Read Ebook: The Cleveland Medical Gazette Vol. 1 No. 4 February 1886 by Various Baker A R Editor Kelley Samuel Walter Editor

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This note is made to show the action of jaborandi as a galactagogue in the recent puerperal state. The preparation used was the fluid extract obtained from Squibb & Co.

Whereas in this case the improved condition of the individual was responsible for the permanent increase in the supply of milk, the use of the jaborandi and the temporary increase were apparently more than coincidental. During the first two stimulations the quality of the milk deteriorated; the quantity of cream diminished; the specific gravity fell; no microscopic examination of the milk was made. After the last increase in the activity of the glands the quality of the milk was good.

Two similar cases were noted. B., aged nineteen years, primipara, had a tedious labor. She recovered slowly. She was well nourished and has previously been well. At the end of the second week of convalescence the milk began to fail. Jaborandi was used as in the case just cited. Marked improvement in the milk was noticed the second day the drug was given. On the fourth day the medicine was omitted. The milk continued to flow in sufficient quantities for ten days. The quantity then gradually and rapidly diminished. The medicine was again given for four days with the desired effect, which remained for the following ten days that the patient was under observation.

D., age twenty-five years, a multipara, was a poorly nourished person, the mother of two children. The confinement was normal. The milk failed soon after its appearance. Following the use of jaborandi the milk increased rapidly in quantity, but diminished in three days on withdrawing the drug. The milk continued to respond to the jaborandi for the four weeks that the patient was under observation, but no permanent result was obtained.

On three other cases the jaborandi was used with scarcely perceptible effect or no effect at all. From a few cases it is impossible to generalize with expectation of a truthful conclusion. We can, however, know that the jaborandi has an effect on the mammary gland, and causes an increase of the milk in puerperal women. This effect is by no means a constant sequel to the administration of the drug. As far as my observation is concerned the effect of jaborandi is temporary, and can be useful only where there is a tendency in the gland to assume its normal function. This tendency may at times be subordinated to general influences and even entirely subdued. In such conditions a timely stimulation of the gland may tide over the threatening arrest of function. Variation in the activity of the mammary gland, especially in the early puerperal state, is not unusual. The close relation of the increase of milk and the use of jaborandi justifies, however, the assumption of effect and cause.

No effect was observed on the children. Jaborandi is excreted by the mammary glands, and it was consequently withheld as soon as practicable, lest the child should feel its presence.

INDICATIONS FOR OPENING THE MASTOID PROCESS.

BY A. R. BAKER, M. D., CLEVELAND, OHIO.

The operation of opening the mastoid process is said by some to have been first performed by Riolan in 1649; according to others, by Petit in 1750, and later by Jasser, in 1776. During the latter part of the eighteenth century the operation was performed frequently without definite pathological indications. But after the unfortunate death of the Danish physician Berger the operation was very seldom or never performed until 1864, by Mayer, following the suggestions made by Tr?ltsch some years previous. Berger, for chronic deafness without suppuration of the middle ear, had the operation performed upon himself, and died on the twelfth day from meningitis. During the past twenty years the operation has taken its place as one of the recognized surgical proceedings owing to the work of the German physicians Moos, Jacobi, Hartman, Bezold, Schwartz and others, who have laid down the real indications for the operation from their extensive clinical observations and pathological researches. The American otologists, Roosa, Agnew, Buck and others were among the very first to perform the operation, and have done much to establish its claim to recognition. And yet it is somewhat remarkable that some of our text books barely mention the operation; and as short a time ago as 1883, Strawbridge, at the meeting of the American Otological Society, said that he had seen over four thousand cases of purulent middle ear disease within twelve years, and yet had not trephined in a single case; and several other authorities looked upon the operation as a questionable one. Knapp took decided grounds in favor of the operation, and cited three fatal cases in which he believed an operation would have saved life. Kipp had seen quite a number of fatal cases in which the post-mortem had shown the mastoid cells filled with pus, which had given rise to cerebral abscess. Dr. C. H. Burnett reported a fatal case which died from pyemia, and he thought if his patient had been operated a year before his life would have been saved.

Gruening said surgery has established that wherever there is a focus of purulent discharge it should be removed. This, is a life-saving operation and should be done under all circumstances. Dr. Roosa said that he believed the revival of this operation of opening the mastoid process has saved many lives. Since his first operation not a year has passed that he has not found it necessary to repeat it several times. He says further that "it is true that we shall seldom need to open the mastoid if an experienced practitioner sees a case of acute aural disease early in its course. It is an operation for neglected cases, where suppuration has been allowed to advance from the tympanic cavity in consequence of not having a free outlet through the drum-head. But purulent inflammation of the mastoid may occur in acute cases that have been thoroughly treated by leeching, poultices, rest, etc., from the start."

