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of instruction or education with which the social hygiene movement deals, this period is probably the most difficult. The problem of the early adolescent period still awaits a satisfactory solution. THE JOURNAL hopes some one of its readers may become sufficiently interested to secure this prize.

DISINFECTION.

The most practical, effective and cheapest disinfectant is formaldehyde gas. Since the war it has been too expensive for general use, but the State Board of Health of Pennsylvania announces a simple and cheap method of generating the gas. To each pint of the official formaldehyde solution add 1 1-2 ounces each of commercial sulphuric acid and glycerine. In a flat bottomed disinfecting pan spread ten ounces (avoirdupois) of sodium dichromate in a thin layer. Pour the prepared formaldehyde-acid-glycerine solution into the vessel and make a quick departure from the room. It is important that the potassium dichromate be kept tightly sealed in containers which protect it from moisture, and in cold weather the liquid mixture, should be kept in a room considerably above freez ing.

The reaction resulting from the release of the gases is more rapid than by the older methods and the deposit remaining in the containers is more corrosive. For this reason all containers should be removed from the room one-half hour after starting the disinfecting process, and the deposit should then be removed and the vessel thoroughly washed out with soap and water. The importance of pasting paper over all openings in windows, doors, and fire places is to be remembered. For each 1000 cubic feet of space to be disinfected, use 19 ounces of the solution and 10 ounces of potassium dichromate.

This method of formaldehyde gas disinfection-to be known as the Pennsylvania method -has been adopted by the State Board of Health as the official method of disinfection to be used by the health authorities and people of Kentucky.

PHYSICIANS AND TUBERCULOSIS.

The National Association for the Study and prevention of Tuberculosis announces through its executive secretary the inauguration of a movement to bring attention to the importance of improving the teaching on consumption in medical colleges and that an effort will also be made to reach individual practitioners by special bulletins prepared for this purpose. Such a movement is of considerable interest and is bound to succeed because the best time to teach anything is during the younger years and in the formative period of life.

SCIENTIFIC EDITORIALS.

INTESTINAL OBSTRUCTION CAUSED BY MECKEL'S DIVERTICULUM.

Meckel's diverticulum is due to the persistence, or incomplete obliteration, of the omphalo-mesenteric duct. It may consist of a tube similar in structure to the intestine, extending from the lower part of the ileum to the umbilicus, or obliteration may be partial leavthe small gut. Its average length is two to ing the tube patent a varying distance from three inches. In structure it is like the small

intestine, possessing a mucous, muscular and serous coat. It is always single, and arises from the intestine opposite to the mesenteric attachment. It usually arises from the ileum within thirty-six inches of the ileocecal valve, rarely nearer the valve than ten or twelve inches. The end of the diverticulum is usually free, but it may be connected with the umbilicus by a solid cord. However, this

cord may break loose from the umbilicus and float free in the abdominal cavity, or become attached at some other point.

Several methods by which Meckel's diverticulum produce intestinal obstruction are. given.

1. A coil of intestine may be strangulated under a partially obliterated duct the same as under a peritoneal adhesion.

A long and loose diverticular ligament, though, attached at both ends, may form a noose and produce strangulation by ensnaring a loop of intestine.

3. The diverticulum may form a knot about a loop of intestine, causing strangulation. It is supposed that the diverticulum, to produce this form of obstruction, must be long, attached only at the intestinal end and possess an ampula at the other extremity. stress is laid upon the action of the ampulla in producing these knots about the intestine. 4. The bowel may be strangulated over a diverticular band, the mechanism being the same as if a thin rubber tube were hung over a tense cord.

5. Strangulation may be produced by kinking of the intestine. The diverticulum may exert enough traction upon the ileum to cause an acute bending at their point of juncture, thus obstructing it.

6. Diverticulum as a cause of, or associated with intussusception. The invagination usually starts with the diverticulum.

7. Volvulus of the diverticulum. The twisting finally involves the ileum at the juncture with the diverticulum.

8. Stenosis of the bowel at the diverticular juncture. Congenital strictures of the lesser bowel are most frequently met with in the region of its juncture with the omphalomesenteric duct, and it is believed that they are due to excessive changes incident to the obliteration of this duct.

