Acute Obstruction of the Bowels. which he could retain a teaspoonful of beef tea occasionally. We abandoned all other REPORT OF A CASE TREATED BY HYPODERMIC medicines and commenced the hypodermic in INJECTIONS OF MORPHINE. Read before the Central Branch Medical Association at Greenleaf, Ks., June 5, 1890. BY M. A. BRAWLEY, M. D., OF FRANKFORT, KS. jections of sulph. morphia, which was given as follows: August 19, 3:40 a. m., % gr.; 7;30 a. m., gr.; 1:00 p. m., % gr.; 4:15, p. m., % gr.; 7:30, p. m., % gr.; 9:55, p. m., % gr. August 20, 12:45, a. m., % gr.; 3:15, a. m., 16 gr.; 6:10, a. m., % gr.; 9:15, a. m., % gr.; 12:10, p. m., % gr.; 3 p. m., % gr.; 6:20, p. m., 1⁄2 gr.; 9:20, p. m., % gr. August 25, 1:05 a. m., % gr.; 3:20, a. m., 泊 gr.; 6:10, a. m., % gr.; 9:15, a. m., % gr. 1:25 p. m., % gr.; 4 p. m., % gr.; 7:35, p. m., 18 gr.; 10:50, p. m., 4 gr. August 23, 1:45 a. m., 1% gr.; 4:23 a. m., 1/4 gr.; 10:15, a. m., % gr.; 1:15, p. m., % gr.; 5:25, p. m., % gr.; 10:00 p. m., 1/4 gr. On the 19th day of August, 1889, I was called in consultation to see Robert T August 21, 12:05, a. m., % gr.; 3:20, a. m., % age 13, who was suffering with a very severe % gr.; 6:25, pain in the bowels. On examination I found gr.; 10:35, a m., 8 gr.; 3.05, p. m., p. m., % gr.; 9:05, p. m., % gr.; 11, p. m., 18 the following condition: Three days previous gr. the patient had been suddenly seized with an intense pain in the right iliac region, accompanied with a strong but ineffectual desire for a movement of the bowels. Constant nausea and vomiting, intense thirst, dry, parched tongue, fever at 103°, pulse 120 and weak, retention of urine and tympanites. The patient was lying on his right side with his legs drawn up, and suffered great pain from the lightest abdominal manipulation. On inquiry I learned 8; 12:15 p. m., % gr.: 4:45 p. m., 1⁄2 gr.; 7:30 the following facts: A few months previous P. m., 8 gr.; 11:20, p. m., 1⁄2 gr. the patient had been thrown from a horse and made complaint then of a pain in his bowels for a few days. At the commencement of the present sickness the attending physician had resorted to the free use of cathartics without obtaining any movement of the bowels, and for twenty-four hours preceding my seeing the case, had been using large rectal injections of water every two hours with no effect. August 24, 3:15 a. m., % gr.; 8:45 a. m., % gr.; % % August 25, 10:10 a. m., 1⁄4 gr.; 1:00 p. m., 8; 4:50, p. m., 8 gr.; 8:20 p. m., % gr. August 26, 1:00 a. m., % gr.; 10:20 a. m., 18 gr.; % Such, gentlemen, was the condition of the case when I first saw it, and I will say here that I have never yet seen a face whose every line and feature expressed more agony and suffering than that boy's. My diagnosis was acute obstruction of the bowels, and for the satisfaction of the family as well as to furnish myself with an answer to the ever inquisitive friends, I said the trouble was doubtless induced by the boy's fall from the horse. Now as to the treatment: A three grain antifebrin powder was given every four or five hours, if fever exceded 1021⁄2°. To allay thirst he was given cracked ice. He took no nourishment for the first three days, after 3:00 p. m., 8 gr.; 9:40 p. m., % gr. The bowels moved at 11 o'clock p. m. on August 26, without much pain, following an injection of a pint of sweet oil. The patient made steady improvement till August 31, when he got up and ate some fruit which had been carelessly left in the room. This indulgence was followed by a renewal of the abdominal pain, at the first return of which the hypodermic injections were commenced again, being given as follows: August 31, 6:30 p. m., % gr.; 8:00 p. m., gr.; 10;20 p. m., 4 gr. September 1, 3:05 a. m., 4 gr.; 8:30 a. m., 4 gr.; 4:00 p. m., 4 gr.; 6:05 p m., 1/4 gr. September 5, 1:15 a. m., % gr.; 5:12 a. m., 16 gr.; 1:45 p. m., % gr.; 5:20 p. m., % gr.; 9:10 p. m., % gr. September 3, 12:35 a. m., % gr.; 6:00 a. m., gr.; 1:40 p. m., % gr.; 5:25 p. m., 1⁄2 gr.; 8:30 p. m., % gr.; 10:15 p. m., 4 gr. September 4, 1% gr. 1:40 a. m., 4 gr.; 5:00 a. m., Shortly after the last injection the bowels jected to the operation on the ground that the moved of their own accord. child had recovered and would never have A tedious convalescence of some six weeks epilepsy, or other manifestation of the cerebral terminated in a full return to health. Most of the time when the patient was under the influence of morphine sufficient to relieve the pain, his respirations were down to between eight and twelve, and his pulse between forty and fifty. injury. Such manifestations, however, did appear, and she has needed the constant care of her mother, while her mind has not developed to any extent. The parents now applied to me for treatment, owing to the fact that she was becom I gave an occasional injection of 12 of a ing, each year, more and more vicious in her grain of atropia. I make this report not for the novelty of the case, but simply because I was fortunate enough to have efficient nurses in attendance who followed instructions