The most recently stated indications for opening the mastoid process are:

As to the time when the operation should be performed, writers do not agree. While one proposes that the operation should be done as soon as there are symptoms of inflammation of the mastoid process, another defers it till the dangerous symptoms set in. The latter proposal must not be followed, as in many cases it would be too late; on the other hand, many cases will recover without an operation. As far as it can be formulated, I would say that in a given case of acute purulent inflammation of the mastoid process I would first apply leeches, poultices, cathartics, antiflogistics. If the inflammation is not promptly subdued, I would make a Wilds' incision, including the periosteum, if the bone is found softened; or if a fistulous opening is found, this should be enlarged at once. If the bone is found healthy and not roughened, if there is no fever, vertigo, headache, etc., I would wait a few days; if the symptoms, pain, tenderness, etc., do not subside, I would then perforate the mastoid process.

For the performance of the operation trepans were formerly used, which were replaced by drills which are still used by Buck, Jacobi, Lucae and others, but by most operators they have been set aside, owing to their uncertain and dangerous advance in the deep parts, and on account of their soiling the wound with splinters. The most rational and safe method is by means of the chisel, as recommended by Schwartz, and is performed as follows: The patient being anaesthetized, a perpendicular incision beginning a little above the linea temporalis, extending an inch and a half in length immediately behind the attachment of the auricle. Formerly I employed a straight incision, but recently have followed the suggestion of Politzer, and from the superior end of the perpendicular incision a second one is made backward at right angles, thus forming a flap, which I have found to simplify the operation very much, as it affords a better view of the locality and extent of any pathological changes which may have taken place, and gives more room for operative procedures, and the periosteum can readily be removed to any desired extent. The linea temporalis and the more or less strongly developed protuberance on the posterior superior orifice of the osseous meatus, so strongly urged by authors, are very nice guides theoretically or to point out on an exceptional skull in the class room, but practically are seldom well enough developed to be of any use to the operator. The best guide to go by is to take the superior wall of the meatus as the upper boundary, and the angle formed by the plane of the mastoid with the posterior wall of the external meatus for the anterior boundary when opening the mastoid. This is best determined by pressing the finger into the meatus. Often in children, and when the bone is diseased in adults, the cortical plate of bone can be removed with the hand chisel, and we come at once upon the pus cavity, or diploe, or cholesteatomatous epidermic masses, or a sequestrum of dead bone, or bleeding granulation tissue, or whatever the case may present. Sometimes the external plate is very thick and we have to chisel our way carefully for almost half an inch before reaching the diploe, or may find the entire mastoid process sclerossed. No absolute rule can be given as to the depth it is safe to penetrate. Schwartz says "never to go deeper than 25 mm." Buck says "it is better to place the extreme limit at 20 mm," about three-fourths of an inch.

Although I do not consider the operation a particularly dangerous one, especially with the chisel where we can watch each step of the operation; and even though we opened into the lateral sinus or the duramater, the injury would not be necessarily fatal. Yet I would not advise any one to attempt it who has not performed the operation on the dead subject. Politzer says "no one should operate on the living before having performed the operation at least forty or fifty times on the dead." I cannot close this article better than in the words of Dr. St. John Roosa, to whose admirable work I am indebted for a large portion of this article.

"Yet, hesitation, when the way is plain, or when the chances are largely on the side of the necessity of the removal of pus, cannot be too sternly condemned. No drug has yet been discovered which can be substituted for the scalpel or trephine when pus has actually formed in the mastoid cells. I wish, however, to repeat what I have said before on the subject of surgical operations. I am in full accord with the great English surgeon, Sir James Paget, who, in his admirable lectures, expresses many times his hesitation to perform any surgical operation, however trivial, that is not absolutely required. We have no right, I think, to perform operations to clear up doubtful diagnosis. If in case the operation proves to have been unnecessary, the patient will be decidedly the worse for it. If we put ourselves in the place of our patients, what we may regard as a trifling thing--"a mere cut"--will not be so esteemed. A mere cut, when unnecessary, may have the most serious consequences, and all the history and symptoms should be carefully weighed before even that is undertaken. Such care will never prevent prompt, rapid and thorough surgical interference when demanded.

In teaching medical students, I have always found them, when fully awakened to the dangers of neglecting certain diseases, to be more apt to do too much than too little, especially with the knife and active drugs. It is possible, also, that the crying ignorance and neglect of the previous decades in regard to the treatment of aural disease has had a tendency to cause us, who see many of the afflictions of the ear, to lean toward the side of surgical operations upon the drum, head and mastoid. This is a leaning no less dangerous to the cure of some cases than was the steering toward Scylla or Charybdis to the safe navigation of ancient mariners."

