Medical Society of the State of North Carolina. An.

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harmless, so far as known. Their number varies greatly and, in my
opinion, has very limited significance as to the sanitary quality of water.

2. Bacteria of animal origin, most of which also are nonpathogenic,
but whose presence can be regarded only as a pollution. The most wide-
spread of these bacteria, and those which may be regarded as the type,
are the colon bacilli. These organisms are probably nonpathogenic ex-
cept to infants, even when swallowed in large quantities. Natural cow's
milk, as it reaches the human consumer, contains many thousands more
B. coli per cc. than any drinking-water, and we all consider such milk a
good food. The coli in milk, however, have a bovine origin, while in
drinking-water they may come from human excreta. Human colon
bacilli are an indication of danger because they are liable to be accom-
panied by specific disease germs, and their presence is therefore univer-
sally regarded as the best single indication of unsuitable drinking-water.

As already stated, an analysis refers strictly to the sample itself, and
not to the source, except so far as it is truly representative.

We have examined in the State Laboratory of Hygiene more than
25,000 samples of water. About three-fourths of these have been of
public supplies, the others of private wells and springs. I regard the
latter as almost useless, except that we in the laboratory have been taught
a good many things. It is almost invariable that an open-top bucket well
has water with abundant B. coli, and that water from a deep bored well
contains only harmless natural water bacteria unless contaminated at the
surface. The health officer or physician should be able to tell more about
a domestic supply from an examination of the local conditions than can
the bacteriologist and chemist by a laborious analysis, especially if they
have not exact knowledge of the source of the sample.



PATHOLOGY AND BACTERIOLOGY. 203

The large majority of the analyses of the State Laboratory of Hygiene
were of samples from the various public supplies in the State. Here we
have a kno^\ai source and a regularly examined water. Each variation
in chemical determination may have a meaning and may be compared
with the preceding record. The source of municipal supplies is most
often a surface stream, and while gross sewage pollution can be pre-
vented, such streams habitually carry some bacteria of human origin.
In order to obtain a safe, palatable, and satisfactory water it is necessary
to use a system of filtratiou, supplemented by dosage with chemicals. It
is no simple matter to run such a plant and keep up a daily efficiency.
The laboratory examination is the best and, aside from the appearance
and taste of the water, is the only means of ascertaining the quality of
the filtered water. In contrast to the examinations of private supplies,
which are comparatively useless, the State Laboratory of Hygiene be-
lieves that much improvement has been accomplished in the public sup-
plies.

In addition to the regular examinations we have for months been mak-
ing comparative analyses of raw and filtered waters from various plants,
and we hope to utilize the data obtained for further improvement.

The practical ideal of each public supply should be a palatable water,
free from bacteria of animal origin at all times, and one in which no
trace of alum, and no taste nor odor of chloride of lime, should reach the
consumer.

I have striven to make clear that a laboratory examination of water
should be merely one part of water investigation, and that it is useless,
in the great majority of cases, to hope to trace the origin of typhoid
fever by an examination of water; but the necessity for a safe water
supply remains one of the first requisites for the public health.



OBSTETRICS.

THE FUNDAMENTAL PEINCIPLES INVOLVED IN
OBSTETEIC SUEGERY.



R. D. McMillan, M.D., Red Springs, N. C.



It is not my purpose, in the presentation of this article, either to dis-
cuss the merits and accomplishments of the brilliant leaders, past and
present, whose skill and judgment have brought honor to this branch of
medicine, or to deplore the mistakes that have been made in the name of
surgical obstetrics by some enthusiasts whose greatest handicap is in-
experience and others whose place is not properly in surgery or obstet-
rics, but to bring before you for thorough consideration a few important
facts regarding this subject from the viewpoint of a general practitioner.

