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The American practitioner online

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contracted gall-bladder was over this large stone, and the second stone
was impacted in the common duct near by. The cystic duct was
entirely obliterated. One incision was made over both ducts and the
stones removed. The common duct was very much shortened, the
duodenal attachment being very near the stone. An effort to suture
the duct was not made except in this manner : Two tubes were passed
into the common duct, gauze was packed around these, and then four
guy-rope sutures were attached to the dilated pouch so as to draw this
as near the parietal peritoneum as possible. They were brought within
three inches of the anterior parietal peritoneum, and then a protection
of gauze was built around these tubes and the abdominal wound closed
up to that point. Bile discharged freely at once, there was no shock,
and the patient got along nicely. Bile commenced to flow through the
intestine in four days, showing that the distal portion of the duct was
open. The external fistula closed rapidly ; probably in three weeks all
bile was going by the natural channel, and the jaundice is slowly
clearing up. The operation was performed about the middle of last



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256 1 he American Practitioner and News.

March. Since that time there has been some edema of the legs
from the heart trouble. This has about cleared up, and it looks
as if his life would be prolonged for a great while by the operation.
The kidney has greatly improved.

Discussion. Dr. L.S. McMurtry : I want to speak of one or two points
that Dr. Cartledge did not mention in detail, which I am sure will be
of interest. This case, as the doctor stated, was one with a g^eat many
interesting features. I am sure it will be so regarded by the Society.
First, as has already been stated, I saw the patient a week before the
operation was performed, and there could have been no doubt as to the
nature of the trouble. The indications of gall-stone impaction in the
common duct were beyond question, and the diflSculties that were pre-
sented in regard to the operation itself were of the most serious
character. The outcome of the case is certainly excellent. One lesson
that it teaches is that radical surgery can be successfully done in a class
of cases that we have hitherto regarded beyond the scope of surgical
interference. Here is a man with cholemia of the most pronounced
character that has been going on for a great length of time ; he had
kidney lesions, he had heart lesions, yet he was operated upon with a
good result. He bore the anesthetic well. The operation was an
exceedingly diflScult one ; the gall-bladder was practically gone ; it was
contracted down to the size of the stones it had contained.

Dr. W. O. Roberts : I would like to ask Dr. Cartledge how he built
around the gall-bladder to keep the peritoneum free ?

Dr. A. M. Cartledge : I made a gauze bridging around the tubes ; I
have done this in several cases operated upon for gall-stones in the
common duct.

Dr. T. S. Bullock : I only wish to state that two or three years
before the operation I examined this man for life insurance and dis-
covered the heart lesion at that time. His urine had a specific gravity
of 1.030-2, and there was quite a large amount of sugar. He was
rejected on this account.

Dr. William Bailey: If I had my hat on, I should certainly take it
oflF to the surgeon in this case. Notwithstanding the complications,
the handicapping was so great, so decided, I think the courage of his
convictions was good, to enable him to undertake an operation of this
kind under the circumstances related. I want to bear testimony to the
fact that I believe Dr. Cartledge is very much indebted to the normal



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The American Practitioner and News. 257

salt solution in preparing bis patient for this work, and I want to say
moreover that I think it ought to be used much more as a medical
measure than it has been hitherto, and believe it will take a much more
prominent place in a large line of troubles in the future. I do not
believe this man could have had such good preparation for the opera-
tion by any other means known to us.

The essay of the evening, "Placenta Previa," was read by Thomas
H. Baker, M. D. [See p. 241.]

Discussion, Dr. T. S. Bullock: I was very much struck with two
features in Dr. Baker's too brief paper : First, the fact that two out of
his five cases of placenta previa occurred in primipara ; this is out of
the ordinary. Second, a point which has been observed before is the
recurrence of previa in the same individual* It seems that multiparity
is a very important factor in these cases, and there is little liability of
recurrence in the same patient.

