« ForrigeFortsæt »
UNDER CHARGE OF T. J. CROFFORD, M.D.
Consulting Gynecologist to St. Joseph's Hospital, Memphis, Tenn.
Vesical Calculus in the Female.
Happel (Jour. Am. Med. Assn., vol. 32, no. 18) reports four interesting cases of vesical calculus in the female. In operating on three of these cases he used an operation devised by Emmett of New York for the relief of cystitis, which consisted in the formation and temporary maintenance of a vesico-vaginal fistula. In the first of the four cases reported by Happel, an anemic child of 5 years of age, a stone measuring four inches in circumference was removed, with much difficulty, but the child never fully rallied from the shock of the operation, and died in seventy-two hours.
The second case was a child not quite 2 years of age; the calculus was seen at the meatal orifice, and removed without difficulty.
The third case occurred in a large, fleshy woman of about 65 years of age; a large stone was removed per vaginam, leaving a fistulous opening through which the bladder was to drain and be washed out. In eight weeks the fistulous opening had closed.
The fourth case was in many respects similar to the third, the same operation being done as in the preceding case.
The author says, with reference to dilating the urethra and washing out after crushing, that to have dilated the urethra in these last two cases would no doubt have resulted in incontinence of urine, and in the sacculated condition of the lining of the bladder it would have been almost impossible to have fully removed all the detritus, and the result would have been one or more nuclei for the form. ation of new calculi. Since both stones were large, some may ask, why not have done the suprapubic operation, preferred by many? Of this Happel says, in his opinion, the suprapubic operation, even though the stone be large, is not to be compared with the vaginal route where this canal is fully developed, as in the adult female, especially in cases of married women. In the suprapubic operation you have no natural drainage. The bladder must be flushed either through the abdominal incision or the urethra. In either case the outflow is unsatisfactory, and the urine must be retained in a bladder already inflamed, where it acts as a still further irritant, or must drain out through the abdominal wound at the risk of urinary infiltration and of setting up inflammatory action in the site of the wound; while in the vesico-vaginal route the urine flows out constantly at first, thus allowing no new irritation of the inflamed lining of the bladder, but on the contrary permitting a free and ready escape of urine, pus, mucus, and any remaining portion of the calculus. Thus the bladder is placed in a most favorable and scientific condition for a rapid recovery from its diseased state superinduced by the presence of the calculus. In no other way can we obtain as favorable conditions for recovery.
In the crushing operation, which can be done with more ease in the female than the male, no arrangement is made for drainage; nor is it possible to prevent at all times a fragment of the calculus from imbedding itself in the bladder walls, where it cannot be and is not found till grave symptoms have developed,
necessitating a new exploration of the bladder, when again it may not be located. The only drainage in these operations of crushing is obtained, as stated, through the urethra, which must be dilated to some extent, and which, if not overdistended so as to allow the urine to escape continuously from a paralysis of the sphincter, at once contracts and holds the urine and all other irritants, in the bladder till expelled per urethram, or till drawn off and washed out again.
The vesico-vaginal route affords all the good that is presented in any of the other routes, with none of the drawbacks, and gives, above all things needed for the relief of a chronic cystitis, rest and freedom from irritants of all kinds.
The Prognosis and Indications for Radical Treatment of Myomatous Tumors of the Uterus.
Byford (Western Clinical Recorder, vol. 1, no 3) presents the following rules for operating borne out by his experience:
1. Intrauterine polypi may grow to a large size and cause serious impairment of the health by hemorrhage. They are liable, however, to be expelled after attaining a size equal to that of an orange or a cocoanut. In the latter class of cases the capsule, or even the whole tumor, becomes gangrenous and hangs in the vagina, causing dangerous septicemia, from which death has been known to result.
2. Submucous tumors, when few in number, grow to a large size, and are apt to become dangerous by reason of hemorrhages.
3. Intramural and subserous tumors usually grow to large size, and after many years cause serious impairment of health, or even death, by reason of hemorrhage.
4. Subperitoneal tumors extending between the folds of the broad ligaments exert dangerous pressure before becoming very large, and show but little tendency to stop growing. The same may be said of cervical myomas.