As every puerpera is a wounded woman, it is best to regard every
obstetric case as a surgical case. It is good surgery to limit the operative
wound, and avoid injuring tissues as far as possible. The same is
urgently indicated in all obstetric work ; so it is a surgical case with more
than the usual surgical aspects. Like the surgeon, the obstetrician should
have a clear knowledge of the patient's condition, especially of the heart,
lungs, kidneys, and blood. He must know accurately what is going on
during labor ; he must be thoroughly acquainted with the mechanism of
that particular labor, the strength the patient may bring to bear to with-
stand the ordeal, the strength of the powers of ex])ulsion, the greatness
of the resistance encountered and the relation between them. He must be
aware of all possible complications and the particular ones likely to arise
in this particular case; to know how, if possible, to prevent them, and
treatment, should they arise. We must practice the strictest asepsis and
antisepsis the latest standards demand, and forever keep in mind that the
primary purpose of conception is reproduction, and that obstetrics is suc-
cessful only when we deliver a live, healthy child from an unmutilated
mother. If we practice this thoroughly and conscientiously we will begin
a new era in obstetrics and bring this branch of medicine into a field
more inviting to the ambitious physician, as well as conducive to a more
rapid advance in both its science and its art.

Eegardless of the surgical progress which obstetrics has made in the
past few years, we have been unable to define distinctly the fields belong-
ing to csesarean section, high forceps, version and extraction, or even
craniotomy and pubiotomy, and it is here the judgment of the obstetri-



OBSTETRICS. 205

cian is put to the test, when in the course of his study of a case he is
determined that some method of delivery is imperative in the interests of
mother or child, or both. It is here that there are no situations in medi-
cine or surgery that require broader knowledge, more logical reasoning,
for their control than do these problems ; at the same time we must
remember the most important indication in all obstetric work is to inter-
fere only when the mother or child is in danger. It is art to enter only
when Nature fails.

Except for the few cases in which hydrocephalic heads and monsters
are encountered, craniotomy and the other mutilating operations on the
child have no place in obstetrics, except on the dead foetus.

Pubiotomy, to my mind, is barbarous, though held by some as having
a limited field. If patient be slenderly built, she may recover sufficiently
to walk, but never with any degree of ease or comfort; if stout, she is
more or less a cripple the rest of her life.

Csesarean section in this day of advanced surgical progress is being
robbed to a great extent of its former terrors of infection and is no longer
considered a last resort procedure of utmost danger. Statistics still show
a rather high mortality rate ; yet, if these cases are carefully analyzed
they will show the bulk of the fatalities can be traced to careless obstetri-
cians who allow their cases to drag until patient is exhausted, or becomes
infected, finally sending them to the surgeon to do the best he can.
Unquestionably many women and babies have been saved by this pro-
cedure that would have been hopelessly lost by any other operative
means ^ and it is true that many have died by the very means intended to
save their lives ; but a death following operation is the exception, if done
in time. Still there is a wide range of opinion as to the indications for
its use.

In a general way caesarean section is indicated in marked contracted
pelves, abnormally large child, and some cases of placenta previa, espe-
cially the central variety, when dilatation and delivery cannot be properly
effected in the presence of violent hemorrhage. The mortality, maternal
and foetal, is less in caesarean section than in placenta previa. This may
seem a bold statement, but, nevertheless, it is true. In the various toxe-
mias of pregnancy, where rapid evacuation of the uterus is imperative in
the face of a tightly contracted cervix so often encountered in a primi-
pera, it eliminates forcible dilatation of the cervix and the trauma inci-
dent to such a procedure both to mother and child. It is also indicated
in occlusion neoplasms, such as cancer of the cervix and fibromata of the
lower uterine segment. It is in this class of cases the field of caesarean
section is increasing. Here again I lay especial stress on the general
practitioner who undertakes to deliver a woman, to study his cases before



206 NORTH CAROLINA MEDICAL SOCIETY.

the exi^ected date of labor. If you find contracted pelvis, unless it is
very marked, our decision for operation sliould be based on the degree of
contraction, size of child's head, and its reducibility, for the purpose of
determining if the patient in question can be delivered safely at home,
or is the hospital to be preferred, as the best hospital facilities are none
too good and trained assistants are very essential.