In regard to the treatment of these cases, I was especially interested
in a report I saw some time ago made by Jardine in the Transactions
of the Glasgow Obstetrical and Gynecological Society. He reports
fifty-one cases; of this number, twelve were complete, and of these he
was able to save ten of the mothers and eight of the children. His
mode of treatment is somewhat different from that outlined by Dr.
Baker and that which has been generally practiced in former years.
In the fifty-one cases the tampon was used only nine times. He states
that the treatment which gives the best results is not to await the slow
process of dilatation by means of the tampon, but to at once anesthetize
the patient and mechanically dilate the cervix, and do a version at the
same sitting. The indications for treatment he gives are first to
empty the uterus, control the hemorrhage, and, as has been spoken of
by Dr. Bailey in discussing another class of cases, the third indication
is to brace up the patient from the loss of blood by the injection of
normal saline solution. Of these fifty-one cases, in forty-three there
was a vertex presentation. In thirty-six of these version was done, in
four forceps were used, and in three the bipolar method of version was
employed. Only six were primipara, and two had. had previa in earlier
confinements.

Hirst, in his recent work, reports one hundred and four cases of
placenta previa which occurred in the practice of Lomer, Hofmeier,

20



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258 The American Practitioner and News.

Behm, and himself. In these the maternal mortality was only one out
of the hundred and four (Hofmeier, who had thirty-seven cases), which
he regarded as an extremely fortunate occurrence. The fetal mortality
was about forty per cent, and he states that we may expect a fetal mor-
tality of at least fifty per cent. The same method of treatment is
outlined by Hirst as advocated by the other author mentioned, viz.^
mechanical dilatation of the cervix and rapid emptying of the uterus.
He, however, does not allude to the extremely important factor in the
treatment of these cases, that is, the introduction of saline solution to
supply the enormous loss of blood.

I do not believe it is proper under these circumstances to spend very
much time in disinfection of the vs^na. I believe that this thing has
been very much overdone, and recent reports on the subject of the
vaginal douche and vaginal asepsis and antisepsis show that the vagina
is normally sterile. Quite an exhaustive report has been made by Dr.
J. W. Williams in which this matter is thoroughly gone over, and I do
not believe we ought to do any ante-partum or post-partum douching
of the vagina unless there are some strong indications therefor. Of
course a strong indication for the ante-partum vaginal douche is the
existence of gonorrhea. In giving the ante-partum douche under these
circumstances we may avoid ophthalmia neonatorum in the infant, but
unless there is some direct indication we should spend no time in dis-
infecting the vagina. If we will probably disinfect our hands, arms,
etc., we will fulfill all the indications.

Dr. William Bailey : I am very much pleased with the paper read
by Dr. Baker. In regard to treatment, I think a great deal depends
upon the individual case and the facility with which the operator will
perform the different obstetrical operations. For myself, I believe
it would be better for me to neglect every thing else and secure dilata-
tion of the cervix and deliver by version. If the foot is brought down^
it wnll serve the purpose of a tampon until the delivery can be accom-
plished.

I do not believe the time will ever come when we will have absence
of mortality for both mother and child, and 1 further believe that
oftentimes the child is lost by the excessive hemorrhage before any
obstetrical operation has been performed, before even dilatation has
been completed. And I want also to emphasize what Dr. Bullock has
mentioned, that we have in the normal salt solution perhaps a means
of preventing the loss of life to the mother, and possibly to the child.



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The American Practztzoner and News. 259

Another thing in this connection, I believe it is admitted that these
cases are more liable to septic troubles than almost any other condition
in labor. The woman with a placenta previa, with great loss of blood,
has rather an increased liability to septic infection, whether it is from
the manipulations necessary in her delivery, or whether it is the
anxiety or hungriness of the absorbents by the loss of blood ; possibly
the absorption is more marked, the absorbents are more anxious, and
absorption of morbific material is more certain to take place ; then it
occurs to me if that is true, the use of the normal salt solution would
supply to the blood-vessels an abundance of fluid substitute, and in this
way perhaps there is less disposition on part of the absorbents to take
up the poisonous material.

Dr. T. S. Bullock : In regard to the last point mentioned by Dr.
Bailey, I have seen lately several reports of puerperal sepsis having
been cured alone by the introduction of the normal saline solution.

