- Email: [email protected]
THE IDEAL PRACTITIONER.
631 anaesthesia was employed for the donor, but no anaesthesia for the patient. Five or six minutes after the transfusion had) begun the lips became feebly coloured and the pulse became perceptible. It was a veritable resurrection. As the donor had a small radial artery, which at times appeared to be in a state of spasm, the transfusion was continued for an hour. It was intended to stop after three-quarters of an hour, but the husband, who showed no signs of weakness, insisted on. DIRECT TRANSFUSION OF BLOOD FOR SEVERE continuing. During the whole time the continuance of theACCIDENTAL HÆMORRHAGE DURING flow of blood was verified every ten minutes by palpation of LABOUR. the vein, in which a thrill was felt. When the transfusion AT a meeting of the Académie de Medecine of Paris was stopped the patient’s pulse was 120. Her further recovery M. Oui, of Lille, has reported a case in which he had was uninterrupted. The portions of the artery and vein which successfully treated accidental haemorrhage during labour so were sutured were resected and examined. They showed na severe that death was imminent, by an unusual method-the signs of clotting of blood. This appears to be the first direct transfusion of blood. A young woman, who had pre- case recorded in France in which direct transfusion of blood viously had five normal pregnancies and labours, ceased to was performed for haemorrhage during labour. After severemenstruate on Sept 15th, 1911. In the early months of this hasmorrhages patients can almost always be saved by pregnancy she suffered from constipation, for which she took stimulants and saline injections, but some succumb in spitelaxatives from time to time. On Feb. 4th she complained of of all efforts. In this case the renal insufficiency contraacute pain in the right lumbar region, and on the following indicated massive saline injections.
artificial illumination, and the fatuous notion a dazzling and brilliant light is necessarily a that dissipated good light. Artificial illumination is a branch of hygiene which possesses greater significance than it has been credited with, and the more this fact is recognised the salutary and pleasant, we may hope, will modern systems of lighting become.
glossary of
more
-
day M.
Oui found that the right kidney was enlarged and THE IDEAL PRACTITIONER. that there was a considerable quantity of pus in the urine, but after filtration there was little albumin. A lactoAMONG all classes of men are to be found at least a few vegetarian diet and urinary antiseptics had little effect from time to time who approach more nearly to the embodion the condition of the urine. At the beginning of ment of the ideal of their class than do their fellows-. June the lower limbs became very oedematous, but the Medicine has no monopoly of them, but we rejoice in the albuminuria was not increased. On July 2nd labour began, grounds for believing that there are proportionately more of and she was examined at 3.15 A.M. The pulse was 70. The them in the ranks of the medical profession than of any uterus was slightly tense, and the sounds of the fcetal heart other. The regrettable feature is that from the very nature The head presented and had not engaged in of their idealism their influence is mainly and necessarily were muffled. the pelvis. The os was of the size of a two-franc piece. A local, and it is usually only when the local grief at their few minutes later there was a sudden flow of liquid blood loss breaks bounds and becomes articulate that the outer M. Oui ruptured the membranes, the head world hears much, if anything, of them. and clots. If we may judge engaged, and the haemorrhage ceased. He then noticed a from a recent report in the Dalkeitle Advertiser of the unmarked increase in the size of the uterus, which had become veiling in the churchyard of Lasswade, N.B., of a memorial of wooden hardness. The haemorrhage was evidently due to to the late Dr. Charles Allan, who for nearly half a century The pulse had lived and laboured there, earning the confidence, the detachment of a normally inserted placenta. became small and rapid. The head was born at 3.45. There affection, and respect of the whole countryside, such a one was difficulty in delivering the shoulders. Finally a big child was he, and we may well ponder a moment over the characwas delivered, but succumbed. A formidable quantity of liquid teristics, as disclosed in an admirably sympathetic address blood and clots followed, flowing over the bed in a veritable by the Rev. Mr. Hardie, which made him what he was. sea. M. Oui introduced his hand into the uterus and found The first thing noticeable is the combination of general the placenta completely detached. He extracted it and com- culture with sound professional skill, which developed, if it pletely removed the clots which had accumulated in the did not originate, the toleration, sympathy, tact, and repose uterus. An intra-uterine injection of hot water was imme- -the aquanimitas—which are the most potent factors in diately given and caused the uterus to contract and arrested gaining the confidence of man, more especially suffering man. the hoemorrhage. In a few minutes the general condition The next characteristic which the reverend gentleman became much worse. The pulse