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J. A. (Joel Asaph) Allen.

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pulse, in the recumbent posture, and which do not occur in the
upright, afflicting a person supposed to be in good health, indicate
a lesion of the myocardium, and a fatal issue from asytole may
be predicted at an early date, according to the degree of the
disease.

If this be true, applicants for life insurance should be postured



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DAGGETT: CONCERNING POSTURE. 87

for examination ; indeed, in all obscure cases diagnosticians could
profitably utilize natural attitudes and assumed postures when con-
ducting physical examinations.

Sims discoTcred and demonstrated the advantages of the side
posture ; still, with all that has been said and written, a compara-
tiyely small number of physicians employ it.

Many specialists use the side position for ocular examination,
and treatment ; the dorsal recumbent posture for executing biman-
ual examinations, and perineal operations.

The vagina, in its usual desolate condition, is a collapsed sack,
preserved in its closed condition by pressure of the superincum-
bent, surrounding viscera, so that ocular examination cannot be
made, or local treatment applied, without dilatation or expansion
of this structure.

There are two methods of opening the vagina for these pur-
poses, one is direct mechanical dilatation by means of cylindrical
or valvular specula, the other is by elevation of the pelvis to induce
prolapse of the viscera toward the diaphragm by the traction of
gravity, at the same time retracting the perineum.

Dr. Joseph Price declares the cylindrical and valvular specula
do barm in the hands of the inexpert, and the expert do not need
them ; that if ocular examination is necessary, or local treatment
is indicated, the side position and Sims' speculum should always
be used.

In the side position upon a horizontal plane the viscera still
press upon the vagina, so that traction upon the perineum and
repression upon the anterior surface of the vagina are necessary to
provide a free field for the purposes of inspection and treatment.

To carry out these manipulations requires the aid of a skilled
assistant or a deft operator.

This obstacle is overcome by placing the patient in the knee-
thigh-chest posture^ described in the following paragraphs :

This position is not uncomfortable, and it combines the advan-
tages of both the knee- chest and side (Sims') postures ; it may be
called the exaggerated Sims.

The knee-thigh-chest posture, — The patient mounts the step
with the left thigh towards the table, lifts her drapery upon the
tablets top, in order that it may not bind her limbs at she reclines,
or obstruct the operator. Reclining, she rests her left thigh across
the table's end, carries her left arm backward, parallel with the
body, places her left ankle upon the rest and draws the right limb



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8UBOBBY. 89

To avoid this, the table top is given a double tilt. The high
lateral tilt inclines the body so that the patient turns upon the left
thorax, and the knees rest upon the side rail, the longitudinal tilt
accentuates this position, which gives a decided dip to the long
•diameter of the abdominal cavity, and the viscera settle towards
the diaphragm.

For this position, the side tilt should be raised to an angle of
twelve or more degrees from the horizontal line ; the long tilt to
an angle of five or six degrees ; more than this for the long tilt
renders the patient uncomfortable and is unnecessary.

The tilting is to be done after the patient is placed as described.
A line drawn through the sacral plane is transversely with the
body, at an angle of forty-five degrees ; lengthwise with the body,
at an angle of six degrees from a perpendicular line.

Thomas made a study of this subject, and as a result of his
experiments constructed the gynecological table which bears his
name.

As bodies differ in conformation, set rules are modified in
accordance with the tact and judgment of the operator.

The cut on the opposite page illustrates the knee-thigh-chest
posture, in which it will be observed that the body is comfortably
supported by the knees resting upon a wide side-rail.

258 Frankun Street.



progreAA in Meilicaf Science.

#

SURGERY.

CoDductedbyJOUX PARMENTER. M. D.

