of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

. (page 30 of 109)
Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 30 of 109)
Font size
QR-code for this ebook


has been made by the dilator, I could not do it. Some one
spoke of the difficulty of perforating a uterus where you held
it in your hand after hysterectomy. I remember on one occasion
seeing Dr. Tuttle remove a uterus, ruptured by an instru-



Digitized by VjOOQIC



292 TRANSACTIONS OF THE

ment, probably a sound, in the hands of a careful man, Dr.
Tuttle removed this uterus, passed it over a sound standing on
end and the weight of the uterus was sufficient to press the
sound entirely through its substance. Do we wish to let this
Society go on record that it is perfectly safe to let these patients
go?

Dr. Jewett. — I wish to endorse Dr. Coe's views of the curette.
The curette is comparable to a razor. The dull instrument does
more harm and less good than the sharp one.

As to the harmlessness of perforating the aseptic uterus,
I had the misfortune to perforate a uterus at the isthmus, laterally.
The uterus was apparently aseptic and the technic as clean as it
could be made but the woman developed a crural phlebitis.

One or two cases may perhaps be of interest as curiosities. In
one her physician had treated a supposed abortion. He said
he pulled down something which he could not identify, and, to
make sure, he cut it with scissors. When I saw the case, several
inches of intestine protruded through the vulva and it had been
cut squarely across. So much mesentery had been torn off that
the patient was moribund from hemorrhage.

Recently a patient brought into the hospital, after miscarriage
in the service of Dr. Pool, was found to have a large hole in the
anterior wall of the cervix. Through this the examining finger
passed into the bladder. A portion of the bladder wall, prolapsing
through the opening in the cervix, had been mistaken for secun-
dines and twisted off. The injury was a difficult one to repair.

Dr. Stone. — Our distinguished member, Dr. Emmett, a
year or so ago in an anniversary address before one of the large
American societies remarked the close relationship of sepsis to
injuries of the cervix and subsequent troubles. He said that
in the last few years of his active practice he did not see so many
cases in which the cervix was hard and indurated and in which
there was the necessity for his operation of trachelorrhaphy; and
this illustrated clearly the progress that had been made in ob-
stetrics and the good results which followed asepsis.

Dr. McLean. — The point Dr. Brodhead made, that rupture
may occur in a multipara who has had easy and even rapid
labors previously — that in the course of a normal delivery she
may have a rupture and a fatal one at that — is very interesting,
and a very good thing to recognize and remember.

Just to support the instance Dr. Brodhead has given, I will
call attention to a case which occurred some years ago. The
woman was a multipara who had had several children with easy
deliveries and she was in her fourth labor. The second stage
had proceeded to the point where the head was upon the perineum,
everything going favorably, when she began to scream and the
head disappeared. The case was so plain that the diagnosis
was made instantly because not only had the head raised, but
the child's feet could be seen kicking about under the skin of
the liver region. I was called over to see the case, made as rapid



Digitized by VjOOQIC



NEW YORK OBSTETRICAL SOCIETY. 293

preparations as possible, went in with my hand and found the
head and one arm in the uterus. The rest of the child's body,
the other arm and legs were all outside of the rupture, which
extended from very near the top of the fundus down to the broad
ligament, so that the whole side of the uterus was opened. I
drew the child down into the uterus and then turned it, brought
the feet down and delivered it within a few moments. I noticed
the amniotic sac from which I drew the child was protruding
from the wound in the uterus, and it is interesting to note that
this had remained intact. In other words, the child had been
in the amniotic sac out in the peritoneal cavity kicking about in
this manner and when I withdrew the child the sac remained. I
carefully drew the placenta down and the membranes came down.
I compressed the uterus and held it very much as Dr. Harrison
described, and allowed the case to go to a natural course of
recovery.

Now the sequence, that is in regard to the after-eflFects when
hemorrhage has taken place in these ruptures, it so frequently
ploughs its way down under the peritoneum and makes its way
up the broad ligaments and outward under the skin. This
woman had an ecchymosis all the way from the axilla down to
the thigh. She was perfectly black for several days and went
through the ordinary changes of ecchymosis.