was 140 and very feeble, emphasised was the possession of "a purely professional and the patient had lost all colour. Injections of ether, mind," a mind that has no joy in turning over the pages of caffeine, and camphorated oil caused momentary improve- the ledger to see how much one’s patients owe one, or in ment. An injection of 500 c.c. of saline solution produced summing up the columns of a bank book to see how much only passing improvement in the pulse. The legs were one possesses. "He had no interest in a profit and loss tightly bandaged so as to drive the blood from them. The account ...... he was amongst us as one that served." In same passing improvement was produced, and then the pulse these words is summed up the ideal of the profession of became imperceptible and the general condition relapsed. At medicine, an ideal that, however comparatively easily it may 6 o’clock M. Oui decided that transfusion of blood should be per- come to the man who has embraced the medical calling in formed, and summoned by telephone from Lille-a distance the true spirit of a vocation, is proportionately difficult of of 20 kilometres-a surgeon, M. Lambret. In the mean- attainment by him who looks at it from a business point of time he gave stimulants and injections of camphorated oil view. But such an ideal devotion to service can exist only and ether. The patient became worse. The pulse could be among the free ; it cannot be attained as the result of a felt only as almost imperceptible waves. The respira- system which, while placing the subject beyond the need or tion was intermittent and spasmodic. The skin was care for the provision of food and shelter and clothing, subcovered with cold perspiration, and the patient showed ordinates him to restriction and control by others necessarily M. Lambret could not arrive before less fitted than himself to decide the circumstances and condino signs of sensibility. He immediately anastomosed the right median tions under which his work shall be done. He must be, as the 7.45. cephalic vein of the patient with her husband’s right radial Rev. Mr. Hardie said, a "work-first-man, never a fee-firstartery. He used a circular suture of fine silk and performed man" ; but also he must be an essential-first-man, not a reguAnd this is the more important in that upon end-to-end anastomosis after the method of Carrel. Local
lation-first-man.
632 at is dependent the final characteristic of the ideal practitioner referred to by Mr. Hardie-that of " a strict, almost a stern, disciplinarian." It is rare to find so apt an appreciation of the ideal practitioner of medicine as that of Mr. Hardie, and we welcome it accordingly. -
June lst the names of those they deem worthy of any of the prizes, together with a copy of the work upon which the nomination is based. A candidate may present his own
application.
Dr. Frederick Taylor has been reappointed to represent the London on the General Medical Council.
University of
HEMIPLEGIA IN TYPHOID FEVER. HEMIPLEGIA in typhoid fever is very rare. In an exhaustive article published in 1907 Smithies could tabulate 43 cases from the literature of the subject.1 In the Canadian Medical Association Joicrnal for last December ’Dr. J. IVI. Pearson has recorded the following case. The /patient. a Scandinavian, aged 30 years, was admitted into the Vancouver General Hospital on Sept. 16th, 1911, ’having been ill for a week. The diagnosis of typhoid fever For six days the was confirmed by the Widal reaction. -disease ran a mild course, the temperature gradually ’falling. On the evening of the 22nd he was slightly .delirious, and an involuntary action of the bowels ’occurred. He slept well that night. When he was roused the next morning for nourishment he had difficulty in - swallowing, and two hours later the left arm and leg were found to be paralysed. He was conscious, rational, and .able to speak. On the 25th he took food more easily, and *ihhere was some evidence of returning power in the leg. During this time the temperature had been rising to 104° F. and the pulse to 108. On the 28th a large haemorrhage from the bowel occurred, and during the next two days six others followed. He died on Oct. 3rd, the twenty-fourth day of the illness and the tenth after the onset of the paralysis, having been unconscious for some hours. At the necropsy the usual intestinal signs of typhoid fever were found. The heart was normal. The brain was somewhat flattened over the right parietal region, where also there was slight thickening of the meninges. On section, softening was found involving the greater part of the second and third frontal and ascending parietal convolutions, part of the supra-marginal and angular gyri, and the upper part of the temporo-sphenoidal lobe. ’This area, which was of the size of a small orange, was of a - dirty yellowish-grey colour. There were no cavities. The left side of the brain, basal ganglia, and internal capsule on both sides were normal. The right middle cerebral artery was completely blocked for about an inch after entering the Sylvian fissure. The artery was thickened and its lumen filled with a firm semi-fibrous adherent thrombus. This began at a point beyond the branches going to the anterior perforated spot, and extended a short distance into each of the terminal branches of the artery.