exactly, and whose record of the case was perfect, thereby making this valuable for any one who may have a like case in the future, and who may have any doubt as to dose and frequency of the use of hypodermic injections of morphine. habits. She had a few severe epileptic seizures, and many times each day, attacks of petit mal. A paralysis of the muscles of the opposite or left side followed the injury, and on exam-. ination a depression was found over the right side of the skull, beginning on the anterior border of the parietal bone above the temporal ridge, and extending backward and downward in a curved direction, to the posterior inferior angle of the same bone. The deepest part of A Case of Trephining for Epilepsy and Im the depression was found just below the pari becility. Read before the Eastern Kansas District Medical Society at Leavenworth, Kansas., July S, 1890. etal eminence. I called in consultation Prof. W. S. Lindsay, who made a careful and systematic examination, and he has furnished the following report: "In consultation with Dr. McClintock on BY J. C. M'CLINTOCK, PROFESSOR of surgERY March 22, 1890, I saw Anna Richey, aged nine M'CLINTOCK AND CLINICAL SURGERY IN THE KANSAS MEDICAL COLLEGE. years, who had the following history: Seven years prior she had sustained a fracture of the skull by falling about eighteen feet, lighting The patient, Anna Richey, nine years of on a board walk, from the effects of which she age, has a history as follows: When two years of age, she was playing on the portico of the State Capitol building in Topeka, from which she fell to a wooden sidewalk below, a distance of eighteen feet, striking on the right side of the head, causing an extensive fracture with depression of the skull. was comatose several hours, but from which she recovered with nervous disturbances. "I learned that she had had several epileptic attacks during the seven years, and had become destructive and difficult to manage. Her manner was that of a child of three or four years of age. She had learned some things from books, but was not able to study or engage in a coherent conversation. There was paralysis of the left side of the body, and inability to walk steadily. Several physicians, members of the legislature then in session, were summoned, and later the physician in charge objected to the advice of the other physicians, which was that the depressed skull should be raised. His objections were first based on the ground that death was inevitable, after such a severe fracture as existed in this case, and that, "When we take into account that epilepsy therefore, it would be worse than useless to was increasing, and likely to result in impairattempt any such procedure. Later, he ob- ment of the mind, thus rendering the girl a "I recommended trephining of the skull, which was done two days later by Dr. McClintock. great charge on her parents, the operation was ing the scalp, and the patient returned to her warranted, even though she may not regain bed, where she was secured by having each perfect use of her limbs and complete restoration to mental vigor. "It will, of course, be necessary for her mental powers to develop, since at this early age she knew but little. "I understand from the family that she is very much improved in every way since her recovery from the operation." I advised the operation of trephining for the removal of the depressed portion of the bone, and obtained the consent of the parents to such a procedure. As the child became worse all the time, they were anxious to try anything that offered any prospect of relief. Accordingly the child was placed in Christ's Hospital, the head shaved, well washed, and a compress, wet in a 1 to 2000 solution of bichloride of mercury, was applied for twentyfour hours previous to the operation. With the assistance of Drs. W. S. Lindsay, M. B. Ward, J. W. Donaldson and R. S. Magee, the operation was performed by raising a curved flap and exposing all of the depressed part of the bone. At the place of the deepest depression there was an absence of bone. This part was bridged across by a tough, fibrous membrane which, on being opened, gave exit to quite a large quantity of cerebral fluid. The trephine was then applied, and two buttons of bone removed. Their under surfaces were very rough and uneven, and at the side of the deepest depression a piece of bone, with a long, needle-like process was found imbedded in the brain substance to a depth of at least half an inch. This had evidently been a large piece of bone which had partly disappeared by absorption, until only this much was left. extremity tied to the bed rail, and a nurse detailed to hold the head. This was necessary because the child was entirely uncontrollable, and she would undoubtedly have injured herself if left free, especially with the clamp in the wound. The patient did well all day, but during the night an elevation of temperature occurred which rose to 105° Farenheit. In the morning the dressing was removed, the clamp and the drainage tube were taken from