Слике страница
PDF
ePub

upper segment, lower segment and cervix being involved in spasm, the cervix being very close and resistant, abdominal section seemed our only choice of methods. The operation was performed under ether, a living child delivered and the mother made an uneventful recovery.

Remarks: We consider eclamptic conditions and kidney lesions a contra-indication to major operations, but to our certain knowledge the conditions had existed for less than two weeks in this case and the result confirms our opinion that no permanent damage had been done to the kidneys.

I am satisfied that the duration of these conditions are of as much vital importance as their severity. In brief, a mild degree of toxemia or kidney lesion extending over a prolonged period is more serious than a more pronounced degree extending over a brief period.

Case V. A multipara, three living children, about 40 years of age, sent in from the country in the last month of pregnancy. She gave a history of a sudden severe hemorrhage with pain about two weeks previous. Fetal movements disappeared. She consulted no physician until one day previous to her coming to the city. On examination there was high pulse tension, albumen and casts in urine, absence of fetal pulse and movements with board-like hardness of uterine muscle. Entire muscle including lower segment in a state of firm tonic painful spasm. Full doses of morphin failed to relieve the spasm.

Diagnosis, ablatio-placente, uterine tetany, dead baby. Abdominal section seemed the only safe method of delivery of mother, the child already dead. The operation was performed and the mother made an uneventful recovery and returned to her home in good health.

Case VI. Mitral Stenosis. This patient, a primipara, consulted us previous to marriage as to the safety of child bearing. An older sister had died of heart complications following a first labor. We gave her three alternatives: remain single, be sterilized by removel of tubes, or risk a cesarean section. She got pregnant very promptly following marriage. She was watched carefully during pregnancy. At one time she went to bed in a hospital for three weeks on account of decompensation. At the thirty-ninth week of pregnancy she was delivered by abdominal section and sterilized by removel of tubes. Both patients made uneventful recoveries and are in good condition today, four years later.

Remarks: Mitral stenosis is the most serious heart lesion confronting child-birth and in this instance it was considered advisable to let the woman take no chances by going into labor or even getting pregnant again.

Case VII. Primipara taken with sudden severe hemorrhage during last month of preg

nancy without pain, very slight dilatation of cervix. Diagnosis, placente previa. Mother in good condition except for loss of twenty or more ounces of blood. Baby alive. Effort made to bring on labor by packing cervix with iodoform gauze under very strict aseptic precautions. Uterus did not respond after two days and cesarean performed, both patients made an uneventful recovery.

Remarks: In our opinion, any other method of delivery would have incurred far greater risks for both mother and child. In future labors unusual care should be given this mother on account of scar.

Case VIII. Primipara, pelvis obstructed with ovarian cyst, decided to let patient go to full term, do cesarian and remove cyst at same time. Both patients recovered. Subsequently this woman delivered a full grown child by normal labor.

Case IX. Primipara developed insufficiently of kidneys during last six weeks of pregnancy with albumen casts, dropsy. The condition of the mother became so critical that immediate delivery seemed imperative and cesarian section was the method chosen. The baby lived and is well today but the mother died about two months later of acute kidney conditions.

If I had this case to do over again I would try some other method of treatment on account of kidney lesion. Major operation being contraindicated. Vaginal cesarian had not been popularized at this time and if performed would very

likely have resulted disastrously to the child. It is possible that medical treatment with induced labor would have been a safer method than operative procedures.

In my entire experience, the mortality has been two mothers, both being toxemic cases with kidney complications that resulted disastrously about two months following delivery.

Case X. Primipara 45 years of age, married fourteen years. Long, firm, close cervix. Scar where uterine fibroid had been removed, another palpable fibroid in uterus. palpable fibroid in uterus. Decided that risks to mother and child were sufficiently great in this case to justify a cesarian delivery. Operation performed near full term and both patients saved. I believe that any one of the three conditions; scar in uterus, palpable fibroid, and long, close cervix in a primipara forty-five years of age were sufficient justification for cesarian.

