TREATMENT OF ANAL FISSURE AND then removed, enabling him in this way to gain about half an inch on the pedicle. One should seek to get a long pedicle, and relieve the strain on the broad ligaments and dragging on the supporting pins. If the broad lig. Anal fissure, or irritable ulcer, according to aments or the peritoneal covering appeared statistics, ranks third in frequency among the redundant, the operator should remember not diseases of the rectum, is found in the infant to cut away any until he was ready to stitch as well as in the octogenarian, and is due it over the stump. The intraperitoneal principally to the passage of hardened feces method of treating the stump had been held through the sphincters. Although insignifiup as the ideal method, but as a matter of cant in character, it causes fully as much exfact we were not yet able to adopt an ideal quisite agony as any ill that human flesh is method. Dropping the stump had in his heir to. Very many simple fissures get well hands proved about as uniformly disastrous promptly, but where, by frequent mechanical as the extraperitoneal method of treating it irritation, they come to stay, it is then that had proved successful. He had employed the beneficial treatment is desirable. Many former method in two cases, both of which cases will, however, refuse a radical operation, proved fatal. In some cases the broad liga- and for this reason Dr. H. O. Walker (New ments were so long and the ovaries so easily York Medical Journal, July 30, 1887) recomlifted out of the pelvis that it was a simple mends the treatment of such cases by gradual matter to include the whole in a loop. Or dilatation. He was led to employ this proone ovary might be included in the loop, cess in a case which refused operation, and while the other had to be secured separately. in which various forms of treatment by supOr both might have to be secured separately. positories failed to produce relief. Dr. The tumor might be situated so low as to Walker in this case introduced a bivalved render it necessary to separate it from the speculum, slightly separating the blades, and peritoneal envelope before sufficient pedicle allowing them to remain in situ for about could be obtained. As to after-treatment of two minutes. This procedure was continued the pedicle, it should be thoroughly protected daily, gradually increasing the dilatation at with gauze, and then the less it was interfered each sitting until the blades were separated with the better. The prime object was to get to their fullest extent,-about two inches in the stump dry. As soon as the dressings be- diameter. This treatment was continued uncame moist they should be changed. Per- til there was an entire subsidence of all prechloride of iron should not be applied; it vious symptoms, with a full healing of the was unnecessary, and might be injurious. fissure and hemorrhoidal tumors and disapIn regard to tightening of the instrument, pearance of constipation; entire treatment very little interference would be required. If lasting about five weeks. Dr. Walker likethe pedicle was very thick, it would probably wise reports in detail four other cases taken be necessary to tighten the instrument. from a record of upward of fifty, which he There should be no hurry to get rid of the has treated by this method, and which he stump so long as it remained dry. If pus ap- considers are fair representatives of the charpeared, measures should be taken to give it acter and results of the whole. In all of free discharge. He had performed suprava- these cure was produced. In conclusion, he ginal hysterectomy fifty-seven times, with recommends the treatment of anal fissure and forty-five recoveries and twelve deaths. In hemorrhoids by gradual dilatation on the folonly two of the twelve was the death due to lowing grounds: peritonitis and septicemia. Of hysterecto mies for the removal of pedunculated fibroid, thirteen cases had been treated by the extraperitoneal method, all of which had ended in recovery. Two cases in which enucleation was practiced and the extraperitoneal method carried out, had both ended in recovery. In five cases treated by the intraperitoneal method, one patient had recovered and four had died. The discussion on this paper was postponed. first two or three distentions. 2. It does not tear the parts, nor does it produce paresis, as occasionally occurs after forcible dilatation. 3. Neither does it leave cicatrices that are apt to produce stricture, as in the method of hypodermic injection or ligature of hemor rhoids.