Billeder på siden

trephining was done on November 24, 1893, two buttons of bone being removed in order to allow the raising of eight pieces of tightly depressed bone, which had been driven in on the brain just to the left of the superior longitudinal sinus, over the leg center. The sinus was torn and considerable bleeding occurred, which was controlled by packing with gauze; the trephine buttons were re-implanted but had to be removed subsequently. The paralytic symptoms soon entirely disappeared and the patient left hospital on February 2, 1894, cured.

I do not desire to make any extended remarks in regard to these cases but will merely call attention to a few facts in connection with them. Case I teaches us not to despair of any injury to the head and to use our best efforts for the relief of the patient. This patient was also much under the influence of liquor when he had received his injury and such patients do not seem to suffer from shock to the same extent as others who are injured whilst sober. Dr. Stephen Smith of New York makes use of this fact and when about to perform serious operations has his patients brought un

der the moderate influence of alcohol in advance.

Case II had likewise been indulging in liquor. His symptoms were first those of concussion, but later showed evidences of pressure and his paralytic symptoms were at once relieved when the skull was trephined, and some blood allowed to escape. He suffered subsequently from epileptic seizures. It is difficult to ascertain whether Case III was benefited by the trephining or whether he would have recovered equally as well without, but I am of the opinion that the operation was salutary in its effect.


Mrs. a primipara, twenty years of age, was taken in labor on the morning of March 17. The pains were irregular; but her health had been excellent in every respect, and at the onset of labor no untoward symptoms were present; her temperament, however, was excessively nervous and apprehensive.

The pains were inefficient, almost becoming suspended, and I was not summoned again until 2 A. M., on the 18th, when the symptoms still pointed to a protracted labor. I returned at 8 o'clock, and, for the first time, made a vaginal examination, finding the bag of waters ruptured and the head well down, but

In regard to Case IV there can be no doubt, a depressed fracture, impinging upon the leg center and causing a paresis of the right leg, was followed by almost immediate relief, after trephining and elevation of the depressed fragments. I think we may learn a lesson from these cases, to operate early when symptoms arise referable to pressure on the brain, whether a depression can be felt or not and if a depression does exist, operate whether compression symptoms are present or not. Do not give them a chance to occur.



By William S. Gordon, M. D.,

President of the Richmond Academy of Medicine and Surgery, Professor of Physiology University
College of Medicine, Richmond, Va.

engaged in a rigid and incompletely dilated os. Believing that I would have some trouble, I called in Dr. Hugh M. Taylor, and, in the meantime, gave sufficient chloroform to deaden the pains. By the time Dr. T. arrived the os had relaxed slightly under the anesthetic, and the head was somewhat advanced; but the progress of the case was very slow, and our decision was to deliver with the forceps. This was done under anesthesia very skilfully by Dr. T., with only a nick in the commissure, which was slightly enlarged by the passage of the shoulders.

In about ten minutes I expelled the

[ocr errors]

placenta into the vagina by Credé's Imethod, and traction on the cord completed the delivery.

Immediately afterwards, there was profuse hemorrhage, which was attributed to a cervical tear; but in spite of all effort to locate the lesion, we were frustrated on account of the free bleeding and the weakness and shock from which the patient suffered.

The hemorrhage was checked with hot water and ergot; recurred subsequently during an examination of the cervix, and was checked again by hot water. We then decided to do nothing more until the next day, when Dr. Taylor closed a moderate tear in the cervix with two sutures. The os had a boggy, bruised, mottled look, which neither of us liked. The lochia were normal.

[merged small][ocr errors]

March 21. Temperature about the same the whole day.

22nd. Temperature 103° in the evening. Dr. Taylor saw her with me. No change made.