Dr. Coe. — ^There are several interesting questions which I did
not consider because of lack of time. Dr. Jarman's point was
well taken. I tried to emphasize that. If there is sepsis,
hemorrhage or extensive lesions, we should do a laparotomy.
The sound is not an instrument to be used indiscriminately in
the examining room. The more we teach the general practi-
tioner not to use it, the better it will be. Its use under strictly
aseptic precautions is of course a different matter.

Rupture of the parturient uterus has always interested me
because I was so unfortunate (from my own stand-point) as to
have a brilliant case early in my practice, which quite turned my
head. A case in a tenement house before the days of asepsis, and
at that time was unique in its way. As a result I was asked to
operate in four other cases, all of which terminated fatally.
I once happened to be making my rounds in the old maternity
hospital and found a patient there in a state of collapse, an hour
after her return from the lying-in room. Nobody had noticed
that anything was the matter with her. I introduced my hand
into the vagina and discovered an immense rent in the broad
ligament. I opened the abdomen (the patient died on the table),
but there was no blood in the peritoneal cavity though an
immense extraperitoneal extravasation had occurred, extending
as high as the kidney.

The practical deduction from my paper is of course that the
skilled operator may use any instrument that he wishes; it is
the hand behind the instrument that counts.

Dr. Cragin. — I only want to reply to my good friend. Dr.



Digitized by



Google



294 TRANSACTIONS OF THE

Harrison. Not everyone is as fortunate as Dr. Harrison in never
finding remnants of placenta in the uterus. There are two things
to think of in the care of a woman after delivery. One is her
mortality and the other is her morbidity, and if you can shorten
the latter by clearing out from the uterus retained products of
conception, I think we are in duty bound to do it, although I
believe thoroughly in the care needed in using any instrument
in the uterus. It should be borne in mind that a neglected
sapremia will sometimes lead to a bacteriemia, hence I believe
that we want to get the uterus clean but to do it with the least
possible injury to the erineut wall.



TRANSACTIONS OF THE

WASHINGTON OBSTETRICAL AND

GYNECOLOGICAL SOCIETY.



Meeting of November 5, 1909.
The President, J. T. Kelley, M. D., in the Chair.

The committee on Ophthalmia Neonatorum* reported in
extenso through its chairman. Dr. Moran, giving an account of
some of its original investigation on the subject. It was voted
that the committee be thanked, and that a copy of the report
be transmitted to the health officer.

Dr. George N. Acker read the paper of the evening on

THE DIAGNOSIS OF TYPHOID FEVER IN YOUNG CHILDREN. f
DISCUSSION.

Dr. Adams said that there was a general hesitancy on the
part of physicians to accept the diagnosis of typhoid fever in
children. He had, however, seen one case in a child five months
old whose mother had typhoid. The infant had nursed for ten
days after the mother had been taken ill. The malarial type of
fever was more common than the typical typhoid. The Widal
reaction was negative in most of the cases, and therefore should
not be considered as reliable as in adults. The bacterial cultures
had not been made. The spleen was not palpable. At present
he had under his care a child with retracted neck, set eyes, and
an appearance suggestive of tubercular meningitis. But the
pupils reacted to light, were not dilated, and there were no rose
spots, no spleen palpable, the Widal was negative, the tem-
perature ran between 102 and 104.5; clinically, the case was a
typhoid. Cultures had not yet been taken. The diagnosis of
typhoid in children under one year had not been made by some

♦ See original article, page 367.
t See original article, page 361.



Digitized by VjOOQIC



WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY. 295

of the best men until their attention had been called to the
diagnosis.

Dr. Moran called attention to the statement that Peyer's
patches were said not to develop until after the first year and
asked if the autopsies had shown analogous lesions in the
intestines.

Dr. Wall asked what the typical syndrome of tjrphoid in
infants presented. He had not seen a case which was to him
characteristic in a child under two years of age. The tendency
at the Children's Hospital was to call too many cases typhoid.
The Widal reaction should be just as positive in children as in
adults. Cases of typhoid in children were much more apt to
be of the ambulant type. He noted the characteristic diflFerence
in pulse between typhoid fever and scarlet fever in the much
more rapid pulse of scarlet fever.