A CASE OF ANOMALOUS DEVELOPMENT OF THE ANTERIOR PILLARS OF THE SOFT PALATE.

BY B. L. MILLIKIN, M. D.,

Oculist and Aurist to Charity Hospital, Cleveland, O.

Some time since, Mrs. G. D., age about 23, applied to me on account of deafness and tinnitus of both ears. In pursuing my examination I found the following unusual anatomical relations of the anterior pillars of the soft palate, which I deem not unworthy of record.

The uvula and posterior border of the soft palate are normal in appearance and formation; but, beginning about the middle of the anterior pillars, these gradually widen out into thick, heavy, broad, muscular folds, which attach themselves firmly to the sides and dorsum of the tongue, extending two or three lines upon the dorsum. They seem to be intimately connected with the muscle of the tongue itself, making them very firm. The posterior pillars are much less well developed than the anterior, and do not control or prevent the drawing forward of the soft palate when the tongue is protruded. The tonsils are small in size but normally located.

The attachments of these bands give a peculiar appearance to the throat. When the tongue is in a state of rest, in the bottom of the mouth, or, better still, when the tongue is depressed, these bands hang like two large curtains, narrowing very much the faucial opening. When the tongue is protruded they are put upon the stretch, and narrow very greatly the faucial opening by drawing forward and downward the whole of the soft palate, so that the posterior border of the soft palate and uvula rest firmly upon the dorsum of the tongue. When the tongue is thus protruded the attachments of these membranes are brought forward almost to the teeth.

In a state of relaxation there is formed back of these folds, on either side, quite a deep cavity, which often collects quantities of solid food, to the great annoyance of the patient. She even sometimes is obliged to remove these obstructions with the fingers, or, by gulping or swallowing frequently, is able to dislodge them. She has no difficulty in swallowing liquids.

There is some impediment in her speech, a peculiar lisping as if she did not have good control of her tongue, which she has always attributed to the fact that she is of German parentage. Her English is, however, very good, other than as above indicated.

In looking up what anatomical literature is at my command, I find no reference to any anomalies of this kind, although I have been able to consult the standard French, German and English works on general anatomy. I myself have never seen a case with an anatomical construction approaching this, so I, therefore, present it for record.

HINTS ON VOCAL TRAINING--THE BREATH.

The prevalence of throat troubles is so marked in America, and by no means least so in this city, that if one hundred individuals, collected at random, had their throats examined, it is probable that four out of every five would be found to have these delicate organs more or less affected. Whatever cause may be assigned by the medical expert in each particular case, the importance of a thorough mastery of the art of correct breathing can hardly be insisted upon too strongly. If it be urged that the widely distributed works of Behnke and others must have put an end to any general ignorance of the importance of this branch of vocal training, I can only reply that a defective style of breathing is by no means uncommon even in public singers, while among amateurs it is so rare that a perfect management of the breath excites in a critical observer a feeling of gratified surprise. The name and works of Behnke have, of course, been known in this country for a considerable time, but some of his statements are too striking to be omitted in an article on this subject. When lecturing at the Tonic Sol-fa College, London, he took ten students and measured their lung capacity in cubic inches, by means of the spirometer, with wrong or "collar-bone" breathing. He then showed them how to breathe correctly, that is, midriff and rib breathing. The average increase among the ten was twenty-five cubic inches of air; the least increase twelve inches, and the greatest forty-five. He adds: "I imagine that these figures are more eloquent than any words, and I think it superfluous to make any further comment on them."-- Now, putting aside the extreme increase of forty-five inches, let anyone consider what an increase in lung capacity of twenty-five cubic inches of air must mean to the vocalist in the execution of difficult passages, to the speaker using his voice by the hour, and, lastly, to the running athlete. It will surprise a young man commencing vocal training to inform him that, at the same time, he will become a better man in the gymnasium and the race; but unless good lungs are an advantage to the athlete in name only, the above figures tell their own tale. I may add that, in teaching young men and boys, I always put this view of the subject before them, knowing that it will be an incentive to their acquiring a thorough mastery over the interesting art of "taking breath."

Some years since, an English clergyman had to give up all ministerial duty from "Clerical Sore Throat." Acting under the absurd advice of a London teacher of elocution, he resided in Spain for five years without the slightest benefit. He then returned, and at the house of the elocutionist who had made him an exile saw a copy of Behnke's celebrated work. Coming to the conclusion that the author must be rather clever, he at once consulted him. Following his advice he had his throat made medically sound by Lennox Browne, and then took the usual course in breathing and voice production under Behnke. A short time after I was with Herr Behnke, when a post card arrived from the clergyman: "I preached yesterday in Chichester cathedral, and was congratulated on the strength of my voice and the ease with which I filled the building."