I have seen one baby fatality from morphin narcosis, the mother having had by direction of the operator 4 gr. of morphin hypodermically, fifteen minutes before taking anesthetic.

I believe all cesarian patients should receive a minimum amount of anesthetic extending over a minimum length of time.

I have seen two cases of great difficulty in

[blocks in formation]

7. Ideal time after labor begins. Uterine contractions safeguard against hemorrhage, facilitates separation of membranes, insures drainiage by dilating cervix and reduces dangers of infection to a minimum.

8. The danger of uterine scars depends on the scar. If the uterine incision is clear cut, the edges carefully coaplated and sutured with the most rigid asepsis and no infective complications following, the scar will stand the test of a labor of normal severity. On the other hand, an obstructed labor with powerful muscular contractions or a version might be disastrous. It is well to have such a patient in a hospital under skilled care and be prepared for emergencies.

DISCUSSION

F. B. DORSEY, Keokuk, Iowa: When we conipare the gravity of a cesarian section with the results obtained, both to the mother and the child, with deliveries under certain circumstances that are attempted and accomplished, we are decidedly in favor of cesarian section.

We have had quite an extensive experience in cesarean section. If we read our text-books and the description of the various operations advised, we may think it is a very complicated operation, but to a skilled abdominal surgeon it is one of the most simple, I think, of operations in connection with the abdomen.

We are all acquainted with the disastrous effects on the mother where posterior rotation takes place. It means the inevitable use of the forceps, and with it the inevitable destruction of the pelvic floor to a greater or less extent-usually greater. We certainly would not think of performing manual dilatation under the conditions that the doctor mentioned in his essay, because of the time consumed and the danger to the mother as well as to the child. The danger to the mother and to the child, if this operation is performed under proper circumstances and conditions, is almost nil. In his report of some ten or twelve cases the doctor has had but two deaths, and those were not due to the operation, but to the poisonous constituents from the kidneys. In my experience I have had three deaths: one from exhaustion. The woman had been in labor for 84 hours, with a funnel pelvis, and it would have been better if I had arrived about two hours later, both for the doctors and perhaps for the patient, too. The other two deaths were due to uraemic toxemia, the patients dying from three to five weeks after delivery.

I think the day is not far distant when cesarean section will be a popular operation under conditions demanding it, when we get a fuller view of it—when we recognize how little danger it is to the woman, and very small mortality to the child, and the fact that it does not leave a woman impaired for future labors. As recited by the doctor, because a woman has one cesarean section does not mean that for her it is a cesarean section always; that is not the case in my experience.

The doctor mentions the sterilization of a woman because she has to have a cesarean section. In the case reported by him a man would be perfectly justified in sterilizing her, so that she could not become pregnant again, because of her heart action. But if a woman is normal, other than her pelvis, if she has a normal heart and lungs, I do not see why simply because she has a pelvic deformity she should be denied the privilege of offspring, or why we should be justified in recommending sterilization. I have a little woman on whom we have performed two cesarean sections. She had a justo-minor pelvis, and she has given birth to two hale, hearty children, and in the middle of next month she expects to be delivered of a third by the same route. Their convalescence is usually uninterrupted and uninteresting, and why should we deprive them of this privilege if it is their desire to have children?

D. C. BROCKMAN, Ottumwa: I was very much pleased with the able paper the doctor has given us. I have an objection to one of his statements, which in this particular case was probably justifiable; that is, he did a cesarean section for placenta praevia after the cervix had been dilated. If we knew posi tively, that the uterus was not infected, it might have been done. He might have known that; I do not. For that reason I think that that part of the paper should be criticized. As a general statement, no man has any right to do cesarean section without doing the Poro Muller operation on a case where the cervix has been packed. If he did the packing himself may be he has confidence in himself; I haven't that confidence on him, or anyone else.

