Imagini ale paginilor
PDF
ePub
[ocr errors][merged small][merged small][merged small][merged small]
[ocr errors]

but in subjects who are pale and delicate, bleeding must be considered of questionable propriety and when practiced in such either before or after delivery of the child, must be resorted to with great care.

In those grave obstinate cases that we meet, during the latter months of gestation, and as a rule in the primipara, we may be obliged to consider the advisability of inducing premature birth as advised by Sir James Simpson. Fortunately this procedure is but seldom required. When this is deemed necessary, or when we desire to hasten the expulsion of the child at full time, great care must be taken to empty the uterus by such methods as will be the least productive of peripheral irritation.

We have in these eclampsia patients a peculiar condition of the whole nervous system brought about by the loss of albumin, rendering the blood both imperfect and impure. By detention of the urea this impure blood produces a preternatural excess of irritability, or as Sir James Simpson expressed it, polarity of the nervous system, the spinal system of nerves in particular, and in this way a morbid predisposition to convulsions from irritation of the uterus, vagina or bowel.

One question may yet be considered as unsettled; that is, whether the urea is the poison, or whether the urea is changed into carbonate of ammonia by decomposition in the blood. Another factor which causes albuminous urine, as shown by Brown-Sequard, is the pressure of the distended uterus on the kidneys.

If we conclude to empty the uterus, we must do so by such methods as will cause the least irritation. I consider the method practiced by Meigs both efficient and superior to all. This consists in the use of a small rubber or gutta-percha bag or soft pessary with a flexible stem of the same material, on the end of the stem a stopcock; this may be filled with water or air with an inflator or air syringe, and dis tended from time to time as required. When the case requires rapid dilatation, no matter what method may be selected, the patient should be placed under chloroform, Keith's method of continuous flow of hot water from a considerable elevation against the cervix, must be considered too slow, I fear, to be practicable in the major portion of the cases we meet.

When we are called to attend a case of labor, and these convulsions have preceded our visit or come on while in attendance, if the patient be a strong plethoric person,

Ана

I would bleed, also give croton oil, elaterium calomel, or gamboge. Give clyster to unload the lower bowel, draw the urine, then try to control the convulsions with chloroform inhalations. So soon as the cervix is dilated or dilatable and the soft parts yielding, make the effort to hasten delivery.

If we fail to take in consideration the above condition of cervix and soft parts to some extent, we will occasion not only a rupture of the perineum but cause peripheral irritation to such an extent as to increase the volume of the convulsion and induce them to continue after delivery has taken place.

In all cases of acute or chronic albuminuria from the usual changes found in the kidney, I am convinced that morphia will. induce or increase coma. I have been called several times in consultation where prior to my visit the attending physician had given quite large doses of morphin hypodermically, and in every case one, consciousness never returned.

But

I desire also to discourage the frequent examinations per vaginam-because the nervous system is in no condition to be irritated--either by these frequent examinations or any noise or excitement. the head must be kept cool with ice-bags, and mustard or counter-irritants may be applied to the neck and loins. While diaphoretics are also valuable yet we are warned by the highest authority never to give pilocarpin or jaborandi in these cases.

A blanket wrung out of very hot water and the naked patient wrapped in them save only the head, with dry blankets placed over them, will be most serviceable. When we find the breathing bad-cyanosis

heart's action feeble, I would stimulate with brandy, both by the mouth if possible, or rectum, and hypodermically. Also give hypodermics of atropia and strychnin. The atropia not only quiets the nervous system but lessens the quantity of blood to the spine and brain, while the strychnin stimulates the heart and vaso motor system.

It is a safe rule not to be induced to make a positive prognosis, nor question the treatment employed by other doctors, so long as we have not seen the case and can have but a vague idea as to many of the important factors required to reach conclusions that are tenable. Johnstown, N. Y.

WORLD for four years for $3.

DR. J. LEFLer.

Muscular Rheumatism.

Editor MEDICAL WORLD:-Perhaps no condition that never kills is more difficult to combat than the one under consideration, and mainly because the causes giving rise to it come so close home, and have to do so much with the likes and dislikes of the person afflicted, that he is loth to give them up.

You may be sure that the man who suffers the transient aches and pains of musculas rheumatism is a dyspeptic of one type or another; that he doesn't properly digest his food, or else that he is taking more at a time than he can digest, or of a kind unsuited to him. The result is that a great quantity of the products of indiges-. tion is thrown into the circulation, and these floating in the body fluids produce an irritation that ultimately results in local congestions, and more or less bodily pain. Therefore the only rational treatment is such as will do away with all this. An examination of the excreta will tell the story. From such examinations we may learn the character of the residues thrown off, and working backwards over the chemistry of digestion we soon arrive at the source from which they come. This particular substance must then be eliminated from the diet-list, or else must be so modified or reduced in quantity that it can be taken care of properly. This having been accomplisht and a proper diet-list made out, we must then set to work to get rid of the accumulated debris.