Dr. L. S. McMurtry : I have nothing to say on the subject except
to congratulate the essayist upon his paper. His experience has been
an unusually large one ; I think you will fixid very few gentlemen in
the room who have seen five cases of placenta previa.

Dr. J. G. Cecil : I am glad that Dr. Baker selected this subject for
his paper, and, like Dr. McMurtry, I think his experience has been
rather unusual. Certainly it does not fall to the lot of many of us to
see as many as five cases of placenta previa. I have in mind now one
case of central implantation in a primipara which has always given me
a very bad impression of placenta previa. I have seen several cases of
marginal implantation in which there was no diflSculty except unusual
loss of blood, with salvation to both mother and child in prompt deliv-
ery. The one case referred to I would like to report briefly, and in
doing so outline the treatment which was adopted at that time ; and,
although the result was fatal to both mother and child in the end, it
appealed to me at the time as being an ideal treatment for placenta
previa under circumstances similar to that, and I should be disposed to
adopt it again under like circumstances. This case was in the person
of a young woman, probably twenty-four years of age, a primipara — a
rather fleshy, well developed woman. The implantation was central.
I was called to see her in consultation with Dr. Graham, of Jefferson-
ville, Ind. As soon as I reached the patient and made up my mind as
to what we had to deal with, I told Dr. Graham that I thought the case
was exceedingly dangerous to the child and to the mother, and that we



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26o The American Practtttaner and News.

had better get all and the best assistance we possibly could ; and at his
suggestion, in which I heartily concurred, Dr. Turner Anderson, of this
city, was called. Hemorrhage had been very great. The mother, how-
ever, being robust, had stood the loss of a large quantity of blood very
well. After Dr. Anderson came in consultation we agreed that the best
thing to do was to separate the placenta as far as it could be reached,
and then all of us remain with the case, which we did, by simply sitting
down and watching it. Separation of the lower portion of the placenta
from the neck of the uterus that was within reach of the finger stopped
the hemorrhage completely, but up to this time dilatation was not suf-
ficient to proceed with any thing like operative procedures ; neither did
we attempt forcible dilatation. After waiting some hours, dilatation
proceeding slowly, we were able to introduce the finger up to one
side — the side which seemed to offer the least resistance — and break
through the placenta on that side, and evacuated the liquor amnii ;
this brought the head down low well into the pelvic cavity, of course
filling up the cervical cavity very well, acted as a tampon, and we still
waited. The woman was turned crosswise of the bed with a clean sheet
underneath her, and one of us sat by the bed all the time watching foi
hemorrhage and waiting for the pains that we expected to come on.
After sufficient dilatation had taken place. Dr. Anderson, with his
unusual skill in obstetrical operations, succeeded in applying the for-
ceps. Then, of course, we had complete control of the case. With
the forceps on and the head well down there was no further risk;
neither did there occur any hemorrhage subsequently. The child was
delivered alive, but died shortly, probably from loss of blood previous
to the delivery. The placenta was delivered after the birth of the child
without any difficulty. The woman did very well for some days^ and
then developed infarctions of the lung. She got through this after a
few days' extreme illness and bid fair to recover, when the same condi-
tion apparently developed in the brain, and this ended her life.

It was a very sad case, and one in which I was extremely interested,
from the complications, from the situation of the placenta, and from
the final outcome of the case. It seems to be that the prognosis in all
cases of placenta previa will vary very much, according to whether the
patient is a primipara or not. In multiparous women we have a much
better chance for both mother and child than we do in primipara. The
plan adopted in this case seemed to me to be a good one, and ought to
have been followed by better success than we had at that time.



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The American • Practitioner and News. 261

I also think well of the plan outlined by Dr. Bullock, of rapid dila-
tation. Very much can be done with this practice, especially in mul-
tiparous women. Dilatation of the cervix can be done very rapidly
with little danger. I believe further that the suggestion of injection
of saline solution is of a great deal of value. It ought not to be neg-
lected ; it ought to be impressed upon the general practitioner, espe-
cially the obstetrician; and it certainly ought to have a large field of
usefulness, and thereby cause salvation of a great many lives.

