Copyright
J. A. (Joel Asaph) Allen.

Buffalo medical journal online

. (page 8 of 78)
Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 8 of 78)
Font size
QR-code for this ebook


muscles to any irritation that might be made. The heart was pulsa-
ting at the rate of from forty to fifty per minute. The usual methods
of artificial respiration were resorted to in all, to the extent of
introducing the catheter into the trachea, and thereby insuring a
passage of air into the bronchial tree and alveolar spaces. That
the air did penetrate, was further evinced by the slight crepitus,
easily heard during compression of the chest in the expiratory
part of the respiratory act. Artificial respiration was maintained
until the heart ceased beating ; until it ceased to respond to the
stimulus presented by the areation of the blood by the artificial res-
piration. In none of them were there any external evidences of
pathological conditions, development having been well accom-
plished. The umbilical cords were not without the normal limits,
and it was only when the placenta was reached that there were any
conditions present that might possibly account for the peculiar
condition of the children. Here in all three of the cases were there
found blood-clots, occupying the placental surface in over half of
its area. These clots were well formed, intimately attached to the
placental tissue, smooth upon the uterine side. There was noth-
ing indicating the fact that the clot had been torn from the uter-
ine surface, but rather that placental separation had taken place
and the clot had formed and become adherent to the placental
tissue. So far as the mothers were concerned, they were in aver-
age good health — the first, primipara; the last two, multipara. The
character of labor was not over twelve hours' duration, and pre-
sented nothing attracting special attention, outside of the fact
that the first was one of those cases which might be termed << pis-
ton rod" form of delivery, in that the head was forced down to the



Digitized by



Google



uulbebt: intea-uteeine asphyxia. 67

perineam at each pain, and upon the diRappearance of the pain
promptly receded to the brim. This was frequently repeated, so
much 80 that I seriously contemplated applying the forceps, and
regret that I did not, in order to enable the head to catch beneath
the symphysis. The character of the pains was not sustained and
vigorous in any of them, but rather more short and inefficient. In
none of these cases was chloroform used; and in only one — the first
— a rectal injection of twenty grains of chloral given during the
first stage. The element of compression upon the head was not at
all excessive and would not have attracted attention.

In the last two cases there was no pulsation appreciable in the
cord ; the first case I have no record of this fact. The children
were separated from the mothers immediately, and in the first a
small amount of blood was permitted to flow through the severed
end of the cord. Unfortunately, in none of them did I obtain a
post-mortem, and, as before stated, the only anatomical lesion that
I can testify to is the presence of the blood-clot occupying an
extensive part of the area of the placental surface. There was
only a moderate amount of the amniotic fluid following the birth
of each child. In the first two cases, dilatation was well advanced
before the membranes ruptured ; in the last case, rupture occurred
at the beginning of dilatation. The points for consideration in the
above are :

(a) The presence of the fetal heart pulsations so soon before
delivery.

(b) The normal character of the labor.

(c) The extreme pallor and relaxation of the child, at birth.
{d) The presence of the cardiac pulsation after delivery.

(e) The absence of any attempt upon the part of the child to
perform the respiratory act.

(/) The response upon the part of the heart to the benefits
of accomplished artificial respiration.

(g) The anatomical conditions presented at the placenta.

The presence of the condition "a" is, and justly can be, con-
sidered one of the evidences of safety, as far as the child is con-
cerned. That the conditions presented in the subsequent develop-
ments in these three cases could be accomplished in one-half hour,
is a possibility, but hardly a probability. The practical conclu-
sion to draw at this point is, that there was going on, or had been
going on, a gradual separation of the placenta from the uterine
surface and the development of this clot without any outward



Digitized by



Google



68 HULBKRT : INTEA-UTERINE ASPHYXIA.

manifestations in the way of an accidental or concealed hemor-
rhage. There were none of the symptoms presented by the
mothers which are usually considered to indicate this state of
affairs. The only variation from the normal was, as stated
before, the evident weakening of the force of the fetal heart
action. I testify to this as a fact appreciated by me in the repeated
examinations made from the beginning to the time when this loss
of strength became apparent. The conclusion we draw here is,
that the possibility of placental separation may be determined by
the evidences of weakening fetal heart vigor developing during
the course of delivery, even though there may be no external evi-
•dences presented in the way of hemorrhages, or subjective symp-
toms in the way of sudden or severe localized pain. It simply
-emphasizes the necessity for judicially repeated examinations in
legard to not only the presence of the fetal heart, but the charac-
ter of its action and comparisons from one examination to
another.