It is upon the general practitioner, especially in our rural districts,
the grave responsibility rests of seeing and recognizing these conditions
early enough that something may be done to save these valuable lives.
It is too late after they have become exhausted, infected, or injured by
the injudicious attempts at delivery by the hand or forceps. I will go so
far as to say that every general practitioner should be able to form at
least a fair estimate of the amount of contraction, as it is far easier to
measure a contracted pelvis than a normal one. Such an estimate should
be within the skill of an ordinary general practitioner, on whom so many
lives are dependent. If not, he should sink to the level of the ordinary
ignorant, meddlesome midwife.

While the enlargement of the field of this operation marks one of the
advances made in modern obstetrics, it does not mean that the operations
of high forceps, accouchement force, version and extraction, the opera-
tions that have served us so well in the past, are to be relegated to the
background. They will continue in their place as long as women have
babies.

The vital importance of a diagnosis of extra-uterine pregnancy cannot
be too greatly impressed on our minds, because a failure of a diagnosis,
in a great many cases, means a fatal result to the patient. With a patient
complaining that she thinks she is pregnant, or did a while think she was
pregnant, with some menstrual disturbance, as she has missed one or
iiiore periods, or they are irregular, with cramp-like pains in lower abdo-
men at intervals of several days or weeks, following the pains she some-
times has a very dark bloody discharge, and considerable time has elapsed
since the birth of her last child, don't be misled by a hasty diagnosis of
abortion, or threatened abortion, but keep in mind this form of preg-
nancy until the pelvic examination clears the diagnosis ; being very care-
ful in making pelvic examinations, for fear of rupturing the impregnated
tube. Most cases, however, do not come under observation until after
rupture. Then what is more characteristic than the sharp, agonizing
pain, severe enough oftentimes to make patient faint, accompanied by
nausea, vomiting, thirst, great restlessness, subnormal temperature, and
collapse. These, together with an internal examination, tell the tale, and
will deliver your patient at the very threshold of death in a very short
time if proper treatment is not instituted.



OBSTETRICS. 207

What is the proper treatment? These women, Avithout exception, are
desperately ill from the moment of rupture, and a great many recover
under "watchful waiting" treatment. A woman may live a long time
with a ruptured ectopic pregnancy in her abdomen — may be months,
possibly years — and recover; but, in the writer's opinion, treatment is
exclusively surgical. While recovery in some cases may eventually take
place under expectant treatment, the larger proportion Avill be saved by
prompt abdominal section and removal of the affected tube and its con-
tents. The rupture case is one of hemorrhage, and to arrest the bleeding
here is as imperative as to secure the severed ends of blood vessel in any
other part of the body. The peril is too great to indulge in unnecessary
delay; therefore, the operation is clearly one of emergency, often to be
done immediately on seeing the patient and recognizing the condition,
with all the haste that is compatible with due regard to reasonable asep-
tic precautions, often under the most unfavorable surroundings.

Lastly, no matter what the degree of perineal laceration, the immediate
repair by suture is urgently indicated, unless the condition of the patient
is so serious as to contraindicate it at once. It is then sometimes advisa-
ble to wait twenty-four hours, never longer, unless the delay is for several
months. If we attend to these things promptly and properly we will
greatly lessen an immense amount of invalidism resulting from child-
birth. I venture to say at least 50% of women who have had children
bear the marks of injury, and this explains why every year hundreds of
thousands of women flock to our hospitals for the late consequences of
neglected cervical and perineal lacerations.

The conduct of labor is not a simple matter intrusted to every one.
Educate the people to know that having a child is a very important
aifair, deserving the watchful attention of a qualified practitioner, and
that even a normal confinement is worthy the dignity of the greatest
surgeon.



PITUITRIN IN OBSTETRICS.



C. H. PuGH, M.I)., Stanley.



The recent successful introduction of the pituitary extract into the list
of drugs used by the obstetrician and the amount of discussion in regard
to its advantages and disadvantages is my reason for presenting this
paper.



208 NORTH CAROLINA MEDICAL SOCIETY.

After having promised the chairman of this section (Dr. Garrison) to
write an article upon this subject, I realized that my experience had been
too limited to add anything from a standpoint of statistics, for the con-
clusions I have formed are based on a series of fifty cases occurring in
general practice. This is a small number, indeed; but it has been so
uniformly successful in these cases and so practical is the subject that
I feel justified in discussing it before this society.