Dr. Lakphear, (American JoumcU of Surgery and Gynecology,
June, 1898,) after describing briefly the methods of Senn and
Wyeth, giving the preference to Wyeth's procedure, goes on to
relate four cases of bloodless amputation of the hip, operated upon
by his own modification of the Wyeth method. This consists in
inserting the outer pin higher up and drawing the rubber tube
Tery tightly, and has the advantage of completely preventing
hemorrhage and permitting disarticulation of the femur without
preliminary amputation, thus saving considerable time. Of the four
teases, three recovered and one died subsequently from septicemia,



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90 PBOGBKSS IN MEDICAL SCIENCE.

the very condition for which the amputation was made. The
operation in this particular case was completed in twenty-nine
minutes from the beginning of anesthesia. The author concludes
with the following remarks :

So far as I can learn, twelve cases have been operated on by this
method, with two deaths — a mortality rate of less than seTenteen per
cent. The significance of this will be appreciated when we recall the
facts that heretofore hip-joint amputation has been regarded as one of
the most fatal and bloody operations ; that the death-rate has }>een
from sixty per cent, to ninety per cent, by other methods ; and that
seventy per cent, of all deaths have been from hemorrhage ! Here are
twelve cases without any hemorrhage — with one death from shock and
one from septicemia. Surely this is a method which is about as suc-
cessful as could well be expected, considering the gravity of the opera-
tion. It certainly controls bleeding completely — the great desideratum,
since it is hemorrhage that usually causes death, that brings on
" shock, ^^ (in most instances) that predisposes to the development of
germs introduced during the operation, and, finally, that retards the
process of healing.



Keen (American Jimmal of Surgery and Gynecology y June, 1893,)
describes a case of apparent intestinal paralysis, which caused
arrest of the intestinal contents, and was equivalent to intestinal
obstruction, and for which he performed laparatomy. The history
is so minutely, yet simply, given, the treatment so scientific, and
the deductions so clear and logical, that we reproduce the article
in toto :

Mrs. S., oet. forty-five, mother of several children, has had a great
deal of sorrow and consequent mental distress for the last few months.
Was first seen by me in consultation with Dr. S. Mason McCollin on the
evening of December 24, 1890.

Some months ago, Dr. McCollin removed a soft polyp from the
mouth of the womb, and the patient returned to him from time to time
for treatment after its removal. Of late, she has had a very offensive
vaginal discharge, so much so that Dr. McCollin suspected possible
cancer of the uterus, and it was so diagnosticated by another competent
gynecologist, who had even advised the removal of the entire uterus
the day before I saw her.

On December 18, 1890, the patient came to town, and reached Dr.
McCollin's ofllce utterly exhausted. He put her to bed and gave her
some vaginal douches to relieve the odor. She seemed somewhat
dazed on the 18th and 19th ; on the 20th, she became delirious, and
her strength failed to such an extent that Dr. McCollin feared she



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SURGERY. 91

would die during the night. From then until the 24th she has been in
a precarious condition. There has been much elevation of temperature,
and she has been continually out of her head, and has had an exces-
sively fetid breath. On the 23d and 24th she vomited a great deal,
sometimes for nearly an hour at a time^ She said she had had a
movement of the bowels on the 19th, but this was not confirmed. From
that time until now there has been no movement whatever, nor has any
flatus escaped, and yesterday (23d) an enema of half a gallon was-
entirely retained. No gurgling in the bowels has been heard. Her
menstruation began today.

December 24, 1890. On examining the abdomen no especial tender-
ness was discovered, excepting over the right iliac fossa, and not very
much there. There -was also, it seems to me, more resistance at that
point. On examining the bowel, I found that the rectum was abso-
lutely empty. It was ** ballooned '^ into a cavity, certainly as large as
the fist. No strictures were observed, and the tube with which the
half-gallon enema had been injected had been inserted eighteen inches
into the bowel, with no obstrut^tion. On examining the uterus, it was-
found to be movable, not enlarged, the os slightly patulous, so that the
tip of my forefinger could be inserted for a scant half inch, and felt
the stump of the polyp. There was no cauliflower or other growth
about the womb. The odor of the menstrual discharge was not
offensive.

Inasmuch as she seemed to be going down hill very rapidly, and a&
she would certainly die very shortly if nothing was done, I recom-
mended an exploratory laparatomy on the next day, unless a large
enema, with elevation of the hips, should be followed by any result.

December 25, 1890. Dr. McCollin reports that almost a gallon of
fluid was injected last night and the hips were elevated. The entire
enema was retained. She was even more delirious last night than
before.