23rd. Temperature 104° in the morning. Stitches removed; womb curetted, flushed out with bichloride solution and Blair's chloral thymol, and packed with iodoform gauze saturated with iodoform and glycerin. In four hours the temperature fell to 103. Stimulants and quinine were given. 24th. Temperature 103° at 10.30 103° at 10.30 A. M.; 102° at 5 P. M. 25th. Temperature 104° at II A. M. Womb flushed out and repacked at 2 P. M. Temperature 104° at 7 P. M.

[ocr errors]
[ocr errors]

26th. Temperature 1023° at II A. M. 104 at 5 P. M. Tenderness and hardness not so marked. Womb repacked.


27th. Temperature 101° at II A. M.; 100 at 5 P. M. Womb repacked. Much less tenderness. Chill, with tem

[ocr errors]

perature 1033°, soon after the packing. This was due to shock. Temperature normal at II P. M.

28th.- Temperature 100° at II A. M.; 1033 at 5 P. M. Gauze removed. Temperature 1033° at 8 P. M.

29th.- Temperature 100° at 10 A. M. No pain. Temperature 1023 at 5 P. M. Only vaginal douche used, the womb having contracted quite firmly.

30th.- Temperature 983° at 11.30 A. M. 983° at 5 P. M. No local treatment.

31st. Temperature 99° at 12 M. Slight chill in the afternoon.

April 1st. Temperature 100° at 12 M. 2nd.- Temperature 983° at 12 M.; 99° at 6.30 P. M.

From this time convalescence was well established, and the patient has made an excellent recovery.

This was a case of puerperal sepsis, manifesting itself in metritis, salpingitis and ovaritis. Although the patient's pulse and facial expression were good throughout the whole course of the disease, there was decided lymphatic involvement and blood contamination, causing several hemorrhages from the nose. Neither Dr. Taylor nor I was guilty of any known sin of omission or commission so far as the cause of infection was concerned.

An interesting question to ask is, whether the os should have been sewed up at once, or at all. The shock and exhaustion due to hemorrhage predisposed the patient to infection, and my belief is that the wounded os was the source of the trouble.

The main lesson to be learned from this case is the value of local treatment in puerperal infection. A certain amount of good was done by tonics, stimulants, full feeding and careful attention; but in my opinion the patient's life was saved by the surgical measures which Dr. Taylor wisely suggested, and, for the most part, skilfully executed.

The rapid subsidence of the hardness, tenderness and pain was far from what we expected; and although we could hardly hope for perfect tubes after such damage, still is too early to say exactly what benefit may not be derived from tonics and absorbents.

The pa

tient has been walking for several weeks, and is improving daily, while, at my last examination, the induration on the left side had decidedly decreased.

There were two other important lessons taught by this case. One was, never to trust vaginal douches to an untried monthly nurse, no matter what her reputation may be; and the other was never to delay local measures when the temperature, after a reasonable interval, does not decline. I am no rou

WOUNDS OF VULVA FROM FALLING ASTRIDE. Taffier and Lévi (British Medical Journal) have prepared an instructive article on this subject illustrated by drawings of dissections of the vulva relations when the subject is erect. The urethra is rarely injured. The bulb and surrounding venous plexuses are often torn and bleed very freely. Not rarely the skin and mucosa remain intact. Then a thrombus forms which may burst or harden, or suppurate or end by becoming a cyst. Skin wounds. inflicted by a sharp object on which a woman falls astride seldom run from without inwards. More often the inner More often the inner side of the vulva is wounded and the hard ramus of the ischium prevents retraction of soft parts, hence dangerous hemorrhage may occur. It is, however, generally venous. To check hemorrhage firm pressure is unsuited on account of the extreme tenderness of the parts. Compression by antiseptic gauze is the best way to stop the bleeding. Indeed, as recurrence is very common, it is best always to compress a contused wound. The thighs must be tied together and at catheter retained or frequently passed.

