the passage of these calculi or aid in their dissolution. Nor have we any remedy that exerts any specific curative action on any of the symptoms of the disease." He then proceeds to display the narrow limits of his therapeutical attainments by adding that "the best we can do with medicine is to relieve the colic with morphine, and judicious ly prescribe cholagogue cathartics, digestive preparations and dietetic treatment." We may justly, we believe, take this position as illustrative of that of the surgeons en masse, and our comments apply rather to them than to Dr. Mason individually. The statement shows their ignorance of the pathology of the attack of hepatic colic, and of the nature and application of therapeutic agents. When a biliary calculus enters one of the ducts the stone is spasmodically grasped by the circular muscular fibers and held until their irritability is exhausted and they relax, when the stone moves forward and is grasped by the next set of such fibers, The obstacle is the spasm, and its relief the object of therapeutic endeavor. Morphine is not as effective as a relaxant of spasm as atropine. When morphine is administered its analgesic action is combatted by the pain, each neutralizing the other to some extent, but the pain continues. More morphine is given; still more; and as the pangs increase the physician becomes desperate and injects a huge dose and just then the calculus rolls into the duodenum, the spasm ceases, the pains stop, and relieved of their antagonism, the whole effect of the morphine is exerted on the weakened forces of the patient, and he is narcotized. Bad therapeutics. Substitute atropine, which is a far more powerful relaxant of spasm, and add glonoin to do the same thing more quickly and to open the cirulation to take up the atropine promptly. These may be safely pushed to full effect, and the relief will be quicker, better, safer than from morphine, because directed from correct views of the pathologic condition to be relieved. Add strychnine, which will stimulate the expuisive lognitudinal fibers and aid in restoring nervous control over the spasmodic ones. Yes, even while atropine and glonoin are relaxing the spasm-drop the a priori doubts and try it. Naturally, the surgeon looks to the gross material lesions found on autopsy, and does not consider the living conditions as we do. The stone impresses him as the main thing. We know that the stone is harmless as long as it lies quiet, and we consider the irritation of the biliary passages that disturbs the quiet. We look to inflammation and infection of the biliary passages, to the duodenal conditions preceding these, and we endeavor to restore normality here. So we regulate the diet, clean out and disinfect the whole alimentary canal, keep it clean and clear, and we give such remedies as we believe have a favorable influence over the biliary passages. Chief among these is sodium succinate. Whether it does or does not induce the flow of bile possessing great solvent powers, we know that the persistent use of this salt in doses of a scruple a day for a year is invariably attended by the steady subsidence of the attacks in frequency and severity, so that long before the close of the year they have ceased, and from a clinical point the disease is cured. Other remedies have been found similarly useful, especially boldine and chionanthin, while dioscorein has unquestionable power in controlling the spasm and relieving the paroxysm, though it is not as well known as the remedies mentioned Our own rule is this: If the establishment of the full atropine effect, as denoted by dry mouth and flushed face, is not followed by complete relief, a few drops of chloroform may be inhaled to complete the relief. But if this method fails, we believe it is fair to assume that there exists a mechanical obstacle that demands surgical intervention, and we call on our brother for his mechanical skill. The writer ventures the assertion that very few surgeons ever heard of the treatment above outlined, and that not one of them ever applied it. Certainly not one would have the patience to administer a drug for a year, when the stone could be removed in a few minutes. But-the removal of the stone is by no means all there is to the case. We general practicians do not pretend to pronounce final judgment upon the surgeon's special procedures-why should he assume the right to thus condemn ours? DOUBLE MONSTROSITY. (Prosopothorakopagus). W. H. Sharp, M. D., Parkersburg, W. Va. The mother of the twin monstrosity, whose photograph accompanies this history, was a native of West Virginia, aged 42 years, and had been married 10 years and never been pregnant before this and has had no children since their birth. Husband was 10 or 12 years older than his wife. When she was about 72 months pregnant, she summoned her physician, Dr. L. C. Ahlborn, of Waverly, W. Va., to see her, as she thought that she was about to have a premature birth. Dr. A. found that she was in commencing labor, but there was very slight dilation of os uteri. On careful examination he could not detect any fetal heart sounds, nor did the mother feel any fetal movements. The doctor gave her an anodyne and went home, leaving instructions to be summoned if pains became severe. Saw her next morning at 6 o'clock. She had not rested, having had labor pains all night. On examination he found labor well advanced and the fetus low down, resting on the perineum. There was a condition so peculiar that he could hardly tell what presentation it was, but concluded it to be a cephalic one, the head to be larger than usual, but it was also softer than usual, yielding to hard pressure. Everything progressed well, but towards the close the pains were very severe, so chloroform was used. The child was dead when born. The doctor thus describes the child: "The combined heads were larger than the head of a child at term. The children were male. The bodies were united as though they were hugging each other. The heads, thoraces and abdomens were united; the heads and thoraces were firmly united, but the abdomen nicely tucked in, in folded pleats like an accordion, so that by taking hold of the legs with opposite hands and pulling apart, the bellies would stretch enormously, folding together again when released. There was but