As is v^^ell known, the pituitary gland consists of two lobes, an anterior
and a posterior, but only the posterior concerns us in this paper. Ex-
tracts of this lobe cause a rise in blood pressure and a slowing of the
heart beat. It causes a dilatation of the renal vessels, an internal secre-
tion of the urine, a dilatation of the pupils, and stimulates the muscu-
lature of the uterus, intestines, and bladder. It has been called a "utero-
vasculo-heart tonic." However, the drug has achieved its greatest suc-
cess as an oxytocic, and there can be no doubt that it is the most valuable
agent we now possess for that purpose.

The preparation I use is Park, Davis & Co.'s "Pituitrin," put up in
1 cc. ampoules. The drug is administered intramuscularly, usually in
the muscles of the arm. Uterine contractions begin in from three to
twelve minutes after injection and continue from forty to sixty minutes.
The contractions are increased in intensity and the interval diminished.
In other words, it increases the power and frequency of ordinary labor
pains.

Pituitrin is of decided value in uterine inertia, primary or secondary,
and in post-partum hemorrhage. Its greatest value is in the uterine
inertia occurring in the second stage of labor. Here, in many instances,
its action is little short of wonderful. Many women are able to dilate
the cervix, but make no further progress, or may fail to engage a head
in a slightly contracted pelvis, or may partially advance the head through
the birth canal, or may even bulge the perineum, and then succumb to
exhaustion. For one reason or another it is usually the second stage of
labor which has brought about exhaustion, so fatal to our hoped-for
spontaneous deliveries. It is in these cases that pituitrin shows its
remarkable qualities, terminating sometimes in a few minutes cases
which have dragged on for a long time with no indication of advance-
ment, or quickly changing a slow and exhausting case, with the pains
weak and far apart, into forceful, efiicient bearing-down pains. Through
its agency many of the cases that Avould linger for hours and then possi-
bly necessitate the use of instruments are terminated in a short time with
no harm to either mother or child and no more effort on the part of the
physician than the giving of an ordinary hypodennic. The result is a
lessening of the suffering and mental and physical fatigue of the mother.



OBSTETRICS. 209

The drug has a much Larger field of usefulness in nuiltiparfe than in
primiparse. In primiparas there is usually more obstruction; the tight
perineum is too easily torn to allow a rapid delivery, such as follows the
use of pituitrin. In most of my cases of primiparse, where there is an
indication of a decrease in the pains either in intensity or frequency, and
where there is good dilatation, I usually give 1/2 cc, to be repeated in
thirty minutes if the pains are not harder. This method has invariably
been attended with good results.

In the third stage of labor I am convinced that there is less hemor-
rhage after delivery in cases treated with pituitrin than in those in which
it is not used. The action lasts after the delivery of the child and tends
to prevent relaxation of the uterus. The placenta is more easily sepa-
rated, usually descending into the vagina in a few minutes, and being
expressed spontaneously or by easy pressure on the fundus. In no case
in which I have used pituitrin has there been constriction of the cervix
or retention of the placenta.

As to the toxicity of the drug, there seems to be abundant testimony
in favor of the harmlessness of the drug, to either mother or child.

Pituitrin should never be given unless the cervix is three fingers dilated
at least, except in tentative doses to stimulate the pains, because if given
in full doses sooner the severe contractions produced may cause pressure
on the foetus, rupture of the uterus, or severe laceration of the cervix or
perineum.

The drug is not indicated and should not be used in cases steadily pro-
gressing, with good pains. In such cases there is no definite indication
for artificial aid, and I do not think it right to use the drug without
definite indications. Its routine use in all cases would be a great mistake.
The drug is definitely contraindicated in any malposition such as trans-
verse presentation, in case of impassable obstruction, or where the child
is too large for the birth canal. It should not be used where the uterus
is much stretched out and thinned from a twin pregnancy, hydrocephalus,
or one that is atonic from any cause. Pituitrin should never be used in
full doses unless we can be sure of the diagnosis of the position of the
child.