REPORT OF CASE.

R. C., age 11 years. Family and previous Family and previous history negative. Well developed boy. On July 4, 1912. ate indiscretely and had an attack of colic. His mother used home remedies and did not call a doctor. Was sick two or three days and apparently recovered fully. At 8 a. m., on July 26, 1913, after usual breakfast complained of cramping and nausea and vomited contents of stomach. Felt so badly that he voluntarily went to bed. Refused food the rest of the day and vomited slightly several times. I saw him at 7 p. m. At that time his temperature was 96 degrees F. pulse 108, and somewhat irregular. Facial expression was anxious. Abdomen was not distended. A sausage shaped tumor could be distinctly felt in the right iliac region. A diagnosis of either appendicitis or an intussusception was made and operation advised and accepted. At 9 p. m., assisted by Drs. W. H. Smith and O. L. May the abdomen was opened and an intussusception of the last ten or twelve inches of the ileum through the ileocecal valve was found. The ileum was tightly grasped by the ileo-cecal valve and the invaginated portion of the ileum was distended with gas. Repeated efforts were made to reduce the invaginated gut, but with no success, and resection seemed the only course left. The distension of the invaginated portion of the ileum was so marked that it was decided to attempt to relieve this by puncture before attempting a resection. A sterile hypodermic needle was plunged through the cecum at the most distended point, and the result was most striking. As the gas escaped and the distension subsided there was no difficulty whatever experienced in reducing the intussusception. As the terminal end of the invagination appeared, a dark button-like tumor came into view, which on examination proved to be a Meckel's diverticulum. The two photographs show this interesting specimen, one from the mucous side and the other in cross section. A Lembert stitch was passed around the needle puncture in the cecum, but the two punctures through the intussusception could no the located. The diverticulum was removed and a

running catgut stitch passed through the cut. edges of the stump to prevent haemorrhage, the peritoneum brought over this with a few Lembert stitches, and the abdominal wound closed. So little damage had been done to the intestine that convalescence was uneventful and the boy has remained in good health since. F. H. MONTGOMERY.

WHAT THE PRACTITIONER SHOULD KNOW ABOUT X-RAY ERYTHEMAS.

Ten years ago we had our first experience with an X-ray burn: one not entirely our fault either. We were compelled to apply the X-ray to a patient with a severe case of Tie Douloureux. The patient had a very sensitive skin, and I was not inclined to use the X-ray, but the physician in charge of the case insisted upon it and the result was a severe X-ray dermatitis. The patient for a while was relieved of Tic Douloureux pains. but we had a hard time to rid her of the dermatitis. Under careful treatment we had no bad consequences. Since then we have made it a rule to apply X-ray only in pathological cases, and then we have used the utmost care to avoid any ill consequences.

Since the X-ray has become a very important factor in diagnosis and therapy of certain diseases we will give the reader some important points as noticed by us in experiences covering a period of twelve years. The reaction of the skin caused by the action of the Xray has such a characteristic beginning, course and end that under favorable conditions it should be easily recognized. The most important point to remember in the usage of the X-ray is that the reaction does not come at once. It may come in twenty-four hours or later. The reaction is rather a "latent" one. The sooner the reaction appears, the stronger must have been the application of the X-ray. We must distinguish four degrees of reaction:

First Degree: The latent period lasts about three weeks and the reaction is expressed by falling out of the hair, slight seal ing, and feeling of heat, without visible inflammatory appearances: this condition lasts from one to three weeks and disappears without having any sequelae except a slight temporary pigmentation.

Second Degree: After a latent period lasting two weeks there appears a hyperemia, with a dropsical-like condition, infiltration of the skin, falling out of the hair, pruritus, feeling of heat and sharp pains; the inflammatory appearance lasts from three to six weeks and afterwards leaves pigmentation and a slight localized scaling which, after a certain time,

disappears; but at times we may have hard telangiectasis as a sequelae.