Dr. Donally did not think Peyer's patches essential to
typhoid. Cases of typhoid fever had been reported even in
the fetus by Morse. Holt, in 10,000 cases at the Children's
Hospital, had up to a few years ago seen no cases of typhoid in
children under two years. Since then he had seen two cases
in infants of one year of age. There had been no cases diag-
nosed at the Foundlings' Hospital in twenty-five years. Per-
foration was estimated to occur but half as often in children* as in
adults. All of the cases reported by Dr. Acker had been proven
typhoid at autopsy or by laboratory. The clinical diagnosis
was not satisfactory. The Widal reaction or culture from blood,
urine, or feces should settle the diagnosis. At the dispensary
of the Children's Hospital in the past eighteen months there had
been seventeen cases in which on the first visit a provisional
diagnosis of tjrphoid had been made. Five of them had been
acute intestinal disorders as shown by the subsequent visits.
Eight of the cases had never been seen a second time. The
other four had been admitted to the hospital and the diagnosis
confirmed. Of these four three had had a sudden onset; two
with vomiting, and one with epistaxis.

Dr. Morgan thought that the difficulty in diagnosis lay in
the inability to get a history of prodromal symptoms. In
infancy the breast-feeding and the general custom of pasteur-
izing the milk tended to prevent the infections. He considered
the laboratory diagnosis very helpful.

Dr. Sprigg doubted the infection of an infant from a mother
with typhoid. He had had several cases with typhoid in
mothers who had nursed their infants a week or so until a posi-
tive diagnosis had been made and then had begun nursing their
children after recovery. None of these cases had infected the
infants.

Dr. Adams thought that in his case the child got the typhoid
from its mother by nursing. He had had three autopsies in
children under one year in two of which the Peyer's patches were
visible. One of the cases died of hemorrhage.



Digitized by VjOOQIC



296 TRANSACTIONS OF THE

Dr. Acker thought that it was possible to make the diagnosis
of typhoid in the milder cases much better since the introduction
of laboratory methods. In the intestines he looked for in-
volvement of the solitary follicles rather than the Peyer's patches.
He had had one case in which the mother during the entire
course of her typhoid nursed her infant and the infant had not
developed the typhoid.



TRANSACTIONS OF THE SOUTHERN SURGI-
CAL AND GYNECOLOGICAL ASSOCIATION.



Twenty-Second Annual Session^ Held at Hot Springs ^
Virginia^ December 14, 15 and 16, 1909.

The President, Stuart McGuire, M. D., o/i?ic/jf»on4,
Virginia, in the Chair,

The Association met in the ball-room of the Homestead
Hotel, and after announcements by the Chairman of the Com-
mittee of Arrangements, Dr. Lewis C. Bosher, Richmond,
Virginia, the scientific work was begun.

A brief discussion of some of the surgical junk demanding

FURTHER SURGICAL INTERFERENCE.

Dr. Joseph Price, of Philadelphia, stated that a short time
ago a patient entered his office and asked him to reopen
her abdomen, and to correct, if possible, a distressing con-
dition that she could no longer bear. Her abdomen had been
opened three times, a pelvic operation having been followed
by two gall-bladder operations. She complained bitterly of a
griping sensation in her epigastric region, followed by nausea
and starvation. In a short period of six days he had reopened
four abdomens for postoperative pathological and operative
sequelae. Large numbers of these patients were objects of pity
and mercy. One of the number had her abdomen opened eight
times. Fortunately, the last operations were complete proce-
dures, the reproductive organs and appendix were gone, leaving
only a ventral hernia, omental and bowel adhesions to be freed.
One of the late operators drained her gall-bladder, leaving a
fistula and distressing adhesions. He liberated the stomach,
bowel, and other adhesions, exposing the gall-bladder, disorgan-
ized and charged with pus; its clean removal would probably
result in a cure.

Dealing with surgical junk required more than the ordinary
hospital apprenticeship. The operations done by the pioneers
in abdominal surgery were free of operative sequelae. The per-
centage of recoveries was good in the country. He had had the



Digitized by VjOOQIC



SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION. 297

opportunity of seeing a large number of the patients operated
upon by the first school of abdominal surgeons. They consti-
tuted an interesting group of patients, none of them complaining
of those common symptoms of modern operations. The high
death rate in the hands of some few operators explained surgi-
cally the distressing condition of the few that did recover, but
commanded more surgery.