Another subject of great importance is the hemorrhages-accidental hemorrhage-separation of the pla centa. I feel in these cases the abdominal operation should be done as soon as possible.

I think the general practitioner should be more careful about the statements he makes to his patients. Six weeks ago a man came to me to have a premature delivery done upon his wife because she had such hard labors in two former cases. The doctor told her that she never would be delivered of another child unless it was done prematurely. I said, "Bring your wife over and let me see her, and if there is any condition there that precludes an ordinary delivery we will do cesarean section." I found she had a normal pelvis and was a big woman. I told her to stay in town and go to the hospital when the time came, which she did, and was properly delivered normally. These are statements that the ordinary practitioner has no business to make. But with the indication that the doctor mentioned, where it was a question of the election between premature labor and cesarean section, I would always decide in favor of cesarean. I don't think he touched on that.

In regard to Dr. Dorsey's case, after the woman had been in labor 84 hours of course it absolutely prohibits cesarean section. I was called not very long ago into such a case. The woman had been in labor 36 hours. The forceps had been applied after 24 hours, and the child had been dead for 12 hours. We performed a craniotomy and delivered the baby.

Any work done on the cervix precludes absolutely cesarean section, unless the doctor is positive that there is no infection. When a woman has such a defect that it is going to be difficult to deliver her she should be sent to the hospital. I take issue with the doctor that cesarean section is always an emergency operation; I think it should be very largely a remedial operation. We can induce labor whenever we want it; we can induce contractions; and everything being prepared for section makes a very simple operation of it, and I very greatly prefer to make it

an elective operation instead of an emergency operation.

DR. SOMERS: I want to thank the gentlemen for their criticisms; they are just, all of them. Of course this report covers a much larger number of cesarean sections than twelve cases. As a matter of fact there are probably more than a dozen cesareans on justominor flat pelvises with previous disastrous results included under one head; in all twenty-five or thirty; and the only disastrous results came from defective kidney conditions, from which the women died two months later. That is simply my personal experience extending over a period of ten or a dozen years.

My experience in these cases that Dr. Dorsey speaks of, pelvic posterior rotation, is that it is too late to do a cesarean section; you had better do a craniotomy to begin with. After the head has gone into the pelvis and fails to rotate, it is a disastrous condition as far as the baby is concerned, we will admit right off. But that woman doubtless has been tired out by hours of labor; has been examined numerous times, unless it is one of your own cases; and the chances for that woman, or for the child, with

cesarean section at that time, are bad, in my judg

ment.

There is no way in the world that the average primipara can be delivered so safely and so easily, both for herself and for her child, as by cesarean section, but you have to select your cases.

I no longer examine my pregnancy cases by the vagina. You can tell when you come to labor; and I don't examine half of them when they get into labor. If I absolutely want to know about the condition of that cervix I don't know any way to tell except by a vaginal examination, but I make just as few as possible.

I will admit that the criticism of Dr. Brockman in regard to my cesarean section in a placente previa, in which I packed the cervix. is just as a rule, and yet to explain: I am but a few years younger than my friend over here, and I haven't any kith or kin of my own. About ten years ago I conceived the idea of training a boy to take my business and to succeed

me; so I took a man who had taken a full university

course of six years, and taken a year in a hospital as an interne. I trained him the best I knew how for three or four years; then sent him down to New York and had him put in eight months as house surgeon of the New York Lying-In; and he has been back working with me about two years. Now I am not the obstetrician any longer; he is the obstetrician. He is a trained obstetrician from the word go-an Iowa boy, too. Now, then, I knew in advance that this little woman was absolutely clean; I knew we ought to empty that uterus after she had bled about twenty ounces. When I pack the cervix I always use iodoform gauze, and only allow it to remain twenty-four hours at the outside. So her cervix was packed with iodoform gauze and it did not bring on pain. Now, I had so much confidence in that case being clean under my own hands, or under the hands of my associate, that we took our chances on a cesarean section. If any other live man had packed that cervix we would not have done a cesarean section.