FUNCTIONAL APHONIA :
- only
AT the Seventeenth International Congress of Medicine, rto be held this year in London, the following prizes will be .awarded : (1) The Prix de Moscou, instituted in com,memoration of the Twelfth International Congress, value ;5000 francs, for the best work on medicine or hygiene, or for eminent services rendered to suffering humanity ; (2) the Prix de Paris, commemorating the Thirteenth International ’Congress, value 4000 francs, for a single discovery, or for a collection of original works not dating farther back than ten years, and relating to medicine, surgery, obstetrics, or the anatomical or biological sciences in their applications to medicine ; (3) the Prix de Hongrie, commemorating the :Sixteenth International Congress, value 3000 crowns, for a work in the domain of the medical sciences, which has appeared in the interval between the two Congresses. The Bureau of the Permanent Commission of International .Medical Congresses (10, Hugo de Grootstrat, The Hague, ,Holland) invites the members to forward to it before 1 Journal of the American Medical Association, vol. xlix.,
____
p. 389.
A METHOD OF CURATIVE AND PREVENTATIVE TREATMENT. BY CORTLANDT
MACMAHON, B.A. OXON.,
INSTRUCTOR FOR SPEECH DEFECTS AT ST.
BARTHOLOMEW’S HOSPITAL
AND ETON COLLEGE.
THE treatment of aphonia by the method herein described as the title suggests, applicable to cases in which, whatever the original cause of the loss of voice, the non-return of the voice is entirely due to functional causes. The treatment is not advanced to take precedence of intralaryngeal faradism in hysterical and neurotic subjects, but it is especially advocated for stubborn and long-standing cases which have hitherto failed to yield to ordinary treatment. In considering what may be termed the vocal treatment of functional aphonia one may usefully consider what really constitutes the phenomenon, Voice. Voice is air vibrating in the resonating chambers of the body, and these resonating chambers consist of the thorax, the larynx, and the pharynx, the nasal and oral cavities, the ethmoidal and sphenoidal sinuses, the maxillary antra, and the frontal sinuses. In a normal voice these resonating chambers are able successfully to carry out their function of amplifying the minute tone and pitch originating in the larynx caused by the due approximation and requisite tension of the vocal cords. In aphonia there is no adequate approximation of the vocal cords, and consequently no vibration ; the resonating chambers are accordingly rendered inoperative, and what speech is audible is produced mainly by friction caused by the ascending air column being passed through a constricted throat and then articulated. In dealing with cases of aphonia the first thing to be acquired is the ascent of a definite and adequate air column which can be passed at will through the larynx. This is brought about by teaching the patient to acquire a marked inferior lateral costal expansion during inspiration, great care being taken that while this is being attained there is no protrusion of the abdominal wall; then, when the lungs can be properly filled, the second movement, consisting of the strong and deliberate contraction of the abdominal muscles, must be taught. The action of the abdominal muscles, when in contraction;, is to pull downwards and inwards the lower ribs and to bring about the very definite ascent of the diaphragm by pressure on the abdominal viscera ; as a result of which movement, as a whole, the internal thoracic capacity is reduced at will and the force and quantity of the ascending air column easily controlled. Having acquired a definite air column the next step is to turn the patient’s mind to the lips. The orbicular muscle must be made to move as freely as possible, and the patient must be told that when the voice is to be produced it must, This free-lip movement, as it were, be lifted into the lips. combined with the ascent of an adequate air column, will automatically help to get rid of the constriction of the muscles above the larynx, and will leave the soft palate free to perform its function of properly apportioning the ascending air column into the nasal and oral cavities when
is,
phonation again occurs. A short digression is
now necessary so that the science of the resonators may be very briefly explained. When vocalisation is occurring there are six vowel sounds or " resonators " which are brought into use. They are "oo," oh, "aw,""ah," " a,"and "eye. They are used alone in words, as,’for example, "00" in° droop " and eye " in " deep,"or they are used in combination as "all"" and " 00"in"sound,""aw"and ee"in "boy," "ah" and "ee"in"my,""oh"and" 00"in "road," and so on. Two of them, "ah"and ee,"are also used sub" ordinately. For instance, the word "love " is on the ah
resonator, "little"" is
on
the "ee"" resonator.
