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THE TREATMENT OF STRABISMUS.
254 Unlike hæmorrhage, perforation demands the permanent suspension of bathing, and there can be no doubt that Dr. Caiger is right in stating that laparotomy, and laparotomy at the earliest possible moment, is in almost all cases the only correct procedure. Writing in 1897 I said:’ "There can be little doubt that the treatment of perforation, in hospitals at any rate, will in future be mainly by laparotomy ; and that those hospitals in which the routine treatment is by systematic cold bathing will provide by far the largest supply of sicitable cases for this operation." The reason for this is clear. "Systematic bathing ...... has so altered the symptoms of this accident and rendered so certain the possibility of its immediate diagnosis that the whole question of treatment requires reconsideration. Under expectant treatment the diagnosis is not infrequently impossible at the time. At the Brisbane Hospital up to the end of 1886 it was not uncommon to find perforative peritonitis for the first time in the post-mortem room....... In contrast to this is the experience of the Brisbane Hospital during the first three years ......
as shown in Fig. 2. excellent results.
extremities,
given me
I am,
Paris, Jan. 17th, 1905.
The
operation has already
Sirs, yours faithfully, DR. LANDOLT.
THE PRINCIPLES OF TREATMENT OF PNEUMONIA. To t7te Editors of THE LANCET.
SIRS,-In a rather remarkable address on the Principles of Treatment of Pneumonia, published in THE LANCET of Jan. 21st, p. 138, Dr. W. Ewart lucidly presents his views and his practice as derived from numerous and careful clinical observations and also from certain conceptions as to the pathological processes in the lungs and elsewhere. It is, of course, on this broad basis that all successful treatment must be reared and tested. Regarding the directing of treatment in conformity with what one conceives to be the pathology of the disease, this, though a most laudable ambition, is sometimes hazardous, and should no ill-results of the bath treatment. During this time 34 cases suffered follow, the treatment may be right ; but, on the other perforation, but so clear was the mental condition in all hand, the patient may recover in spite of the treatthese ’patients that in every instance they were able to fix ment. As to the indications for treatment which almost exactly the time of the accident. Not only so, but are supplied by the pathology of pneumonia I venture they were able as a rule to give so significant an account of to notice briefly two of these, both of high importance, the onset, site, and character of the pain, that usually a though differing widely in range. One of them is conpositive diagnosis could be made even before the signs of siderably exploited by Dr. Ewart ; the other is not alluded to peritonitis were apparent." directly in his address but is suggested by his acute obserThe history of many cases was a sudden pain in some vations. That discussed by Dr. Ewart refers to the influence definite part of the abdomen ; later an access of vomiting and import of the fibrinous coagulation in the lungs. He with a concurrent exaggeration of the pain, indicating ex- begins by quoting the opinion of a New York physician to travasation of bowel contents. And it was found that very the effect that "the extensive effusion of fibrin is reallya often the administration of a hypodermic injection of ’ breeding ground’ for the diplococci and this enormous morphia (one-third to one-half grain) immediately after the supply of pabulum is the explanation for the overwhelming commencement of the pain was capable of deferring the amount of poison manufactured by them in the lung and onset of vomiting for some hours. That is the opportunity thrown into the circulation." Then, in discussing the for laparotomy in my opinion. principles of action, Dr. Ewart advocates " defibrination," I am, Sirs, yours faithfully, observing that two discourage the local consolidation by FRANCIS EVERARD HARE, M.D. diminishing the supply of fibrin factors is the end towards which our treatment and diet are made to converge." Further on it is explained that the consolidation is dhecked by administering citric acid, a precipitant of THE TREATMENT OF STRABISMUS. calcium which is essential to clotting. Other measures to this end are also advocated, including the possibility of To the Editors of THE LANCET. impairing the solidification of the fibrin by withholding salt SIRS,-As the brief account of my operation for strabismus, from the diet in view of the fact that the fibrinous exudation which appeared in THE, LANCET of Jan. 7th, p. 61, is not is rich in sodium chloride. In studying the pathology of this disease for several years sufficiently clear to prevent the possibility of misinterpretation, I should like to supplement it by a few remarks of nothing more strongly impressed itself on my mind than the view that the pneumonic consolidation is nature’s method of my own. My principal object is to replace as much as possible localising the