I won't always trust any man's word as to how many times he has made an examination. If it came out all right, good and well, possibly the next time we might come out all wrong.

I haven't done a premature delivery, except in the case of a toxemia, in the last ten or twelve years. If a woman has a defective pelvis, don't do a premature delivery; leave her alone to full time, and then do a cesarean. But if a woman is in a toxemic condition, it is dangerous to leave her. The longer we wait

with the toxemic conditions, after we begin to get albumen and casts in the prine, the worse it is for that mother. If we know that a woman has had albumen and casts only a week or ten days, we are pretty safe; but if she has had them for weeks, or possibly months, we are absolutely unsafe in doing a cesarian section.

THE TREATMENT OF PNEUMONIA N. H. D. COX, M. D., Arlington, Md. The selection of a rational treatment presents a problem that deeply concerns a physician who is called to treat a case of pneumonia. Not until recently have I found a remedial agent that fully meets the requirements of a successful treatment for this disease. I refer specifically to pneumonia phylacogen.

My first success in the application of phylacogen therapy was in the treatment of a very stubborn case of rheumatism in an elderly lady who had received other antirheumatic treatments and obtained but little or no benefit. After administering several doses of rheumatism phylacogen she was at least temporarily relieved of the rheumatism. After this the patient passed from under my observation for more than three years. I recently met a relative of this patient who informed me that there had been no return of the rheumatic condition. While this is but a single case, the results were so very much in evidence that I decided to give the phylacogens a further trial.

My next case was that of a boy about three years of age who developed bronchial pneumonia. The remedies usually applied in such cases failed to reduce the temperature or influence favorably the progress of the pneumonic condition. The patient was then given a few doses, at three day intervals, of catarrhal vaccine combined, Parke, Davis & Company. As this vaccine did not seem to produce a prompt effect upon the temperature, I began the administration, on the days intervening, 1⁄2 c.c. pneumonia phylacogen, repeating the dose every twelve hours. Following each of these doses there was a marked favorable effect upon the temperature and general condition of the patient. On the ninth day the child was up and walking about the house, and two days later there was no sign of cough or expectoration.

A second case was that of the oldest brother, aged 19 years, of the former case of pneumonia, who developed an onset of pneumonia on the seventh day of the progress of the first case. Following initial chill the patient developed a fever of 104, with considerable cough, temperature continued to rise to a maximum of 105.2. This was followed by delirium and complete consolidation of the right lung and involvement of the left bronchial area. I first tried the old time "tame" remedies, as I now called them, but the stomach rebelled and refused to retain any reme

dies given by mouth. I then began to consider pneumonia phylacogen, but, owing to my familiarity with bacterial vaccine therapy, gave 1⁄2 c.c. catarrhal vaccine combined. This brought the fever down two degrees, but it soon returned to the high point. Remembering the former experience with phylacogens, I gave the patient, on the morning of the second day, 1 c.c. phylacogen and repeated the dose each twelve hours, increasing the quantity of each dose by 1 c.c. until the maximum of 4 c.c. was injected at one time. Following each dose of phylacogen the temperature dropped from two to three degrees. While there was a tendency for the fever to rise several hours after the injection, it never reached an alarming degree.

Following the administration of each injection of phylacogen the patient perspired freely, which seemed to offer considerable relief so far as the general condition was concerned. On the third day of the phylacogen administration, which was the fifth day of the disease, the bloody sputum ceased and became more of the prune juice character. On the ninth day the temperature was normal and there was but occasional slight coughing. The general physical condition of the patient was exceedingly good, promptly developing normal appetite. Throughout the entire treatment of this case the patient was given plenty of fresh air, which seemed to be essential; any time the windows were closed the patient complained of respiratory depression.

