As the result of personal experience and of studying the reports of recorded cases, I am lead to the following conclusions: Ist. The simple fact that a penetrating gun-shot wound of the abdomen has been received, does not justify laparotomy, unless other unequivocal symptoms of intestinal perforation or hemorrhage are present. 2d. Small pistol wounds do not demand laparotomy. 3d. Wounds of the back or side are not to be treated by abdominal section, until it is positively certain that perforation has occurred, as it is impossible in many cases to tell what abdominal viscera have been injured, and it would be useless to open the belly for wounds of the liver or other large solid organs, to say nothing of the probability of finding the injury confined to the soft parts, spinal column, etc. 4th. All penetrating wounds from fire-arms of large size, inflicted upon the front of the abdomen, in which it is highly probable that the small intestines have been lacerated, demand exploratory incision, suturing of holes, and ligature of bleeding vessels. 5. Cases in which the nature of injury is doubtful, are best treated by large doses of opium, and rigid abstinence from food for several days. DISCUSSION ON DR. WINSLOW'S PAPER, ON PENETRATING GUN SHOT WOUNDS OF ABDOMEN. DR, HARRIS said that he fully approved of the conclusions in this paper, and he reported a case in point where the conservative line of treatment was carried out. DR. J. E. MICHAEL spoke on two of the cases mentioned by Dr. Winslow and still further elucidated them, and reported the case of a man who, in anger, struck the stock of his gun against the ground. It went off and the shot penetrated his abdomen. Peritonitis occurred but he recovered under the conservative treatment. He spoke also of a colored man who was stabbed with a carving knife in the left side over the spleen. The symptoms showed that internal hemorrhage was going on. The patient died and the autopsy showed that the spleen had been cut, and that the bleeding had come from its vessels. In the light of the autopsy, it seems that he might have made an exploratory incision. He would have had to ligate the vessels and extirpate the spleen. The strong probabilities were that the patient would have died, and the law would have been unable to ascertain who had killed him. DR. BRANHAM said there was another side to the question; and reported a case that died from a gun-shot wound. The autopsy revealed that the colon only had been perforated, the shot having gone through to the skin at the back. In this case had laparotomy been done the patient might have been saved. DR. MICHAEL. That was a diagnosis from the autopsy. Such precision is impossible during life. The operation in question is a very serious one, especially in a hospital, and should not be undertaken unless there is very clear evidence that it is required. DR. BRANHAM said the position of the wound in the case he referred to, and the concomitant symptoms were such as to point to the true state of the case before death. OBSERVATIONS ON THE ORIGIN AND CURE OF THE DISEASE CALLED “HAY ASTHMA" (CORYZA VASOMOTORIA PERIODICA). BY JOHN N. MACKENZIE, M.D., of Baltimore, Md. The therapeutic history of the disease commonly known as "hay fever" fürnishes a striking illustration of the way in which errors in medicine are perpetuated through lazy subscription to prevailing ideas and blind acceptance of the dicta of “authority.” Ignorance of intra nasal pathology on the part of those investigating the complaint, false theories founded on the examination of solitary cases, and especially the so-called pollen theory have, by drawing attention to less essential conditions, not only been insuperable barriers to therapeutic progress in the disease, but have also by the measures based upon them, in no small measure contributed to the sufferings of the unfortunate victims of this complaint. The orthodox treatment of the advocates of the pollen theory is to keep the patient indoors, and, if possible, confined to his room during the hay fever season. He must wear spectacle frames fitted to the orbits and fill his nostrils with cotton. When out of the range of pollen he must remove the tampons from his nasal passages and add a fresh source of distress by the inhalation of irritating powders or snuffs. Apart from innumerable other inconveniences attendant upon such a line of treatment, imagine the tortures of confinement to a closed chamber through the intense heat of our summer months; picture to yourselves the spectacle which the sufferer presents with his eye balls covered with an unsightly apparatus, and his nasal passages stuffed with cotton, uncomfortable and unavailing, as those who have tried it will tell you. The use of snuffs in the nasal passages is a questionable practice under any circumstances, and the general practitioner had better write it down as a law of his practice to be extremely cautious in the use of medicine of any kind in powder form for the relief of nasal affections. But, if there is one thing above all others which contraindicates the use of powders in the nose, it is the exquisitely sensitive condition of the nasal passages during the paroxysms of