Third Degree: The latent period lasts about a week; soon there is observed severe pains, a persistent characteristic redness, oedema of the skin, vesiculation, excoriation, and falling out of the hair; the reaction lasts. from one and a half to three months and leads to destruction of follicules, fat and sweat glands in greater or lesser degree, with formation of pigmented sections and bald spots. Sometimes after an apparent recovery inflammatory reactions may occur in the course of one or two years, in consequence of which there may be the beginning of formation of necrotic processes, scars and telangiectasis.

Fourth Degree: Erythema appears within from two to eight days, giving a dark violetred color with various pigmentations; bulli and excoriations appear; a great many areas of the skin may become more or less necrotic; the pains are very severe. This may result in atrophy of the skin,telangiectasis, alopecia, or prominent hard sears which sometimes lead to ugly deformities. The center of the skin which has been X-rayed is usually the more strongly affected.

From the above described forms of reaction which usually occur from improper administration of X-ray doses and which are called by Braur "secondary effects," we must differentiate the so-called "early" and prolong ed type, as described by Speder. Freund and others. The latter forms of X-ray reaction. are characterized by the appearance of an X-ray ulcer wit ha prodromal dermatitis, from four to twelve months after the administration. Such burns or reactions have been particularly noticed on the abdomen and back with inflammatory processes affecting the deeper structures and blood vessels.

It must be also remembered that the skin which has suffered from a dermatitis follow

ing the administration of the X-ray, is liable to react from all sorts of irritations (mechanical, thermic and chemical), and this reaction may cause ulceration which is particularly prone to degenerate into malignancy.

M. L. RAVITCH.

Coxitis. Three cases cf coxitis in which there was an apparent relationship between faulty posture or intestinal derangements and coxitis, the discovery of which relationship rendered needless any prolonged local treatment. are re

ported by R. B. Osgood, Boston, (Journal A. M. A., Dec. 19, 1914). It is possible, he says, that if the experience of others coincides with his, the physician can be saved much anxiety and some families be spared the distress which a diagnosis of tuberculosis gives, and the patient saved a prolonged and irksome treatment.

ORIGINAL ARTICLES

HISTORY OF FADS AND FANCIES IN MEDICINES.*

By JOHN E. L. HARBOLD, La Grange. Permit me in a very brief manner to speak of the history and some of the fads of medicine. As far back as the written history of medicine can be traced: there have been fads and fashions. Some one has said, "There is nothing new under the sun." When we read the archaic history of medicine this expression is very forcibly brought to mind. Egyptians are among the first of ancient nations to keep a record of what was done in medicine. In those days the Priests were the principal doctors: they were the learned ones: though others practiced medicine.

The

The surgeons of to-day must not think that there were no surgeons in ancient times. On the walls of the ruined temples of Amen of Thebes there are baso-reliefs displaying surgical instruments: not very unlike some in use in modern times.

The Egyption physicians plugged cavities of teeth with gold, as has been proven by mummies with gold plugs in their teeth.

They performed lithotomy both by suprapubic and perineal operation. They operated successfully for cataract. They were expert in bandaging as the mummies show.

There are, and have been, many different schools or sects in medicine: but there are only three at present who are sufficiently large to have a national association.

We will now note some of the fads that have passed and also some that are with us

now.

Beginning with the time of our independence, the first fad we will notice, bleeding, purging and vomiting considered together as one great fad. In the early years of our independence there were few medical schools. The majority of the doctors in those days studied a few years under preceptor then he began to practice medicine without attending a school.

Thomas Jefferson, writing to Dr. Wistar, declared he had seen the various schools and theories of medicine. "Disciples of Hoffman. Boerhave, Stahl, Cullen and Brown, succeed each other like the shifting figures in a magic lantern, and their fancies, like the dresses of the annual doll-babies from Paris, becoming from their novelty the vogue of the day, and yielding to the novelty of the ephemoral fa

vors.