In bacterial vaccine and phylacogen therapy I feel that we have a treatment of far greater value in the treatment of acute infectious diseases than any other remedial agents available at this time, and can be relied upon providing they are given in properly selected cases and administered early in the disease, before irreparable damage has been done.

The

Since tabulating the cases referred to I have treated a very interesting case of rheumatism, following tonsilitis, with rheumatism phylacogen. When the patient was first seen all the joints of extremities were involved, there was also developing endocarditis. As the case had failed to yield to ordinary antirheumatic treatment I started on rheumatism phylacogen, giving 1⁄2 c.c., repeating the dose at 24 hour intervals, gradually increasing the size of the dose to 2 c.c. pain was gradually relieved and after a total of 10 c.c. of the phylacogen was given the pain was entirely gone, and the endocarditis had practically disappeared. She is now receiving streptococcus vaccine, 50 million per c.c., every third day. From this supplementary treatment we hope to establish permanent immunity against the possible return of rheumatism or endocarditis, which appears to be a complication coincident to the joint infection.

While rational therapy cannot be established

from results following the treatment of any small group of cases, yet the rapid disappearance of dangerous and alarming symptoms that follow the administration of phylacogens is at least deserving of very careful thought and consideration. This is especially true in the treatment of cases for which our former therapeutics have so little to offer.

KANSAS CITY EYE, EAR, NOSE AND THROAT CLUB: ITS OBJECTS AND AIMS

HAL FOSTER, M. D., Kansas City, Mo.

About five years ago a number of physicians engaged in the practice of eye, ear, nose and throat surgery felt the necessity of establishing a society where they could meet, read papers, hold public clinics and witness each other treat and perform surgical operations on patients. They also desired to become better acquainted with each other, and in this way cultivate a better and higher professional standing among all of its

members.

A meeting is held on the third Thursday of the month, from October until May, at 6 o'clock preceded by a dinner at the Coates House, after which papers are read, new instruments and cases shown. Every other meeting a surgical clinic is held at some of the hospitals in greater Kansas City, where patients are operated upon by some of the members of the club, appointed by the program committee. Occasionally some distinguished man from some other city is invited to read a paper or hold a surgical clinic.

This club has had a wholesome and uplift effect among its members in every way. Physicians of these states are eligible for membership, Arkansas, Kansas, Oklahoma and Missouri. They must be members of their state and county societies and have limited their practice to these specialties for five years, and be in good and regular standing.

Officers for 1918-19 are: President, Dr. J. E. Sawtell; first vice-president, Dr. D. E. Esterly; second vice-president, Dr. J. S. Lichtenberg; secretary-treasurer, Dr. J. H. Laning; program committee, Dr. Hal Foster, chairman; Dr. F. E. Curran, Dr. W. H. Schutz.

The first meeting for 1918-19 was held October 17th at the Coates House; 6 o'clock dinner, as usual, preceded the business and professional program. At this meeting Dr. J. H. Thompson, the dean of the club, delivered a lecture on "The Use and Abuse of Glasses." Dr. Thompson was at his best on this subject and all enjoyed and were instructed by it. It was discussed by Drs. F. E. Curran, Curdy, Miller and Schutz. Dr. Hugh Miller reported some very interesting eye cases. The cases were presented and demonstrated by the doctor. Dr. O. P. Bourbon read a

very timely paper on Influenza, and gave a historical review of the disease, its prevention and treatment. This paper was liberally discussed by all present. The president appointed Dr. R. J. Curdy, Dr. H. W. Schutz and Dr. Hal Foster to write some rules and regulations as to the best methods of preventing and treating the disease. They were ordered by the society to be printed in the local papers and a copy sent to the Health Board of Greater Kansas City, for the guidance of the public.

