66 *** 7. Let the patient be enveloped in a light blanket, and with no more bed-clothes than are sufficient to keep him from feeling cold. (The idea is to keep the patient cool and not to sweat him as in former times. Dr. L. claims that he has given salicylic acid in aortic and mitral lesions, and in rheumatism complicated with pericarditis and, no bad result from it." He says that in pericarditis complicated with delirium, the remedy must be used cautiously. "Further, if pericarditis or endocarditis, or pleurisy have developed, the remedy is powerless over the mischief which is done; it will neutralize the poison producing the mischief so as to stop its extension, but the inflammatory exudations will undergo their usual changes unabbreviated in their course. Dr. L. says that by the judicious use of cholagogue purgatives the bile is eliminated from *** the intestines. and a quantity of glycocine is thus removed from the system, which if reabsorbed would lead to consequent formation of uric acid." *** claims He has seen marked relief follow the administration of calomel and a saline cathartic in sudden attacks of gout. He that when there is high arterial tension, as in the gouty paroxysm, this may be relieved by these remedies. * * * necessitate an increased elimination of urea, and consequently a greater tax on the powers of the kidneys. * * * The simpler the diet then the less tax there will be upon the kidneys and the better they will do their workLet the diet be chiefly farinaceous, with just sufficient nitrogenous food to satisfy the wants of the system, and in acute attacks let that be in the form of milk, diluted even, if necessary." BRAIN SURGERY. - We learn the following interesting account from the British Medical Journal: "A man was recently admitted into the National Hospital for the Paralysed and Epileptic (Queen Square), suffering from a severe form of epilepsy consequent upon an injury to the head which had involved the brain. About three weeks ago, Mr. Victor Hosley, who is assistant surgeon to the hospital, trephined in the neighborhood of the scar, cleared away the injured bone, and excised the scar in the brain. In order to remove the whole of the scar tissue it was necessary to excise from the upper end of the fissure of Rolando a mass of mixed cicatricial and brain tissue measuring about an inch and a half long, and an inch deep, and three quarters of an inch broad. A drainage tube "In some cases calomel has a very depress-moved on the following day; a little serum was introduced at the operation, but resing effect, and when the kidneys are unsound is injurious in its action. When this is the case a gentle laxative, such as rhubarb, is of service. * * * A few grains of rhubarb with double the quantity of magnesia every day; or some light bitter infusion with tincture rhubarb and about fifteen grains of bicarbonate of potash will act as a prophylactic against gout. *** The diet should often be simple and nutritious; jellies and food containing gelatine should be avoided, as this taining gelatine should be avoided, as this substance furnishes glycocine." "Animal food in a healthy system will not produce uric acid; but from all kinds of meat a certain amount of glycocine will be produced, and even if all the rest of the nitrogenous portions, after being absorbed in the system were converted into urea, this would had to be let out from the cavity of the wound on the fifth day, but the wound was practically healed within a week, and all The patient never had a bad symptom, but dressings were removed on the tenth day. it is as yet too early to form any opinion as to the prognosis with regard to epilepsy, though when inquiry was made we informed that he had had no fit since the operation. It is interesting, in the face of the reiterated misstatements of a certain knot of agitators, to learn that the operator, in this were successful, that is, so most successful case, animals." was guided not doctrines, with wounds, but by experiments on ORIGINAL ARTICLES. THE INFLUENCE OF PREGNANCY AND PARTURITION UPON ORGANIC CARDIAC DISEASE. BY T. A. ASHBY, M. D. bances of the blood-supply to the uterus, call for the expenditure of great energy and force upon the part of the heart and its vessels, a force which is not easily measured by any other standard of exercise to which woman is subjected. When the heart is prevented by disease from adjusting itself to the conditions mentioned, variable influences will be experienced. Read before the Gynecological and Obstetrical Society The extent of these influences must depend of Baltimore, May 11th, 1866. During gestation the heart is called upon to perform increased duty in maintaining the circulation of an increased arterial tension, and in distributing the blood supply into new and rapidly developing vessels and tissues. As a result of this assumption of greater exercise and frequency of ventricular contraction, hypertrophy of the left ventricle is constantly found in the pregnant woman. The heart is prepared in a physiological way for the extra duty exacted of it, and it continues to perform this duty until the influence of pregnancy is withdrawn. Of the various modifications imposed upon the female organisms by pregnancy, none is more astonishing than the functional activity of the heart under the influence of gestation and parturition. The test of cardiac soundness seems to be thoroughly tried. If any defect exists in the circulatory apparatus, it is most likely to be made manifest under the trial to which it is subjected. Assuming that a healthy