Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 166

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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EXERCISE X. KIDNEY.

Table I. Acute nephritis in rabbit due to injection of 0.06 gm. potassium chromate. Essentially a tubular injury. 48 hours. Table II. Acute nephritis in rabbit due to injection of 0.05 mg. rattlesnake venom. Essentially a vascular nephritis. 48 hours.

Table III. Acute nephritis with edema in rabbit. Due to in- jection of uranium nitrate and the administration of an excess of water by stomach tube. 5 days.

Table IV. Demonstration of factors influencing vascular reac- tions and diuresis in experimental nephritis. Oncometric studies.

Table V. (a) Urine of each of above showing albumin and casts. (b) Stained sections of similar lesions.

Table VI. Hydronephrosis. 6 weeks after ligation of one ureter.

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EXERCISE XI.

HYPERSUSCEPTIBILITY (Allergy).

Table I. Peculiar natural hypersusceptibility to rabbit et. and to rabbit serum in case of a human patient. Table II. Experimental anaphylaxis:

(a) Morbid anatomy and histology of the lungs of the. lactic guinea pig.

(b) Physiology of anaphylactic " shock" in dog.

IMMUNITY.

1 Table III. Combination of toxin and anti-torin:

(a) Guinea pig injected with diphteria toxin; (b) = pig injected with diptheria toxin and protected by anth :: (c) control animal injected with anti-toxin alone. (d) Similar series with tetanus toxin and anti-toria. Table IV. (a) Agglutination of bacteria and of blood cela specific immune sera.

(b) Precipitation of dissolved proteins by specific inn sera.

Table V. Cytolysis: (a) Hemolysis by means of specik : mune sera in high dilutions, by natural hemolysins 1: hematoxic agents, e. g., rattlesnake venom.

(b) Fragility of erythrocytes as shown by the use c. solutions of varying tonicity. Table VI. Complement Fixation: (a) Phenomenon wit : cipitins and other immune sera. (b) Wasserman reaction.

EXERCISE XII.

DUCTLESS GLANDS. INTERNAL SECRETION.

Table I. Local Vaso-constrictor effect of adrenalin as rabbit's ear.

Table II. Effect of adrenalin on blood pressure as seen in t: Table III. Adrenalin glycosuria. Rabbit.

Table IV. Result of extirpation of adrenals. Dog.

Table V. Effect of extracts of hypophysis on blood press .: diuresis, as seen in dog.

Table VI. Tetany in parathyroidectomized dog. Table VII. Effect on tetany of injection of a calcium sa Table VIII. Review Exercise VIII, Demonstration III, Re: extirpation of pancreas.

EXPERIMENTAL PATHOLOGY AND PHYSICAL DIAGNE .: EXERCISE XIII.

(In collaboration with Dr. W. T. Longcope.)

(All dogs under ether anesthesia and with tracheal & artificial respiration and mechanical ether dropper. Table I. Normal dog: By percussion and auscultatio normal physical signs of respiration and the outline: lungs.

Table II. Pneumothorax: Normal dog. Note changes .: sical signs produced by injection of air (200 cc.) inte : cavity.

Table III. Hydrothorax: Due to injection of 400 cc. DOTE. solution into pleural cavity. Note change in level of on altering position of dog and of percussion notes ar:" ratory sound above and below level of fluid.

Table IV. Acute Pleuritis: Right side, 3 cc. turpentine into pleural cavity one hour before demonstraties side, same amount injected at beginning of demors". Compare friction rubs on both sides.

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At autopsies on the above animals note:

le I. Collapse of lungs and their position in relation to thor- acic wall. Appearance of pleural surface.

le II. Clamp tracheas before opening thorax, note condition of lungs.

le III. Clamp tracheas, note level of fluid and compare with level determined by percussion. Note compression of lungs. le IV. Note amount and character of exudate on each side and appearance of pleura.

le V. Note condition of bronchi; look for sclerosis and con- gestion.

