtless in a large measure due to the effects of the anesthetic upon the heart. He had seen several hospital cases succumb to either heart failure or renal insufficiency following an anesthetic-at least, attributable to the anesthetic. the Bottini method could claim this advantage, he thought it would be a most important one provided it would accomplish the result. Another feature which seemed to him objectionable was that of hemorrhage following the operation. The essayist also spoke of septic infection leading to septicemia; this would constitute a great disadvantage. However, this method might protect the patient from the danger of anesthesia, and at the same time expose him to other dangers. He asked Dr. Bryson what had been his results in prostatectomy in restoring the function of the bladder, and how much difficulty he had in preventing suprapubic fistula.

If

DR. F. REDER said he would infer from Dr. Bryson's remarks that he was inclined to favor prostatec* See page 423, this number.

The

tomy over the more recently advocated BottiniFreudenberg operation; he probably felt that with a knife in his hand he was more certain of his work. A cure was of course what was aimed at and desired; but an individual who attained the age of three score and ten, the number of years allotted to man's life, would feel grateful if only relief was afforded. two operations, Bottini's and the radical, might be looked upon at present almost as rivals. He thought there were cases in which the one operation would do more good than the other, and cases in which neither operation would be of benefit. Recalling the various forms of prostatic hypertrophy, one in which there was the glandular proliferation, and the other in which. muscular and connective tissue is abundant and dense, these two forms he thought had their individual chances for one of these operations. The gland normally weighs some six drachms. In an hypertrophic condition where the gland attains a size weighing from six, eight to ten ounces, obstructing the flow of urine by a large middle lobe jutting from the vesical floor, obstructing the vesico-urethral orifice, the burning of a canal of sufficient depth into this hard and sclerous tissue is almost impossible. Such a condition would demand the more heroic operation of prostatectomy. It is improbable that we shall ever be able to know which would entail the least mortality, but it is almost certain that prostatectomy would carry with it the greatest number of deaths. The BottiniFreudenberg operation may eventually be given the preference, because it can be performed early, when the manifestations of hypertrophy are in their incipiency. Then, too, the modus operandi is simple and almost free from immediate danger to life. Complications that may arise, however, can increase the mortality rate. Another factor favoring the Bottini operation is, that the operation of prostatectomy is advised to be performed after all means to evacuate the bladder have been exhausted, that is, after catheter life has terminated. The general condition of patients with enlarged prostates is usually bad; their vitality is low; they are fagged out and ill nourished. He did not believe any patient under such circumstance should be charged to either operation until his general condition can be brought up to the best possible notch. Another condition constituting a contraindication, would be a purulent state of the bladder; also degeneration of the kidney, or any condition of the patient where surgical tolerance might be looked upon as more dangerous than the operation.

Dr. H. TALBOTT asked if Dr. Bryson had made any selection of cases operated on, and if he had refrained from operating on cases because of degenerative changes. The age at which we find prostatitis is one in which we usually find other lesions, and the condition of the patient is not calculated to stand an

operation as well as a person of younger years. He thought the Bottini operation carried with it less of danger than prostatectomy, and from that standpoint was much to be favored.

DR. BRYSON said he had begun to operate with the early introduction of prostatectomy, and the mortality ran up so high that he contemplated abandoning it and tried palliative measures. At first it was thought necessary to operate upon every man who presented himself; there was no selection of cases. Later on, the lines on which selections could be made were drawn and this put theoretical ideas out of court. In regard to the question of hemorrhage, he said all operators were now in favor of interfering as little as possible with the vesical wall. Whenever the bladder wall is incised about the vesical outlet there is danger of hemorrhage, and that is one of the advantages of having a supra-pubic incision, because then the part can be packed and kept clean. In regard to anesthetics, he said he first began using ether altogether. In fifty-three operations he had two deaths from what was supposed to be anesthesia anemia. Both of these were chloroform anesthesias, however. He now used chloroform and usually preferred it. The danger from chloroform was immediate, whereas with ether the danger comes later on—often after a week. He said he had only one patient die of hemorrhage, and it proved to be malignant-probably sarcoma of the prostate. In regard to suppression of urine after prostatectomy, he had never seen a case; on the contrary, some of the cases which died had polyuria up to the time of death. What the condition of the urine is, was impossible to determine, as it leaked out in many places, and the amount passed was judged by the saturation of the dressings. In reply to the criticism, he said he had no prejudice whatever against the Bottini operation. His desire was to operate with the least mortality and ascertain whether this operation did one of two things-whether it simply made a gutter or brought about involution of the hypertrophy. He had heard a good deal about gutters, but said he would not trust to one. Unless the operation did more than that he did not see how it was to be of any material advantage. One feature which would probably make the operation popular was that it required no anesthetic. If this method will enable the surgeon to operate on people at an earlier stage of the disease, he thought the mortality would be greatly reduced, and we should also be able to ascertain what effect the electro-cautery had in bringing about involution of the hypertrophied prostatic tissue. In regard to the normal mortality of prostatectomy, he had seen it stated by a surgeon in the International Medical Congress at Moscow as being nineteen per cent. Just how he ascertained this or what method he pursued in arriving at it was not plain to the speaker. He had only one patient

die, he said, after prostatectomy, under ten days, so that he might fairly say none had died of shock. The patient referred to died, he thought, of iodoform poisoning. He had never been able to make out any connection between glycosuria and prostatic overgrowth. He had seen prostatic hypertrophy in diabetes, but could discover no causal relationship.