circulatory system is required to meet the extra strain and ordeal of pregnancy and labor, we should expect to find organic heart disease unfavorably influenced by these conditions,and especially by the latter function, as the disturbances of the heart's action are more pronounced under the ordeal of severe exercise than at any other time. Under the influence of uterine contraction, the large volume of blood distributed to the uterus, is suddenly thrown back into the general circulation and must be provided for by vaso-motor influences. Alternate contraction and relaxation take place with great suddenness, and unless the compensatory laws which preside over the entire circulatory system, work with promptness and energy, disturbances, of a more or less serious character, are unavoidable. The equilibrium of the circulation must be maintained by the promptness with which the heart and blood-vessels-arteries, veins and capillaries -adjust their action to the rapid change of conditions which occur in labor. Aside from the profound moral impression which labor makes upon the majority of parturient women, the physical exertion and the sudden distur upon the character of the organic changes, or upon the character of the labor. It is wellknown that patients suffering from serious organic disease, pass through the ordeal of labor triumphantly. The compensatory action of the heart, if disturbed at all, is fortunately adjusted, and delivery takes place, it may be, with no alarming symptoms. If such be the happy termination of labor in even the majority of cases suffering from organic cardiac disease, it is not the invariable rule. The late Dr. Angus Macdonald some years ago collected 28 cases of pregnancy complicated with cardiac disease, of which 17 died during labor. Macdonald's observations led him to formulate the opinion that the evils resulting from pregnancy in connection with cardiac diseases, are due to two causes: first, destruction of the equilibrium of the circulation which has been established by compensatory arrangements; secondly, the occurrence of fresh inflammatory lesions upon the valves of the heart already diseased. Spiegelberg attributed the grave symptoms of mitral disease presenting themselves during labor, or soon after confinement, to excessive distention of the right heart with blood forced from the contracted uterus. Fritsch opposed this idea and attributed the morbid phenomena of mitral disease to the accumulation of blood in the abdominal vessels, recently released from the pressure of the gravid uterus, and to the cardiac paralysis resulting from an insufficient blood supply and consequent defective nutrition of the heart. The influence of pregnancy and labor upon the circulatory apparatus may be viewed from three standpoints: 1st, the influence exerted upon the heart and blood-vessels affected with organic disease prior to pregnancy; 2nd, the influence exerted upon the heart's valves and upon the heart's action during uterine contraction; 3rd, the permanent damage which the heart sustains from the influence of pregnancy and labor. It is proposed to consider these conditions in the briefest manner. As the discussion of this subject can not be elucidated by any important clinical facts within our posession, we must draw surmises rather than offer data to establish conclusions. 1st. The influence of pregnancy and labor upon organic cardiac disease may be considered as unfavorable. A heart already crippled by disease, is poorly prepared for the increased exercise and disturbing influences of labor. The heart is called upon to put forth unusual effort during uterine contraction, in consequence of the irregularity of the bloodsupply to the uterus and pelvic organs. The entire circulatory apparatus is required to function under extraordinary conditions, and any weak point in the construction of this circulatory apparatus,is exposed to imminent danger. If the heart itself is at fault, the damage will be inflicted upon it, resulting in impaired or suspended action, or if the defect reside in artery, vein or capillary, rupture of one of these vessels may be the result with circumscribed or general extravasation of blood into surrounding tissues; cerebral hemorrhage, pelvic hematocele, or effusions of blood into cellular tissues, are not unknown results of the influence of labor upon the vascular system. 2nd. The influence exerted upon the valves of the heart and upon the action of the heart during uterine contraction is extremely variable. As the general rule, the cardiac valves are capable of sustaining the increased tension thrown on them by uterine contraction. The right heart may, however, become overdistended, and the phenomena of mitral disease may manifest themselves. We have elsewhere stated the opposing views of Spiegelberg and Fritsch in regard to this question. It seems to us that there is truth in both of these theories, and that over distension or insufficiency of the blood-supply to the heart, may equally well account for the phenomena of cardiac irregularity or paralysis. The heart's action may, undoubtedly, become tumultuous, labored or disturbed by the diminution, or by the increased pressure, of the blood-supply. The exceedingly rapid action of the heart following violent post partum hemorrhage is an explanation of the effect of diminished blood-supply to the cavities of the heart. It can make but little difference whether the blood-supply is simply diverted and thrown into the pelvic vessels, as suggested by Fritsch, or whether it is lost by escape from the uterine