First of all, the ingestion of irritants such as excessive quantities of food, alcohol in any form, and other stimulants, tobacco and other narcotics having been stoppt, large amounts of pure water should be given, and such remedies should be added to this water as stimulate elimination. Colchicin, for example, being one of the first. The lumen of the capillaries should be increased by the free use of aconitin, one granule, gr. 1-134, being given every two hours during the day with one of colchicin, and at night it should be pusht, by the exhibition of one large dose (three or four granules) to physiologic effect. Strychnin and digitalin may well be called upon to aid the heart in its effort to throw off this waste material, and the saline laxative should always be used to sweep it out of the alimentary canal, and prevent reabsorption.

The importance of proper regulation of diet cannot be over-estimated. A recent case will serve to illustrate this point:

Miss M., a healthy, robust young woman, presented herself at my office complaining of long-standing and changeable pains at different points in the muscles of the back and sides, radiating around to the abdomen. Her mother having just been promptly relieved of lumbago by two or three applications of the Wilkins' vacuum cups, she asked for the same treatment, which was instituted.

The patient claimed a good appetite, no constipation, proper rest at night, etc., etc., therefore the vacuum treatment was used alone for some days but without the desired result. While continuing the vacuum treatment, recourse was then had to mild laxatives and general eliminants. Underthis treatment improvement was manifest,. but the pains still hung on. I then determined to discard all the leadings of the subjective history of the patient and carry out my own ideas of the proper treatment of a typical case of muscular rheumatism.

In this particular instance my procedures were largely determined by the fact that the patient always presented a flushed face and a somewhat glassy eye, showing an extremely full and irritable state of the circulatory system. I therefore asked that the use of meat and coffee (of which she confessed to being a great user), be entirely suspended, that not more than half a glassful of water be drunk with meals, and that two glassfuls at least be taken in the middle of the forenoon, the middle of the afternoon, and duringthe evening before retiring. I continued the cupping over the spine and gave colchicin, gr. 1-67, and aconitin amorphous, gr. 1-134, one of each together every two hours, with a double dose of each at bedtime, advising the use of a teaspoonful of saline laxative in a glassful of water early every morning. Improvement was manifest in three days. No change whatever was made in the treatment, and in less than two weeks the girl had entirely recovered. The pains were all gone, the face had assumed a normal color; the eyes had taken on a more restful look than they had borne for months; and the girl expressed herself as "feeling splendidly".

The gist of the matter is that by rational methods the patient had been relieved of an ever-present irritation, by the removal of the cause and the elimination of the accumulated residues.

Instructions were then given to continue the nightly dose of the granules (two each of aconitin and colchicin) and the morning

[blocks in formation]

Chloroform in Childbirth. Editor MEDICAL WORLD:-In most of the medical journals publisht now-a-days one comes across one or more articles bear ing on this subject, advocating the use of anesthetics during labor. The overwhelming evidence in its favor has been reiterated so often, authors of greater and lesser light so frequently quoted to bear out this evidence, and cases upon cases advanced to sustain articles in its favor, that there is really nothing left unsaid or unwritten that will add weight to the claim that its influence is beneficent in these cases. But, have all these articles, all these authors and all these cases made it a universal practice? We well know the answer. If not, why not?

Occasionally we come across an article by an opponent of its use, based chiefly on so-called moral grounds, such as interference with nature, and even, in some instances, sustained by biblical quotations; but these objections have been met again and again and irretrievably demolisht by irrefutable evidence.

Custom has again been brought forward as a reason for its non-administration, and in this there is some slight reason for failure to administer an anesthetic during parturition. Of all the reasons against the practice cowardice is the strongest, tho one, of course, which is never admitted in articles against such practice, for those who are afraid to employ this means of alleviating suffering are the last to admit that as being the reason. To understand this statement fully, you must first of all try to put yourself in the place of one of these cowards. You are practising in a country remote from any help, you are called to a case of confinement, you find on your arrival a so-called midwife, perhaps two, and several well-meaning female neighbors. Your patient is in the throes of agony, you know your duty is to relieve that suffering, and you are not afraid of losing your patient thru giving an anesthetic, but, and here comes the cowardice, if the child should be still-born, if there should be post-partum hemorrhage, if there should be rupture of perineum, if it should be necessary to use instruments, if your patient should afterwards develop