Operation, — An incision was made in the median line, which was
eventually extended to a little above the umbilicus. As it was found
that there was a marked tendency towards an umbilical hernia, the entire
umbilicus was dissected out and removed. There were no adhesions,
no fixation of the pelvic viscera, no intussusception, (which to my
mind, in spite of her age, was the most likely prior diagnosis,) and no-
band or other obstruction to be found. The large intestine, as had
been determined by percussion before the operation, was enormously
distended, and the small intestine, in its lower half, was contracted and
empty, but in its upper half evidently contained feces. The large
bowel had a rather sharp V-shaped attachment to the spleen, but not
enough to produce any obstruction. At two points in the ascending
colon and the sigmoid flexure an incision, over half an inch long, was-
made in the large bowel, and an enormous quantity of gas let out. The



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92 PB06BESS IN MEDICAL SCIENCE.

intestinal incisions were then closed with Gushing' s right-angled con-
tinuous suture. The large bowel was followed from the rectum to the
cecum, and the small bowel rapidly gone over from the cecum to the
duodenum, but no obstruction was found. The gall-bladder was dis-
tended with bile. Both it and the liver were healthy. The abdomen
was then closed as speedily as possible. A glass drainage-tube was
inserted, going down into Douglas' cul-de-sac. Before the patient had
been removed from the table, the bowels were freely moved. During
the operation she suffered deeply from shock. This was admirably
relieved by hypodermatics of strychnine. The urine had been exam-
ined repeatedly, and found normal, but urine drawn a few minutes
before the operation, and examined afterwards, showed moderate albu-
minuria.

December 26. 1890. She passed a very bad night, being almost
wildly delirious at times, so that she had to be restrained by physical
force. She has made no complaint of pain, but if the abdomen is
pressed upon she winces as though hurt. Just after the operation the
drainage-tube was cleaned by suction every fifteen or twenty minutes,
blood-stained serum^being removed. The intervals were rather rapidly
lengthened, until this morning, after five hours, only one drachm had
accumulated. This fluid is entirely sweet. Her temperature is only
a little above 100 ; tongue coated ; breath still very foul. Her
pulse has increased in frequency to 124 and has lost in force.
Since the operation absolutely nothing has been given her, except
a little ice and champagne, and a little brandy and water.
In view of the paralysis which had existed, at least in the large bowel,
and possibly in the lower part of the small bowel, I deemed it best for
her simply to be stimulated moderately and have no food whatever for
at least twenty-four hours. At 11 A. M. to-day, a distinct gurgling was
heard in the intestine, and has continued at intervals since. A rectal
tube was inserted once in four hours, and has given exit to some gas,
and she has also passed some spontaneously, the first in seven days.

The drainage-tube was removed after twenty-eight hours, there
being scarcely any further accumulation of fluid in it. Her general
condition was very bad, and it looked as if she could live only a few
hours. The wound itself looked perfectly well. During the afternoon
she rapidly failed, and for a short time there was no appreciable pulse
•even at the wrist, while her respirations were shallow, quick, and
irregular. Once or twice it seemed that the respirations were perma-
nently suspended. There again, strychnine, hypodermatically admin-
istered, was of the greatest value.

December 29, 1890. On the 27th (second day), to my surprise,
she was somewhat better, and we began cautiously to feed her a little
milk and liquid peptonoids only. Flatus occasionally escaped spon-
taneously, and almost always whenever the tube was inserted, and not



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8UBGEBT. 93

unoommonly small quantities of fecal matter also were passed by the
tube. On the 2dth (third day) she was about the same physically, but
her mental condition had improved. The wound, on examination,
appeared to be in perfectly good condition. Two or three doses of
sulphonal, in ten-grain powders, were enough to reduce and almost to
control her restlessness.

January 1, 1891. By the 30th (the fifth day), her temperature had
touched the normal, with a slight rise at night. On the Slst (the sixth
day), as her bowels had not been freely opened, we decided to give her
a dose of thirty grains of Epsom salt every two hours, very cautiously
to empty the bowels. Soon after she had the second dose, and
not probably as a result of it, but accidentally, an attack of
diarrhea began, and within twenty-four hours she had thirty to forty
liquid movements, a number of them of considerable amount. The
odor, especially of the earlier ones, was excessively fetid. With this
diarrhea her mind seemed to clear up considerably, so that she herself
observed the odor of the passages : but she developed a great disincli-
nation to take either food or medicine, due chiefly, it seemed, to her
mental condition. The wound had healed throughout by first inten-
tion, and I removed today all the superficial and half the deep sutures.
Her temperature was normal.