These six
artificial illumination, and the fatuous notion a dazzling and brilliant light is necessarily a that dissipated good light. Artificial illumination is a branch of hygiene which possesses greater significance than it has been credited with, and the more this fact is recognised the salutary and pleasant, we may hope, will modern systems of lighting become.
glossary of
more
-
day M.
Oui found that the right kidney was enlarged and THE IDEAL PRACTITIONER. that there was a considerable quantity of pus in the urine, but after filtration there was little albumin. A lactoAMONG all classes of men are to be found at least a few vegetarian diet and urinary antiseptics had little effect from time to time who approach more nearly to the embodion the condition of the urine. At the beginning of ment of the ideal of their class than do their fellows-. June the lower limbs became very oedematous, but the Medicine has no monopoly of them, but we rejoice in the albuminuria was not increased. On July 2nd labour began, grounds for believing that there are proportionately more of and she was examined at 3.15 A.M. The pulse was 70. The them in the ranks of the medical profession than of any uterus was slightly tense, and the sounds of the fcetal heart other. The regrettable feature is that from the very nature The head presented and had not engaged in of their idealism their influence is mainly and necessarily were muffled. the pelvis. The os was of the size of a two-franc piece. A local, and it is usually only when the local grief at their few minutes later there was a sudden flow of liquid blood loss breaks bounds and becomes articulate that the outer M. Oui ruptured the membranes, the head world hears much, if anything, of them. and clots. If we may judge engaged, and the haemorrhage ceased. He then noticed a from a recent report in the Dalkeitle Advertiser of the unmarked increase in the size of the uterus, which had become veiling in the churchyard of Lasswade, N.B., of a memorial of wooden hardness. The haemorrhage was evidently due to to the late Dr. Charles Allan, who for nearly half a century The pulse had lived and laboured there, earning the confidence, the detachment of a normally inserted placenta. became small and rapid. The head was born at 3.45. There affection, and respect of the whole countryside, such a one was difficulty in delivering the shoulders. Finally a big child was he, and we may well ponder a moment over the characwas delivered, but succumbed. A formidable quantity of liquid teristics, as disclosed in an admirably sympathetic address blood and clots followed, flowing over the bed in a veritable by the Rev. Mr. Hardie, which made him what he was. sea. M. Oui introduced his hand into the uterus and found The first thing noticeable is the combination of general the placenta completely detached. He extracted it and com- culture with sound professional skill, which developed, if it pletely removed the clots which had accumulated in the did not originate, the toleration, sympathy, tact, and repose uterus. An intra-uterine injection of hot water was imme- -the aquanimitas—which are the most potent factors in diately given and caused the uterus to contract and arrested gaining the confidence of man, more especially suffering man. the hoemorrhage. In a few minutes the general condition The next characteristic which the reverend gentleman became much worse. The pulse was 140 and very feeble, emphasised was the possession of "a purely professional and the patient had lost all colour. Injections of ether, mind," a mind that has no joy in turning over the pages of caffeine, and camphorated oil caused momentary improve- the ledger to see how much one’s patients owe one, or in ment. An injection of 500 c.c. of saline solution produced summing up the columns of a bank book to see how much only passing improvement in the pulse. The legs were one possesses. "He had no interest in a profit and loss tightly bandaged so as to drive the blood from them. The account ...... he was amongst us as one that served." In same passing improvement was produced, and then the pulse these words is summed up the ideal of the profession of became imperceptible and the general condition relapsed. At medicine, an ideal that, however comparatively easily it may 6 o’clock M. Oui decided that transfusion of blood should be per- come to