a

puerperal fever, if-if-if and so great many of these ifs crowd thru your brain in a wonderfully short space of time), it would be the result of that chloroform which "never ought to have bin giv," that is the verdict of the midwife and the well-meaning female neighbors, and this verdict goes abroad thru their agency, and, say what you will, and prove what you will, the result to your future practice in that neighborhood is disastrous and hard to face. For this reason you are "skeered" out of doing a good deed. No matter if in some districts you have had several cases in which you have used an anesthetic, the first unavoidable mishap, of the character above mentioned, is put down by these well-meaning meddlesomes to "that there chloroform." So uneducated is the lay mind on this subject, and so backt up is this ignorance by these supposed moral grounds that we practitioners of this time have to be the pioneers of this practice and bear the brunt of their antipathy to it. Thank goodness that, tho no longer a coward, I have not experienced it yet. But some time doubtless I shall, for it will be a long time before all such tattlers are dead, and death is the only relief from them because they either would not be subject to an anesthetic after such a direful experience of its effects, or they are mostly past the age at which they will require it.

This brings me to the other cause advocated against the use of anesthetics, custom. I have in my practice many who, altho they have witnessed the beneficial results of chloroform, are so against being subjected to its influence that nothing can induce them to allow it. In most of these cases one cannot force them to submit to the administration of it.

I would not do without THE WORLD.
GEO. HARWOOD, M.D.
Johnson City, Texas.

Shoulder Presentation and Spontaneous Evo

lution.

Editor MEDICAL WORLD:-I was called at 12.30 p. m. to see Mrs. K.-, multipara. She was having hard pains and informed me that the amniotic fluid had just passt off. On examination I found the cervix well dilated, a shoulder presenting, and the hand protruding from the vulva.

As a matter of course, my first thought was of performing a version, and I at once gave her morphia hypodermically. Chloroform was administered during each pain. I wanted to control uterine action until I

could call assistance and prepare to turn and deliver; but the pains kept on, and to my surprise, each one brought the child lower down into the pelvic cavity, and in less than one hour the child was delivered by spontaneous evolution. Thorax, breech and legs were born in the order named.

So frequent were the pains, and so rapid the descent of the child, and so fully was the vagina distended with the child, that version seemed out of the question at that period in the case. The child was well developt, and would weigh fully eightand a half or nine pounds, but was still born. This was owing, I think, to there being a knot in the cord, and as the child descended, the knot was drawn so tight as to cut off the circulation in the cord. Yet in this form of delivery the prognosis is invariably bad for the child.

In an obstetric experience covering seventeen years and four hundred and three cases, I have never before met with such a presentation, so easily and by natural forces delivered, nor have I ever met a case before with a perfect knot in the cord,--a --a knot that was drawn tight at delivery of child, but had evidently been loose and allowed free circulation in cord before labor.

W. H. THOMAS, M. D.
Steele's Tavern, Va.

What Should be Done to Such Doctors as These?

Editor MEDICAL WORLD:-A few weeks ago I was called to consult with a doctor over the case of a woman having the following history:

She had been South, and had returned about seven weeks before, having a fever of a remittent type. She was attended by Dr. Y. for five weeks, and treated for remittent fever and "change of life." Dr. Z. was called in consultation with Dr. Y. once during the time. While Dr. Y. was attending her, she told him that she had not had her courses for several months, and askt Dr. Y. if she was not pregnant. Dr. Y. examined her and told her that she was not pregnant-that her "uterus was empty" and that she was going through the "change of life."

Shortly after the "examination" was made, Dr. Z. was called upon to take the case, and did so, and the next day she gave birth to a five months' fetus, which breathed after it was born, Dr. Z. continued to treat the case for three weeks longer, and as she did not improve in her

condition, I was called in consultation. After seeing and examining the patient, I told Dr. Z. that whatever else she had had, I was sure that she was then suffering from blood poisoning arising from the condition of the womb. I askt him if he was sure that all the membranes had come away, and he said he thought they had, but that he had not doucht the patient. I advised clearing out the uterus at once, and that medication for blood poisoning be immediately begun.

One week later I received the following letter from Dr. Z., which speaks for itself: Wayback, September 7, 1898.

Dear Doctor :-I intended to have seen you and report progress in regard to the case of Mrs. Am glad that I met you, as you assisted me.

In my anxiety to arrest the chills, the toilet of the uterus was not properly attended to, and the microbes took possession, and on the second day after you saw her, it was a plain case of uterine phlebitis, which ended in coma about four o'clock this afternoon. Yours, etc., Dr. Z.