one cord, attached directly midway between the bodies. The hips, arms and legs were distinct and perfect, as were also the backs of the bodies. The heads had separate faces, each face having on opposite sides two eyes. In the picture but one face shows and the back of one head; on the other side or reverse, was another face and back of head. Eyes, mouth and nose are plainly visible, as also two ears on opposite sides of the heads. third ear was present, but is not shown in the picture. The location of the fourth ear was within the line of union of the two heads." A Had these children lived to full time there would have resulted a dystocia which would have required, in all probability, an embryotomy before delivery could have taken place. Nature fortunately helped herself by the death of the fetus at a period sufficiently early to avoid this. ARTERIO-ARTERIAL ANASTOMOSIS BY TELESCOPING A BRANCH INTO A TRUNK. William W. Golden, M. D., Elkins, W. Va. (Superintendent and Surgeon in Charge Davis Memorial Hospital; President West Virginia State Medical Association, etc.) From the few reports which have been published of late on the subject of artificial anastomosis of blood vessels it is evident that no one method will prove applicable to all cases. It is for this reason that I deem the method used in the following case worthy of publication. If any one else has ever used this method I am not aware of it. On Sept. 5th, 1906, R. S., a lad of six, fell off the front of a light-weight car which was moving by gravity down a hill of moderate grade. He landed on his back between the rails in such a manner as to have his left arm lie across one of the rails in an abducted position, with his axilla resting on the rail. The front wheel of that side of the car rolled into the axilla, cut into it, and then was blocked by the shoulder, bringing the car to a stop. The boy was brought to the Davis Memorial Hospital within a few hours after the accident occurred. A superficial examination showed a laceration through the anterior fold of the axilla completely severing the pectoralis major. The humerus at this point was fractured, and the lower fragment punctured the skin on the outer aspect of the arm. Most important was the fact that there was no evidence whatever of any blood circulation in any part of the extremity below the point of injury. When the parents were informed of this fact they insisted that no amputation be considered, regardless of all consequences. Under anesthesia a thorough examination was then made, for which purpose the wound was enlarged and vessels, nerves and muscles clearly laid bare. The axillary and brachial arteries were found anomalous in the following respects: The subscapular branch was of a size almost equal to that of the axillary. the axillary. The posterior circumflex was very small, and sprang from a point verv close to the origin of the former. There was no anterior circumflex. Immediately after giving off the posterior circumflex, the axillary was much diminished in size, and continued of this size as the brachial to the junction of the upper and middle thirds. of the arm, where it bifurcated into the radial and ulnar. There was no visible solution of continuity of the axillary or the brachial. Pulsation was normal down to a point immediately below the origin of the posterior circumflex. From there on it was entirely absent. At this point a smail aneurismal dilatation of the artery was noted, and was venous in color. At first it was supposed that this marked the location of a thrombus, and efforts were made to dislodge and "side-track" it into the large subscapular branch. It soon became clear that this was not the case, but instead that the intima was ruptured and that by its retraction and coiling it had effected hemostasis in the same manner as it does when purposely ruptured by an artery forceps. The following procedure was then resorted to: The posterior circumflex was dissected out for a sufficient distance, its distal end lighted permanently and its prox imal clamped temporarily between the fingers of an assistant. A small slit was then made in the brachial at a point within easy reach of the cut end of the posterior circumflex. A fine silk thread was passed through one lip of the cut edge of the latter. The ends of this thread were passed into the lumen of the brachial through the slit, and by means of needles brought through its wall from within outward a short distance below the slit. Traction on the threads and manipulation soon telescoped the posterior circumflex into the brachial. One of the threads was then made to pass through a few fibres of the coraco-brachialis externally, and the other through some loose cellular tissue internally, and the two tied, thus adding security against leakage. A dressing and splints were then applied. An examination of the extremity on the completion of the anastomosis showed the presence of arterial blood all through it. The deathly paleness gave way to a color nearer the natural one; warmth returned, and small incisions in the hand oozed with arterial blood. Later, when the patient recovered from the anesthesia, it was found that sensation had returned in the hand and forearm. Pulsation in the arteries below the anastomosis was not expected to return for obvious physiological reasons, and none did return. In a few days the general condition of the patient became gravely septic. An examination of the wound where the anastomosis was done showed it to be healing by first intention, but the wound made on the outside of the arm by the bone fragment looked infected. It soon became evident that the boy was suffering from an acute infective. osteo-myelitis affecting the fractured ends of the humerus, and that an amputation was imperative in order to save the patient's life. This was steadfastly refused by the parents until the morning of Sept. 12th, when the boy was in a moribund condition. The arm was then hastily removed, but the patient. died within a few hours afterwards. Just before the member was severad a hasty examination was made of the parts. concerned in the anastomosis. Everything was found in good condition, and there was no trace of leakage. The telescoped branch was pulled out and found bleeding. The following colleagues assisted at the operation and watched