morbid process and of curing the disease. tenotomy by the "advancement" of the muscles in the The statement quoted by Dr. Ewart as to the fibrinous operation for all imperfections of the motility of the eyes exudate forming a breeding ground for the pneumococcus (paralytic as well as concomitant squint, insufficiency, &c.). belongs to the realm of fancy and is neither scientifically During last year I performed 100 "advancements,"always correct nor borne out by actual observation. In the first with very good results, but in the same period I performed place, the fibrinous exudate is dead, in a state of coagulation necrosis, and so does not offer a suitable pabulum for only two tenotomies. There are some rare cases of convergent strabismus of the micro-organism. The organisms, imprisoned in this rigid very old standing, with strong contracture (not contraction) dead substance, behave as they do in certain artificial and marked alteration of the structure of the internus muscle. media-viz., secrete an acid which quickly inhibits their vitality and their virulence. Some have supposed that FIG. 2. FIG. 1. this acid in the pneumonic lung is secreted by the pulmonary tissues and have termed it pneumic acid, but when engaged a few years ago in a research on this subject I extracted from pneumonic lungs an acid giving identical reactions to that obtained in artificial In examining microscopically sections of pneucultures. monic lung in various stages of hepatisation I have been struck with the absence of active growth of pneumococci within the alveoli. Moreover, in cases of pneumococcus Muscle advanced and sutured. Lines of incision in muscle. infection showing little or no tendency to pulmonary hepaThe x, y, Gap in muscle. a, b, Points of suture. tisation ; when the pneumococci run riot in the organism remaining letters signify the i, Insertion of muscle. same as in Fig. 1. so to speak, the result is always grave and, indeed, generally fatal. Consolidation is doubtless the natural and wholeA surgical operation on this muscle seems to be admissible, some reaction of the tissues to the disease, and though simultaneously with "advancement"of the opposing muscle. any attempt to modify the virulence of the organism and in Only, instead of setting back the shortened"- internus by a this way limit the extent of the consolidation is not only tenotomy, I propose to preserve its normal insertion on the justifiable but the object most to be desired, yet any intereyeball and to lengthen it by a special procedure. The new ference directly, as by drugs, with the normal deposition of operation consists in severing the muscle so that t1iè divided I fibrin is, according to the view here propounded, simply to extremities are left somewhat in the form of steps of a stair, direct one’s weapons against the vis medicatrix naturæ. as shown in Fig. 1, and lengthening it by uniting these The other topic suggested by Dr. Ewart’s address refers t’o the scientific treatment of this affection in accord5 The Cold-bath Treatment of Typhoid Fever, F. E. Hare, 1898, ancedefinitely with certain recent discoveries.. Alluding to the objects pp. 186 et seq.
as shown in Fig. 2. excellent results.
extremities,
given me
I am,
Paris, Jan. 17th, 1905.
The
operation has already
Sirs, yours faithfully, DR. LANDOLT.
THE PRINCIPLES OF TREATMENT OF PNEUMONIA. To t7te Editors of THE LANCET.
SIRS,-In a rather remarkable address on the Principles of Treatment of Pneumonia, published in THE LANCET of Jan. 21st, p. 138, Dr. W. Ewart lucidly presents his views and his practice as derived from numerous and careful clinical observations and also from certain conceptions as to the pathological processes in the lungs and elsewhere. It is, of course, on this broad basis that all successful treatment must be reared and tested. Regarding the directing of treatment in conformity with what one conceives to be the pathology of the disease, this, though a most laudable ambition, is sometimes hazardous, and should no ill-results of the bath treatment. During this time 34 cases suffered follow, the treatment may be right ; but, on the other perforation, but so clear was the mental condition in all hand, the patient may recover in spite of the treatthese ’patients that in every instance they were able to fix ment. As to the indications for treatment which almost exactly the time of the accident. Not only so, but are supplied by the pathology of pneumonia I venture they were able as a rule to give so significant an account of to notice briefly two of these, both of high importance, the onset, site, and character of the pain, that usually a though differing widely in range. One of them is conpositive diagnosis could be made even before the signs of siderably exploited by Dr. Ewart ; the other is not alluded to peritonitis were apparent." directly in his address but is suggested by his acute obserThe history of many cases was a sudden pain in some vations. That discussed by Dr. Ewart refers to the influence definite part of the abdomen ; later an access of vomiting and import of the fibrinous coagulation