(In connection with above, review Exercise VI.)

EXERCISE XIV.

(In collaboration with Dr. W. T. Longcope.)

1 dogs under ether anesthesia with tracheal canula, artificial respiration and mechanical ether dropper.)

le I. Normal dog: Note normal heart sounds, over different regions of thorax. By palpation and percussion note area of cardiac dullness.

le II. Normal dog: Thorax and pericardium opened. Note action of heart. Study heart sounds by auscultation directly over various regions of heart.

e III. Aortic regurgitation: (a) Aortic cusp destroyed by instrumentation through left carotid artery. Note changes in heart sounds and cardiac dullness. (b) Same with thorax and pericardium opened; direct auscultation.

e IV. Aortic stenosis: Thorax and pericardium opened. Aortic stenosis produced by tightening ligature about base of aorta. Note heart sounds and changes in shape, size and position of the various chambers of the heart.

(In connection with above, review Exercise V.)

hese demonstrations, it is seen, include the presentation ecrosis and the degenerations, inflammation and repair, 1 destruction and jaundice, thrombosis, embolism and

testines, liver, pancreas, and kidney, and the problems of infection and immunity, of shock and hemorrhage and the physiology of the ductless glands.

With the exception of Exercises II, III, IV, XI, the ex- perimental work was presented in connection with the gen- eral pathology and pathological histology of the subject under consideration. Physiological methods of graphic registration were used whenever possible; changes in the urine and other secretions demonstrated; and the methods of chemical diag- nosis emphasized.

The planning of the course is no small matter and the labor of preparation * is great, but the actual demonstrations are not difficult; even if they were, the change in the attitude of the student toward pathology, which such a course brings about, makes it well worth while. This is particularly true of Exercises XIII and XIV which, given in collaboration with Dr. W. T. Longcope as a part of the course in Physical Diagnosis, were received with the greatest interest. To let the student produce, or see produced, certain anatomical lesions, and to allow him to study the alterations of function which result, applying thereto many of the clinical methods, and eventually at autopsy to correlate the disturbances in physiology with the anatomical changes, is, I believe, a most valuable preparation for clinical study in that it bridges the gap between pathological anatomy and clinical observation. Herein lies the chief value of courses in experimental pathology and pathological physiology.

* The success of this course, as given during the past year, is due in largest measure to the efforts of my assistants, Drs. A. B. Eisenbrey, H. T. Karsner, B. S. Veeder, and J. H. Austin, upon whose shoulders fell the burden of preparation.

PROTEST AGAINST THE INDISCRIMINATE USE OF THE ORGANIC COMPOUNDS OF SILVER IN OPHTHALMIC PRACTICE .*

By SAMUEL THEOBALD, M. D.,

Clinical Professor of Ophthalmology and Otology, The Johns Hopkins University.

natever be the explanation, whether due to their chemical osition, the greater freedom with which they are used, their supposedly greater penetrating power, there can doubt that the organic compounds of silver-at all s, those with which I am familiar, protargol and argyrol : responsible for many more cases of conjunctival argyria ever was, or is, silver nitrate.

fore these compounds came into use, argyria of the con- iva was a rare condition-practically never seen except 1 cases of trachoma. Now, it is relatively common, and t with not only in chronic conditions, such as trachoma, 1 acute affections as well, in which the silver treatment een of comparatively brief duration.

ad before the American Ophthalmological Society, July 11,

I believe I am warranted in saying that I have never pro- duced a case of ocular argyria from the use of silver nitrate. I regret that I cannot say the same as to the newer silver compounds. In several of my cases of gonorrhoal conjunc- tivitis in the adult decided staining, especially of the bulbar conjunctiva, has resulted from the employment of protargol, and the same has happened in a case of acute trachoma after only a few weeks treatment.

