THE AMERICAN PRACTITIONER AND NEWS "NEC TENUI PENNÂ." VOL. 31. APRIL 15, 1901. No. 8. H. A. COTTELL, M. D., M. F. COOMES, A. M., M. D., Editors. A Journal of Medicine and Surgery, published on the first and fifteenth of each month. Price, $2 per year, postage paid. This journal is devoted solely to the advancement of medical science and the promotion of the interests of the whole profession. Essays, reports of cases, and correspondence upon subjects of professional interest are solicited. The Editors are not responsible for the views of contributors. Books for reviews, and all communications relating to the columns of the journal, should be addressed to the Editors of THE AMERICAN PRACTITIONER AND NEWS, Louisville, Ky. Subscriptions and advertisements received, specimen copies and bound volumes for sale by the undersigned, to whom remittances may be sent by postal money order, bank check, or registered letter. Address JOHN P. MORTON & COMPANY, Louisville, Ky. ACCIDENT INSURANCE COMPANIES VERSUS DOCTORS. It would seem that the accident insurance companies and casualty companies of this country are organized and working against the interests of the doctors. The premiums paid upon their policies are always sufficient to meet all losses and leave enough in addition to pay handsome dividends. They are not satisfied with this, however; they are constantly trying to take advantage of the physicians who work for them by reducing their bills without even so much as consulting the doctor. Recently a number of cases of this kind have come under our observation. A young physician was employed by a manufacturing firm to look after their injured. He told me that he had recently sent a bill for services which was hardly sufficient to cover car-fare, bandages, and actual time at wage rates, and after. some weeks' delay the insurance company had the him a check for one third of the amount of the bill. of our acquaintance presented a bill for services rendered and received a check for less than half the amount of the bill. He, however, returned the check and told them they must have made a mistake cheek to send Another friend by leaving out some of the figures. This was hint enough, and they very promptly sent a check for the full amount. The prices paid by these insurance companies are niggardly and mean at best, and the idea of having them deliberately cut the fee which has already been reduced is a thing that no respectable doctor can afford to tolerate. The sooner the profession as a whole realizes that this thing is an imposition, unwarranted in every particular, and refuses to work for these companies at such unjust and unreasonable rates, the better it will be for all concerned. Current Surgical and Medical Selections. LOCAL AND REGIONAL ANESTHESIA.-Matas' paper (Philadelphia Medical Journal) is a valuable historical and critical review of the methods of regional anesthesia as employed in surgical practice, including the subarachnoid method. He gives full credit to Corning, Halsted, and others as pioneers in the local use of cocain. He describes the methods at length, illustrating the different operations for regional infiltration, etc., and reports cases in his own practice, which has been extensive with these methods. He considers anesthesia with cocain or its allies most often impracticable and unsatisfactory in the following conditions: I. All operations or manipulations in which complete muscular relaxation is required to accomplish the object of the intervention, as in the reduction of fractures and dislocations of the larger bones and joints—the hip, the shoulder, the elbow, and the knee-in relaxing ankylosed joints, spastic muscular contractures, stretching sphincters of the rectum and bladder, etc. 2. In all extensive atypical operations on the head and trunk in which the neuro-regional method is inapplicable and the field of the operation can not be well defined or circumscribed, as in the radical extirpation of mammary cancer by Halsted's and Meyer's methods; in the extirpation of bilateral and multiple chains of adherent lymphatics in tuberculosis of the neck, etc. 3. In all atypical operations involving prolonged and complicated maneuvers in the splanchnic cavities, especially when the organs operated upon are adherent and inflamed. 4. In all operations upon patients whose emotions are beyond the control of reason or the will, as in the violently insane, in delirious patients, in children, in hysterical and extremely timorous patients, and in all those in whom the mere consciousness of the operative act, without physical pain, is sufficient to produce great mental excitement and distress. In spite of these, he says the number and character of the cases in which the most rebellious conditions can be brought under the domain of the new technic by a patient, tactful, and skilled operator is astonishing. Spinal cocainization is considered at length, and its advantages and disadvantages discussed. The author's personal experience, begun in 1899, has been limited to nine cases, and shows very little objection to this method. Judging from this, he would limit its indications for application for the pres 1. To adults, and to reasonable persons who have good self-control, thereby excluding children, hysterical patients, and the insane. 2. To patients in whom the methods of local or regional anesthesia are inapplicable. 3. To patients suffering from emphysema, advanced asthma, chronic bronchitis, and other respiratory affections in whom a general inhalation anesthetic is absolutely contraindicated; in advanced cardiac cases with degenerative lesions he would fear the possible depressing effects of the injection and excitement on the circulation. 4. In the majority of cases in which the painful part of the operation is not likely to be prolonged beyond one hour and a half, as he would be averse, in the present state of our knowledge, to repeat a second cocainization or to increase the total dose of the cocain to more than 2 cgm., especially in exhausted subjects. The danger of repeating the intradural injections to prolong the anesthesia is also one of the objections to the use of the method in ordinary labor. But its advantages in instrumental cases, as shown by the successful experiences of Dupaigne, of Louviciennes, France, who, according to Tuffier, first applied the subarachnoid method in labor January, 1900, and of Bumm and Kreis, of Basle; of Doleris and Malartic, of Paris; and of Marx, of New York, can not be doubted, especially in nephritic patients.-Journal American Medical Association. INFARCTS OF THE PLACENTA.