Under " ^" we have classified those patients as presenting what
may be termed normal deliveries, and yet there was an element of
incompetency and inefficiency in the character of the uterine con-
tractions, in that unnecessary repeated efforts were made to attain
the usual and necessary results. It is possible that in this fact of
inefficiency in the character of the pains lies an explanation for
the premature placental separation, for it is well known that
inefficiency in uterine contractions only too frequently means
localized unrythmical areas of contraction, and during the cours'j
of the delivery these more or less localized areas in contracting
have so disturbed the placental attachments as to break and
separate them ; for it is easy to conceive that the area of contrac-
tion may possibly occupy one particular part of the placental
surface, whereas the area of relaxation may occupy another and at
the same moment, and that necessarily there must be more or less
irregular traction brought to bear upon the tissue, insuring adhe-
sion of the placenta to the uterine wall.

Certain it is, that as far as the normal concept is concerned,
the element of compression or long continued compression cannot
be accepted as contributing to the conditions presented by the
child. The conclusion that we draw here is the positive influence
of irregular areas of contraction, being a contributory cause to
premature placental separation; and taken in conjunction with the
conclusion drawn from the conditions presented in "a," may be



Digitized by



Google



UULBEBT : INTRA.-UTERINE ASPHYXIA. 69

of considerable importance and value in the future conduct of the
delivery.

The conditions presented under <^ c," to my mind, simply
exhibit the final stage of asphyxiation, in that the vigor and vital-
ity of the child has become so profoundly affected that the nerve
centers failed to respond to the usual stimulus, all sufficient in the
healthy living child at birth ; and we have simply left enough
vitality for the time being to perpetuate and continue the heart
action. I conceive that so far as the nervous system is concerned,
it is a general systemic condition, and its manifestation is only too
apparent in the extreme and persistent pallor and profound and
permanent relaxation of the voluntary muscular system. I do not
see where we can account for this state of affairs on any other
hypothesis than that it was asphyxia, gradually brought about by
the placental separation. This, possibly of itself, would not be
sufficient to accomplish such a profound degree of asphyxia as to
be the cause of the conditions presented, but with this lesion pres-
ent, with this much support taken away from the child in utero,
and the presentation of the subsequent compression which, under
ordinary circumstances, would be natural and normal, and this
continued only within normal limits, is sufficient to consume the
lowered vitality that must recessarily have been present, evidenced
in the change of the character of the fetal heart pulsations, and
would accomplish the conditions presented at birth.

The conditions presented under " 6 " clearly establish the fact
that somewhere there was resident and remaining, vitality suffi-
cient to carry on cardiac action, and let it be understood that the
character of this cardiac pulsation was what would be considered
good and sufficient for the propulsion of the blood from the sys-
temic channels. To those who have witnessed this state of affairs
and examined the child in this condition, whose heart was acting
at the rate usually observed — of from forty to fifty per minute —
steady and regular, it can be understood that my purpose at resus-
citation would be strengthened, and that I should feel a certain
degree of hope and look forward to a happy termination, providing
successful efforts were made to introduce air into the lungs. This
hope was readily increased by responses, positive and heartily
appreciated after each stance of artificial respiration, for almost
immediately did the cardiac pulsations increase in rapidity, and «
finally attain a normal rate and vigor, yet at no time in any of
these children was there the slightest response toward a relief of