January 3. 1891 (ninth day). The remaining sutures were
removed today. Her mental condition is very much improved. The
bowels are a great deal better and have lost-their excessively offensive
odor, as a result, probably, of the administration first of salol and then
of naphthaline, especially the latter. Two thirty-grain doses of bis-
muth, following several drachm doses of sulphate of magnesia, seem to
have arrested the diarrhea completely.

From this time on her recovery was progressive, but slow. Her
mental condition especially was clouded for a considerable time, but
eventually she recovered entirely.

June 12, 1891 (six months). She saw me today, and was in better
health than she has been for years past. Her mental condition is
entirely restored.

Remarks, — There are several interesting features in this case
which demand attention. First, the pathological condition.
From the middle of the small bowel down to the ilio-cecal valve,
the lamen of the bowel was diminished to less than one-half the
caliber of the upper portion, whereas the large bowel was dilated
very greatly with gas. Neither the constricted half of the small
bowel nor the dilated large bowel contained any fecal matter, only
a few drops exuding through the two incisions made in the large
bowel, and so far as could be judged by stripping with the finger^
the contracted small bowel was equally empty. It did not, how-



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94 PB06BB8S IN MEDICAL SCIENCB.

ever, seem to be in a condition of spasm as far as coald be jadged ;
there was no rigidity or special hardness. There was no occlu-
sion at the point of sadden narrowing, nor any other extensive
constriction, but certain it was that for a week, and possibly
longer, no peristaltic gurgling had been heard, nor, from the
absence of any fecal matter, had any peristalsis probably existed.
My opinion, prior to operation, was that most likely, in spite of
the patient's age, there was invagination at the ileo-cecal valve,
or, possibly, appendicitis. Her mental condition was such, how-
ever, that all the subjective signs were doubtful, and even the
objective signs, such as tenderness, etc., were very difficult to
establish. I have never before seen apparent arrest by so sudden
a contraction of the small bowel and the dilatation of the large
bowel without assignable cause.

Whether there was any sapremia as a result of the continued
presence of fecal matter in the bowel and absorption of the
ptomaines of decomposition, will always be doubtful, but it seems
reasonable to suppose that this was the cause of the mental and,
to a large extent, of the physical condition. The evidence of this
rests on the horribly fetid discharges which took place soon after
the operation, with the simultaneous clearing of a very foul tongue,
the disappearance of a very fetid breath, and the betterment of
her mental condition.

Secondly, the laparatomy was entirely exploratory, and the
case shows the wisdom of it. The laparatomy was done to make
a diagnosis, as well as to institute such treatment as the conditions
found would warrant. The case shows also the wisdom of small
incisions in the bowel, incisions which can be perfectly well made
and closed by any of the ordinary intestinal sutures, rather than
making punctures and leaving them to heal without sutures. The
distended large bowel was relieved of its tension and resumed its
function, whether by the stimulus of the handling and washing
out of the belly-cavity with hot water, or the reestablish ment of
the peristalsis of small intestines, I cannot say. Probably each
one of these factors had some influence in bringing about these
results.

In closing the intestinal incision I used Cushing's continuous
right-angled suture, as shown by him in the Boston City Hospital
Reports for 1889. I think it very easy of application and very
speedy and satisfactory. I did not use the rather complicated
method he described of securing the two ends. The first end I



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SUBGEBT. 95

simply tied in an ordinary knot and the last end I slipped through
its own loop two or three times and cat it off short.



Joseph Pbice, (Virginia Medical Jlfon^A/y, August, 1893,) in a
lecture before the Post-Graduate School, of Chicago, discusses the
Post-operative SequelsB of Pelvic and Abdominal Surgery. He
divides his subject into three headings, viz. :