I have also observed a number of cases of similar character which have occurred in the practice of my confrères. A well- known physician of Baltimore was given a five per cent solu- tion of argyrol for a mild chronic conjunctivitis. As its action was beneficial, his wife-in need only of glasses for the correction of a decided fault of refraction-also began to use it, and the two continued to employ it, p. r. n., until the physician had acquired one of the most marked cases of

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408

JOHNS HOPKINS HOSPITAL BULLETIN.

argyria I have ever seen, and his wife's eyes had become con- spicuously stained.

Let me make it plain, that I have no unreasoning prejudice against these newer silver preparations. On the contrary, I have such faith in protargol, especially, that for some years I have employed it in the treatment of gonorrhoal conjunc- tivitis, both in the infant and the adult, to the exclusion of silver nitrate, and in trachomatous conjunctivitis, especially in the acute stage, it has also been my chief reliance.

It is, therefore, not against the use, but against the in- discriminale-or, perhaps, I might say indiscriminating- use of the organic silver compounds that I would protest. When a remedy is at hand, that is, at least, as efficacious as they are in the condition to be dealt with, that is cleanly and that cannot by any possibility produce the untoward con-

sequences to which, as has been pointed out, they not : give rise, common sense would seem to dictate that it be :. the preference.

These observations apply with especial force to the: almost, it would seem, universal habit, particularly az the younger generation of ophthalmologists and of za: practitioners, as well, of employing argyrol or protaras the treatment of acute and chronic catarrhal conjunct -: This practice, in my judgment, and it is based upon att :. observation, is wholly indefensible, since we have a rer-"- in a collyrium containing half a grain of zinc sulphate ten or twelve grains of boracic acid to the ounce-fax: cleanly, and that is not simply as efficacious, but is : . surely and more promptly efficacious in these conditions . either of the silver compounds mentioned.

NOTES ON JAUNDICE IN PNEUMONIA.

By FLETCHER McPHEDRAN, M. B., Assistant Resident Physician, The Johns Hopkins Hospital.

Since Bettelheim and Leichtenstern first reported the oc- currence of jaundice in lobar pneumonia, many explanations of its pathology have appeared in the literature. Bouillaud considered it due to a transfer of the infection to the liver ; Niemeyer to pressure of the hepatized lung on the torpid liver; Virchow and Leyden to an associated duodenal catarrh resulting in simple jaundice.

Banti1 thought it due to a specific hemolytic action of the diplococcus pneumonia, probably general in its distribution but maximal in the spleen. He found that hæmoglobinuria occurred in rabbits after infection with the pneumococcus. This hæmoglobinuria was not an index of the virulence of the germ, but was caused by a pneumococcus that had pro- duced jaundice in man. In dogs he produced bilirubinuria, and concluded that in man the pneumoccoccus produced bilirubin which was changed in the tissues to urobilin, caus- ing jaundice, and was excreted as urobilin.

Obermayer and Popper' investigated 134 cases of pneu- monia, demonstrating pathological amounts of pigments (bilirubin, urobilin and biliverdin) in all urines, and found that these pigments had been described as urobilin, because the tests employed had not been sufficiently accurate to differ- entiate them. When the pigments were present in sufficient quantities to give the less delicate tests, jaundice appeared. They considered the jaundice haemolytic and dependent upon the intensity of the infection. At autopsy they found large quantities of pigments in the hepatized and slight amounts in the congested areas, but felt that the color might be due to the pigments in the serum of the affected regions.

Herzfeld and Steiger ' found pigments with great difficulty or not at all in the urines of patients whose sputa readily yielded them. As the pigments were only found when blood was mingled in the sputum, they concluded that they came from the extravasated red blood cells of the hepatization, and

in vitro were able to show that the pneumococcus- por .. from hæmoglobin a body giving the color reaction: bilirubin.

Troisier ' had meanwhile described the icterus a: d. this local destruction, comparable to that observed in b .: rhagic pleurisy, where diminished corpuscular resistaz . hypotonic sodium chloride solutions is found, and whi :. bile pigments are produced apart from the liver. For local area of destruction the pigments are carried thros: the body.