The resolutions were as follows:

"In view of the facts that there is no known medicine, spray, vaccine, serum or other treatment that is a dependable preventive of influenza; that perfect isolation of carriers of the disease is impossible; that the closing of schools and theaters and the limiting of street car traffic and retail business, though helpful, are not sufficient to prevent the continuation of the epidemic; that influenza is communicated by the secretions of the nose and throat passing from person to person in talking, coughing and sneezing; that the use of properly made gauze masks, as practiced in the hospitals treating contagious diseases, is a measure entirely effective in preventing the spread of diseases which are communicated from and through the nose and mouth; that the use of masks does not interfere with the ordinary activities of work and business; we recommend that the constant wearing of properly made masks be made obligatory on all persons appearing in any public place in the limits of Kansas City, Missouri and Kansas; that no person be allowed on any street, in any street car, office, store, shop or other public place unless wearing a properly made mask, providing for the few necessary exceptions, such as patrons of restaurants and barber shops."

The club recommended that under no circumstances should douches be used in the nose, because nasal douches are so dangerous they should never be used, because the fluid is very apt to find its way in to the Eustachian tubes and cause abscess of the ear drum and even mastoid abscess.

The October 17th meeting was one of the most enjoyable and instructive meetings in the history of the club and was well attended. Each member should urge his medical friends engaged in this work to attend. Kansas City needs such a club as this, and its members owe obligations to the medical profession, and should be willing to read papers and gladly hold surgical clinics, or do anything to serve the club, especially since so many of our younger members are now on active war service of our country on the fields of France, fighting that liberty and freedom may not perish from the face of the earth.

The social feature of the club is doing great good among the members.

The following named members of the club are now in active service of the army in France or in the cantonments: Drs. Moss, Kimberlin, Blakesley, McAlester, Wyeth, San Roberts, Bellows, McCarty, May, Lichtenberg, Leonard, Forgrave and Look.

These are doing duty either on local or medical advisory boards: Drs. Thompson, Case, Hal Foster, Lorie, Curdy, Sherer, Sawtell, Schutz and Tureman.

The next meeting will be a clinical one. Patients will be operated upon at the Bell Hospital 8 to 12 a. m., Thursday, Nov. 21st, by Drs. F. E. Curran and J. E. Sawtell. 1 to 4:30, Kansas City General Hospital, Dr. J. S. Lichtenberg, Dr. J. H. Thompson and Dr. A. J. Lorie. 6 p. m., dinner at the Coates House, followed by this program: Dr. J. E. Logan, "Tumors of the Nose." DisH. E. Tureman, "Plastic Surgery of the Face and cussion opened by Dr. Alkaire of Topeka. Dr. Nose." Discussion opened by Dr. Neighbors of Emporia.

The club is anxious that every man attend and do his duty in order that the work may continue while so many of the younger men are absent in war work. It will be expected when a member is called upon by the program committee to either hold a clinic or read a paper he will at once do so. These are busy times with the club members, and each member has greater responsibility resting upon him than ever before. We should strive to keep the club alive and full of the spirit that made the middle west great, so when the war is over, our members can return field of usefulness in this great and growing city. and take up the work and carry it on to a larger

A Candy Emergency Ration-Chocolate bars containing three other highly nutritious foodswheat, nuts, and raisins-the first consignment of an order for 1,100,000 similar cakes for the use of the American Red Cross in England, have just arrived in London from an American factory. The confection will be distributed gratis to the soldiers. Each bar is enclosed in a wrapper decorated with the American flag and the Red Cross emblem. A small card inside says the package is a well balanced emergency ration, equal in food value to any one of the following: Two lamb chops, two eggs, two plates of clam chowder, one big glass of milk, two baked potatoes, three apples, two ordinary cups of custard, or two helpings of beans.

Pneumonia and Alcoholism-At a time when pneumonia is prevalent it is interesting to know that the death rate among confirmed alcoholics is three times as great as among persons who do not drink. Alcohol has no place in a community or nation that desires to be efficient..-K. C. Star.

« ПретходнаНастави »