-"Ther. Gazette." -Mrs. De Buffington says her husband suffered from suffusion into the plural, but the doctors drew off the water with an exasperator, and now he is incandescent. COMMUNICATION. MEMPHIS, TENN., Sept. 29th, 1887. EDITOR REVIEW: In regard to the communication of mine appearing in August 6th is. sue of the REVIEW and in reply to the Indiana Medical Journal, I would say, that to assume a stomach consciousness is neither paradoxical nor absurd, that animate nature even to the lowest cell displays purposive activities that can neither be explained by the crude theological conception of an anthropomorphic director, nor by the antagonistic and strained conception of mechanical necessity; that we know absolutely nothing of the essence of consciousness, and that consciousness as elaborated by the protoplasmic cells of the brain is a great mystery, as consciousness elaborated by the protoplasm of a simple cell remote from that organ; that mechanical physiology has by no means crushed vitalism beyond all hope of resurrection; that there is knowledge and truth outside of the Academy of Sciences and the mass of concepts which authority has bequeathed to us as an unchangeable mental diet; that we can hardly say the massive brain of the editor of the Indiana Med. Journal carries within it the wisdom of the two hemispheres and a great part of the Cosmos like Von Humboldt's; much less can we say that his limited experience has taken in all, and that when his experience fails to vibrate to and comprehend the experience of another, the experience of the other becomes too lucid for his comprehension. FRANK W. VANCE, M. D. NOTES AND ITEMS. "A chiel's amang you takin' notes, And, faith, he'll prent 'em." -The crime of substitution of one child for an other after accouchment may now be very much facilitated by the introduction of a sonambulistic state during labor. -A "funny" correspondent to the "Jour. of Reconst." says that there is no use in having a a similar position himself, and found by making use of a piece of india rubber tubing that while lying stomach downwards, and with the feet higher than the rest of the body, and putting the piece of rubber tubing in the water, he was able to drink a large tumblerful without stopping and with the greatest ease and comfort, although in the ordinary position a teaspoonful of fluid was as much as he could manage to get down, and this was accomplished only at the cost of much pain and terrible paroxysms of coughing. -TESTS OF PEPSIN.-These tests recently made by the "American Analyst, consisted of twelve samples of pepsin manufactured by six different firms. All of these were obtained at drug stores, and, after being emptied into clean glass bottles, were numbered from 1 to 12, and handed to two different chemists without any knowledge on their part as to the maker of any of the samples submitted. Their reports are as follows: "Number of grains of egg albumen in finely pulverized form dissolved by two grains of pepsin in six hours at a temperatere of 100-103- F. Sample No. 1 18 grains. 19 66 It is fair to add that specimens Nos. 7 and 8 were Carl Jensen's crystal pepsin. With this statement we leave the matter to be judged by the reader." -A proposition made to line the interior of the Arcueil aqueduct with lead met with great opposition from the Parisian public through their fear of contamination of the water by the metal. To satisfy their minds chemists were employed who proved most conclusively that the water passing through the aqueduct was of such a character that it was impossible for it to act upon the lead. -An infuriated Italian mob shot a postman because they believed that the letters which he carried acted as a carrier of cholera. -The "Brit. Med. Jour.," as a close to a lengthy editorial on the International Congress, says that "although many of the discussions and THE WEEKLY MEDICAL REVIEW. VOL. XVI. No. 16. ST. LOUIS, OCTOBER 15, 1887. ORIGINAL ARTICLES. POSTHUMOUS DELIVERY. BY WALTER COLES, M. D., Professor of Obstetrics and Operative Midwifery, Beaumont Hospital Medical College. Read before the St Louis Medical Society, Sept. 24. In considering the subject of post mortem delivery, several questions of practical importance naturally present themselves, which we will endeavor briefly to consider. 1. As to the power of the child to survive somatic death of the mother, and the duties and responsibilities of the medical attendant in cases of sudden death of the mother at or near full term. 2. As to the capability of the uterus to contract and expel its contents after death. 3. The effect of gaseous distention, the result of decomposition, as an expulsive force. The second and third of these inquiries are chiefly interesting in a medico-legal point of view, but the first is an eminently practical one, of grave importance, which may sud denly confront any one of us at any moment, and from its very nature, will require prompt and decisive action. Cases are not rare where from heart clot, or other causes, women have died in labor, or at an advanced stage of pregnancy. In such an emergency, actual death being assured, the question of saving the child naturally arises, and the physician should be possessed of such knowledge as will direct him when and how to act under these trying circumstances. All obstetrical writers agree that the fetus may survive the death of the mother for a certain length of time, and it is also a well known fact that an immature child will retain TERMS: $3.50 A YEAR. its vitality longer than one at full term. Numerous instances are recorded in which living children have been extracted, both by turn. ing and the Cesarean section, after the death of the mother. Blundell mentions the case of a woman who was run over by a car, which crushed the liver and produced instant death. The dead body was taken into the hospital near by, when, seeing that she was in an advanced stage of pregnancy, the abdomen was opened and a child delivered, which, though apparently dead, he succeeded in resuscitating. The same author relates the still more remarkable case of a pregnant heifer, whose uterus was opened