the wound, the wound washed out, and a dressing re-applied. From this time on the temperature fell until the next day it reached 100° and after this became normal, and so remained until the healing was complete, which was within ten days. In another week the patient was taken to her home in an adjoining county. Union by first intention occurred at all points, except that point which gave exit to the tube and clamp. While open, the wound gave exit to quite a large amount of cerebral fluid, requiring an abundant quantity of absorbant cotton in the dressing, and this was changed every twenty-four hours, of necessity. The patient was liberated as soon as the clamp was removed, took nourishment, became more tractable, and in less than two weeks from the time of the operation an improvement was noticed in the paralyzed muscles, as well as in the mental condition of the child, which improvement the parents and friends have informed me has continued to the present, time. This case should, undoubtedly, have been operated upon at the time of the injury or soon after. It was wise, probably, to wait until the recovery from the injury was assured, before attempting elevation of the depressed portion of the skull, rather than to add the effects of the operation to the existing shock. An early operation would probably have avoided the cerebral and other manifestations of the injury presented in the history of the The remainder of the depressed or roughened and splintered bone was removed by the Rongeur forceps. A branch of the middle meningeal artery was cut during the operation, and gave rise to troublesome hemorrhage. Several unsuccessful attempts were made to tie it, but each time the vessel was cut into by the least force in applying the ligature. It case. Any functional derangements would was finally clamped, and the clamp left in situ, alongside of which was placed a drainage tube. An antiseptic dressing was applied after sutur easily have been corrected at an early day, whereas, if allowed to continue, the abnormal cell action becomes almost a normal action in that case, and its correction problematical in SOCIETY PROCEEDINGS. the future. Cells respond to a certain stimulus, and to that stimulus a second time more Topeka Academy of Medicine and Surgery. readily than the first, and after a time the habitual repetition of the same process renders the action very easy, and whether that action be a normal or an abnormal one, the habit is established, and as time goes on its change becomes more and more difficult. This is as true in the brain as in any other part of the body. Abnormal operations of the mind are difficult to change in a ease such as we have reported to-day, where the trouble has continued so long, hence the prospect for the ultimate recovery of this case is not so bright as if the operation had been done soon after the injury. I say a recovery; this is not the proper term, for we cannot speak of the recovery and restoration of a mind which was in a degree lost in a babe of only two years of age. In reality, if this child is improved as a result of the operation, it will be by a process of education-a building up of a new mind, and, what is more difficult, the unlearning of all she has heretofore learned. This will be the most difficult part of her training, for the cells have formed the habit of acting in a certain manner; that manner cannot easily be changed. It is too early now to report this case as one of cure, for although there have been no returns of the epileptic seizures, still we know that they frequently do not return for some time after many operations. The case will, however, be watched, and its future progress reported. The Topeka Academy of Medicine and Surgery met in regular monthly session at Lincoln Post hall, Tuesday evening, August 5, president Dr. L. H. Munn in the chair. There were present Drs. Hogeboom, Wall, Donaldson, Longshore, Righter, Cazier, W. E. McVey, McGuire, Magee, Gibson, Minney, Bradley, Peers, Alexander, Lindsay, Stewart, Chapman, Ward, Messrs. McClintock, Gilbert and Boettger, the latter from Wilwaukee, Wis. Dr. C. H. Guibor was elected to member ship. Dr. D. F. Rodgers presented a case of aphasia in a little girl of seven years, who also had some mental peculiarities. The object in bringing the girl before the academy, aside from the interest in the case, was to determine whether she should be admitted to the deaf and dumb asylum, or the asylum for feeble minded children. A committee consisting of Drs. Lindsay, Peers and Alexander was appointed to examine the case and report. In addition to the examination by the committee, most of the physicians present examined the case. The conclusion reached was that the girl should be sent to the asylum for feeble to the deaf and dumb asylum. minded, as she was too young for admission Dr. W. S. Lindsay read a paper on hypnoit has been practiced, the early history and tism, giving the different names under which the present status of its uses. Thought it worthy of some thought and investigation, for