It was needless to detail the variety of pathological compli-
cations from the pelvic basin to the pyloric orifice of the stomach
in the great variety of surgical afflictions found between those
two points; but if dealt with scientifically, according to surgical
light, junk would not be the result. In the suppurative forms
of disease of the pelvic viscera above the head of the cecum, and
on up to the suppurations about the liver the advanced thinkers
and workers had given us perfected procedures, and, if practised
completely and scientifically, but few uncomfortable sequelae
would follow. It was exceedingly rare to get junk from the
operating tables of the experts. There was prolonged and pains-
taking effort on the part of the clinical schools to correct the
common errors and calamities. Our precise knowledge of patho-
logical calamities and the early efforts of relief now gave us
about a nil mortality.

We must have more prolonged hospital apprenticeship in our
young men at the hands of skillful operators. All of our gradu-
ates should go through a hospital. The public hospitals, like
the private hospitals, should be made clinical schools, and from
this clinical schooling, on top of a thorough scientific education,
we would get a new class of practitioners, better pathologists,
and better diagnosticians. The resulting thoroughness, scien-
tific and clinical, would give us a stronger profession with better
judgment. Doctors with better education would give us the
patients early, while the troubles were simple, free from invasion
and infection, simple operations demanded, extensive and com-
plicated procedures rare.

All junk surgery was uncertain; it might be simple or it might
be too complicated for completion.

DISCUSSION.

Dr. Lewis S. McMurtry, of Louisville, said that Dr. Price
had called attention to one of the greatest evils prevalent at this
time in relation to abdominal surgery. He alluded particularly
to incomplete operations being done and to a large number of
men who were operating in the abdomen who ought not to do so
without having served an apprenticeship in this work. When
this association was first organized it was far more difficult for
men who were not qualified to do abdominal surgery than at the
present time. To illustrate: let us take any well-appointed
hospital in any city in this country and it has a well-appointed
operating-room. There was a nurse who was well qualified
to prepare patients for operation and who understood the technic
8



Digitized by



Google



298 TRANSACTIONS OF THE

of modern aseptic surgery and an operator who had no operative
skill could put on a pair of rubber gloves that had been boiled,
and, if the preparation had been carried on by this competent
nurse, the operator could open the abdomen of the patient, stir
around in there a good deal and the paitent might not die. We
all know that fifteen or twenty years ago if an operator under-
took to do this kind of work the patient would die of sepsis.
He could not clean his hands, he did not have the facilities of
the modern hospital and sepsis was the result, and that soon
finished his career. At the present time there were more men
who where doing tyro-surgery in the abdomen than before.

There were men, who, without having served any apprentice-
ship, undertook surgical operations which Dr. Price had charac-
terized as junk, in that they were incomplete and done by men
who were not qualified to do them. Hence, patients went to
surgeons with adhesions of all kinds and ptosis of the viscera,
and other troubles. It was the duty of members of an asso-
ciation like this publicly and privately to condemn men entering
upon this work without having served an apprenticeship and
without being properly qualified before they undertook it.

Dr. a .Vander Veer, of Albany, New York, said he always
felt that there was a certain amount of risk in encouraging
abdominal surgery in small hospitals because much of the work
was necessarily done by men who had not served a sufficiently
long apprenticeship to do the work throughly and completely.
Not infrequently a correct diagnosis was not made and incom-
plete operations were undertaken which did not reflect credit
upon American abdominal surgeons. Within ten or fifteen years
there had been a sort of feeling on the part of our younger sur-
geons to do as many operations as they could upon a particular
patient. In this regard they sometimes erred. He had seen
many cases that had terminated in what Dr. Price had termed
surgical junk. He appreciated this paper because it was not only
timely, but it dealt with a subject to which more attention
should be paid at the present time. It was the kind of paper for
the younger surgeons to read carefully.