Lemierre and Abrami' found in two cases pure cults: the pneumococcus in the bile associated with no ds" tion, but a definite degeneration of the liver cells. ! thought all pigment must come from the liver.

It seemed that it might be a matter of interest to c. the corpuscular resistance in a series of cases of lobar ; monia with and without jaundice, in order to determit- question as to whether any of these cases might & diminution of corpuscular resistance. During the last . fourteen cases have beeen examined. The corpusches tested against solutions of chemically pure sodium ct': progressively diminishing in strength from 0.6 per cent to 0.26 per cent. The blood was received into a citrate tion in 0.85 per cent sodium chloride, washed three times" sodium chloride solution, and then the sedimented corp. dropped into tubes, each of which contained 3 cc. .. hypotonic sodium chloride solution. After two boz: 37 degrees C., the tubes were placed on ice and era." again after twenty-four hours. All glass ware was ke ?! and the solutions sterile. Three readings were made. point of initial, marked and complete hæmolysis. N. initial hæmolysis should be at 0.42 per cent, marked &: per cent and complete at 0.26 per cent.

The urine was tested for urobilin, but in no case wi Google

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Id be discovered by vital staining as described by ighan." There was not any increase of the number of red d cells so stained.

PNEUMONIAS WITHOUT JAUNDICE.

Race.

Sex.

R. B. C.

Initial.

Marked.

Complete.

5,200,000

5,232,000

5,416,000

3,300,000

5,300,000

4,900,000

PNEUMONIAS WITH JAUNDICE.

Race.

Sex.

R. B. C.

Initial.

Marked.

Complete.

4,500,000

4,704,000

4,300,000

5,250,000

4,080,000

5,280,000

5,300,000

M. 4,800,000

se No. 5 is noteworthy in view of the increased fragility e cells found, but attempts to follow up the patient out- the hospital have been unsuccessful. He was not in the jaundiced and showed no increase in reticulated cells. is interesting that in cases Nos. 7, 8 and 13, where :ally the jaundice was most intense, and bile pigments readily found in the urine, the fragility was diminished, is, the same condition obtained as was described by er in obstructive jaundice.

e use of saponin (Merck's "purissimum") for hæmoly- advocated by McNeill was also tried, but the results series of control cases were not sufficiently accurate to nt its continuance. He took a suspension of washed scles in such an amount that there were about 50,000,- ells, to which varying amounts of a saponin solution 04 gm. to 100 cc. of 0.85 per cent sodium chloride were . Then the mixture was brought to a volume of 2 cc. ore of the same sodium chloride solution and the, num- ' red blood cells were counted on a Thoma Zeiss hæmo- eter. After incubation at 37 degrees C. for two hours, maining cells were enumerated and the amount of lysis observed.

NORMAL ADULT.

R. B. C. suspen- sion in NaCl 0.85 per cent.

Saponin. NaCl 0.85

Corrected Number R. B. C.

R. B. C. after 2 Hæmoly- hours. sis.

cc.

.15

.08

1.77

43,000,000

41,700,000

. 15

.08

1.77

50,500,000

34,500,000

. 15

.12

1.73

42,000,000

28,000,000

.15

.12

1.73

41,200,000

27,600,000

.15

. 16

1.69

42,000,000

28,000,000

.15

.16

1.69

41,200,000

36,400,000

.15

1.65

42,000,000

31,000,000

.15

1.65

40,300,000

26,200,000

.15

.24

1.61

42.000,000

1,000,000 97

.15

.24

1.61

42,000,000

24,600,000 41

No.

sion in NaCl 0.85 per cent.

Saponin. Na 01 0.00 Corrected per cent. Number R. B. C.

R. B. C. For ceny after 2 hours.

of Hæmoly- sis.

cc.

