On the 25th ultimo this accomplished physician and estimable gentleman
died at his home in Farmdale, Ky. He had been in failing health for
something more than a year. His ailment was Bright’s disease, and the
end was precipitated by uremia.
Dr. Stewart was born near Louisville, Ky., in 1829. In 1849, having
secured a good common school education, and graduating in law, he went
to the gold fields of California, where he sojourned for seven or eight
years. Returning to his native State, he entered upon the study of
medicine, and graduated from the Kentucky School of Medicine in 1859. He
began practice in Daviess County, Ky., but after a few years moved to
Owensboro, where a larger field of usefulness and fuller success awaited
him.
In 1878 Dr. Stewart was called by Governor John B. McCreary to the
position of Medical Superintendent of the Kentucky Institution for the
Training of Feeble-Minded Children. It was here that the chief work of
his life was done. And it was here that he served humanity and the State
with honor, with ability, with fidelity, and with an earnest,
self-sacrificing devotion to the welfare of these rejected waifs of
humanity which entitles him to place and rank among the higher
philanthropists of our philanthropic profession.
In the care of the feeble-minded Dr. Stewart added to his executive work
the habits of a careful student, and became one of the best known
alienists of the land. His address as retiring President of the Kentucky
State Medical Society in 1894 was an able and scholarly treatise upon
the management of the feeble-minded. It was received with great favor by
the Fellows, and has since been the subject of high encomiums from
doctors, lawyers, and political economists.
After sixteen years of State service Dr. Stewart purchased the old
Kentucky Military Institute near Frankfort, where he established the
“Stewart Home for the Feeble-Minded.” The venture was successful beyond
expectation, and here in the bosom of his family he passed serenely and
blissfully the closing years of his gentle, useful, and beautiful life.
[Illustration: DR. J. Q. A. STEWART.]
Notes and Queries.
THE SURGERY OF THE THYROID FROM A NEUROLOGIC STANDPOINT.—In a
suggestively written paper in the January number of the American Journal
of the Medical Sciences, Dr. J. J. Putnam uses the following words: “We
are rather in the habit of assuming that the removal of large portions
of the thyroid does no harm, provided it does not cause myxedema. But
the probability is that we shall learn to recognize affections which lie
between myxedema and health, as well as peculiarities of development and
disorders of nutrition for which the thyroid is more or less
responsible.” ... That this is a statement of fact will hardly be
disputed by any neurologist, but that it expresses a truth that has as
yet been insufficiently impressed on the profession generally is another
fact the importance of which is not likely to be overestimated. It is
only within a comparatively brief period that we have learned that the
thyroid had any definite function and our knowledge of its physiology is
still very far from being exhaustive. The dangers also of interference
with it are as yet also only partially known, but it is certain that
they are not confined to the operation itself. The cases of sudden fatal
dyspnea occurring hours after an apparently prosperous operation in
Graves’ disease, recently reported by Debove and others, are in evidence
of this, and Dr. Putnam adduces other important facts and arguments
against any too venturesome surgery of the thyroid gland. Among these
are the experiments of Halsted, showing that excision of the gland in
dogs had a serious and very evident disturbing effect upon their
offspring, and that even very slight operative interference produced
hypertrophic changes and apparent increase of secretion in the gland
itself; and the observations of Kocher of goiter and cretinism inherited
from parents with no disease other than impaired thyroid function are
also cases in point. Still another fact brought forward by Putnam is the
one that removal or atrophy of the thyroid in infancy checks the growth
and function of the reproductive organs, and gives rise to the various
disturbances of development that follow the suppression of this very
important function. The close relations of the various internally
secreting glands, the thyroid, the testicles and ovaries, the suprarenal
glands, and the pituitary body, for this it seems probable must be
included in this category, are revealed in many pathologic conditions,
and the thyroid as the largest, and presumably the most important, has
apparently a larger part in the disturbances than any of the others. It
seems to be involved to some extent in many cases of acromegaly; its
relations with the genital development have already been mentioned, and
its implication in many pathologic conditions of organs is probable and
is strongly suggested by the clinical history in certain cases of
Graves’ disease. Seeligmann has indeed recently reported a case of this
affection apparently closely associated with genital disorder in which
he obtained decided benefit from the administration of ovarian extract,
thus adding another suggestion to the therapeutics of the disorder.