Dr. William M. Polk, of New York City, stated that the
trouble with some of us was that perhaps we had been endeavor-
ing to work out pathological problems on live subjects and
in so doing we might have left conditions within the abdomen
in our endeavor to preserve structures, and so forth, that really
had no business there. And in so far as he had been a sinner in
that direction he was free to confess that probably he deserved
all the criticism that the distinguished essayist had made. He
was particularly obliged to him because in his paper he opened
up the whole field of surgical work. He found that the average
person had been so well educated that his or her mind was made
up as to what they wished their physicans to do long before they
interviewed them, and if he failed in any way to fall in with their
preconceived notion they at once went elsewhere. He stated



Digitized by



Google



SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION. 299

that we all know perfectly well that there were a great many
of the younger members of the profession who had not that stiff-
ness of spine that comes with age, that kind of ankylosis of the
vertebral column which was beneficent in its influence, and which
did come with age and experience. Dr. Price had very aptly said
something that we could not trifle with. He had alluded to the
craze for medical education. While this was not an opportunity
for moralizing, yet he thought he was correct when he said we
were absolutely responsible for this state of affairs. Self-right-
eousness would not help the situation one bit. We had simply
got to get down to the first principles as to what our knowledge
of the situation taught, or what was the correct thing to tell our
people, whether they are patients or medical students, and
when we had reached that frame of mind we would get some-
where and we would not move one inch in the direction to which
Dr. Price alluded until we made up our minds to rid our own
minds of the junk that was in them.

ADHESION OF SIGMOID TO THE TUBE AND BROAD LIGAMENT AS A
CAUSE OF PAIN IN SALPINGITIS.

Dr. Hubert A. Royster, of Raleigh, North Carolina, stated
that the Fallopian tube was the most frequent seat of inflamma-
tory disease in the pelvis. It was the narrowest portion of the
channel from the vulva to the ovary and was the least resistant
to infection. Pain there was more concerned with salpingitis
then with ovaritis, whether attended by a gross lesion or not.
Too many times the ovary has been regarded as the offending
organ, and needlessly removed. In some instances a diseased
tube has been blamed as the sole cause of pain, while other factors
produced by the salpingitis, or rising independently of it, might
be overlooked. Somewhat less than three years ago he made
a clinical observation, which bears upon this question.

Mrs. S., thirty years of age, married seven years, had given
birth to one child about a year before. Previous to that she had
had an abortion performed on account of pernicious vomiting.
Several weeks before he saw her the same procedure had been
again gone through with for the same reason. For two or three
years she had suffered from typical tubal dysmenorrhea, the
pain began a week before the flow and continued throughout
the period. Intermenstrual pain was constant, and referred
chiefly to the left iliac region; there had been several slight
attacks of pelvic peritonitis. Defecation was particularly
distressful. Almost every day the patient took morphine and
heroin. Examination revealed extreme tenderness in either
side of the pelvis, especially in the left. A diagnosis of chronic
salpingitis was made. At operation, March 28, 1907, both tubes,
tortuous and thickened, were removed. Their removal was
considered justified in view of the history. The ovaries were
what are called ** cystic." He removed the left and excised
two-thirds of the [right one. In bringing up the left tube



Digitized by



Google



300 TRANSACTIONS OF THE

for inspection he found that the sigmoid flexure was adherent
to its fimbriated end, and also to the upper surface of the broad
ligament. These adhesions wese carefully divided, and the raw
areas were closed by fine catgut sutures. The result was all
that could have been expected. The patient immediately
improved, but not until six months had passed was she really
relieved. She was now entirely well, menstruating regularly
without pain.

He had the records of eight similar cases in which the sigmoid
adhesion was apparently the whole source of left-sided pelvic
pain. He was convinced that the condition was one to be reck-
oned with. Its association with salpingitis or other disease of the
pelvis could not, as a rule, be determined beforehand, but it
might be suspected in the absence of other lesions, to account
for the suflFering and more especially in the presence of painful
defecation. This had been a constant symptom in the instances
which he had observed.

When discovered the adhesions must be dealt with as seemed
proper in the given case. After snipping the bands which fix
the sigmoid to the broad ligaments there were left two triangular
raw surfaces, one on the bowel and the other on the ligaments,
with their bases together. These formed a diamond-shaped
area. The peritoneal edges were then closed over this space by
a continuous catgut, applied from below upward. The sigmoid



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 30 of 109)