Bleeding continued until about 1820 when it began to wane. So firm was this fad established that they thought blood must flow: so

*Read before the Oldham County Medical Society.

in lieu of the lancet, cuping and leeches came into use. As late as 1841 Dr. Sleight, a physician of Philadelphia, while holding a public discussion asserted that five-sixths of the blood was superfluous, and being loaded with seeds of disease it was better discharged from the body. In 1874 or 1875 the American Medical Association met in Louisville. I heard Dr. S. D. Gross read a paper on "The Lost Art in Medicine," that was bleeding. I believe we do not bleed enough. I am satisfied that I have saved three lives by bleeding. But the fad has passed.

There are other fashions and fads and now let us notice the great fashion: surgery. For a number of years this fashion has held sway: one day the young man is awarded his diploma: the next day he is a specialist in surgery: performing all the operations as they may

come. Two very eminent surgeons have declared that surgery is on the wane, that thousands of operations are performed which should not have been. So great is the rage to operate that one or two states have passed, or the bills were introduced, making it a severe penalty to operate when there was no need of the operation. The trend of articles in medical journals show surgery is on the wane. Some years ago ovariotomy was the fashion, now appendicitis is the rage.

I am certain that many ovaries and appendices have been removed which should not have been.

Some time ago I saw in a medical journal a table quoted from the French army record: Six hundred cases were reported of appendicitis; 400 were not operated on, death rate less than three per cent; 200 were operated on, death rate between 10 and 11 per cent.

We should pay more attention to internal medicine and therapeutics and the action of drugs.

For years the old school ridiculed the teaching of Hahneman: that "like cured like.”

When

Now for our newest fad, serums. we use serums I believe we get very near the teaching of Hahneman. For those serums as I understand it, each serum or bacterin contain the germs of the disease we wish to cure.

In conclusion, I thank you for the honor conferred upon me when you elected me president of our society. Also for the support and encouragement you have given me. I hope you will give my successor the same support and encouragement. Our meetings have been pleasant and profitable and trust they will continue thus.

DIAGNOSIS, MANAGEMENT AND
TREATMENT OF LOBAR PNEU-
MONIA.*

By R. C. ADAMS, Salyersville,

Lobar pneumonia, an acute infectious, croupous inflammation involving the vesicular structure of the lung, characterized by a severe chill, headache, fever, thoracic pain, dyspnoea, cough, rusty sputum, and great prostration.

Cause: Croupous pneumonia is an infective disease; all ages are liable. As a rule males are more liable than females, and again one attack predisposes to another, as a general rule, debilitating individuals are more susceptible. Lobar pneumonia is most frequent in winter at times occurring epidemicically the result of atmospheric changes and condition. exposures to draughts and cold, damp weather, gout, rheumatism, diabetes and Bright's disease.

Pathological Anatomy: The most frequent seat being the lower right lobe, the next most frequent seat being the lower left lobe, the next subject to affection is the upper right lobe of lung, although I have found it true in a number of children and in aged patients this lobe is affected equally as often as the right lower lobe. In all patients we find the changes are thus divided, first stage is that of hyperemia or (engorgement) second stage is that of exudation (or red hepatization) third or last stage is that of resolution, or (gray hepatization) or it may undergo purulent transformation or the development of abscess in such case it would be termed yel low hepatization.

I do not think it necessary to go into pathological detail as the average country practitioner is familiar with the pathological stages of this disease. It is true in a number of cases abscess of the lung may result from the lung structure becoming involved in purulent disintegration, abscess may be solitary or in great numbers, these abscesses may terminate fatally or open into the pleural cavity causing empyema and exhaustion, or open into the bronchi and expectorated, in some cases an intestinal pneumonia may develop in many cases of blocking up of the bronchial or pulmonary arteries, causes gangrene. my opinion this may occur at any stage of the disease, and again, death may result from general oedema of the unaffected lung. Such cases often erroneously termed double pneumonia. If inflammation of the pleura be associated with a pneumonia the so-called pleuro-pneumonia, the changes in the pulmonary pleura are characteristic.