Digitized by



Google



70 IIULBEBT : INTRA.-UTERINE ASPHYXIA.

the conditions mentioned under "€," namely, an absolute want
of respiratory effort on the part of the child. The only positive
conclusion or deduction to draw from these two conditions being
present was, that, as far as the respiratory centers were concerned,
irritability had been absolutely annihilated, and the nerve tissue
had reached that state where the possibility of functional activity
was gone. Certainly, with the conditions presented by "t^" and
"/," there was somewhere remaining, in the organism of the child,
sufficient vital energy, or nerve centers sufficiently active to respond
to the invigorating influences presented by the artificial respira-
tion. Exclude, as we must, the respiratory centers from any part
in this evidence of remaining vitality, we are narrowed down to
those situated within the cardiac muscle itself ; for, bearing in
mind the fact of the dual function of the pneumogastric, it is
hardly rational to conclude that the invigorating infli^ence could
be carried so far distant as it would necessarily have to be in order
to influence the cardiac centers situated at the origin of this nerve.
For, if the nutritive changes have been so profound as to influence
the respiratory centers, certainly the presumption would be that
the not far distant cardiac centers, or those centers presiding over
the cardiac action in the origin of the pneumogastric nerve, would
remain active. Hence, the only possible explanation we can offer
is, that the artificial respiration aerating the blood, which must
necessarily return into the heart, thence through the aortic valves,
thereby insuring fresh arterial supply to the cardiac tissue through
the coronary arteries, and in this way maintaining the cardiac
activity. That this could be long continued with the assumed
conditions at the more distant centers, is not at all probable, and
the time must sooner or later come when, even here, the nutritive
changes must take place which established the molecular death of
the child.

Somatically, so far as the systematic nerves and muscular sys-
tems were concerned, the children were dead ; molecularly speak-
ing, they were living — only at the heart. It has occurred to me,
and probably will to those who peruse this report, that the proper
explanation of the peculiar condition of these children is, that
there was a fault or lesion in development, and that, regardless of
any other influences, these children would probably have pre-
sented the same conditions, and the results would have been the
same, whether the placental attachments were maintained or not.
This is simply jumping at conclusions, and is, scientifically speak-



Digitized by



Google



HULBEBT: INTRA-UTKBINE ASPHYXIA. 7l

ing, at variance with the testimony at hand. True it is that we
have none of the evidences that might possibly be revealed in a
post-mortem and microscopical examination of the parts concerned
in the conditions presented, and it is only the want of this that
prevents me from speaking authoritatively in regard to the proper
interpretation to place upon the phenomena presented. Notwith-
standing in oar search for the truth, scientifically speaking, we
can only be gnided by the evidences and testimony at hand, at the
same time freely confessing what we lack in order to establish
beyond peradventure that we have arrived at the truth. Hence,
our interpretation and conclusion is, that the conditions presented
under ** <3?," " e," and "/," are to be accounted for as explained
above. Finally, under "^," do we present the only single tangible
evidence as the cause to the effects attained. How long a fetus
in utero can live, and how much of the area of the placental tissue
is absolutely necessary for this life, can justly be a subject for
differences of opinion. Mathematically speaking, if one-half of
the area of the placental attachment becomes inoperative, one-half
of the vitality of the child up to the normal standard should
be sacrificed ; two-thirds in area of placental separation would
reduce the possibility of a normally sustained vitality two-thirds.
In these cases all of two-thirds of the placental area was involved;
hence, the child probably only had one-third of its capacity to exist
present during some part of the process of parturition.

The moment at which this separation is begun is undetermined.
The only point that c;an be given in evidence is, that only up to
within one-half hour of delivery were there positive evidences of
some disturbances having taken place, influencing the functional
vigor of the fetal heart. After that time up to the point of deliv-
ery was probably brought to bear the final impressions which were
sufficient to culminate in the conditions observed. Artificial res-
piration was continued for from one-half to three-quarters of an
hour, when the heart ceased beating. The practical conclusions
and lessons to draw from the foregoing, or possibly the query to
propound : *' Is it possible to appreciate the conditions necessary
to establish intra-uterine asphyxia, and the best and probable
means to resort to in order to save the child when these conditions
become operative, or reasonably inferred?" The only symptoms
heretofore in my experience which I have felt presented the possi-
bility of this condition, were those described to accidental or con-
cealed hemorrhage, namely, more or less persistent loss of blood