Dr. F. C. Wilson : There is only one point that I would like to refer
to, and that is the possibility of accounting for the occurrence of pla-
centa previa in connection with the time of conception. In tracing the
ovum down from the ovary through the fallopian tube to the uterus
and out through the vagina, it is estimated that it takes a certain time
to reach the os — perhaps, on an average, about ten days — and then if
not impregnated it passes out and is lost. Now, we know that one
method of preventing conception practiced among married women is
to avoid coitus for ten days after cessation of the menstrual flow, with
the idea that the ovum will by that time have passed out. Suppose
that coitus takes place during the latter part of this period, could that
have any bearing upon the occurrence of placenta previa? Of
course, the lower the ovum has passed in the uterus at the time it
meets the male elements and becomes impregnated, the more likely it
will be to attach itself at once at that point upon the surface of the
uterus, and the later the period the lower the point of attachment will
take place. It seems to me it must bear some relation to the occur-
rence of these cases. Statistics might be gathered which would throw
some light upon the question, and I thought this might be an interest-
ing point in the discussion.

Dr. T. S. Bullock: In regard to the etiology of placenta previa, I
think cancer, fibromata, and the various forms of endometrial inflam-
mation play quite an important part. I hardly think the site of impreg-
nation, which we know occurs most frequently in the fallopian tube, has
much bearing upon the subject, because we know that as soon as the
ovum falls into the uterus, in those cases where impregnation has taken
place in the normal way, the ovum is caught in one of the crypts of the
mucous membrane (decidua vera), and the decidua reflexa rapidly
envelops it. If any thing has interfered with the development of the
decidua vera near the orifice of the tube, the ovum might drop further
down in the cavity of the uterus, and a lower implantation of the pla-



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262 The American Practttumer and News.

centa would result. There are also some anatomical reasons to account
for it; where the fallopian tube enters low down upon the uterine wall,
for instance. I can hardly see how the time at which conception takes
place has any thing to do with the question.

Dr. F. C. Wilson : The only statistics I can present are two cases.
In these two cases there was placenta previa, and inquiry developed
the fact that in each case conception had occurred nine or ten days
after cessation of the catamenia. There was no question as to the
time of impregnation in these two cases, as coitus had not been prac-
ticed until nine or ten days after the period had ceased.

THOMAS L. BUTLER, M. D., Secretary.



See our Special Offer to new subscribers on one of tlie advertising pages.



.foreign (Eorrcsponbcncc.

LONDON LETTER-

[PROM OUR SPBCIAI« CORRBSPONDBNT.]

The End of the Holidays ; A Dangerous Trade ; Increase of Lady Doctors ;
The Inebriates' Act ; A Royal Visit : Army Nurses ; The Medical Super-
vision of Elementary Schools ; The Institute of Preventive Medicine ;
Our Milk Supply.

The leaders of the medical profession are rapidly returning to town
from their summer holidays, ready for the opening of the various medical
schools in October. There promises to be a smaller entry of fresh students
than usual.

The final report of the Departmental Committee appointed to inquire into
certain miscellaneous dangerous trades has just been published. One of
the most curious subjects they investigated was label-licking, which appears
to be extensively resorted to in thread mills and aerated water factories.
From a minute drawn up by Dr. Oliver, he shows from a medical point of
view it is most prejudicial to health, his analyses of the labels showing
that they frequently contain copper and lead. The report goes on to say
that at one of the large thread mills in Lancashire the tickets for the bob-
bins were at the first visit of the committee almost entirely moistened by
application to the mouth. There were employed at that time some twelve
full timers, who licked from forty to fifty gross of labels per day each, and
thirty-five half timers, who accomplished from twenty to twenty-five gross
per day. To give an indication of the amount of licking possible, Dr. Oliver



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The American Practitioner and News. 263

discovered one woman who could complete forty-five gross of bobbins a
day, or allowing a ticket for each end of the bobbin, ninety gross of labels a
day. Most firms since the inquiry have the whole of this work now
done more expeditiously and better by artificial methods than by the
mouth.