* *


CHRONIC SEMINAL VESICULITIS.Chronic seminal vesiculitis as a result of an old gonorrhea is a disease difficult to treat. Dr. Edmund E. King of Toronto, in a short paper read before the Ontario Medical Association and published in the Canadian Practitioner, relates several cases with his method of treatment which consists principally of deep urethral injection of solution of silver nitrate not more often than every fourth day. His conclusions are:

[ocr errors]
[ocr errors]

tinist, for each case must be met with its own indications; but I am firmly convinced that the various forms of puerperal fever have largely a local starting point, and that the water must be thrown where the fire originated, and where it continues to burn the brightest. It would be well if women could behave as animals after labor, walking about and draining thoroughly, instead of lying down with torn cervix dipping into a pool of pent-up lochia.

1. That seminal vesiculitis is an analogous disease with salpingitis.

2. That it is of very frequent occur


3. That it is the so-called cystitis, prostatitis and prostatic abscess that follows gonorrhea.

4. That, with proper treatment, it is a curable disease.

5. That it is easily recognized per



HEMOGLOBINURIA. Chauffard, at the Société Médicale des Hôpitaux (British Medical Journal), related a case of paroxysmal hemoglobinuria from cold. Ehrlich's experiment was repeated, that is, blood was examined from the two hands, one having been exposed to the air, the other tightly ligatured at the wrist and exposed to iced water fifteen minutes. In the latter the serum was a pinkish cherry color, while in the former it was yellow. The clot did not redissolve in either case, as it should do in an attack of hemoglobinuria. This is explained by supposing that a central nervous disturbance is required in addition to exposure to cold for the production of a typical attack. The relation to the nervous system was shown by this case, for the exposure of the hand isolated by ligature to intense cold produced all the prodromal symptoms and premonitory albuminuria of a general attack. The mode of action and the path taken by the nervous reflex are uncertain, but that some nervous reflex is the starting point of the chemical process which results in an attack of hemoglobinuria seems clear.





Dr. H. H. Levy said that in many instances he had followed the line of treatment laid down by the President; but in many other instances, this plan could not be followed. Each case required a certain course according to indications.

Dr. Hugh M. Taylor said it had been his misfortune (he looks upon every such case as a misfortune), to see in consultation three cases of puerperal sepsis. There was no disease he more feared, none he endeavored more to prevent, and none that he thought called for more decided radical treatment. In most of the cases that had come under his observation, he could assign the focus of infection to cervical laceration. He thought if some of those who advocated the do-nothing policy would look at some of these infected lacerations, mark how nearly they approach in appearance a foul, swollen, sloughing, infected sore seen elsewhere, they would appreciate the importance of rendering aseptic such a wound. If they should, remember that a continuous mucous membrane and rich lymphatic circulation present a most favorable condition for extension of the local septic condition and general septic infection. When sepsis originated in, or extended to the uterine cavity, its mucosa became pussecreting, a condition of septic phlebitis and lymphangitis ensued, foci of septic infection occurred in the uterine walls, and extension to the tubes and their peritoneal investment was not infrequent. The sooner we look upon such a cavity as a pus-secreting and pus-retaining cavity, the quicker will be our appre

ciation of the importance of directing all our efforts towards removing necrotic tissue by curettement, and debris, by irrigation and drainage. Not until the focus of sepsis is destroyed by sterilization can we hope to tide the patient along until the absorbed poison is eliminated.

Dr. J. S. Wellford thought that the tendency was toward meddlesome midwifery. The use of the forceps, douches, packing, curette, interferes with the processes of nature, which is fully capable of taking care of itself, and the introduction of sepsis is the result. He did not believe there was danger of sepsis from a tear, unless it be a large one. In tamponing the uterus we dam up every means of outlet, thereby bringing about trouble. We try to do too much. Some conservatism is necessary.

Dr. Taylor:-The tendency on the part of surgery to invade the domain of midwifery has been often decried. Meddlesome midwifery and masterly inactivity embody principles as potent for harm as for good. There is a time to hold hands off, i.e., in the first stage of labor and in all stages where Nature is equal to the task of delivery and subsequent restoration to health.