so-called "hay fever." For not only do they increase the suffering of the patient, but by the excitability of the cavernous tissue which they produce, lay the foundation for future and more aggravated inflammation. Indeed there is no more striking commentary on the inadequacy of the pollen theory than the absolute darkness which it has thrown around the treatment of this disease. Equally untenable is the theory for which Helmholtz has been held responsible that the affection is due to a minute form of animal life, a position for which there is not the slightest foundation in fact. That the disease is one of the protean manifestations of gout is a proposition which rests upon the manifestly insecure foundation, that in a certain proportion of cases a gouty tendency is discernable in the individual. Its alleged almost invariable appearance in the higher walks of life, and notably in those of superior intellectual attainments, together with its assumed absence among inferior races or those low down in the social scale, have been dexterously wrought by Beard into the conception that the affection is the offspring of a higher civilization, the outcome of a hypersensitive nervous organization, the result of the enervating influences of nineteenth century social and intellectual life. As maintained elsewhere, I do not regard this disease as an affection of any particular century or confined to any condition of mankind. Comparatively little is known and written concerning pathological processes among inferior races, and it is quite possible that the territorial limits of some diseases depend less upon local or race peculiarities than upon the geographical distribution of intelligent medical observers. If the affection be in truth due to derangement of the nervous system, the result of education and enervating modes of life, were not these agencies in operation amid the culture and refinement of ancient Greece and the debauching influences of the Imperial City? Since the subject has received careful attention mainly at the hands of English, American and German physicians during the past sixty or seventy years, are we to proceed straightway to the conclusion, that the affection is peculiar to the Anglo-Saxon race and to the nineteenth century? Indeed, in the light of our present knowledge it is inconceivable that 'it made its first appearance at the beginning of the present century. As Dick and afterward Matthew Baillie thought, that in describing their first cases of acute laryngitis they had discovered a new disease, so Bostock in portraying the phenomena of "catarrhus aestivus" was led into a similar error. That certain morbid processes referable to the nasal apparatus such as coryza and asthma, are evoked through so called idiosyncrasy pertaining to individuals or families has been known from the earliest times. The diagnostic acumen of Galen led him to the observation that in certain persons, the presence of various foods is sufficient to excite a coryza, and scattered here and there through the literature of succeeding centuries, isolated cases are found in which similar peculiarities in regard to flowers and other objects are recorded.* The medical scholar may find, too, grounds for the belief that this affection is included in the varieties of periodic coryza and convulsive asthma of the older writers and nosologists. The difference between acute coryza and the aggravated form known as hay cold is only one of degree, and it is therefore not surprising that the older writers should not have resorted, in the state of their knowledge to the nosological refinements which flow from the more advanced pathology of the present day and century. In the days when medical writings were published in the Latin language, the necessity of recording one's observations in a foreign tongue, led to a terseness of style and incompleteness of description which often surrounds with uncertainty the exact nature of the observations recorded; but whether the cases which have descended to us were examples of true hay coryza or not, they may be placed in the same category of affection and the predisposing influences be considered identical with those provocative of the disease called in the present century, rose cold. I do not propose to reiterate on this occasion my views concerning the etiology and pathology of this disease which have been given elsewhere. As stated in a recent communication to the Clinical * In certain individuals or even families this peculiar antipathy or susceptibility to particular flowers or foods takes the form of nose bleed, in others violent purging occurs or even epileptiform convulsions. + Vide. Trans. American Laryngological Association, 1884, p. 113; N. Y. Med. Record, July 19, 1884; A Contribution to the Study of Coryza Vasomotoria Periodica, etc. Ibid Oct. 18, 1884; Coryza Vasomotoria Periodica in the Negro, with Remarks on the Etiology of the Disease; Maryland Med. Journ., April 11, 1885; Abstract of a paper on Rhinitis Sympathetica; Read April 3, at the Clinical Society of Maryland. The second paper contains an historical account of the development of modern views in regard to the pathology and treatment of the affection. |