When any organ is removed, as Putnam says, two factors are set in
operation which may have more or less important effects upon the system
generally. One of these is the action of toxins, the other is the effort
of the organism to adapt itself to the new and changed conditions. The
first of these is important enough in the case of removal of the thyroid
gland, but the other, from what we are beginning to know of its
physiology, must be even more important. Because the function of the
organ is already deranged, it does not necessarily follow that matters
will be remedied by its removal. The operation may only make a bad
matter worse. The mortality of thyroidectomy, according to Poncet, is
from fifteen to thirty per cent, which is alone enough to induce
caution. When the facts brought forward by Dr. Putnam are also
considered, the known and the possible and hinted though yet unknown
effects of thyroid ablation, there is still more reason for prudence and
hesitancy in this operation.
Of course when a goiter has become a dangerous mechanical
embarrassment to important functions, or when a tumor exists in the
thyroid that by its growth and situation has become a threatening
danger, the case is clear, and operation may not only be justifiable
but necessary. It is in such affections as Graves’ disease, in which
thyroid operations are still somewhat popular, that we are likely to
have not only useless but dangerous surgery, and the time seems to
have come to emphasize the cautions implied in Dr. Putnam’s paper. The
theory of hyperthyroidization in this disease, though it has
apparently much in its favor, is not yet sufficiently demonstrated,
and even were it so, would not form a justification for any
indiscriminate or frequent practice of operative interference. Graves’
disease is not by any means a hopeless disorder under medical
treatment, even in its advanced stages; it is therefore impossible to
say when surgery is indicated as a last resort. When the facts of its
absolute inefficiency in perhaps the larger proportion of instances in
which it has been tried, the immediate dangers of the operation which
are not slight, and the remote ones pointed out by Dr. Putnam, are all
taken into consideration, it would seem that it ought to be relegated
to innocuous desuetude.—_Journal of the American Medical Association._
THE TREATMENT AND PROGNOSIS IN GRAVES’ DISEASE.—This short article is
prepared solely with the view of eliciting from medical men who have met
with cases of exophthalmic goiter in their practice, the results of
their observations regarding many points of interest in connection with
this curious disease. I do not intend to give a systematic description
of the affection in question. This can be found in any good modern
text-book. Described many years ago by Parry, Basedow, and by others
more recently, it is much better understood and more widely known than
formerly.
Opinions differ radically as to its real nature. The best modern
authorities regard it as a pure neurosis, and functional only in
character, although organic changes often develop during its course in
the heart, thyroid gland, and elsewhere. Some still speak of it as due
to changes in the medulla oblongata; others again look upon functional
and structural changes in the thyroid gland as the real cause of the
malady. My own experience inclines me to view it as a neurosis pure and
simple, although marked and characteristic structural changes supervene
during its course, and may become permanent. Probably in the near future
we shall learn more as to its exact nature. Already it is satisfactory
to note that cases are far earlier and more frequently recognized, and
that their treatment is more successful.
From their first appearance its special features attract attention.
These are few in number, and easily borne in mind: 1. An unusual and
more or less constant rapidity of the heart’s action; 2. The early
presence of more or less protrusion of the eyeballs; 3. A marked
enlargement of the thyroid gland; a tendency to tremors or tremblings
under very little, and sometimes no excitement, although this always
increases it. It is not surprising that these indications of
exophthalmic goiter which develop more or less rapidly and become often
most distressingly marked, should cause much anxiety to the patients and
their friends, as well as to their medical attendants.
With regard to the duration of ordinary chronic cases (for acute ones
are seldom met with), what has been the experience of those who may read
this article? I have never met with an acute case, but have seen months
and one or two years pass before there was more than a partial
improvement.