the man who has embraced the medical calling in formed, and summoned by telephone from Lille-a distance the true spirit of a vocation, is proportionately difficult of of 20 kilometres-a surgeon, M. Lambret. In the mean- attainment by him who looks at it from a business point of time he gave stimulants and injections of camphorated oil view. But such an ideal devotion to service can exist only and ether. The patient became worse. The pulse could be among the free ; it cannot be attained as the result of a felt only as almost imperceptible waves. The respira- system which, while placing the subject beyond the need or tion was intermittent and spasmodic. The skin was care for the provision of food and shelter and clothing, subcovered with cold perspiration, and the patient showed ordinates him to restriction and control by others necessarily M. Lambret could not arrive before less fitted than himself to decide the circumstances and condino signs of sensibility. He immediately anastomosed the right median tions under which his work shall be done. He must be, as the 7.45. cephalic vein of the patient with her husband’s right radial Rev. Mr. Hardie said, a "work-first-man, never a fee-firstartery. He used a circular suture of fine silk and performed man" ; but also he must be an essential-first-man, not a reguAnd this is the more important in that upon end-to-end anastomosis after the method of Carrel. Local
lation-first-man.
632 at is dependent the final characteristic of the ideal practitioner referred to by Mr. Hardie-that of " a strict, almost a stern, disciplinarian." It is rare to find so apt an appreciation of the ideal practitioner of medicine as that of Mr. Hardie, and we welcome it accordingly. -
June lst the names of those they deem worthy of any of the prizes, together with a copy of the work upon which the nomination is based. A candidate may present his own
application.
Dr. Frederick Taylor has been reappointed to represent the London on the General Medical Council.
University of
HEMIPLEGIA IN TYPHOID FEVER. HEMIPLEGIA in typhoid fever is very rare. In an exhaustive article published in 1907 Smithies could tabulate 43 cases from the literature of the subject.1 In the Canadian Medical Association Joicrnal for last December ’Dr. J. IVI. Pearson has recorded the following case. The /patient. a Scandinavian, aged 30 years, was admitted into the Vancouver General Hospital on Sept. 16th, 1911, ’having been ill for a week. The diagnosis of typhoid fever For six days the was confirmed by the Widal reaction. -disease ran a mild course, the temperature gradually ’falling. On the evening of the 22nd he was slightly .delirious, and an involuntary action of the bowels ’occurred. He slept well that night. When he was roused the next morning for nourishment he had difficulty in - swallowing, and two hours later the left arm and leg were found to be paralysed. He was conscious, rational, and .able to speak. On the 25th he took food more easily, and *ihhere was some evidence of returning power in the leg. During this time the temperature had been rising to 104° F. and the pulse to 108. On the 28th a large haemorrhage from the bowel occurred, and during the next two days six others followed. He died on Oct. 3rd, the twenty-fourth day of the illness and the tenth after the onset of the paralysis, having been unconscious for some hours. At the necropsy the usual intestinal signs of typhoid fever were found. The heart was normal. The brain was somewhat flattened over the right parietal region, where also there was slight thickening of the meninges. On section, softening was found involving the greater part of the second and third frontal and ascending parietal convolutions, part of the supra-marginal and angular gyri, and the upper part of the temporo-sphenoidal lobe. ’This area, which was of the size of a small orange, was of a - dirty yellowish-grey colour. There were no cavities. The left side of the brain, basal ganglia, and internal capsule on both sides were normal. The right middle cerebral artery was completely blocked for about an inch after entering the Sylvian fissure. The artery was thickened and its lumen filled with a firm semi-fibrous adherent thrombus. This began at a point beyond the branches going to the anterior perforated spot, and extended a short distance into each of the terminal branches of the artery.