sinuses; the temporary effect upon the heart must prove the same. Over-pressure of the blood-column upon the heart's valves might be sufficient under extreme conditions of arterial tension to induce temporary or even permanent insufficiency, or a rupture sufficient to destroy cardiac action 3rd. Permanent damage to the heart and vascular system is not an impossible result of the influence of pregnancy and labor. The physiological hypertrophy of the left ventricle is undoubtedly compensatory, and, so far as it goes, actually improves the circulation; but whilst this may be necessary to maintain an increased blood-pressure and arterial tension under ordinary circumstances, it is probable that under certain conditions permanent enlargement and even dilatation of the heart may persist after gestation. As a result of the extra strain of pregnancy, valvular inflammation may supervene and permanently impair these structures by plastic deposits or by ulceration. During labor the pressure exerted upon the valves may likewise result in permanent incompetency. There may therefore persist a stenosis or incompetency of either the mitral or aortic valves. There is no clinical evidence, however, in our possession to establish these conclusions, but they seem tenable on purely anatomical and pathological grounds. Where organic lesions exist prior to preg nancy, the case is different. The influence of pregnancy and labor can scarcely do otherwise than promote further pathological changes, even though the ordeal of labor is successfully passed through. Macdonald takes an unfavorable view of the prognosis of labor associated with cardiac disease. His statistics show a mortality of 60 per cent. He was so impressed with this idea, that he considers marriage contraindicated when cardiac disease is known to exist. This suggestion, if acted upon by those who have knowledge of the existence of cardiac disease, would, no doubt, do away with not a few of the serious complications of childbearing. The dangers of wedlock should at least be explained to such persons by the family physician whose advice is often sought, if not always accepted by his patients. Should cardiac trouble be recognized after pregnancy has been established, the existence of a diseased heart should arouse the obstetrician's interest and anxiety. The ordeal of labor is not to be considered with levity, if the history of the following case is in keeping with the usual behavior of such cases. During the latter half of the month of December, 1880, Mrs. M. called at my office and engaged me to attend her in her approaching confinement. She was between six and seven months advanced in her second pregnancy. The appearance of my patient made an unfavorable impression upon me, and I made close inquiry into her condition. She was tall, at once. The slender and anemic, and was below par in general health. She had suffered with distressing nausea, weakness and anxiety during gestation, and expressed serious forebodings of her approaching confinement. I found, upon physical examination, that both the mitral and aortic valves of her heart were defective. She had a decided mitral regurgitant and an aortic obstructive murmur. heart was hypertrophied. It was performing its duty with regularity and force. Pulse good; no edema or dropsy. Her condition was one of general debility, anemia and nervous excitement. I saw this patient several times during the next few weeks, and gave her such instructions in regard to her confinement as were deemed advisable in the way of prophylaxis. On the night of February 28th, 1881, I was hurriedly called to attend this patient in labor. Being absent from my office at the time, it was over a half-hour before the message reached me. I hastened to the patient's bedside, and, upon entering her room, found her in the most alarmed and excited condition. She was tossing herself from one side of her bed to the other, throwing her arms about in confusion, and crying "Help!" "I am dying!" "Do save me!" and other wild and terrifying exclamations. I soon restored a degree of quietude, and made an examination. The child had been delivered fifteen or twenty minutes prior to my arrival, but the placenta had not come away. Introducing my finger into the vagina, I found the placenta firmly attached to the upper left segment of the uterus. I removed it with some difficulty. The uterus at once contracted firmly, and hemorrhage ceased. Ergot and brandy had been given hypodermically. The amount of blood lost prior to my arrival was considerable. I estimated it at between sixteen and twenty ounces. There was no bleeding after the detachment of the placenta, and, as far as I could determine, the amount of blood lost was not sufficient to account for the great depression and alarming condition of my pa tient. The firm contraction of the uterus and suspension of the flow of blood failed to exercise any beneficial influence upon the patient. Her nervous, excited and alarmed frenzy broke out with renewed violence, and in spite of every injunction she would not be quieted nor comforted. Her circulation may be de. scribed as horrible. The heart was beating with great violence, irregularity and excitement. Its action was thumping and tumultuous. It vainly and vigorously attempted to expel the flow of blood emptied into its cavities, but with such poor success that pulmo nary congestion was soon established, respiration was hurried and embarrassed, and dyspnea was becoming alarming. The circulation at the wrist, and in the lower extremities, was barely perceptible, though