the possible good that might be derived therefrom, but did not think it worthy of general practical application, and said it should be under the control of honest, conscientious physicians. Spoke of its dangers and the advantages taken of even what virtue there might be in it, by charlatans. Dr. Longshore was inclined to the belief that there was a great deal of deception practiced in its use. Spoke of a lady who made a practice of attempting to relieve pain in labor, but when a hot cloth was placed to the patient's back the hypnotist lost her power. Dr. Peers said it was a question who were able to produce hypnotism. Had seen nothing of it except stage exhibitions. Judging from tize have no special magnetism. Thinks any what he had read, it could be used in minor one who studies and practices can do it. surgery. Every one has an individuality that Strong persons are as susceptible as nervous makes them offer resistance. Was not able to ones. Insane persons can hardly be hypnosay what harm it would do to the mind. tized. Hysterical persons susceptible. Adjourned to meet the first Tuesday evenD. H. RODGERS, M. D., Secretary. Dr. Magee does not think the hypnotist has ing in September. any special gift, it lies in practice. Dr. Minney witnessed the hypnotising of a Swede by Dr. Axtel at a meeting of the Southern Kansas medical society. After the Swede was hypnotized, the doctor pricked him with a scalpel without pain. The doctor had the patient perform other feats. which if no malingering on the part of the patient were remarkable. Is persuaded that concentration to exhaustion is necessary, and that is liable to produce serious trouble with the brain. Thinks hypnotism should be practiced only by the physician. Dr. Ward.—It is a very dangerous proceeding. Every physician has more or less influence in that direction. Thinks every physician should have the fullest confidence of his patients, and whenever we do not have their confidence we cannot expect to do them much good, and it would be better to have some other physician treat them. Mechanical hypnotism is harmful. Dr. Stewart said mesmeric experiments in France were suppressed years ago by the authorities on account of insanity, etc., following. Spoke of the ill results on the cases operated upon in Vassar. Charcot says very few persons can hypnotize and few can stand the effect. Charcot exhibited a person who had been operated upon frequently, and the result was imbecility. Dr. Wall.-Persons with normal or even strong organizations can be hypnotized. Not necessary that they be of weak or over-susceptible. As a therapeutic measure we have other remedies more effective. Dr. Stewart said there was danger to the operator as well as the patient. Related the case of a physician who died from the strain on the nervous system. Thought suspension from concentration not being the same as exhaustion or tiring out. Labette County Medical Society. The Labette County Medical Society held its first annual meeting at Parsons, Thursday, August 7, the physicians present being Drs. E. E. Leggett and Hill, of Oswego; F. J. Smith, of Dennis; L. L. Wheeler, of Montana; and Drs. Kleiser, Rockhold, Maser, Gabriel and Harvey, of Parsons. A larger gathering was expected, but sickness in their own families and other professional business kept away many who would otherwise have attended. A paper on the use of "Ichthyol" in skin diseases was read by Dr. E. E. Leggett, of Oswego, and referred by consent for publication. Dr. McEwen, of Mound Valley, who was to have read a paper on salol in the treatment of summer diseases of children, was prevented from attending on account of the serious sickness of one of his children, so his per was laid over to the next meeting, when he and Dr. Harvey were appointed to prepare papers for that occasion. The question of how best to treat the summer diseases of infants and young children was fully discussed, each giving the treatment which in the past ten years has been found to give the best results. pa The question for discussion at the next. quarterly meeting in November will be, "How to best treat pneumonia." The society now numbers sixteen members and has applied for a charter; a president, secretary and a board of nine directors having been elected. The president for the coming president is Dr. J. B. Hill, of Oswego, and the year is Dr. Harvey, of Parsons; the vicesecretary is Dr. E. E. Leggett, of the same city, and the board of directors are Drs. Kleiser and Harvey of Parsons, Geo. and E. E. Leggett of Oswego, G. D. Boon of Chetopa, Wheeler of Montana, C. W. Campbell and J. W. W. McEwen of Mound Valley, L. L. W. Henderson of Labette City. The place of business will be Parsons, and the quarterly meetings will be held in accordDr. Lindsey spoke of the inhibitory influ-ance with the vote of its members. It is earnestly hoped that all responsible physicians of ence on the rest of the brain. The effort not the county will join in this society. Persons who hypnoDR. E. LEGGETT, Secretary. the same as exhaustion. |