of Rhodes. Spurious works Andronicus.

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

. (page 53 of 109)
Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 53 of 109)
Font size
QR-code for this ebook


present could not have been severe or it would have shown itself
in symptoms. The small amount of chloroform used shows that
the patient was unusually susceptible, and this susceptibility
which is common in pregnancy and with poorly fed infants shows
itself in some cases in a deranged nitrogen partition. The metab-
olism in these cases may be very unstable or distinctly ab-
normal without there being any definite symptoms. Yet when
the added strain of excessive meat diet or nervous shock, or
chloroform comes along, the patient goes to pieces apparently
without warning. I do not know what your patient's nitrogen
metabolism was like during the last months of gestation,
but I should expect it to have been deranged, with high test
nitrogen. I should say that a latent toxemia, or rather a dis-
ordered metabolism existed and constituted the increased
susceptibility to chloroform, but of course I do not know that such
was the case. I have recommended the routine determination
of the nitrogen partition just for the purpose of detecting these
states, but it is difficult to say how often it would be successful.
Chloroform is so dangerous in pregnancy that I think it ought
to be eliminated entirely from obstetricaJ practice.

I hope you will publish the case as a warning against the use of
chloroform in such subjects, and I thank you for the opportunity
of learning about it.

Very sincerely yours,

J. EwiNG.

DISCUSSION.

Dr. Fry had seen the case with Dr. Moran after the develop-
ment of coma. The condition was interesting as a postpartum
toxemia. There had been no urinary signs at any time during the
pregnancy or up to death. The chloroform evidently had been
the cause of the liver toxemia.

Dr. Stone asked if there was any compilation of the number
of cases of toxemia occurring during pregnancy.

Dr. Bovee said that it was unfortunate that there had been no
autopsy in this case. The tedious labor, instrumental delivery
and the temperature elevation shortly after delivery raised other
factors as possible causes of death in addition to the chloroform
toxemia. He did not believe that the changes in the liver went
on so rapidly nor would they show any improvement. The pos-
sibility of sepsis from the laceration was not excluded. He had
not seen any cases of slow chloroform poisoning in spite of exten-
sive use. Chloroform aggravated the liver more than the kid-
neys, but he did not think that the jaundice appearing as late
as the third day ought to be attributed to the chloroform.

Dr. Balloch considered the presence of diacetic acid in the
urine as significant of chloroform poisoning.

Dr. Wall said that diacetic acid was more common after



Digitized by



Google



WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY. 517

anesthesia in children; and that leucin and tyrosin in the urine
were characteristic of the liver degeneration.

Dr. T. C. Smith said that chloroform has always been con-
sidered the most satisfactory anesthetic in obstetrics and safer
than ether, that the quantity of chloroform given was not suffi-
cient to produce great harm, and that while there was in this case
a toxemia he did not believe that it was due to the chloroform.

Dr. Miller considered the case clearly one of acute yellow
atrophy of the liver but doubted the chloroform cause. Preg-
nancy produced diacetic acid in the urine. He had not long
since seen a similar case of acute yellow atrophy of the liver
during pregnancy, but before labor.

Dr. Abbe noted a case of late chloroform poisoning following
a mild appendicitis attack. The patient was a boy of ten who
had done well for two days then developed jaundice and died
on the fourth day after chloroform. The quantity of chloro-
form given apparently was not an important factor in the degree
of poisoning that followed. In the anesthesias at Columbia
Hospital given in the past few years, some of the worse cases
of late chloroform poisoning, as shown by the effects on kidneys
and persistent late vomiting, had followed the administration
of less than two ounces of chloroform, the quantity given in
the case of Dr. Moran, and many of them received less than a
half ounce. In obstetrics there seemed no better reason for
using chloroform than ether as given by the open drop method,
and the possibility of overbalancing a latent toxemia, as perhaps
was present in Dr. Moran's case, was certainly a strong argument
against chloroform and in favor of ether in obstetrics.

Dr. White reported a case of late chloroform poisoning and
said that the liver infection or destruction seemed to be secondary
to intestinal infection.

Dr. Stavely reported a case of late chloroform poisoning
accompanied by jaundice that recovered. He understood that
the jaundice might be due to decomposition of the blood by
the chloroform.