I firmly believe that more damage occurs to the perineum in cases in
which pituitrin is used than in corresponding cases of spontaneous de-
livery, owing to the rapidity of the delivery in many cases. However,
when this is offset by the number of forceps deliveries from which
patients are saved, and the relief that comes to mothers who otherwise
would have long hours of physical suffering and anxiety, the balance
certainly is on the side of pituitrin.
14



210 NORTH CAROLINA MEDICAL SOCIETY.

In conclusion, pituitrin will avoid a large per cent of operative deliv-
eries when combined with careful preliminary examination and a close
observation of the progress of labor.

The third stage of labor is shortened and there is less bleeding after
the delivery of the placenta.

Its greatest field of usefulness is in the second stage of labor, especially
where there is much uterine inertia. It should not be used until there is
good dilatation.

It should not be used Avhere there is much disproportion between the
mother's ^^elvis and the child's head, or where there is serious obstruction
from any cause.

Its usefulness is limited, but is of some benefit in the first stage of
labor.

The apparent harmlessness of the drug, its easy method of administra-
tion, its satisfactory results in properly selected cases, the saving of
many patients from operative delivery, the almost immediate termination
of labor after hours of tedious waiting by the physician and painful and
exhausting labor for the patient, and the fact that one can find help in
its administration Avithout the necessity of sending for another physician
— all make a very strong appeal to the general practitioner, because he
is the man who needs just such an addition to his obstetrical methods of
practice. I consider it the most valuable agent that has been added to
our obstetrical equipment in recent years.

Dr. D. a. Garrison, Gastonia : Dr. Spears was to be here from 'New
York, to speak on "Twilight Sleep," but he wired me yesterday that he
couldn't come. I haven't anything to say, as it was a subject that I
expected to write on myself, and I decided to get him, he being an
authority; so I have no paper on the subject.

Dr. E. T. Dickinson, Wilson : I am somewhat responsible for Dr.
Morton, so I am speaking to take up time until she gets here. I am sure
that Dr. Pugh's paper was a very creditable one. I want to say a little
with regard to my experience with pituitrin. It was for more than a
year that I used pituitrin rather freely, and got regularly no results. I
had heard so many men say that it was such a splendid remedy that I
kept trying to get a case that I could get an effect in ; but it was as much
as a year before I ever got a dose to 'take effect. I wish now that I had
never found a dose, not because it is entirely out of place, but because it
is a remedy that carries too much potency and inducement. It is a
remedy that has the same inducement that making frequent vaginal
examinations has. The object of the use of pituitrin is not always for



OBSTETRICS. * 211

the benefit of the patient, I fear. The object of making frequent exam-
inations is not for the benefit of the patient. It's for the benefit of the
doctor, to know when he can go, whether he will get home in time for
dinner. And the same inducement applies to pituitrin. I don't believe
that it is possible for human nature entirely to overcome inducements,
and therefore I believe that pituitrin is a remedy that will do more dam-
age, all told, than if we did not have pituitrin. I find that pituitrin is
active now, every time, because I take the fresh substance that has been
kept in an ice box or refrigerator. It becomes inactive by lying in the
obstetric bag for some time. The first year I allowed my pituitrin to
lie in the bag long enough to become inactive. I think the contra-
indications that were mentioned by Dr. Pugh will exclude pituitrin
entirely from the practice of obstetrics. He says it is dangerous to use it
in a thin uterus. Now, it is impossible to tell w^hich is a thin uterus.
Other and very numerous contra-indications are mentioned by every one
that are almost impossible to determine before death. Let us use this
remedy only with prayer and thanksgiving, solely for the benefit of the
patient.

Dr. L. D. Wharton, Smithfield : I would like to take issue with Dr.
Dickinson in regard to the use of pituitrin. I do not see why we could
not have, and we have had, the same objections to the use of forceps in
labor as pituitrin, in order to save time and get home. I also take issue
with him in regard to the good to the woman. It seems to me if we are
ever justified in the use of a drug, it is when we can save a woman hours
of suffering. We can undoubtedly save her that by the use of this rem-
edy, and Avho can estimate the possible saving to the child? We often
have uterine inertia, and when the other indications are present I see



Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 24 of 58)