A few weeks since I heard a sermon in a Cleveland church. The preacher took short "collar-bone" breathings, using twice the power necessary for the building, and towards the conclusion was in evident distress , a failing voice and perspiring face. If before entering the ministry he had learned to breathe and use his voice properly, such troubles could never have existed.

There is yet another unpleasant affliction which correct breathing will rarely fail to cure, a high-pitched and effeminate voice in a man. I quote again a case from the same work:

I must lastly point out that the cure of stammering often entirely depends on the management of the breath, and in all cases it must be an important agent.

The limits of this paper allow but a brief notice of the best course for a breathing instructor to follow. Let the pupil lie down on his back, place the hand lightly on the lower part of the lungs, and tell him to inhale easily through the nostrils, allowing the air to fill the lower part of the lungs, avoiding all motion of the shoulders and heaving up of the chest. When the lungs are fully inflated count four with deliberation, and let the pupil inhale all the air as suddenly as possible. Gradually increase the counting week by week up to twelve, which marks a real control over the unused muscles. The next course is for the pupil to inhale suddenly and exhale slowly. The instruction given is of necessity meagre, but it need hardly be pointed out, no written directions can take the place of personal teaching. From four to six weeks is usually sufficient for the young and vigorous to gain command over the breathing apparatus; older pupils have sometimes great difficulty in mastering the muscles, unruly through disuse.

Herr Behnke allows no use of the voice beyond ordinary speaking while the breathing exercises are going on. I have followed this rule much modified, and do not find the results unsatisfactory.

The total neglect of this important subject in both American and English schools is to me perfectly astounding. Half an hour a week for three months would be ample for the purpose. These few hours would confer a benefit of the highest value, and lasting a lifetime.

The Cleveland Medical Gazette.

One Dollar per Annum in Advance.

All letters and communications should be addressed to the Cleveland Medical Gazette, No. 5 Euclid Avenue, Cleveland, Ohio.

EDITORIAL.

We have mailed the Gazette regularly to a number of our friends who have not remitted their dollar. We hope they will do so soon.

MEDICAL DEFENSE ASSOCIATION.

Last month we urged the necessity of the profession organizing a medical defense association. We publish this month the proceedings of the Chicago Medical Society, in which the same question is discussed very fully.

STATE SOCIETY REORGANIZATION.

The editor of the Cincinnati Medical Journal asks the secretaries of local societies to bring the matter before their respective organizations, and suggests that they invite expression upon the following propositions:

MEDICAL PRACTICE BILL.

A bill to establish a medical board of examiners and licenses, and to regulate the practice of medicine and surgery in the State of Ohio, and to define the duties and powers of such board, will be presented to the Legislature of Ohio. It provides for:

These are the essential features of the bill, and on the whole good. It does not interfere with physicians already in practice, which has caused the failure of nearly every bill presented to the Ohio Legislature becoming a law. Excluding college professors from becoming members of the board is fair to the profession, and saves the bill from being the tool of the medical colleges, unlike the Pennsylvania law, and yet it does not ignore the medical schools entirely as educational and graduating bodies, like the Illinois and West Virginia laws. It is impracticable, even if desirable, to ignore denominational lines in medical legislation.

PHYSICAL EXAMINATION OF YOUNG GIRLS.

The following remarks were made by the president of the Royal College of Physicians, December 28, and were the result of an inquiry into the conduct of Dr. Haywood Smith, by the college, for having physically examined the girl, Eliza Armstrong, without the consent of parent or guardian:

SUET BANDAGES.

A disadvantage of the tallow bandage is its becoming rancid. Vaseline, not becoming rancid, has been tried, but melts too easily. For most purposes the wax bandage is as good as the tallow, perfectly smooth and does not become rancid, but cannot very well be medicated. A useful material for a bandage of this kind is the paraffine, as recommended by Tait.

We observe that Dr. Piffard has retired from his editorial connection with the Journal of Cutaneous and Venereal Diseases. The Journal will be continued under the sole editorial charge of Dr. P. A. Morrow. We may remind our readers that this is the only publication in the English language devoted to Skin and Venereal Diseases, and during the three years of its existence it has won for itself a high reputation for scientific excellence as well as practical utility. In addition to presenting all that is new and valuable in these special departments, the colored lithographs and wood engravings with which the original articles are illustrated are worth more than the price of subscriptions. Judging from the handsome appearance of the January number, which is enriched by an admirable chromo-lithograph and a number of well-executed woodcuts, and the eminently practical character of its contents, this high standard will be maintained in the future.

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