three-quarters of an hour after death and a living calf extracted. I well remember hearing my father say that he had reared a fawn which he had cut from the uterus of a dead doe. It may be remarked here that the lower animals are said to perish sooner in utero than the human subject. Authors differ widely as to the length of time at which asphyxia may be overcome and the child restored. Most of us have doubtless seen resuscitation take place after the lapse of many minutes, and hope should never be abandoned as long as there is the slightest heart beat. Most cases prove hopeless after fifteen minutes, but the numerous authenticated exceptions, where respiration has been established after much longer periods have elapsed, should encourage persevering effort, and lead us to give the child the benefit of the doubt in all cases where the death of the mother is well established. It is probable, owing to the temperature of the mother's body, that the asphyxiated child will retain its vitality much longer within the uterus than outside of it. Aveling believes that the child may thus survive in the womb many hours after the death of the mother. Villeneuve, of Marseilles, in a published paper in 1862, reports a number of cases in which it was ascertained that children survived during as. tonishingly long periods. Four were saved by the immediate performance of the Cesarean operation. Five were extracted alive after a lapse of ten to thirty minutes. Two children were saved after the mother had been dead two hours; one after two and a half hours, one after three hours, and one after four and a half hours. In referring to these latter cases, Tarnier remarks: "Although the operation is generally useless at a later moment, it ought, nevertheless, to be performed, because some cases, whose authenticity I cannot vouch for, would seem to prove that the child's life may remain intact for ten, fifteen or even twentyfour hours." Charpentier, one of the latest French authorities, is disposed to discredit these cases, however, and claims that none of them are sufficiently authentic to merit belief. In all cases when it becomes necessary to effect post mortem delivery we have the choice of two methods; we may resort to hysterotomy or else to forcible delivery through the natural passages. When death occurs during labor, and we find the os well dilated or dilatable, we may readily perform version, or if the head be within reach, forceps may be applied. The distressing circumstances requiring either operation will often prompt friends to interfere and prevent any interference on the part of the physician. His duty, however, is plain, and nothing should deter him from at least urging an immediate operation if he is satisfied that the woman is dead, and that there is hope for the child. By far the simplest and safest method of rescuing the child is by laparotomy, but this may be interdicted by friends who, at the same time, might not object to an attempt per vias naturales. a resort to forcible delivery whenever the mother is in extremis. Such an idea, however, except under peculiar circumstances, is revolting, and should be repudiated. We quite agree with Charpentier when he says, should the woman be in extremis: "Respect her condition, and do not hasten her end by maneuvers which may not save the child. Once the mother is dead, however, act quickly in the interests of the child.". re In accouchment forcé, we should not lose sight of the fact that the uterus is endowed with the power of independent contraction af ter death, a property which greatly aids the physician in effecting delivery, notwithstanding he is deprived of assistance through the cerebro spinal system. Where the pelvis is ample, he may overcome any rigidity or sistance in the soft parts, if necessary, by free incisions. It is a recognized fact that the body of the uterus is under the dominance of the sympathetic, while the chief supply from the cerebro-spinal system of nerves is distributed to the cervix and external os. The effect of somatic death, therefore, is to paralyze the latter class of nerves, and hence to produce a relaxation of the outlet to the womb, rendering these parts readily dilatable, and thus in many cases, preparing the way for artificial delivery. But let us give a further thought to the influence of death upon the uterus. The fact that the womb does not cease its muscu lar activity when the vital spark departs from the body is so well known as scarcely to need an argument. Prof. Dewees, one of the oldest and most reliable writers in this country, in alluding to this subject, says: "However much this circumstance may excite our surprise, or challenge our belief, it is, nevertheless, authenticated by various testimony." We may add that this power of post-mortem contraction has been observed repeatedly in lower animals, as well as in the human subject. Harvey observed it in the doe, William | Hunter in the cat and rabbit, Mueller noticed it in the uterus of the rat and oviduct of the turtle; while Tyler Smith has seen it in the Some writers have gone so far as to advise guinea-pig and other animals. It has been In choosing between these methods of delivery it should not be forgotten that several instances are recorded in which the terrible blunder has been committed of opening women who were not really dead. |