One case, a very bad one, in which the patient’s circumstances were so
poor that she worked on during her illness, when she should have had
care and rest, recovered completely. But so serious was this case, that
the sight of both eyes was entirely lost from the excessive protrusion
of the eyeballs during the disease. When I first saw her, which was
years after her recovery, the story of her case was intensely
interesting, but most sad.
Then as to the frequency with which relapses occur in this disease, it
would be interesting to get the experience of good men. Many speak of
relapses being frequent, even after apparently complete recovery has
taken place. Others think them not of so common occurrence.
There are also many points of great interest in connection with the
prognosis. One of these is the probability of the recovery being
perfect. My own experience has been that the lighter or milder the case
the greater the probability of a perfect cure.
Another matter of interest is in connection with cases in which the
symptoms greatly abate, the health indeed appearing to be perfectly
restored, but in which the exophthalmos and thyroid enlargement continue
noticeable; whether in such patients very slight causes may not lead to
a return of the disease. From what I have seen, the conclusion appears
correct, that provided the heart’s action is normal as to frequency, and
not too easily disturbed, these cases are not specially likely to have a
second attack, which is tantamount to saying that, provided the heart’s
action has become normal, any other relic of the illness is
comparatively unimportant.
I have observed, too, more or less scleroderma present when the attack
has not been by any means of a serious character, and when afterward the
general health became all but perfectly restored. This is an interesting
concomitant. It would be desirable to have others give their experience
as to its occurrence in cases they may have attended.
Then as to the effects of pregnancy during the course of the disease;
some high authorities speak very strongly as to its great danger. Others
remark that the affection has improved during gestation. This is another
matter on which fuller information would be most useful.
As to the percentage of fatal cases, this is hardly as yet to be
determined so as to be useful to the practitioner. My own cases have led
me to the conclusion that every particular case has to be regarded _per
se_, that is, if the symptoms are light and comparatively trifling, and
show signs of abating, the prognosis is favorable, while under an
opposite state of things it is the reverse.
As to treatment, what has succeeded best in my hands has been enjoining
upon patients the necessity of a great deal of physical rest, at least
ten or twelve hours a day if possible, and the avoidance of all mental
worry. On this, great stress should be laid. These patients require
abundant nourishment. Galvanism in my hands has been found most useful;
employed twice a day and so applying the poles that the current may go
from the back of the neck through the thyroid gland, and the heart, and
even (the current being made very weak) through the eyeballs. This
current has been continued for months, and in some cases for a year and
a half, with good effects. Sometimes tincture of digitalis has been
useful in moderate doses, ten or twelve minims three times in
twenty-four hours, in some cases, and useless in others. Iron has been
found of great value and persisted in for a long time. As a nerve-tonic,
strychnine in small doses has been exceedingly beneficial. Quinine, if
used, should, unless malaria complicates the case, be used in small
doses only, such as 1½ grains three times a day, with the iron and
strychnine.
I know that many of the matters I have mooted in this paper have been
quite recently discussed by Drs. Ord and McKenzie, of London, in an
excellent article on exophthalmic goiter in the fourth volume of the new
System of Medicine edited by Allbutt, but a still wider discussion on
the matters alluded to, and on many others, by practitioners who have
met with and treated such cases, will do much good, and tend to make the
care of such cases more pleasant and the results of treatment more
satisfactory. _Walter B. Geikie, M. D., C. M., D. C. L., in Philadelphia
Medical Journal._
DANGERS OF THE NASAL DOUCHE.—Lichtwitz (_Sem. Med._, November 26, 1897,)
deprecates the routine prescription of the nasal douche in all cases of
hypersecretion of the nasal mucous membrane. Irrigation is called for
only when the nasal fossæ require clearing of pus and crusts, for
instance in idiopathic ozena. This affection is mainly limited to the
nasal fossæ properly so called, and irrigation is in such a case the
most fitting form of procedure. An ordinary syringe or enema syringe
with suitable nozzle should be used. In all other nasal affections
irrigation is inadequate or useless; it is even dangerous. Repeated
flooding of the mucous membrane may give rise to olfactory lesions.