DR. SMITH asked what caused the death of these patients.

DR. BRYSON replied that hemorrhage, thrombosis, and one died of pylophlebitis; two had died of pneumonia-probably anesthesia pneumonia.

DR. JACOBSON asked if he remembered how many kidney involvements there were.

DR. BRYSON said it was impossible to estimate that. The ureters could not be catheterized, and ammoniacal decomposition destroys any casts that might come down. In regard to the percentage of cases operated on, he said he thought he did not offer operation to more than ten per cent. of the cases he saw, and this was probably accepted by one-half of those to whom it was offered. The great majority are in such an advanced state of prostration that only palliation could be advised.

Some Complicated Cases of Appendicitis and Surgical Treatment. H. B. ROBINSON* reports four cases of appendicitis which were complicated by other conditions. The first was an appendicitis gangrenosa with abscess, and a secondary collection below the right lobe of the liver. The appendix was adherent and could not be entirely removed, so the gangrenous portion was excised and a drainage tube inserved. The patient experienced relief, but two days later the temperature rose, the pulse became very rapid, and the respiration increased. Examination revealed a track running from the wound up to the liver. Celiotomy was performed, and a quantity of thin, purulent, offensive liquid with some fibrin was evacuated. Drainage was instituted, but for two days the patient's condition was precarious; finally, however, terminating favorably. In the second case, the appendix was found firmly adherent in a pus cavity. Evacuation and drainage were followed by improvement, but five days later the temperature rose again, and a well-defined fullness in the right loin and right hypochondrial region was revealed. An incision was made, and an intraperitoneal pus cavity of about a pint in capacity was found, which, being evacuated and drained, resulted in a normal progress towards recovery. In the third case, the operation showed matted coils of intestine, which were separated, setting free about a pint of pus with some fecal matter. A glass tube was inserted, and for about a week patient did well. About this time a parotid bubo appeared. Becoming necrotic, it was opened *Lancet, May 6, 1899.

two weeks later. Then he complained of pain in the abdomen, and coughed up several ounces of thin, muco-purulent sputum, with very offensive odor. Signs of fluid in the right pleura were elicited, but the insertion of a hypodermic needle revealed nothing. Nevertheless, the persistent nightly rise of temperature was so strongly suggestive of pus that an incision was made over the right tenth rib in the axillary line, with the evacuation of some very foul pus from an apparently localized pleural abscess. This was washed out and packed with gauze, the patient-then very emaciated making a rapid recovery. In the fourth case, examination showed a large lump at the outer edge of the right rectus, about an inch below the costal margin, from which there extended downward a cord-like induration to about the lower quarter of the rectus muscle. The operation was made parallel to the costal margin, over the large lump, and a little pocket of very feted pus was evacuated. An incision was made over McBurney's point, revealing the lower end of the cord-like induration, and also setting free some pus. A probe showed this to be a sinus running from the abscess down into the pelvis. Drainage was instituted, and patient seemed recovering, but in about a week the temperature again began to rise nightly, which a week later was relieved by a fecal discharge from the wound. A week later the sinus was again explored, and the lower end was found connected with a piece of gut, presumably the cecum. An operation was not attempted, but the fistula was allowed to heal by contraction and granulation. When last seen, seven months later, there was still a slight fecal discharge, which could, however, be easily controlled.

Aqueous Suprarenal Extract.-J. MULLEN* uses the suprarenal extract dissolved in distilled water, to which carbolic acid is added, one minim to each drachm of water. When applied to any mucous surface it produces ischemia, and is never followed by constitutional effects; there is no danger of contracting a habit from its frequeut use; it has no effect upon the pupil nor upon the skin and has no anesthetic effect wherever applied; its action is solely astringent, and therefore its efficacy in preventing hemorrhage during operations upon mucous membranes. When applied locally it should be preceded by a 5 per cent solution of cocaine, to secure the combined anesthetic and enhanced effect of both; by preventing hemorrhage, the extract prolongs the effect of cocaine in all operations on the mucous membrane of the nose, the throat, and upon the eye; there is less post-operative swelling, and less danger of secondary hemorrhage. It is also of service in acute laryngitis, inflammation of the pharynx and tonsils.

*Journ. Am. Med. Assn., May 29, 1899.