Dr. Moran considered Dr. Bov^e to be answered by Drs.
Wall and Balloch. This case was typical in its character and
an autopsy could only be confirmative. The case had no
fever or sign of infection. The patient had been given prac-
tically two ounces of chloroform and had been under its in-
fluence a little over an hour. He had recently seen the report
of a case of a death from chloroform after a half hour of anes-
thesia. Chloroform did affect the red blood cells. Recovery
left no scar in liver, and the kidney lesion was secondary to the
liver condition.

Dr. Fry read a paper on

SOME RESPONSIBILITIES OF THE MODERN OBSTETRICIAN.

He wished to direct attention to some of the changes that
have taken place during recent years; changes which compel



Digitized by VjOOQ IC



518 TRANSACTIONS OF THE

the modern obstetrician to renew his youth constantly in order
to keep in touch with modern ideas.

First comes development along the lines of asepsis and with
it the revolution in obstetric surgery. A closer study of the
physiology and the pathology of pregnancy, and of normal and
abnormal labor demands attention. The importance was dwelt
upon of the supervision of normal pregnancy. Formerly the
physician entered upon his duties in absolute ignorance of the
physical condition of his patient and he was liable to be called
to attend a woman in labor who had an unsuspected pelvic
deformity. This emphasized the importance of a careful ex-
amination by palpation and pelvimetry several weeks before
the time of anticipated confinement. Valuable information is
thus obtained in advance, and to be forewarned is to be fore-
armed. Of utmost importance is the early knowledge of existing
disproportion between the diameters of the fetal head and
those of the mother's pelvis. Steps necessary to meet the
indications must be recognized and whatever is to be done
should be elective. This is the secret of success in operative
obstetric work. If the case be one suitable for symphysiotomy
or Cesarean section do not attempt to deliver by version or
forceps, and then resort to surgery. Carefully study the situation
and obtain a clear conception of the character of the pelvis
and of the existing disproportions between the head and the
bony passage: select the method of procedure best adapted to
each case and carry out that method in the first place — not
resorting to it after the failure of inappropriate substitutes.

Under the head of the pathology of pregnancy he referred
only to the responsibilities of the modern obstetrician in the
^ early recognition and treatment of ectopic gestation, placenta
previa, and the toxemia of pregnancy. Success in the treat-
ment of these complications depends very much upon early
diagnosis. The obstetrician must be familiar with the clinical
histories of the complications and he must be ever on the alfert
to look for them.

A few of the responsibilities of normal labor were mentioned.
Occipito-posterior positions were classed among abnormal labors,
and Dr. Fry urgently recommended manual rectification instead
of attempts to turn the occiput forward with forceps.

He concluded what he called his kaleidoscopic paper by
saying: ** I would just mention one more duty of the obstetrician.
It is to promote the welfare of his patient and to restore her to
health. The better the obstetrician does his work, the less
work will he give the gynecologist. Lacerations of the peri-
neum should be sewed up; involution of the uterus promoted,
and displacements of the organ corrected. The patient should
be kept in a reasonable time, and should be encouraged to pass
the puerperal month quietly in the house. Too early getting
up and resumption of household duties are accountable for much
subsequent ill health."



Digitized by VjOOQIC



WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY. 519



Dr. a. F. a. King said that Dj. Fry had not stood up for vaginal
examination which was being put aside by most progressive
men to avoid infection, since washing of the hands to the extent
of disinfection was too tedious to be practical for all practi-
tioners. Many of the septic cases arose from the examination.
The postpartum hemorrhages and malpositions frequently were
due to inadvertence of the physician and could be avoided by
the postural treatment.

Dr. Moran said that the obstetrician frequently made work
for the gynecologist; that the obstetrician was not compen-
sated proportionately for his prophylactic work.

Dr. Bovee said that in ectopic pregnancy early diagnosis
was necessary and that early but appropriate treatment was
also urgent. The symptoms were the same as those of an in-
trauterine pregnancy up to the time of disturbance of the preg-
nancy. Recently he had had two cases which had given no
symptom of trouble till rupture occurred.

Dr. Stavely recalled a case where the woman had made
her own diagnosis of ruptured tubal pregnancy before sending
for the physician.

Dr. Fry did not believe that Dr. Williams's position on the
importance of the ammonia coefficient in the urine of eclampsia
had been upheld by other obstetricians.



Meeting of December 3, 1909.
The Vice President, G. T. Vaughan, M. D., in the Chair.
Dr. LoREN Johnson read the paper of the evening on

BLOOD ANALYSES OF lOO NORMAL CHILDREN.

