Report on Progress in Surgery

H. L. BURRELL, H. W. CUSHING
1887 Boston Medical and Surgical Journal  
blunt or remove the perception of the pain. This I hold to be a mistake, as the irritation of the bowel is injurious iu many cases and the pain should be the signal that such is the case. The irritation is just as bad for the bowel, even when the pain is not allowed to manifest itself. Most laxatives have a secondary, constipating effect, necessitating an increase of the dose or a change to some other drug. This is not the case with cascara, as the usual method of giving it is to diminish the
more » ... s to diminish the dose after a few days. What is its effect on the digestive system ? Its use does not impair the appetite or digestion, but, on the contrary, increases the appetite and promotes digestion. On the intestine it seems to have a tonic action and is particularly adapted to conditions of atony of the stomach and bowels. The stools caused by it are soft, or semi-solid and not watery, unless too large a dose has been taken. I have also found it of good service in the treatment of haemorrhoids, by relieving the congestion and causing a soft, painless stool. It seems to have a beneficial effect apart from and in addition to its laxative effect in these cases as well as in some cases of fissure. The following is a good illustration : Mrs. F., aged thirty-one, mother of five children, had always suffered from constipation and piles, particularly after labor, and had never found anything to relieve her. I attended her in a difficult labor with breech presentation. She had very marked haemorrhoids, which caused her so much trouble after labor that she could not sit on a chair, and every movement was painful. She obtained entire relief by using cascara in twentydrop doses of the fluid extract, four times á day for three days. The importance and at the same time the difficulty of regulating the bowels in gynecological cases is well recognized, but my experience with cascara in such cases leads me to give it the highest rank. I have notes of its very satisfactory use in several cases of endometritis, large uterine fibroids, flexions and versions, large and tender ovaries, one case of retroflexed pregnant uterus requiring forcible reposition, and a number where there were tender places and bauds in Douglas's pouch, readily felt per rectum. According to my experience, the cases for which cascara is particularly adapted are the chronic cases and especially those with weak and atonic digestive organs. For such patients it is far superior to rhubarb, senna, aloes, licorice powder and the usual laxatives, either alone or in their various combinations. For acute cases its peculiar qualities are not so much required, although it generally acts promptly, surely, and without secondary constipating effect. I have generally used the fluid extract, for several reasons. It is an active and reliable preparation, the dose is small and can be easily regulated by increasing or diminishing the number of drops taken at a time. The taste is bitter, to which some object, while others find it not unpleasant. To the latter it can be given in water or with equal parts of glycerine in water. Most of the substances supposed to disguise the taste only add a sweet to a bitter and the combination is to many worse than either alone. I should say that the fluid extract of licorice, is perhaps, as good an excipient as any. Cascara cordial has an agreeable taste, and is preferred by many. The dose is, of course, larger and is not so easily regulated as the fluid extract. The solid extract is given in pill form, and consequently can be taken without the bitter being tasted. If, however, the dose in each pill proves too large, a new lot with a smaller dose has to be procured, which is a disadvantage as compared with the fluid extract. The dose of the cordial is about a teaspoonful morning and night, or oftener. The solid extract is given in doses of two grains or less, three times a day. The dose of the fluid extract is from five to twenty-five drops, and I generally order it to be taken as follows: If the case is of long standing and one in which many drugs have been tried, I direct ten or fifteen drops to be taken in water before each meal and at night. If that does not cause one soft dejection a day, in two or three days I increase the dose to twenty-five drops four times a day, and tell the patient to take sufficient to have one dejection a day. Then in a few days, at any rate, or immediately, if he has more than one stool, a day, he is to diminish the dose from thirty to twenty-five, twenty or fifteen drops, butahvavs enough for one soft stool a day. It is better to diminish the quantity taken at a time than to lessen the number of times. It will be found that five or ten drops at night often prove sufficient. It is well to omit the medicine from time to time and it can frequently be dispensed with altogether. If necessary to resume it, let only the amount be taken that was previously found to be sufficient. -•case of transverse fracture of the right patella, treated in the following manner : A sailor, aged twenty-two, sustained a fracture of the right femur, and a transverse fracture of the right patella. Result: union of femur, with seven centimeters shortening (subsequently relieved by osteotomy) ; non-union of patella. On failure to approximate the fragments during an attempt to suture them together, Von Bergmann made a curved incision around the tuberositas tibiae, and chiselled obliquely through the bone, from below, anteriorly upwards and backwards into the joint. He then, by pushing up the fragment, united the patella. Bony union subsequently united the tibia} fragment. The patieat, when shown about sixteen months after the operation, is reported as walking well, but the motion of the right kuee is quite limited. TAUBER'S AMPUTATION AT THE ANKLE-JOINT. Professor Tauber, of St. Petersburg,21 has demonstrated his operation, which is a modification of Pirogoff's. " He begins an incision at the attachment of the tendo Achillis, and carries the knife forward, below the external malleolus, to the Chopart's line, and then across to the dorsum of the foot. On having reached the middle line on the plantar surface, the knife is carried backward to the heel, and then upward to the starting point. " In this first stage of the operation, Dr. Tauber cuts the skin and other soft tissues to the bone. In the 1
doi:10.1056/nejm188710271171704 fatcat:oi5o7xt3h5fynhjir7k2vum4fi