Antiseptics are highly injurious and pure water is badly borne; the
physiological solutions of sodium chloride, sod. bicarb. or sod. sulph.
are the only harmless liquids. In numerous cases irrigation has caused
the sense of smell to be temporarily or permanently diminished or lost.
Distressing frontal or occipital headache may result owing to the liquid
passing into the sinuses. The injection of irritating liquids may even
set up inflammation of these cavities. The most skilful and careful
irrigation is insufficient in many cases to prevent the resulting
headache. A very grave complication is the penetration of the liquid
into the middle ear, suppurating otitis media occasionally supervening.
In acute coryza, especially in children, douching should never be
practiced. In one such case known to the author mastoiditis followed
irrigation of the nasal cavities. The predisposition to otitis is
increased after retro-nasal operations, in particular after ablation of
adenoid vegetations. For eight years the author has given up all
irrigation after pharyngo-tonsillotomy, and during that period has met
with no case of post-operative complication.—_British Medical Journal._
ANTIPYRIN.—In July of this year the antipyrin patent, held by the Hochst
color-works, will expire by limitation, it having run its course of
fifteen years—the span of life allowed to a German patent. During these
fifteen years the monopolists have sold the drug at about $12.50 a
pound, but it will, of course, fall considerably in price the moment the
manufacture and sale are permitted competitors. It is anticipated that
it will shortly fall to at least half its present price, when the usual
convention of the principal competitors will be called and the
inevitable trust formed, leading to a consequent rise in price. It is
rumored that a number of chemical works are busy with the manufacture of
antipyrin, so as to be prepared with it immediately upon the expiration
of the patent.—_Philadelphia Medical Journal._
PROFESSOR ROBERT KOCH has been invited by the Indian Government to make
another stay in India for the purpose of studying the epidemic and
endemic diseases of man and beast so prevalent there. Koch is now
engaged on work that will keep him in German East Africa for some time,
probably about a year, and does not think of leaving until he has
concluded it.
Special Notices.
RHEUMATOID ARTHRITIS.—Rheumatoid arthritis is a chronic progressive
disease with an almost hopeless prognosis as regards a complete cure.
The most that can be hoped for is to arrest its progress for a longer or
shorter time, and to render the patient’s life more tolerable by
improving his health and relieving the pains in the affected
articulations. Galvanism, massage, baths, and an invigorating diet have
been found of more or less value, as well as the administration of
cod-liver oil, ferruginous preparations, and the iodides. A
comparatively new remedy that seems to have a promising future before it
in the treatment of this disease is Lycetol. Judging from the
observations thus far published its use in rheumatoid arthritis is
capable of effecting considerable improvement. One of its distinct
advantages is that, owing to its pleasant taste and freedom from
irritating effects, its administration can be kept up for a long time, a
point of great importance in the treatment of chronic affections, in
which remedies must be given for a prolonged period before beneficial
results can be expected. In two cases recently reported by Dr. Paul
Norwood (Times and Register, November 6, 1897), one being a very bad one
of chronic rheumatoid arthritis, the results were very encouraging. A
slow but steady improvement occurred in the second case, while in the
first the patient provoked a recurrence by discontinuing the treatment.
In view of the obstinate character of the affection and its resistance
to the remedies heretofore in use, Lycetol should be certainly
considered an eligible remedy in these cases.
MEETING OF AMERICAN MEDICAL PUBLISHERS’ ASSOCIATION.—The Fifth Annual
Meeting of the American Medical Publishers’ Association will be held in
Denver, on Monday, June 6, 1898 (the day preceding the meeting of the
American Medical Association).
Editors and publishers, as well as every one interested in Medical
Journalism, cordially invited to attend and participate in the
deliberations. Several very excellent papers are already assured, but
more are desired. In order to secure a place on the program,
contributors should send titles of their papers at once to the
Secretary.
CHAS. WOOD FASSETT, St. Joseph, Mo.
OBSTINATE CONSTIPATION.—I used Chionia, a teaspoonful three times a day
and at bed times, in a case of long standing obstinate constipation. The
first three nights I directed a hot water enema to be given every night.
This treatment brought about regular and spontaneous evacuations, and
resulted in a complete cure.