.13

1.77 1.67 46,700,000 55,600,000

36,000,000 25,000,000 29,000,000

54 46

Now we see in the above that the same experiment re- peated with the same technique on one individual gives widely variant results; for example, compare tubes 3 and 3a and tubes 5 and 5a. Nevertheless, there is a very slight, if any, difference in the figures of hæmolysis in the case of jaundice in pneumonia and in the normal adult.

'Two cases, Nos. 7 and 8, came to autopsy; in neither was there any obstruction to the bile ducts, nor any destruction of liver cells, nor any increase in pigment found by the usual methods.

The number of red blood cells on admission was interest- ing; it averaged 4,840,000 for the males with jaundice and 4,400,000 for the females. In cases without jaundice, the number was 4,800,000 in males, and 5,200,000 in the only female. A series of typhoid fever patients comparable in age and duration of disease to this pneumonia series averaged 5,900,000 for males and 4,500,000 for females.

From the fact that the cells are in the lungs in such num- bers, and that the pneumococcus has definite hæmolytic pow- ers, together with the property of producing bile pigments, it is probable that the jaundice arises from the pigments pro- duced in the lungs; but as all patients with pneumonia have this extravasation, there must be some other cause, perhaps a variation in the pneumococcus. This is not associated with the general increase in the fragility of the red blood cells.

SUMMARY.

1. In the fourteen cases there was increased fragility in only one case, this without jaundice; but in the cases with most marked jaundice there was, on the contrary, an increase in the corpuscular resistance.

2. The urine in no cases showed any excess of urobilin.

3. Bilirubin was present in the urine in three of the eight cases with jaundice.

4. Autopsy showed no evidence of special changes in the liver.

5. The blood counts showed such a loss that one must con- sider it as due to a sudden great destruction. This loss is probably due to the hepatization.

In concluding, I desire to thank Dr. W. S. Thayer for con- stant advice and assistance.

BIBLIOGRAPHY.

1. Banti: Centralbl. f. Bakteriol. und Parasitenk., 1896, XX, 849. 2. Obermayer and Popper: Wien. klin. Wchnschr., 1908, XXI, 895.

i 3. Herzfeld and Steiger: Med. Klinik, 1910, VI, 1415.

4. Troisier: Compt. rend. Soc. de biol., 1909, LXVIII, 46.

5. Lemierre and Abrami: Presse méd., 1910, XVIII, 82.

6. Vaughan: J. M. Research, 1903, V, 342.

7. McNeill: J. Path. and Bact., 1910, XV, 56.

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JOHNS HOPKINS HOSPITAL BULLETIN.

ABDOMINAL LIPECTOMY. REPORT OF TWO CASES.

By W. F. SHALLENBERGER, M. D., Atlanta, Ga., Late Resident Surgeon, Maryland Hospital for Women, Baltimore.

This operation,' while no longer rare, is uncommon enough to warrant the report of these two cases, which came under my care at the Woman's Hospital in Baltimore.

Mrs. S., age 39, was sent to the hospital by her physician in March, 1910, for symptoms of a chronic appendicitis from which she had suffered for several years and which had been becoming more aggravated. She had a more or less constant pain in the right lower quadrant of the abdomen, which was quite severe at times. There was also nausea and vomiting occasionally, and constipation. No history of jaundice or

FIG. 1.

FIG. 2.

FIG. 1 .- Healed incision in first patient showing the support the umbilicus gives. (Patient is standing.) FIG. 2 .- First patient, showing the abdominal supporter worn after operation.

urinary disturbance was obtained. The menstrual history was negative. The patient had had several children. Back- ache was the only symptom that suggested any pelvic trouble.

Eight years ago the patient had an attack of typhoid fever, after which she began to grow very stout. Prior to this attack she had been of average size.