Digitized by



Google



72 HULBEBT : INTRA.-UTBRINE ABPUITXIA.

through the vagina, or sudden and severe localized pain at that
part of the uterine globe at which the placental souffle presents its
greatest intensity, with more or less faintness and prostration
manifest upon the part of the mother. Evidently, from the above,
we must acknowledge that intrauterine asphyxiation is a possi-
bility without evidence of this character, and the only symptoms
which may suggest the presence of this danger may be a gradual
developing cardiac weakening in the fetal heart sounds, associated
with incompetency and irregularity in the uterine contractions,
and to the character of the sounds of the fetal heart must we
largely turn for evidence. Not only must there be a disturbance
in the vigor of the cardiac sound, but also in the rate, and it ration-
ally must present the same characteristics as we would expect in
asphyxia ex utero, namely, a decrease gradually and steadily in
the pulse rate. Hence, where we find during the course of parturi-
tion a gradual weakening fetal heart, with a decrease in the rate
associated with incompetency and inefficiency of uterine contrac-
tions, although there may be absent any other visible signs of pla-
cental separation, we are justified in assuming such condition to
exist. Certain it is, if we have associated with this condition of
the fetal heart the usual symptoms of placental separation, the
determination of the possibility, or the presence of intra-uterine
asphyxiation, need not be a difficult problem ; for, if the objective
evidences were present, such as hemorrhage, sudden localized pain,
faintness or prostration, etc., and accompanying this we found,
synchronously, a weakening in the fetal cardiac sounds, accompa-
nied with a gradual decrease in the rate, there need be little hesita-
tion in determining that there has been sufficient placental separa-
tion to materially influence the vitality of the child. There is one
other point which was noted in the symptomatology, but which I
am not sufficiently satisfied with to offer any more than a sugges-
tion toward future attention and observation, and that is change
or modification in the placental souffle, whether this sound is pro-
duced in the sinuses, situated in the uterine tissue proper, or
whether it is produced in that part of the maternal circulation
which dips down and comes in contact with the placental tufts
related to the fetal circulation, may possibly be an open question,
but the evidences at band clearly show that as soon as placental
separation is accomplished, the placental souffle disappears.

Now, this may be due to the fact that part of the maternal cir-
culation, more properly within the placental tissue, is entirely sep-



Digitized by



Google



HULBERT : INTRA-UTERINE ASPBTXIA. 7?

arated ; the uterine part having become condensed and contracted^
and more or less occupied by blood-clots, would present difficul-
ties in determining at which of these sites the souffle was genera-
ted. Necessarily, where there would be a placental separation,
and a want of a more or less continued hemorrhage from the sep-
arated surfaces, we would probably have the same conditions
accomplished, not only in the placental part of the maternal circu-
lation, but in a large degree also in the uterine part, in that the
blood channels in the placental portion would be separated in the
same manner as would occur at delivery, thereby being cut off
entirely, the blood ceasing to circulate through them ; whereas, in
the uterine part, there would occur the same tendency towards
thrombosis, and from the fact that condensation in area did not
occur on account of the distension of the uterine walls remaining,
this clot would necessarily be more extensive and must necessarily
penetrate more or less deeply into all the sinuses, which had be-
come inoperative on account of the separation, so that rationally
we should infer that there ought to be some modification in inten-
sity, at least in the placental souffle. In the second case, it seemed
to me as though I appreciated a modification of this character, but
from the other fact that the physics of the condition were fully
recognized, and from the fact that no record on this point i»
made in the first and third cases, I am slow to say positively that
any modification existed in this particular phenomena. I simply
present the physics as they appeared to me, and call attention to
the possibility, and trust it may serve to elucidate the fact of the
modification in the intensity of the placental souffle, if such does
exist. It is to be hoped that others who may have had experiences
of this character, or who may in the future meet these conditions,
will consider the explanation of intra-uterine asphyxia of suffi-
cient importance to make a careful and accurate report of all cases
that may come under their observations. We simply in the fore-
going desire to call attention to the conditions, and, as far as we
are able, present testimony so far obtained, and give reasons <' for
the faith that is in us.''