In

The duration of the stages are thus named; *Read before the Magoffin County Medical Society.

stage of congestion lasts from one to three days, stage of exudation from three to seven days, stage of resolution from seven days to three weeks. In some cases of young and very old or depressed I have seen the stage of red hepatization develop in forty-eight hours. Symptoms begin with a chill followed with a rapid rise of temperature 103 to 104, full rapid pulse.embarrassed respiration, and cardiac actions, dull or sharp pain near the nipple, shortness of breath, respirations are increased to 40 or 50, or even more per minute. Cough at first short ringing and harsh, soon followed by frothy mucus, soon changing or becoming semi-transparent, viseid and tenacious, usually changing to a rusty sputum on the second day, gradually becoming more copoius and of a yellow color. As the disease advances, headache is usually present with more or less delirium, epistaxis, flushed countenance and in all cases that I have treated a flushed or well-defined mahogany blush was over the malar bones. Gastric disturbances highly colored urine and usually scanty. From the onset of the disease prostration is of the most serious character, the above symptoms usually continue for about six to eleven days when a crisis occurs, and within twentyfour hours convalescence is established and as a rule recovery rapidly follows.

Treatment: In most, or I might say, in all forms of pneumonia, the treatment is of the simplest form, in a number of cases but little is indicated. In all forms of pneumonia the general surroundings should be carefully studied. First. is proper ventilation of the sick chamber; this demands the supervision of the physician, as I believe in free ventilation. In very cold weather the nurse or attendant should be guided by his or her sensations in executing the orders of ventilation. The patient is protected against cold by excessive temperature. I do not believe in placing a patient under a window or in a heavy draught, but from the onset of the attack I want my patient to have free admission of oxygen inhalations, especially in the later stages of the disease because it enables us to add to his resources for resisting toxemia.

Food is to be looked after in treating your patient, successfully in as much as the patient is usually attacked in the midst of health and the duration of the disease is short, a modest diet should be adopted. Clinical experience teaches that in many forms of severe types of pneumonia there occurs intestinal distention which so embarasses the patient that sleep is impossible and often hastens a fatal issue by interfering with respiration and disturbing the heart, it is also important to so arrange the diet that fermentation be prevented. I usually prescribe hot broths, or cold milk may be administered in small quantities during

the entire period of the disease. During convalescence and after the crisis the diet may at once be liberally administered. The fear of not sustaining the patient's vitality has often caused the attending physician to administer concentrated foods which have served to handicap your victim in the struggle. When your patient is sleeping normally you should not have him or her as the case may be disturbed or interrupted for any purpose. I make it a rule in all forms of this disease to administer cold water for drinking purposes. I try to impress upon the patient and family the importance of cold drinks. I often and frequently administer some placebo to be given in ice water where the patient is not so inclined to take water as often as I think necessary for their welfare. I find the action of ice water upon the gastric nerves and vessels is the same as its action upon the skin; it refreshes it by the local shock and consequent reaction. It increases diaphoresis and diuresis by free administration of ice water. It has often been observed that the quantity of urine will almost double, the administration of ice water is for more effective as a diuretic, and again large quantities of hot water are an important factor not generally recognized.

Stimulants: A number of writers claim the application of stimulants is rarely necessary, except in persons who are accustomed to its frequent use and to whom it is necessary as a food. I wish to state here that in my practice I always prescribe stimulants of an alcoholic nature every two to four hours, often in connection with some form of ammonia. It is claimed by some few that the prognosis in the majority of patients is fatal because their peripheral vessels have been enfeebled by dilatation produced by alcohol and their nervous systems deprived of capacity to respond to cold applications, so far I have never experienced any fatalities from the moderate administration of alcohol in pneumonia.

My treatment as a whole, is as I have before stated, first, after confirming my diagnosis and arranging my patient comfortably as the surroundings will admit. I then prescribe eight to ten grains of calomel to be administered one grain every hour until all have been administered, this amount usually produces several copious stool and all fermenting materials being thus removed from the intestinal canal. The distention which so often delays. recovery in the advanced cases of pneumococcus toxemia is prevented. I next examine the heart for abnormal conditions in case I find such, and feeble in character, strychnine sulphate is prescribed in doses ranging from 1-60 to 1-30 grain. four to six hours apart. Small doses of coal tar preparations are often used as calmative agents when the restlessness is due to high temperature. As a rule

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