Society Proceedings
1916
Journal of the American Medical Association
not prescribe for other than the particular patient who employs him and who is to receive the drug follows from the language and import of Sections 4 and 8. Section 4, when it treats of physicians, deals only with the delivery of the drug, and permits its delivery by a person (an individual) only when it has been prescribed or dispensed by a registered physician who has been employed to prescribe for the particu¬ lar patient who is to receive such drug. The law contem¬ plates that there shall
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... no promiscuous or covert passing around of the drug to persons who have not employed the physician and received it on his prescription. The regula¬ tion promulgated by the Treasury Department that a physi¬ cian must be actually absent from his office and in personal attendance on the patient in order to come within the exemp¬ tion of Section 2 (a) accords with the design that a physi¬ cian shall maintain supervision over the patient for whom he prescribes. The department thus places, and the court thinks rightfully so, a more restricted meaning on personal attendance than the courts have placed on medical attend¬ ance-it being held that to constitute the latter it is not requisite that the physician should attend the patient at his home, and that an attendance at his office is sufficient. It is by personal attendance that the greater part of the busi¬ ness of a regularly practicing general practitioner is done. The personal attendance clause, therefore, covers the major¬ ity of all the cases in which the drug is dispensed or dis¬ tributed by such a physician. Its effect is to increase the inconvenience and difficulty, and even the expense, of procur¬ ing the drug. If, instead of personal attendance on the patient by the physician, the patient calls on the physician at his office for treatment, in which event such physician is required to make a record of the drugs mentioned in the act which he dispenses or distributes, the opportunity is afforded of personally diagnosing, studying, supervising and prescrib¬ ing for such patient. If a regularly practicing physician may prescribe without seeing his patient, it is in occasional instances only. a patient has had two or three distinct attacks, for a delay often means serious damage not only to the gall passages, but to the neighboring organs as well, such as pancreatitis, bands of adhesions, and other complications necessitating more difficult operative measures, higher mortality, even in the hands of experts, and more likelihood that the patient will not be completely relieved. The Mayos a few years ago were the chief advocates of cholecystostomy. While on a visit to their clinic a short time ago I saw drainage of the gallbladder in only one case, whereas over twenty cases were subjected to complete removal of the gallbladder which showed any great degree of pathology. Naturally, the sur¬ geon concludes from his experience that cholecystectomy is the only method that is a certain cure. The surgeon must decide for each individual case, and to guide us aright, Crile has submitted some simple rules to serve to direct us. If the gallbladder has approximately normal walls, and the cystic duct is patulous, as is manifested by a free appear¬ ance of normal bile into the bladder when it is opened, then no matter what the size or number of the stones, no return of the symptoms will follow a simple drainage. Again, he insists that where we have acute cholecystitis with severe symptoms, with the patient not in the best of condition, mere drainage followed by cholecystectomy, if we have a return of symptoms, is preferable and freer from danger. DISCUSSION Dr. William D. Haggard, Nashville : We now .look on infections of the gallbladder as largely lymphatic ; that is, the infection is from behind and it has come from the various and sundry sources throughout the body. Realizing that fact, we must look on it as an infection, and the stone or stones really as a terminal process. If the case is quite acute and it would add something to the mortality to remove the gallbladder, drainage should suffice; but if the patient is not too sick or too fat, and the common duct is patent, it is a simple and easy matter to remove the gallbladder. Dr. William Litterer, Nashville : All gallbladder trouble is due to bacterial infection. There are a great many cases of typhoid infection that are attributed to infections of the gallbladder, but the patients have never had gallbladder disease. Intestinal Obstruction Dr. W. M. McCabe, Nashville : The treatment of intesti¬ nal obstruction is surgical. If one possessed all the mag¬ nesium -sulphate, castor oil, croton oil and physostigmin sul¬ phate which has been wasted in this condition, he would be a Croesus. If the patient is seen early'before the stage of toxemia, a radical operation should be done by the ordi¬ nary methods, but it is those cases in the terminal stages of toxemia of which I especially desire to speak. Morphin, one-fourth grain, and atropin, one one hundred fiftieth grain, are administered one-half hour before the operation is begun. The deep structures of the abdominal wall are infiltrated with 0.2 per cent, novocain solution containing epinephrin. The skin is now infiltrated and the abdomen opened. A knuckle of ileum as low down as possible above the point of obstruction is caught in a Smith forceps, and a small area is surrounded by two purse string sutures of catgut. The bowel is opened and a Pezzar catheter is inserted and held in place by the first purse string. If the catheter is to be left in for some days the second purse string is tied and inverts the first purse string. If the catheter is to be removed imme¬ diately, the first purse string is to be loosened or cut, and the opening is closed with the second purse 'string. While the bowel is emptying itself through the catheter, a search is made for the point of obstruction, and if found is dealt with according to the pathologic condition of the patient. If the patient's condition forbids a search for the obstruction, the catheter is left in the bowel and allowed to remain for scv-Downloaded From: http://jama.jamanetwork.com/ by a RYERSON UNIVERSITY LIBRARY User on 06/16/2015
doi:10.1001/jama.1916.02580430064030
fatcat:lgfdydmp4ze3to2wwplbwc57ga