FUNCTIONAL APHONIA :
- only
AT the Seventeenth International Congress of Medicine, rto be held this year in London, the following prizes will be .awarded : (1) The Prix de Moscou, instituted in com,memoration of the Twelfth International Congress, value ;5000 francs, for the best work on medicine or hygiene, or for eminent services rendered to suffering humanity ; (2) the Prix de Paris, commemorating the Thirteenth International ’Congress, value 4000 francs, for a single discovery, or for a collection of original works not dating farther back than ten years, and relating to medicine, surgery, obstetrics, or the anatomical or biological sciences in their applications to medicine ; (3) the Prix de Hongrie, commemorating the :Sixteenth International Congress, value 3000 crowns, for a work in the domain of the medical sciences, which has appeared in the interval between the two Congresses. The Bureau of the Permanent Commission of International .Medical Congresses (10, Hugo de Grootstrat, The Hague, ,Holland) invites the members to forward to it before 1 Journal of the American Medical Association, vol. xlix.,
____
p. 389.
A METHOD OF CURATIVE AND PREVENTATIVE TREATMENT. BY CORTLANDT
MACMAHON, B.A. OXON.,
INSTRUCTOR FOR SPEECH DEFECTS AT ST.
BARTHOLOMEW’S HOSPITAL
AND ETON COLLEGE.
THE treatment of aphonia by the method herein described as the title suggests, applicable to cases in which, whatever the original cause of the loss of voice, the non-return of the voice is entirely due to functional causes. The treatment is not advanced to take precedence of intralaryngeal faradism in hysterical and neurotic subjects, but it is especially advocated for stubborn and long-standing cases which have hitherto failed to yield to ordinary treatment. In considering what may be termed the vocal treatment of functional aphonia one may usefully consider what really constitutes the phenomenon, Voice. Voice is air vibrating in the resonating chambers of the body, and these resonating chambers consist of the thorax, the larynx, and the pharynx, the nasal and oral cavities, the ethmoidal and sphenoidal sinuses, the maxillary antra, and the frontal sinuses. In a normal voice these resonating chambers are able successfully to carry out their function of amplifying the minute tone and pitch originating in the larynx caused by the due approximation and requisite tension of the vocal cords. In aphonia there is no adequate approximation of the vocal cords, and consequently no vibration ; the resonating chambers are accordingly rendered inoperative, and what speech is audible is produced mainly by friction caused by the ascending air column being passed through a constricted throat and then articulated. In dealing with cases of aphonia the first thing to be acquired is the ascent of a definite and adequate air column which can be passed at will through the larynx. This is brought about by teaching the patient to acquire a marked inferior lateral costal expansion during inspiration, great care being taken that while this is being attained there is no protrusion of the abdominal wall; then, when the lungs can be properly filled, the second movement, consisting of the strong and deliberate contraction of the abdominal muscles, must be taught. The action of the abdominal muscles, when in contraction;, is to pull downwards and inwards the lower ribs and to bring about the very definite ascent of the diaphragm by pressure on the abdominal viscera ; as a result of which movement, as a whole, the internal thoracic capacity is reduced at will and the force and quantity of the ascending air column easily controlled. Having acquired a definite air column the next step is to turn the patient’s mind to the lips. The orbicular muscle must be made to move as freely as possible, and the patient must be told that when the voice is to be produced it must, This free-lip movement, as it were, be lifted into the lips. combined with the ascent of an adequate air column, will automatically help to get rid of the constriction of the muscles above the larynx, and will leave the soft palate free to perform its function of properly apportioning the ascending air column into the nasal and oral cavities when
is,
phonation again occurs. A short digression is
now necessary so that the science of the resonators may be very briefly explained. When vocalisation is occurring there are six vowel sounds or " resonators " which are brought into use. They are "oo," oh, "aw,""ah," " a,"and "eye. They are used alone in words, as,’for example, "00" in° droop " and eye " in " deep,"or they are used in combination as "all"" and " 00"in"sound,""aw"and ee"in "boy," "ah" and "ee"in"my,""oh"and" 00"in "road," and so on. Two of them, "ah"and ee,"are also used sub" ordinately. For instance, the word "love " is on the ah
resonator, "little"" is
on
the "ee"" resonator.
These six