1. Post-operative Sequela; Due to Complications Induced by
Delay in Operating.

2. Complications Induced by Faulty Work and Methods.

3. Sequels which may be said Naturally to Follow any Serious
Surgical Procedure of the Nature Under Consideration.

The writer regards delay in operating to be at once " the bane
and danger of all pelvic and abdominal surgery — baneful to the
surgeon and dangerous to the patient." Pus is to be invariably
removed as soon as detected. Equally soon should all tumors of
the uterus be extirpated. These conditions not only become worse
themselves with time, but induce other and dangerous diseases,
such as inflammation in adjacent organs, and adhesions, which
latter may only precede gangrene of the bowel. In such cases,
intestinal surgery must be viewed from two standpoints, viz. :
'* Both in the light of operative complications, and of being indi-
rectly the cause of post-operative complications and sequelsB. Its
presence as a complication of the original operation for the
removal of the pus-tube is incident to delay in the original opera-
tion, and is a necessity on account of this delay. Without it, the
operation, as at present necessitated, would be a failure or a very
bleak success." In such cases, after-trouble is unavoidable, (such
as stenosis following gangrene, adhesions, hernia, fistula, etc.,) and
must not be laid at the door of the operation, but to the delay
which made conditions over which surgery could not completely
triumph.

The same reason applies to uterine tumors which have been
allowed to grow and adhere to important organs to such an extent
as to make their extirpation diflS cult and dangerous and some of
the sequelsB of an almost irremediable character.

The writer's words upon the complications due to faulty work
and methods should be read and re-read by every youthful and
many experienced operators in pelvic surgery. These sequelse are
many. Here are some of them :

1. Adhesions due to irritant irrigating fluids.



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96 PROGRESS IN MEDICAL SCIENCE.

2. Adhesions due to imperfect handling.

3. Tears in the omentum neglected and causing subsequent
intestinal strangulation.

4. Unnecessary destruction of the peritoneum.

5. Imperfect breaking up of adhesions between not only parts
removed and those which remain, but also those between all
remaining parts otherwise healthy. (Failure to do this is a fertile
cause of bowel obstructions, resulting fatally in cases that would
otherwise recover.)

6. Faulty handling of hemorrhage. (The writer recommends
the use of silk rather than catgut, torsion of smaller arteries, avoid-
ing the Trendelenburg position, which often leads to the over-
looking of oozing and indirect leakage.)

7. Improper drainage. Dr. Price speaks in no uncertain tone
regarding the use of drainage. He believes in it thoroughly, but
in its simplest form, viz. : a small glass drainage-tube, reinforced
with a long-nozzled syringe.

8. The use of big and unnecessary ligatures, which act as
foreign bodies, and cause fistula.

9. The leaving behind of removable diseased organs or condi-
tions, such as vaginal puncture for pus in the tubes and vaginal
removal of diseased organs.

10. Ventral hernia, from too early rising, too early laying
aside of the bandage, or foolish physical exertion, such as dancing,
riding, etc.

The writer concludes his admirable address by referring to
some after-conditions of operations which may naturally be
expected. He warns his hearers that the phenomena attending
removal of the appendages varies in individual cases. Some enjoy
immunity from discomfort, others suffer with the phenomena
attending the menopause for a long time. Again, in certain chronic
cases, pain and discomfort persist for a long time, so that the
operator must be careful not to promise certain and speedy relief.
As the writer puts it : " Miracles are not to be expected here ;
neither is it fair to promise them. The same careful consideration
of all the probabilities of the case should be here weighed ; the
same honest expectation of life and health afforded — no more, no
less."



Dr. Lee, {Philadelphia PolycliniCy July, 1893,) in a lecture upon
Massage in the Treatment of Sprains and other Injuries about



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SUBGBBY. 97

Joints, discusses this important class of injuries in a way that can-
not fail to be of interest and profit to the general practitioner as
well as tlie surgeon. Remarking that both Nelaton and Gross
believed that a large majority of cases requiring amputation result
from sprain, Dr. Lee adds that, with equal truth, a large propor-
tion of acquired distortions can be ascribed to a similar cause.
The nature of a sprain and the conditions following are then
clearly given, and from these are deduced the indications for treat-
ment. These are (1) relief of pain ; (2) restoration of the lym-
phatic, arterial, and venous capillaries to their normal condition ;
and (3) absorption and removal of the effused material.

Given a case seen immediately after accident, the first indica-
tion is met by placing the part in water, as hot as can be borne,
and beginning massage at once. The writer gives some timely
observations upon the pronunciation of the word << massage," and



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 10 of 78)