Twenty years ago, the clarion voice of the teacher of obstetrics rang out in opposition to " meddlesome midwifery," and in favor of masterly inactivity. No words in the English language, perhaps, have done as much harm. Under the guidance of such teaching, prolonged, exhausting labors; impacted pelvis ; contused, sloughing soft parts; sepsis and dead children frequently resulted.

Masterly activity, when Nature is unequal to the task, is the order of the day, and has almost banished that miserable trouble, vesico-vaginal fistula, and many other post-parturient ills.


A School of Medical Hydrology has been opened at Luchon, in France. It possesses a good laboratory and nine professors on the teaching staff.


GASTRIC ULCER. Podres (British Medical Journal) holds that in cases of purely cicatricial affections of the pylorus, particularly when associated with extensive adhesions, better results can be obtained by Loreta's operation than by gastro-enterostomy. A case is reported of a man, aged 34, who for two years had suffered from vomiting after meals, sharp pains in the region of the pylorus, and constipation. On performing laparotomy, the author found that the pylorus and duodenum were enclosed and bound down by extensive adhesions. On incising the front wall of the stomach, at a point about 21⁄2 inches from the pylorus, he made out (1) a circular ulcer, the base of which occupied a portion of the pylorus and a corresponding part of the smaller curvature, and (2) extensive cicatricial degeneration about the pylorus, so that only the tip of a pair of dressing forceps could be passed into the duodenal opening. This opening was gradually stretched by pass ing at first the forceps and afterwards one and finally two fingers. The base of the gastric ulcer was then scraped with the fingernail and a sharp spoon. The wound in the stomach was closed with Lembert's sutures. The vomiting and pain ceased after this operation and the patient speedily recovered; he regained appetite and was able to sleep well, and when last seen, five months later, had increased in weight.


THE BICYCLE FROM A SURGICAL STANDPOINT. From the medical point of view, says the International Journal of Surgery, this subject has chiefly been discussed in connection with the effects of over-exertion. The latter are well known, are observed in every form of out-door exercise, and form, with the greatest propriety, a text for warnings the neglect of which may bring about, in some instances, quite serious results.

As surgeons, the important question to us is whether bicycling has a tendency to bring about any peculiar bodily malformations due to its use, whether mod

erate or excessive, and to cause any distinct surgical diseases.

In the very first place we must speak of the leaning-over indulged in, to a greater or less degree, by the majority of wheelmen. It would necessitate the printing of many and corpulent volumes to reproduce all the exaggerated and nonsensical statements that have been published in reference thereto. As a matter of fact, the writer, whose experience with bicycles dates back nearly a quarter of a century, is convinced that an absolutely erect position of the body, while riding a bicycle, is a mistaken one and is fraught with possibilities for harm. Sitting absolutely straight in a bicycle saddle tends to throw all the weight upon the rider's seat, whereas a certain amount of leaning forward distributes the weight more evenly, as the shoulders then bear an appreciable amount of the burden. A moderate amount of bending forward facilitates the steering, gives better play to the pull of the arms upon the handles, and allows of greater force being applied to the pedals. An exaggerated leaning forward may certainly produce a gradual vertebral displacement and is decidedly ungraceful.

If a race meet is attended, and the interested looker-on closely observes the athletic contestants, he will certainly notice that they are as straight and well set-up a lot of young men as can usually be seen, and that their bent positions appear to be entirely reserved for the actual riding time. Now that nearly every young man, and a good many old ones, ride, we will certainly occasionally see cases of spinal difficulty in bicyclists, but we will have to use caution in asserting that the wheel itself has been at fault. A hump-backed gentleman of our acquaintance, who rides a wheel and enjoys it greatly, told us the other day that on several occasions he had been asked if the wheel had not "done it," and that he has been pointed out as an awful example. But as his hump dates back from his nursing days he continues his riding.

Upon somewhat better ground attention has been called to the possibilities

« ForrigeFortsæt »