in the lungs. He with a concurrent exaggeration of the pain, indicating ex- begins by quoting the opinion of a New York physician to travasation of bowel contents. And it was found that very the effect that "the extensive effusion of fibrin is reallya often the administration of a hypodermic injection of ’ breeding ground’ for the diplococci and this enormous morphia (one-third to one-half grain) immediately after the supply of pabulum is the explanation for the overwhelming commencement of the pain was capable of deferring the amount of poison manufactured by them in the lung and onset of vomiting for some hours. That is the opportunity thrown into the circulation." Then, in discussing the for laparotomy in my opinion. principles of action, Dr. Ewart advocates " defibrination," I am, Sirs, yours faithfully, observing that two discourage the local consolidation by FRANCIS EVERARD HARE, M.D. diminishing the supply of fibrin factors is the end towards which our treatment and diet are made to converge." Further on it is explained that the consolidation is dhecked by administering citric acid, a precipitant of THE TREATMENT OF STRABISMUS. calcium which is essential to clotting. Other measures to this end are also advocated, including the possibility of To the Editors of THE LANCET. impairing the solidification of the fibrin by withholding salt SIRS,-As the brief account of my operation for strabismus, from the diet in view of the fact that the fibrinous exudation which appeared in THE, LANCET of Jan. 7th, p. 61, is not is rich in sodium chloride. In studying the pathology of this disease for several years sufficiently clear to prevent the possibility of misinterpretation, I should like to supplement it by a few remarks of nothing more strongly impressed itself on my mind than the view that the pneumonic consolidation is nature’s method of my own. My principal object is to replace as much as possible localising the morbid process and of curing the disease. tenotomy by the "advancement" of the muscles in the The statement quoted by Dr. Ewart as to the fibrinous operation for all imperfections of the motility of the eyes exudate forming a breeding ground for the pneumococcus (paralytic as well as concomitant squint, insufficiency, &c.). belongs to the realm of fancy and is neither scientifically During last year I performed 100 "advancements,"always correct nor borne out by actual observation. In the first with very good results, but in the same period I performed place, the fibrinous exudate is dead, in a state of coagulation necrosis, and so does not offer a suitable pabulum for only two tenotomies. There are some rare cases of convergent strabismus of the micro-organism. The organisms, imprisoned in this rigid very old standing, with strong contracture (not contraction) dead substance, behave as they do in certain artificial and marked alteration of the structure of the internus muscle. media-viz., secrete an acid which quickly inhibits their vitality and their virulence. Some have supposed that FIG. 2. FIG. 1. this acid in the pneumonic lung is secreted by the pulmonary tissues and have termed it pneumic acid, but when engaged a few years ago in a research on this subject I extracted from pneumonic lungs an acid giving identical reactions to that obtained in artificial In examining microscopically sections of pneucultures. monic lung in various stages of hepatisation I have been struck with the absence of active growth of pneumococci within the alveoli. Moreover, in cases of pneumococcus Muscle advanced and sutured. Lines of incision in muscle. infection showing little or no tendency to pulmonary hepaThe x, y, Gap in muscle. a, b, Points of suture. tisation ; when the pneumococci run riot in the organism remaining letters signify the i, Insertion of muscle. same as in Fig. 1. so to speak, the result is always grave and, indeed, generally fatal. Consolidation is doubtless the natural and wholeA surgical operation on this muscle seems to be admissible, some reaction of the tissues to the disease, and though simultaneously with "advancement"of the opposing muscle. any attempt to modify the virulence of the organism and in Only, instead of setting back the shortened"- internus by a this way limit the extent of the consolidation is not only tenotomy, I propose to preserve its normal insertion on the justifiable but the object most to be desired, yet any intereyeball and to lengthen it by a special procedure. The new ference directly, as by drugs, with the normal deposition of operation consists in severing the muscle so that t1iè divided I fibrin is, according to the view here propounded, simply to extremities are left somewhat in the form of steps of a stair, direct one’s weapons against the vis medicatrix naturæ. as shown in Fig. 1, and lengthening it by uniting these The other topic suggested by Dr. Ewart’s address refers t’o the scientific treatment of this affection in accord5 The Cold-bath Treatment of Typhoid Fever, F. E. Hare, 1898, ancedefinitely with certain recent discoveries.. Alluding to the objects pp. 186 et seq.