He gave the following figures:

BLOOD ANALYSIS OF 100 NORMAL CHILDREN.



26 Cases

I to 6 mos.



35 Cases
6 mos. to I year



39 Cases
I to 6 years



Hemoglobin


80%


75%


80%


Red bloood cells


5,520,000


5,100,000


4,220,000


White blood cells


13,600


11,470


9,800


Differential Count


Small Lymphocytes, 48 %
Large Mononuclear

Transitional 7 %

Polynuclears 41.2%

Eosinophiles 3 i%


...44 % ...

} .. 6i%....

.... 46.8% ....
.... 2i%....


•..•33 %

.... 5.3%

....59.5%
.... 2.2%



Digitized by VjOOQ IC



520 WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY.

DISCUSSION.

Dr. Donally opened the discussion, saying that to get the
normal blood count of a child it was necessary to know the age
of the child in months. Cabot corresponded with Johnson, finding
quite definite changes with the age of the child. Cabot quoted
Engel on the blood examination of an embryo nine inches in
length that was alive and had R. B. C, 3,300,000; W. B. C,
12,000; and hemoglobin 80 per cent. During the period after
birth in which the child lost in weight nucleated red cells and
megaloblasts were found in the blood; the leukocyte count was
30,000 to 40,000. The most striking part of the leukocytosis of
infancy was the lymphocytosis of 55 per cent, during the first
year, and the drop of 3 to 4 per cent, each year until the fourth
year, after which the lymphocytosis was about the same as in
adults. The polymorphonuclear leukocytes were relatively
low at first and gain as the lymphocytes lose.

Dr. Prentiss was impressed with the drop in the number of
red cells from the second to the third period of 900,000 with an
increase of 5 per cent, of hemoglobin and would like an explana-
tion of the paradox.

Dr. Thomas thought that if Dr. Johnson would give some idea
of the surroundings of his patients it would probably explain
Dr. Prentiss's trouble. If the children could get out of doors
more and get more light the discrepancy might disappear. Per-
sonally he would like an explanation of what Dr. Johnson had
called normal.

Dr. White asked if there was any difference in the size of the
red-blood cells in the children, and what the normal blood pres-
sures were.

Dr. Morgan did not think the blood examination of as much
importance in children as in adults. The polymorphonuclear
relation changed rapidly. The eosinophiles were apt to be in-
creased by slight causes.

Dr. Adams, judging from his own experience in young chil-
dren, found blood examinations far from satisfactory so far as
clinical teaching went. There were many things to be deter-
mined as to the normal child; whether it was nursed or bottle-
fed. What food elements were taken by the child? As yet, no
positive standard of normal children had been established.

Dr. Acker considered it very difficult to come to any conclu-
sion as to the value of blood examinations in children for want
of a standard for comparison.

Dr. Prentiss suggested as a substitute for the word normal
child that of ** child in apparently good health."

Dr. Johnson thought the change suggested by Dr. Prentiss
would be a good one. The cases he had taken were from no
special group; some were bottle-fed, and some nursed. The
blood pressure examination would probably not be of much
value on account of the difficulty of obtaining records, and prob-
ably that was why not much had been done in that line. A
digestive leukocytosis was present in the children.



Digitized by



Google



REVIEWS. 521



REVIEWS.



Praktische Ergebnisse der Geburtshilfe und Gynae-

KOLOGiE. Herausgegeben von K. Franz, Jena, und J. Veit,

Halle. Erster Jahrgang, I. Abteilung. J. F. Bergmann,

publisher.

The authors have associated with themselves the cream of
German gynecologists. In the preface they state that it is their
purpose to eliminate all gynecological material that does not
have upon it the stamp of science combined with proven prac-
tical usefulness.

Extirpation of the Uterus in Puerperal Fever, the first paper,
is written by J. Veit, of Halle. Those who know Veit also know
that what he says is of much value. He reviews the indica-
tions of various authors, but comes to the final conclusion as the
result of his experience, similar to that which the reviewer has
expressed long ago. In instances of f oudroyant sepsis, in bactere-
mia, in which the blood is loaded with streptoccoci, the operation
is useless. Sometimes the appearance of microorganisms in
the blood is temporary, and is no indication for an operation.
The absence of organisms in the blood with the presence of
virulent organisms in the lochia is held to be a contraindication
for the operation.