the course of the case: Drs. W. S. Smith, O. L. Perry, H. K. Owens and F. S. Carey. To the first named I am indebted for referring the case to me. WHAT MENTAL CONDITIONS C. O. Henry, M.D., Fairmont, W. Va. (Read at annual meeting State Medical Asso. June, 1906.) The question at issue might be answered. in one word, insanity; but the laws and expert medical testimony are as varied in their answers and definitions as the many forms of the disease with all its attendant delusions. In civil cases, the physician is constantly appealed to, to determine the testamentary capacity of one making a will, or signing a contract, a deed or contracting a marriage. As to testamentary capacity it is understood that the law requires less testamentary capacity to make a will, than for managing property or enjoying personal liberty. Inmates of asylums have made good wills, especially if their delusions did not affect the provisions of the will, and where these were just and reasonable, the highest courts have held them to be good. For instance, a man may be insane on religion and be perfectly sane on all other questions, and capable of disposing of his property. A testator is not capable, if at the time he makes the will he is in a wild delirium, or if his delusions are that one of his family or a beneficiary is trying to poison him. To draw the line where one is not capable of making a will is a very difficult thing to do; and in this day where the law makes good distribution of one's property, the efforts to prove the testator's incapacity have met with failure. The maker of a will may be extremely old, his understanding, memory and mind enfeebled and weakened by age, and his actions occasionally strange and eccentric, and he may not be able to transact many of the affairs of life, yet if age has not rendered the maker imbecile, so that he does not know the nature and effect of the instrument, this does not invalidate the will. If he be capable at the time to know the nature, character and ef fect of the particular act, that is sufficient to sustain the will. The laws sustain it, and the presumption in law is that the grantor or maker of an act was sane and competent when the act was performed. Members of the medical profession too often have lent their influence and position to the wiles of disappointed legatees; not that they did not know better, but that from a business standpoint it seemed better to have a stand-in with the many disgruntled heirs than with the dead testator's few favored ones. There are instances on record where a father and son, both physicians, testified in opposite directions as to a testator's sanity and capacity to make a will, the father saying the testator had senile dementia, and the son that he had taken the dead testator's note in settlement for his father's account for medical services rendered years before. The medical profession should be a unit on mental capacity. As has been stated in the beginning, perfect soundness of mind, contrary to the lay impression, is not essential to testamentary capacity. A testator may be afflicted with any of a variety of mental weaknesses, disorders or peculiarities, and still be capable of executing a valid will. On the other hand, absolute insanity is not essential to testamentary incapacity. The testator's condition may fall short of that degree of mental aberration generally known as insanity or idiocy, and yet from conditions before stated he may be incapacitated from making a valid will. It is the precise degree of mental capacity which will meet the requirements of the law, or the precise degree of incapacity which will fall short of those requirements, that medical and legal experts have fought over. In conclusion, a good rule to adopt would be that the testator must have sufficient active memory to collect in his mind, without prompting, the elements of the business to be transacted, and to hold them long enough to perceive their relations to each other, and to form some rational judgment concerning them. Never open a prostate abscess per rectum, no matter how much it bulges; always operate through the perineum.-American Journal of Surgery. INFECTION FROM OAT-STRAW. John L. Dickey, A.M., M.D., Wheeling, W. Va. I had a case recently that seemed to indicate a peculiar liability to poisonous infection in a wound made by oat-straw. R. L. T., a young farmer, age 25, while threshing oats, was struck in the left eye by a splinter of the straw. I saw him shortly afterward and found the splinter had penetrated the lower inner quadrant of the cornea obliquely downward, almost, if not entirely, through the anterior chamber. It was removed, the eye was bandaged, and a solution of atropine, cocaine and boric acid was prescribed, to be used every three hours, after bathing freely with hot water. When I saw him the second day afterward the eye was very much injected and the wound was inflamed. In spite of vigorous treatment the poisonous infection spread rapidly until the entire cornea became necrotic and the conjunctiva and deep structures were intensely congested. About two weeks after the accident the eye was enucleated, and found to be considerably attached posteriorly by inflammatory adhesions. Interior degeneration had also begun, as shown by inflammatory products in the iris and anterior portion of the vitreous. Panophthalmitis was evidently rapidly approaching. For three days after enucleation the conjunctiva and all the orbital tissues were so swollen and inflamed that the lids were tense, shining and discolored from the pressure. It was feared that the infection would continue to the meninges. But it gradually subsided and two weeks after enucleation the lids and orbit presented a normal appearance. Of course during all this time there was considerable constitutional disturbance. Dr. Andrew Wilson, who saw the case several times with me, said he had never seen a wound made by oat-straw that did not give trouble; that there seemed to be some poisonous germ in the straw that infected all such wounds. Every farmer I have asked about it said oat-straw was more poisonous than any other, and that they disliked to work with it, especially if they had any sores on their hands. The oat-field would be a favorable place for our bacteriologists to hunt a new germ -the avenacoccus. |