5. Tumors commencing in young women may be expected to attain dangerous proportions, while those commencing in advanced life will probably never do so before the patient dies of something else.
6. Single interstitial tumors, or a small number of comparatively soft interstitial tumors, may be expected to grow almost indefinitely; while a large number of hard ones in separate capsules grow slowly, and may be expected to stop growing before becoming very large, either singly or in the aggregate.
7. The menopause may check the growth of tumors projecting from the serous surface and of small interstitial growth. Large interstitial submucous and intraligamentous tumors continue to grow after it.
8. Tumors that produce excessive menorrhagia delay the menopause from two or three to eight or ten years beyond the natural time.
9. Rapidity of growth renders the prognosis unfavorable. 10. Malignant degeneration is rare.
Brothers (N. Y. Med. Jour., vol. 69, no. 19) interestingly writes of the use of steam, ranging in temperature from 212° F. to 230° F., introduced into the uterus in the treatment of various forms of endometritis, leucorrhea, and uterine hemorrhages. In order to learn the technique, etc., it will be necessary to refer to the original article, but the author, from an experience of twenty-one cases of
varied nature, has been enabled to offer some conclusions. He appreciates that his work is still very incomplete, and does not attempt to make sweeping deductions until the subsequent results, after a sufficient lapse of time, shall have proved the true value of the method. He thus summarizes the present uses of vaporization or vapo-cauterization :
1. As a hemostatic it has been employed most successfully in cases of nonmalignant, post-climacteric uterine hemorrhages. It has proved curative in the various irregular bleedings met with in connection with catarrhal fungoid, or hemorrhagic endometritis. It acts as a palliative measure in certain cases of fibroid tumor or inoperable carcinoma associated with hemorrhages.
2. As a caustic it can be relied on to destroy the mucous lining of the uterus, even to the extent of obliterating the uterine canal.
3. As a bactericide it may be used in cases of gonorrheal and septic puer peral endometritis. Fenomenow has repeatedly had the uterus (which was subjected to vaporization and later removed by hysterectomy) examined bacteriologically and proved it to be sterile.
4. To reduce the bulk of the subinvoluted uterus, Pincus has frequently resorted to intrauterine vaporization with success.
5. In chronic suppurating fistulous tracts, Fenomenow has reported successful results in cases of abdominal fistula of several years' duration, which had resisted all other methods of treatment.
OBSTETRICS AND PEDIATRICS.
UNDER CHARGE OF E. P. SALE, M.D., MEMPHIS.
The Treatment of Asphyxia in Children by the Use of a Soft
Golden (Amer. Jour. Obstet., etc., vol. 39, no. 256) reports two cases of asphyxia in children treated by introducing a soft rubber catheter into the larynx. The first of these cases occurred in a child aged 4 years, suffering with pneumo-thorax, to whom chloroform was administered for the purpose of excis-. ing a rib. Complete narcosis, with no untoward symptoms, was brought about, but upon turning the child upon the side she ceased breathing; the pulse was just perceptible. Inversion with artificial respiration restored breathing, and, this time under ether, the operation was proceeded with, but just as the pus cavity was opened the child again ceased to breathe. Same measures to restore respiration failed. A soft rubber catheter was then introduced into the larynx and artificial respiration continued, exhaling forcibly through the catheter during the inspiratory phase. The child commenced to breathe, first in gasps and then with normal rhythm. Recovery complete.
The other case occurred in a child delivered by version, in a case of hemor rhage during labor, where, after extraction, the child was laid to one side as dead. The same method, practically, as detailed in the previous case, restored the child.
Commenting, in closing his report, the author says:
In regard to the first case, the cessation of breathing at both times was of an asphyxial character. The heart was only secondarily affected. Neither of the anesthetics was a factor in causation of respiratory failure. It frequently happens that patients who have obstructive diseases of the larynx, great abdominal distension, large tumors, any condition causing imperfect interchange of the gases of the blood, often show signs of respiratory failure just at the time the condition is relieved. At this time the anesthetic should always be removed, especially chloroform (which was done in the above case), for the reason that when an obstruction to respiration is removed the patient will first take a deep inspiration and stop breathing. Respiration, after a few seconds, in most cases is spontaneously resumed. It can readily be seen, with a saturated chloroform mask over the patient's face during the deep inspiration, he might take in an amount which, if actually measured, would be very small, yet sufficient to cause death from overdosage.
