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Position of heart beats-Midway between umbilicus and
anterior superior spine on right side.
Distance between spinae-26 cm.
Between cristae-27 cm.
Left oblique-22 cm.
Right oblique-22 cm.
Conjugata externa—20 cm.
Conjugata diagonalis-11+ cm.
Abdominal circumference-94 cm.
Distance of, from symphysis and sternum-40 cm. Vaginal examination :
Cervix-Soft and dilated.
Os externum and os internum-Slightly dilated.
Time of first pains—5 a. m.
Time of rupture of membranes--1:15 p. m.
Duration of second stage-15 minutes.
Ether given from 2 p. m. to 2:15 p. m.
Temperature -99° F.
Examination during the first stage of labor revealed a relaxed vaginal wall and perineum; dilatation of the os to about three fingers' breadth and head down in the pelvic cavity. Labor pains about every half hour. Second examination showed the protruding membranes from the vulva. Membranes were clipped with a pair of scissors and the liquor amnu allowed to escape. Child was born with no difficulty whatever. Fifteen minutes later the placenta was born, attached to an inverted uterus. The placenta was hastily stripped from the uterine wall and uterus pushed back into the pelvic cavity. At this point there was considerable hemorrhage. The os had so contracted after the inversion of the uterus that it was impossible to evert it. Vagina was packed tight with iodoform gauze and Dr. Barney sent for, who removed the packing on his arrival, and after the administration of ether, everted the uterus. Uterus and vagina packed with iodoform gauze— Ergotole m XXV at 3:20 and m XX at 4:30. Poor contraction of the uterus. Iodo form packing removed 4.8 hours later. Part of membranes came away with the packing. Vagina repacked with iodo form gauze. General condition good; good contraction of uterus; temperature, 99° F.; pulse, 104; respiratin, 24. Vaginal packing removed in twelve hours. More of the membranes came with it. Temperature, 99; pulse, 108; respiration, 24. Fairly good contraction of the uterus. Strychnine sulph. gr. 1-30 given every four hours since delivery.
REPORT OF A CASE.
COMPLETE INVERSION OF THE UTERUS.
BY DR. DELBERT BARNEY, WILKES-BARRE, Pa.
I wish to report an unusual obstetric accident which occurred recently at the City Hospital,-that of spontaneous complete inversion of the uterus following delivery at term. This accident is interesting both on account of its rarety and on account of its serious nature. According to Playfair, inversion was
observed only once in upwards of 190,000 deliveries at the Rotunda Hospital, Dublin, since its foundation in 1745. Winckel had not seen a case of complete inversion in 20,000 labors, nor had Braun one in 250,000 labors. Kehrer states that the accident is thought to occur once in 2,000 labors. More recent writers, however, are inclined to think that it happens more frequently than the published reports would make it appear; for in some cases, if the displacement is recognized, the fact is concealed, and in other instances the condition is not recognized.
That inversion of the uterus is one of the most formidable and serious conditions which can occur in parturition is proved by the fact according to Crosse's statistics; one woman out of three dies either immediately or within a month, and even in the more favorable list given by Winckel, twelve died out of fifty-four cases, about twenty-two per cent. If death occurs at once, it is from shock or hemorrhage; if not immediately, it may be due to peritonitis, puerpural sepsis, or from gangrenous inflammation of the uterus.
The diagnosis of complete inversion is easy. The definition given by Richard Norris, "the uterus upside down and inside out", describes the condition accurately, and no observer could fail to notice it, especially when attended by profound nervous shock, hemorrhage and vomiting.
The cause of inversion is most frequently unwise traction of the cord, or improperly applied pressure on the fundus when the placenta is adherent. But relaxation of the uterus always precedes inversion, and it is believed that if the placenta be attached to the fundus, its mere weight dragging down may produce spontaneous inversion. This would seem to be especially likely, if the patient be suddenly delivered while in a standing or sitting posture. Most frequently, however, inversion is caused by ignorant midwives by pulling on the cord with one hand and pressing upon the fundus with the other before the relaxed uterus has had time to regain its tone after the expulsion of the child.
The treatment of inversion is to restore the organ as soon after its occurrence as possible, using one hand in the vagina
to produce taxis, and to try to force back first that part of the uterus which was last to descend; in other words, not to put the force on the fundus alone, for fear of making to much obstruction to pass thorugh the os. The left hand on the abdomen assists in holding the os stationery while reposition is being accomplished. The more recent the inversion the more easily restored.
It is interesting to note that in spite of the gravity of inversion of the uterus, some patients live even when restoration cannot be accomplished, and that in rare instances nature makes a spontaneous restoration. At least ten such cases have been reported. Dr. Robert P. Harris reports a remarkable case, in which a young woman carried about with her an inverted uterus for three years. Then when she was about to be operated upon for removal of the uterus by Dr. W. F. Atlee, and while under ether, spontaneous restoration took place. The inversion of this case was attested by Dr. Agnew. The patient made a good recovery and later again became pregnant.
THE CANCER PROBLEM.
BY DR. HAROLD J. GIBBY, PITTSTON, PA.
A complete discussion of the cancer problem is obviously out of the question in the limited time allowed me for this paper. Untold volumes have been written on the subject, and many more will be produced before the vexing question is. finally solved. I will not attempt to go into the matter of differential diagnosis, nor will I take up the deeply technical side of pathological microscopy, but will rather recall to your minds the salient facts that concern us as practitioners.
The term cancer will embrace in this case the whole array of malignant neoplasms, epitheliomata and sarcomata, and no classical definitions or classifications will be considered.
Since medicine emerged from the dark mysteries surrounding its beginnings and took upon itself the attributes of a fixed science, many wonderful discoveries have been made and many victories over disease have been accomplished.
It has been said that the mere mention of the name Athens recalls more to the mind of the scholar than the untutored can acquire in years of study. So the mere mention of smallpox, diphtheria, yellow fever, malaria and tuberculosis recalls to your minds the heroic efforts which have been put forth in discovering the causes, and the gratifying results in the prevention and cure of those diseases. But in the midst of this pleasant review of past attainments there looms the ever darkening cloud of the malignant neoplasms.
True it is, that tetanus and typhoid fever are now preventable diseases and their prevalence in surely lessening, but quite the reverse is the situation with regard to that ever present menace-cancer. For it is a generally accepted fact that the deaths from cancer among the civilized peoples have increased very markedly during the last twenty-five years and show every tendency to a further increase.
The death rate in England and Wales from cancer in all forms (including sarcomata) in 1890 was sixty-three per 100,000 of population, in 1907 ninety-one per 100,000. In the Netherlands it increased in that same period from seventy to 102 per 100,000. In Switzerland from 114 to 132. The reports for all other countries give like figures. And all this in the face of the untiring work of scores of intelligent investigators both in the United States and Europe. Almost in no other field has so much energy, time and money been spent with so little definite result. Still some encouragement is to be offered, for, though a vast amount of preliminary experiments must be performed before conclusions can be drawn, already much of value has been unearthed. The cause of cancer and sarcoma still remains a riddle, but one which will be solved, and let us hope speedily.
In this connection it will be interesting to glance briefly at the history of cancer. (For part of this I am indebted to Roswell Park, M. D.)
The most noticeable thing in the voluminous literature of cancer is the confusion of names. This is especially noticeable in the earlier writings, in the days before the microscope. It