Medical women are increasing in Great Britain. There are eighty-five
of them in London at the present moment registered and qualified, the
g^reater number of them actively engaged in practice. Some hold posts
in dispensaries, hospitals, children's hospitals, infirmaries, ophthalmic insti-
tutions, as anesthetists, medical examiners, and lecturers. Nearly every
large provincial town is provided with a lady medical, one having pene-
trated so far northward as the Orkney Islands. There does not appear up
to the present to have been objection to the lady doctors' presence by the
male practitioner, but a loud outcry is being made in connection with the
midwife business; the semi-qualified woman is alleged to interfere with the
proper province of the medical man.

The Inebriates' Act which was passed last year is reported to be work-
ing with success. The act gave magistrates power to commit to a reforma-
tory any confirmed drunkard who had been repeatedly convicted of
drunkenness. The government inspector calls particular attention to what
he seems to consider a model retreat, that is, the Royal Victoria Home,
Bristol, the inmates of which work in the garden or do any other work that
is found to be suitable for them. They are supplied with daily papers and
periodicals, and after a time they are removed to small cottages near the
main building, where it is hoped to form a sort of model village, in which
the ordinary life of an English village without intemperance will prevail.
This retreat had over five hundred inmates last year, and it is stated that
in only ninety cases could drunkenness be traced as hereditary. The staff
of the institution have come to think that a man is no more likely to be a
drunkard because his father was, than he is to have a wooden leg because
his father had one.

November 15th has been definitely fixed by the Queen as the date of
her visit to Bristol to open the Royal Jubilee Convalescent Home. The
institution has been erected and endowed at a cost of nearly ;^ioo,ooo,
raised by public subscription in celebration of the Diamond Jubilee.

A detachment of army nurses have been sent to South Africa. It is
necessary for each nurse, after going through a general training of at least
three years in a recognized London or Provincial hospital, to be entered for
six months on probation at the military hospital at Neeley ; when this period
is successfully fulfilled, the nurse becomes an army nursing sister available
for duty wherever the requirements of the Service may call her. The age
clause for pension comes into effect at sixty. For war service the nursing
staff is attached to the base hospitals. All told there are eighty nursing
sisters. The uniform is grey serge, with a little red shoulder cape and
plain white linen cap. A man of the Royal Medical Corps is always told



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264 The American Practitioner and News.

off to wait on the sisters. Sisters* pay begins at ;^30 and rises to ;^5o, and
as every thing is provided, including uniform, there are no war allowances;
but as officers they share in any prize money at the end of hostilities and
receive any medal which may be issued. It has always been an essential
qualification for admission to the army nursing service that its members
should not only be ladies, but possessed of those indescribable attributes
that should commend them socially and in their work.

The annual Harveian oration at the Royal College of Physicians, which
was first given in 1656, will this year be delivered on October i8th by Dr.
G. Vivian Poore.

Dr. D. I^ea read a paper at the Public Health Congress on the advan-
tages of the medical inspection of children in elementary schools. He
referred to the very complete system of medical inspection which was car-
ried on in several of the large towns in America. Dr. Lea considered that
the expense of introducing the system here would be more than counter-
balanced in the early detection of disease and an improvement in the gen-
eral health of the children.

The Jenner Institute of Preventive Medicine has obtained permission
to alter the memorandum of association in order to comply with the condi-
tions of a gift of ;^25o,ooo from Lord Iveagh. The original object of the
institute was to promote the study and treatment of infectious diseases.
Lord Iveagh wished to include other objects and to have the institute con-
trolled by seven persons, one being appointed by the Royal Society, three
by the institute, and three by Lord Iveagh or his successors.

Dr. Anningson, of Cambridge, considers that there is a disadvantage in
too strong an insistence on the practice of " pasteurization," inasmuch as it
throws on the consumer the duty of protecting himself, and thereby in a
measure relieved the producer and purveyor of the moral obligation, at any



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 84 of 109)