-J. Whitridge Williams, in a paper on "The Frequency and Significance of Infarcts of the Placenta based upon the Microscopic Examination of Five Hundred Placenta," gives the result of a thorough study of the subject, illustrated by a series of fine plates. His conclusions are as follows: (1) Infarcts measuring at least 1 cm. in diameter were observed in 315 out of 500 consecutive placentas (63 per cent). (2) Smaller infarcts, many just visible to the naked eye, were observed in the great majority of placentas, while microscopic examination revealed early stages of infarct formation in every full-term placenta which he examined. (3) The primary cause of infarct formation in the great majority of cases is to be found in an endarteritis of the vessels of the chorionic villi. (4) The primary result of the endarteritis is coagulation necrosis of portions of the villi just beneath the syncytium, with subsequent formation of canalized fibrin (as the process becomes more marked the syncytium likewise degenerates and is converted into canalized fibrin, which is followed by coagulation of the blood in the intervillous spaces, which results in a matting together of larger or smaller groups of villi by masses of fibrin). (5) The part played by the decidua in the production of infarcts has been greatly overestimated by many observers; it is more than probable, in many cases at least, that the tissue which they designate as decidual is really fetal ectoderm. (6) Moderate degrees of infarct formation are not pathologic, and exert no influence upon the mother fetus, and are to be regarded as a sign of senility of the placenta, analogous to the changes which take place in the villi of the chorion at an earlier period. (7) Marked infarct formation is not infrequently observed, and often results in the death or imperfect development of the fetus. It is usually associated with albuminuria on the part of the mother, though at present we can not account satisfactorily for the relationship between them. (8) Infarct formation is not particularly marked in cases of eclampsia, being usually observed only in those cases which were preceded by marked albuminuric symptoms. (9) There is no evidence in favor of the bacterial origin of infarcts.Philadelphia Medical Journal. EFFECT OF MENSTRUATION ON THE STATE OF THE STOMACH.-A light flow finds no expression in the condition of the stomach. More abundant bleeding leads to hyperchlorrhidia, either by reflex action or by direct extension of the menstrual congestion to the region of the stomach. The occurrence of hyperchlorrhidia is conditioned on the excitability of the central nervous system. In cases of great loss of blood, as in menorrhagia, a lessening of secretion with a reduction of the acidity may take place. The determination of the state of the stomach by passing the tube after a test breakfast given during the menstrual period is unreliable, because the increase of acidity may lead to a false diagnosis of hyperacidity on the one hand or conceal a loss of acidity on the other. In a similar way the reduction of acidity in case of menorrhagia might lead to an incorrect diagnosis of asthenic gastritis.-Elsner Archiv. f. Verdauenskrankheiten. CONTRIBUTION TO THE Knowledge of THE ETIOLOGY OF SYPHILIS. -Max Schuller (Centralb. f. Bakt. u. Parasit) has also found in syphilis a micro-organism of probably protozoan nature, present in the hard chancre, the secondary and tertiary lesions of the disease, and especially in the hereditary form of the disease. In hard chancres kept in alcohol he was able to find, by one thousand times magnification, exceptionally small oval vesicular bodies arranged in rows. They had double contoured glittering capsules and brownish or brown-yellowish, sometimes darker, contents. In teased and stained preparations larger free bodies were observed. Their appearance and finer structure recall those found by S. in the tumors, though they are obviously different. In addition, by treating sections with iodid of potassium and examining them under a high power, he was able to demonstrate fine zig-zag or spiral passages passing directly from the surface of the chancre in an oblique or transverse direction to tubes or pockets in the deeper part of the inflammatory infiltrated tissue. These were filled with peculiar "shot-like" round or conical dark-brown or violet bodies, in which by appropriate transmitted light doubly contoured vesicles are visible. These parasites were found in all of the tissues examined, and were present in the blood of the spleen of a case of fatal florid syphilis. The presence of the bodies is as constant and of as great diagnostic value as the presence of the tubercle bacillus in tuberculosis, in Schuller's opinion. The experimental cultivation of the organisms was attempted similarly to the method described for the microparasite of carcinoma.-International Medical Magazine. EYE DISEASES COMPLICATING TYPHOID FEVER.--Dr. Schwienitz (Philadelphia Medical Journal) discusses this interesting subject. He says there are no ocular lesions characteristic of typhoid fever, nevertheless a number of diseases of the eye may accompany or follow it. In the following list they are arranged in the order of relative frequency: 1. Affections of the conjunctiva and cornea. 2. Affections of the retina and retinal vessels. 3. Affections of the ureal tract, namely, iris, ciliary body, choroid, and of the vitreous humor. 4. Affections of the crystalline lens. 5. Affections of the muscles (intra- and extra-ocular). 6. Affections of the optic nerve. 7. Affections of the orbit. 1. Under this we may have conjunctivitis and ulcer of the cornea. 2. Here we may have retinal hemorrhage, anesthesia of the retina. 3. Under this may be seen iritis or iridocyclitis choroiditis. 4. Cataract is sometimes caused by typhoid fever. 5. This group may show optic neuritis (which rarely is retro-bulbar), optic atrophy. The optic atrophy may be caused by the antecedent neuritis, by excessive hemorrhage (intestinal, nasal, or menstrual), or by the injudicious use of quinine. 6. Here the intra-ocular muscles may be affected, causing paresis of accommodation. If the extra-ocular muscles are affected, we may have strabismus of various kinds. Some of these paralyses, especially in children, have been considered as due to the basilar meningitis which is supposed to accompany some cases, but they may also be explained by an intense effect of the poison on the nervous system without the production of inflammation. 7. Affections of the orbit and its vessels are very rare. There have been noticed thrombosis of the orbital veins, orbital cellulitis, orbital hemorrhage. In the treatment of these various affections the general principles of ocular therapeutics must be applied, bearing in mind, of course, the extremely depressing influence of the fever under discussion.-Canadian Practitioner and Review. |