The article is fascinating reading, but to properly review it
requires more space than is permissible.

The second paper, by M. Graefe, of Halle, is on the Artificial
Interruption of Pregnancy.

The use of intrauterine injection in the very earliest stages of
gestation is serviceable, but not without risk.

The induction of abortion during the first two or three months
by means of dilatation and curetting, is warned against. Lamin-
aria tents are preferred for dilatation. After the fifth month
of gestation, tents should not be employed; a metreurynter
should be used.

The third paper, on Dietetics of the Puerpera and New-born,
is by Privatdozent Dr. Schickele, of Strassburg.

Practical experience seems to show that it is better to follow
the old treatment of ten days to two weeks' rest in bed,* rather
than to allow early rising after confinement, particularly for
women in private practice. To insure its best development and
future health, the child should always be nursed.

K. Franz, of Jena, discusses the Technic and the Indications
for Cesarean Section, favoring the extraperitoneal method of
Sellheim.

A question of vital importance is whether the so-called extra-
peritoneal method is one that will make the operation safe in



Digitized by VjOOQ IC



522 REVIEWS.

** unclean'* or infected patients. The answer is "no." It is
best in such cases to perforate, even the living child; or, in
instances of absolute obstruction, to do a Porro operation.

Karl Hegar, in speaking of Endometritis in its Practical Se-
quence, says:

The most prominent symptoms of chronic endometritis, are
discharge, bleeding, and, to a limited extent, pain. A good cri-
terion as to the benignancy or the malignancy of the fluor is
its effect on the mucous membrane of the vaginal portion of the
cervix and the vagina, whether it causes ectropium and erosion,
the formation of Nabothian follicles, soreness of the external
genitals.

In recent puerperal endometritis and in postoperative
endometritis, intrauterine douches are advised. In acute
gonorrheal endometritis, all local treatment should be omitted.

The views as to the treatment of the chronic forms by different
authorities are considered. A curette should never be employed
except under due precautions; never in a physician's office
consulting work.

The different methods of making intrauterine applications,
and the medicaments used for this purpose are considered.

Hugo Sellheim discusses Old and New Principles of Forceps
Delivery.

The substance is . . . To exactly determine how far the ex-
pulsion of the child has been accomplished by the natural process,
to complete what is lacking by artificial means. The essential
point is that the head must have descended low enough; then it
must have the proper size, form, and consistency.

The indication is given the moment that danger exists for the
mother or child that cannot be eliminated by milder methods
than forceps delivery.

Ernst Runge, assistant at the Imperial Gynecological Clinic
of Berlin, writes on Cancer of the Stomach and its Relation to
Gynecology and Obstetrics.

In the case of cancer of the stomach or of the pelvic organs,
other intraabdominal organs should be carefully examined to
determine the existence of metastases. In the event of simul-
taneous presence of the neoplasm in stomach and pelvic organs,
the primary seat is usually the stomach. The method of the
occurrence of metastasis has not been definitely determined.

The^Diagnosis and Treatment of Acute Diffuse Puerperal Peri-
tonitis is written on by F. Fromme, of Halle.

While our view as to the prognosis is even more unfavor-
able than that of the author, the article is up to date. The treat-
ment advised is that in each instance of diffuse puerperal perit-
onitis an abdominal section should be made as soon as the diag-
nosis has been established. His reason is that without exception
a diffuse puerperal peritonitis, unless it be of gonococcal variety,
terminates fatally; and the author has some doubt as to whether
the gonorrheal variety really does cause a genuine diffuse



Digitized by



Google



REVIEWS. 523

peritonitis. He advises in the early stages of the disease, after
having made an extensive section, copious washing out of the
peritoneal cavity with physiological saline solution. In the
event that the peritonitis is of several days' standing, only dry
wiping out of the exudative material.

If an examination of the blood shows an abundance of strep-
tococci, the prognosis is doubtful. (In the reviewer's experi-
ence it is always bad.)

In describing Prolapsus of the Genitals and its Treatment,
Hermann Freund, of Strassburg, places an unusual confidence
on the broad ligaments as supports of the uterus, more so than
on any other single structure. He divides his deductions for the
etiological factors of prolapus into anatomic-physiological reas-
oning and clinical observation.