The investigations of Drs. Abbott and MoCormick, of the Johns
Hopkins University, shows that a solution containing seven per
cent, of acetic acid is more effective as a germicide than bichloride
of mercury. — The WomarCs Medical Journal,



Digitized by



Google



14 DUYLK : AKPUTATION OF BOTH LEGS IN AN INFANT.

DOUBLE SYNCHRONOUS AMPUTATION OF BOTH LEGS
IN AN INFANT— RECOVERY.

Bt GREGORY DOYLE, M. D., Syracuse, N. V

On the 8th day of April last, Ambrose MuUin, the infant son of
Michael MuUin, of 1016 Willis avenue, Syracuse, N. Y., was run
over by an electric car, and suffered what was thought at the time
fatal injuries. Both legs were crushed off just below the knee,
and his head was so severely injured as to produce cerebral con-



cussion, large, dark tumors being produced on the forehead and
occiput. He suffered also severe contusions over the sternum.
About an hour after the accident I reached the little patient, and
found him in a complete stupor and very anemic from the immense
loss of blood. By hypodermic stimulation he rallied sufficiently to
warrant me in removing the mangled members. The amputations
were made carefully, but rapidly, as I knew celerity to be a strong
element in possible success. During the operation hypodermic
stimulation was persistently kept up, and we had the pleasure of
seeing our almost hopeless patient slowly but steadily rally from



Digitized by



Google



IVOWLAMLkM : UTJCaiMB FIBROIDS. 75

the shock. He made a good recovery, without any noteworthy
incident. The stumps healed rapidly, with good cushioned ends,
«o that, hereafter, artificial limbs can be worn with comfort, and
the child may grow up to be a useful and honorable citizen. At
present he is able to go about the house and yard on his knees,
and is healthy and cheerful, as the above photograph indicates.

The child was born January 10, 1891 ; two legs were amputated
April 8, 1893 ; his age at the time of the operation was, therefore,
a little over two years. As far as I can learn, this is the youngest
child on record that has recovered from a synchronous amputation
of both legs.

I was ably assisted in this unusual operation by Drs. J. W.
Knapp, N. L. Mulvey, Joseph Roth, and Gregory Reidy.



TTERINE FIBROIDS: SOME FACTS IN REGARD TO
THESE NEOPLASMS.^

By henry d. ingraham, m. d..

Professor of Diseases of Women and Children, NiaK^ra University, Buffalo, N. Y.

Although several theories have been advanced with reference to
the growth and development of these neoplasms, yet our knowledge
of their etiology is yet very imperfect. That they are of frequent
occurrence no one will deny, one writer claiming that one-fifth of
all women over thirty-five have fibroids. They occur in all classes,
being fully as common in the wealthier as in the poorer class.
The general belief that they are more frequent in the colored race
remains to be proven. While the greater number of them may
^xist unnoticed, many of them are of more serious import, often
causing much discomfort and suffering, and frequently leading to
-conditions which result in the death of the patient.

Any woman who has a uterine fibroid, even though it does not
trouble her, or inconvenience her in any way at present, may, at
^Dv time, develop not only unpleasant and uncomfortable symp-
toms, but even dangerous ones. These growths are a perpetual
source of danger.

Whatever may be the seat of the fibroid, it provokes a constant
but varying degree of uterine hypertrophy, and, hence, almost
numberless and varying symptoms. The location and shape of the

1. Read at the meeting of the Central New York Medical Association, held in Roch-
ester, June 16, 1893. *



Digitized by



Google



76 IN6BAHA.M : UTERINE FIBROIDS.

growth frequently are greater sources of discomfort and danger
than the size, owing to its interference with the functions of the
adjacent organs. Often a small tumor produces much more dis-
turbance than a larger one. The changes and alterations that
may take place in the tumor itself are numerous, but I shall men-
tion only a few of them.

Formerly, it was thought that at the menopause these growths
diminished in volume and underwent a senile involution and
atrophy. No doubt, this change occurs in the greater portion of
these neoplasms, yet others suddenly begin to grow or develop



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 8 of 78)