the heart beat was heard some inches from the thorax. The action of the heart continued this irregular, tumultuous beat until about 1 o'clock A. M., when suddenly its action suspended, and my patient died with the the exclamation on her lips, "I am dead!" The closing scene of this drama is better remembered than described. It suggested the total inability of human skill to establish a normal condition when organic disease has entered in to complicate a physiological function. Reviewing the symptoms observed in this case, I was convinced then, as I am at the present day, that the post partum hemorrhage was not sufficient in itself to have accounted for the death of my patient. I doubt not the hemorrhage was an important factor in the disturbance of the heart's action, but had this organ been in a condition to perform its phy; siological function, the loss of blood sustained would have imposed no severe hardship upon this patient. Organic disease had so impaired the working power of the heart that the moment extra effort was required of it to preserve the equilibrium of the circulation, it broke down in the performance of its duty, and failed to adjust itself to the requirements of the situation. -Poor Preller, he not only had to fall a victim to the murderer Maxwell, but his genital aparatus has to be exposed to the vulgar gaze of courtroom attachees and dragged around to medical societies in a sensational manner, ad nauseum. Justice demands that the murderer Maxwell be hung forthwith, and good taste, and decency, and respect for the outraged dead, demand that his urethra, etc., be interred "along with his bones under the stones." -The "Denver Medical Times" says: "The scientific work of the last meeting of the AmeriThe can Medical Association was of low order. International Congress question was sprung on the sly, and passed by a very small vote.' This statement is hardly justified, by the fact that this question had been previously discussed by a large number of the delegates, the time for presenting it thoroughly understood, and there was a full house and a unanimous vote. There was no need for 'sly" work. WEEKLY MEDICAL REVIEW, province and duty of those in attendance this EDITED BY THE MEDICAL PRESS AND LIBRARY ASSOCIATION 914 LOCUST STREET, ST. LOUIS, Mo. Contributions for publication should be sent to Dr. I. N. Love, Secretary Executive Committee, Cor. Grand and Lindell Aves. SATURDAY, JULY 10, 1886. THE MISSISSIPPI VALLEY MEDICAL As SOCIATION. The meeting next week will probably decide the question as to whether this society is to live or die. The friends of the Associa tion must face the issue and abide the result. There was need of an exclu year to remove. Our Association should be in line with the other societies of the country. It should send to and receive from the different state associations, delegates who would carry the interests of the Mississippi Valley Association with them. Nearly all the members are members of local societies. All should be so. Why then should they put themselves in a false position by refusing to announce their true principles here. To accomplish this result, will cost the Association-nothing. To fail in attaining it will be a failure to stay the downward tendency of one of the best medical societies in the country. BRITISH MEDICAL JOURNAL. After the old Tri-State was organized, it THE PHILADELPHIA CORRESPONDENT OF THE grew rapidly. sively Western society, and with each meeting the attendance and interest increased until at Terre Haute and again at Indianapolis, three days were barely sufficient for the work on hand. It was not so at the last meeting nor at the meeting of 1884. It needs no keen analysis to determine the cause. The men of the West and South are almost unanimously in accord with their State Societies, and with the American Medical Association. These all require a certain standard; recognition and adoption of this standard is demanded by these societies, of all who would become members. The Mississippi Valley Association, so far, has not made this demand. It is possible for a physician, even though he may be unable to enter his home society, to join this. For this reason the report has been made that the Association is disloyal,and protests have been filed against the admission of delegates from it to other associations. It is true that delegates have never been appointed, and these protests were made by those ignorant of the fact, but it placed a stigma on the Association which it is the One of our most valuable foreign exchanges is the British Medical Journal, and we regret greatly to see the painfully labored effort made by its Philadelphia corresdondent to influence English sentiment against the coming Congress. We learn that the writer has recently located in the city of brotherly love (?), and, consequently, has some excuse for his ignorance, though he shows a surprising amount. of information in some particulars. As the most of his letter is what we have heard again and again from certain quarters, the suspicion grows upon us that he has been "coached." It is a disgrace for any man to serve up second hand material in so pretentious a manner, at such a "feast of reason" as we generally find in the British Medical Journal. Such a caterer is better designed for a bottle washer. We quote a few samples: "It was from this class that the original congress committee made the appointments to office. They ignored locality altogether, and the cities of the East, being older medical centers, came in for a very large share of these appointments." |