In instances of operations on the perineum and anterior
vaginal wall only local anesthesia is advised. No one method
of surgical procedure is advised; the technic must be adapted
to the condition and not to the device of any one operator.

Especial attention should be given to the prophylaxis of
prolapsus which must be begun from the beginning of pregnancy.

Obstetrical Hemorrhages and their Treatment, by Dr. August
Mayer.

This chapter is ably written and nothing of importance omitted.
Although the reviewer has failed to find anything that is really
new in the article, attention should be called to some important
points, as the assertion of Von den Velden that the intravenous
injection of 5 c.c. of a lo per cent saline solution increases the
coagulability of the blood in a few minutes(!); the desirability
of giving small doses of morphine during the critical period of a
hemorrhage, rather than infusing with normal saline solution,
until it is certain that active bleeding has ceased.

In Tubingen clinic the only indication for the manual removal
of retained membranes is bleeding or an existing infection.

The Contracted Pelvis is considered by K. Baisch, of Munich.
He also briefly treats of deliveries with such abnormality. Per-
foration of the living child is rarely indicated.

Lumbar Anesthesia, in comparison with other methods of
anesthesia based on 1,232 cases, is analyzed by Busse; his con-
clusions do not vary materially with those expresssed by observ-
ing operators of this country.

Zangenmeister brings up the question, whether, in instances of
ovariotomy, the other ovary, though apparently normal, should
also be extirpated. He leaves us none the better informed as the
result of his contribution.

J. Veit, of Halle, considers disinfection of the vulva in obstet-
rics immaterial. Disinfection of the hands during the manage-
ment of labor is necessary. Veit enumerates what he does with-
out disinfection; and while it is correct that one can do very
many things about an operation, in the way of assisting, even
some parts of the operation, manipulating only with sterile



Digitized by



Google



524 BRIEF OF CURRENT LITERATURE.

instruments, yet for a teacher it would not do to give such
instructions where exceptions may be made, because this would
soon lead to negligence.

When doing a second operation, it is unnecessary to change
gloves if they were not injured during the first operation.
Washing the gloved hand for two minutes in an 8 per cent, for-
maldehyde solution is suflficient to resterilize them. These disin-
fection rules apply to obstetric practice only.

Gynecological interventions are to be looked upon, so far as
concerns disinfection, as is taught by all modern teachers.

BOLDT.

Transactions of the Edinburgh Obstetrical Society,
Vol. XXXIV, Session 1908-1909. Edinburgh: Oliver &
Boyd, publishers to the Society. 1909.
These transactions afford ample evidence that the work done
by this society is of a high order. Some of the contributions
in this volume are of unusual merit. Particularly commendable
are two papers by D. Berry Hart on *'The Physiological Descent
of the Ovaries in the Human Fetus" and "The Nature and Cause
of the Physiological Descent of the Testis." These papers to-
gether comprise about 100 pages of text, and are painstalang and
exhaustive studies in embryology. Other contributions worthy
of mention are *' Renal Decapsulation in Puerperal Eclampsia,"
by Sir J. H. Croom; **The Anatomy and Histology of the
Pregnant Tube," by James Young; "The Physiological Basis
for Decapsulation of the Kidney in Eclamptic Anuria," by H. O.
Nicholson; ** Thyroid Extract as a Preventative of Dystocia
from Large Child," by T. M. Callender; and "Mendelian Action
on Differentiated Sex," by D. Berry Hart.



BRIEF OF CURRENT LITERATURE.



OBSTETRICS.



Rapid Development of Tumors During Pregnancy. — ^Michele
Monforte (Ann. di OsteLe Gin,, Oct., 1909) records the histories
of five cases, two of which were personally observed, in which
tumors of various locations, which had been stationary or slow-
growing before pregnancy occurred, began to increase in size with
pregnancy, and after labor regressed again. The author brings
forward as causative factors in this abnormal development and
increase in vascular tension, changes in blood composition, in
quantity of the blood, and in size of the heart, which are known to
occur in pregnancy. There is increased congestion of the inter-
nal organs, one factor in which is the suppression of the menstrual
flow. During pregnancy there is an increase of formation
of nutritive elements and of toxins in the body. It is conceivable
that these toxins may cause an increase of cell formation at some



Digitized by



Google



BRIEF OF CURRENT LITERATURE. 525

given point and thus an increase in the size of existing tumors.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 53 of 109)