Uterus Myomatosus Gravidus.
Wertheim (Cor. Med. Press & Cir., vol. 67, no. 3130) exhibited a preparation at the Gesellschaft der Aerzte, which he had removed from a patient, æt. 32, in her first confinement, by the Cæsarian section. The myoma was situated immediately behind the neck of the uterus, occluding the channel so completely that embryotomy was impossible. The fetus weighed 4680 grams or 10.296 lbs., and was 56 centimeters or 22.047 inches in length. On opening the uterus, a penetrating odor was intense; the decidua was purulent, which excluded, in Wertheim's opinion, any conservative operation, and therefore extirpated the entire organ, which was followed with perfect recovery.
The Kaiser operation, he said, was not uncommon in uterus myomatosus, but the mortality was so high that little or no favor had been extended to it, as thirty-one deaths out of thirty-eight cases operated on with conservative endeavors was not at all encouraging.
By Porro's method the conditions are better, three deaths occurring in fifteen. The Kaiser operation, with total extirpations, is by far the most successful. Wertheim is convinced that this case would have decidedly died of septicemia had he attempted conservative principles.
SYPHILOLOGY AND NEUROLOGY.
UNDER CHARGE OF C. TRAVIS DRENNEN, M.D., HOT SPRINGS, ARK.
Analysis of the Cases of Tabes in the Johns Hopkins Hospital and Dispensary from its Opening in May, 1889, to December, 1898. Thomas (Bul. Johns Hopkins Hospital, vol. 10, no. 77) makes a most valuable contribution to the literature of tabes, in a study of the records of the dispensary of Johns Hopkins Hospital. Of most pertinent interest is the part of his article which considers the etiology. The reporter says that since he believes that syphilis is the cause of the vast majority of cases of tabes, he has practically confined his attention to this factor. The following table, in which only men have been considered, there being definite records in ninety-five of the ninety-seven cases, has been compiled by him:
By certain syphilis is meant the definite history of a chancre which was believed to be syphilitic and was treated as such, or the history of a chancre which was followed by secondary manifestations, and in two instances where skin eruptions were recognized as syphilitic, although there was no history of the primary sore. All other venereal sores have been tabulated as indefinite chancres.
In taking the histories the supposition has been that in all cases of tabes syphilis has preceded, and the burden of proof has been with the patient who denied its presence. The results are: certain syphilis, 42.1 per cent.; possible or probable syphilis, 63.1 per cent. These figures fall below those obtained by many of the later observers, but it is not due to lack of zeal.
An analysis of the sexual histories of 1238 men who came to the neurological dispensary suffering from all sorts of troubles, resulted in the finding of certain syphilis in 10.9 per cent., and possible or probable syphilis in 21.4 per cent. These percentages are much smaller than those found in tabes, and the inference that syphilis bears an important relation to the development of tabes is plain. A summing up of the cases studied seems to show:
1. In a large proportion of cases of tabes, a history of syphilis can be obtained. 2. In a certain and not inconsiderable number of cases, there is no history of a venereal sore or other syphilitic manifestations.
3. In negroes tabes is relatively uncommon, whereas syphilis is much more common in them than in the white population.
4. The partial immunity of women is greater than can be satisfactorily accounted for by the relative infrequency of syphilis among them.
The author does not take these conclusions as indicating that syphilis is not the most important cause of tabes; on the contrary, they seem to him to speak in favor of this belief. The fact that he was unable to elicit the history of syphilis in thirty-six per cent. of his cases, does not of course prove that syphilis was not present in a large proportion of these cases.
Although tabes does not seem to be common in the negro, when it does occur it has usually been preceded by syphilis. In four of the author's five cases there was the history of a venereal sore, and the same has been shown in the cases of tabes in women. That syphilis is not the only factor in this causation of tabes does seem to be shown. What the factors are that make white men so much more liable than black women to the development of tabes, the author is sure