Examination .- The patient was quite fat, weight 227 pounds, of medium height. The outlines of her figure were good, except of the abdomen, which was very full and flabby, with a regular apron of fat that hung down over the symphy- sis when the patient was standing. One could pick the fat up in a great ridge or fold across the lower abdomen. The greatest deposit of fat was below the umbilicus, and it pre-

1 Kelly, H. A .: Excision of the Fat of the Abdominal Wall- Lipe . Surg., Gyn., and Obst., 1910, X, 229.

vented the wearing of an abdominal supporter because .: flabbiness. The abdominal walls were firm beneath the

On the right side there was tenderness over the aps : region, with slight muscle rigidity. The temperatur ; normal. The pelvic organs were normal except for a: laceration of the cervix uteri and a moderate relaxa:»: the perineum. The backache I thought was due to the ?: lous abdomen.

The patient received the suggestion that some of t. be removed with much enthusiasm and was very eage:" the operation be performed.

Operation .- A double incision was made from dar flank below the umbilicus and embracing an elliptoil a: skin 45 cm. or 18 inches long, and 15 cm. or 6 inches :" widest part. The incisions were carried down to the ..

FIG. 3 .- The slab of skin and fat removed in the second (##

and the wedge or slice of skin and fat removed. Its s. was a trifle over 7 pounds.

All the bleeding points were carefully secured and i- of the two sides of the open area was brought together a number of double figure-of-eight catgut sutures. The. edges were then approximated. Three silver-wire suturs : first placed, and silkworm gut used to complete the sz:" mation. Four rubber tissue drains were inserted, one is angle of the incision and the others midway betwe? angles and the median line. These drains were rem-if. the third day.

Before the incision was closed, the peritoneal cavit opened on the right side by a McBurney incision t ... the muscles and fascia and the appendix removed. It : large, injected and adherent.

The incision, which was 18 inches long, healed nio the patient had a rapid convalescence. She was gre. lieved, not only of the appendix symptoms but al:) backache. I have seen her a number of times since, a: is highly pleased with the results. We had an aber supporter made for her and this fits perfectly now. (F:

Mrs. P., a patient of Dr. Kelly, came to the best" Google

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e several years ago, and the patient had an incision in- ion and a peritonitis following. Aside from the hernia 'e were also extensive intestinal adhesions giving rise to siderable abdominal pain. There was a considerable de- it of fat in the abdominal wall.

'peration .- A double transverse incision was made from k to flank, 38 cm. long and the two lines 12 cm. apart in median abdominal line. The slab of fat was removed g. 3) and the peritoneal cavity opened through the nial sac. The intestinal adhesions were all separated and hernia repaired by overlapping the fascia in the mid-line. : fat and skin edges were then brought together in much same manner as in the first case, silkworm gut alone ig used for the skin. Cigarette drains were placed in 1 angle of the incision.

'he patient made an uneventful recovery and left the pital greatly benefited by the operation.

n neither of these cases was there an umbilical hernia, and ish to bring out a point here; namely, that where there tot an umbilical hernia the incisions should be made be- the umbilicus, leaving it as a supporting point. This is wn in Fig. 1, where the highest point of the incision, as

down on each side.

Dr. Kelly did the first operation of this kind in 1899." Since then he has had eight more cases, including the one reported here.

Maylord ª reports three cases in which he did extensive lipectomy in fat women with umbilical hernia. The first of his cases was done in 1903, and ten pounds were removed.

Weinold ' reports a case in a woman with an enormously fat abdomen.

The results of such an operation are, to quote Dr. Kelly : "The removal of a slab of fat and a decrease in weight. Great addition to personal comfort generally. Convenience and comfort in dressing. Better pose in standing and better poise in walking. Increased activity. Cleanliness greatly facili- tated. Figure changed from unsightly and awkward to one much more natural. The sensitive patient occupying after- wards a more normal and natural relation to society."

" Kelly, H. A .: Excessive Growth of Fat, Johns Hopkins Hosp. Bull., 1899, X, 197.

3 Maylord, A. E .: Direction of Abdominal Incisions, Brit. M. J., 1907, II, 895.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 166

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189