What do the readers of the WORLD think of Dr. Y. as a diagnostician and of Dr. Z. as an obstetrician? Could anyone with feeling sense in his fingers and com

mon sense in his head have failed to know that there was something in the uterus when a five months' fetus was there? Yet Dr. Y. claims to be a specialist in obstetrics.

Has any doctor any right to allow the "toilet of the uterus" to be neglected under any circumstances? And if the "toilet of the uterus" is neglected, and the patient dies on account of "the microbes taking possession," should not someone be hanged? How about punishing faith curists for not doing anything? Wayback, Tex. DR. DOALITTLE.

[There is a possibility of extenuating circumstances in the case of misst diagnosis, since there are a number of cases on record where the most expert in the special line of obstetrics have been deceived both as to the existence or the non-existence of pregnancy, and this may have been one of these exceptional cases. Yet in regard to the proper toilet of the newly-delivered woman, there can be no doubt but that every possible means should be employed to prevent sepsis, and that neglect of obvious measures should constitute a punishable offence.-ED.]

Proper Care of the Infant.

Editor MEDICAL WORLD:-The care of the infant presents problems of unusual interest to the conscientious physician,

[blocks in formation]

since the obscurity of the disorders is such that in many cases one is working in the dark. The extreme youth of the patient too often prevents the adoption of very active measures, and we frequently hear of doctors telling anxious mothers that the "child is too young for me to do anything for it." In my opinion this is a mistake. More care and judgment is necessarily required in dealing with a child only a few days old than with a patient who has reacht adult years, but there are always symptoms and signs that will tell the story to the experienced man of science, and the diagnosis once made, a treatment can be instituted that will meet the indications.

Many infantile disorders are primarily due to some form of digestive disturbance, and it is always well to direct inquiry especially in this direction. There is nothing of greater importance in such cases than perfect cleanliness, fresh air and fresh, clean and well-cookt food. I have seen some of the most stubborn and obscure cases readily yield to the thoro and energetic use of an antiseptic mouth wash, while others are cured by measures apparently most trivial.

The moral of all this is,-do not neglect the little points, but heed the employment of the hygienic measures as well as the giving of drugs.

CHARLES M. DOTY, M. D.

Vergennes, Ill.

Self-Castration in a Youth. Editor MEDICAL WORLD:-A case was recently presented to me that is in many respects unique, and concerning which I would like a comparing of notes. I was called in great haste, October 18, to attend E. H., aged fourteen, who, his father said, had castrated himself.

I found the youth literally weltering in blood, and on inspection found that he had cut off the scrotum and both testicles completely, leaving scarcely enough of the skin to sew up the wound. He stated that nightly erections bothered him, and that he had concluded to obey the biblical injunction "If any part offend thee, cut it off." He drew the parts down with force, and severed them with two strokes of a butcher knife, throwing the severed portions in a cluster of briars, where they were afterward found. The boy seems intelligent, leads his class in school, and is past puberty.

I ligated the bleeding vessels under chloroform, and stitcht the parts together.

There was little difficulty in the healing process, and the child is now able to be around again.

Has anyone else had a similar case?
Ewing, Ind. C. L. WILSON, M. D.

[In that classical work of George M. Gould and Walter Pyle, "Anomalies and Curiosities of Medicine," nine cases of selfavulsion of some portion or all of the external genitals are narrated, and allusion is made to fifteen other cases. Various reasons are assigned for the act, varying from religious insanity, to remorse for marital unfaithfulness, desire to lead the life of an ascetic, or fear of the contraction of venereal disease.-ED.]

A Plea For Greater Care Among Physicians.

Editor MEDICAL WORLD : I was very much pleased with the letter of Dr. Landers in December WORLD, "Easy Road to Mistakes." Physicians are often led to prescribe for patients by inspection alone without going into a physical examination. Yet many times one may examine the pulse and to all intents find it quite normal. Still, upon a further examination, by ear or stethoscope things will be found. very different with the heart.

Again, if a patient says he has sore throat and a physician prescribes without making a physical examination he will often err and come far short in treatment as well as diagnosis.

Whenever I hear a doctor say he has treated one hundred cases of diphtheria and never lost a case, I think he has made a mistake in his diagnosis; and the epidemic he has just passt thru was not diphtheria, luckily for him, and more so for his patients. Because a brother physician does not treat pneumonia with the same remedy, and in the same way, is no reason why we should say he is wrong; so that his patients get well, it is all the same. We have taken different roads for the same haven.

In Dr. Landers' letter I was reminded of a patient who lived near our town, who in withdrawing a gum catheter broke off three inches of it in the posterior portion of the urethra. He sent for one of our learned doctors who passt another catheter, thereby pushing the broken one back into the bladder, where it remained several weeks, setting up a great inflammation attended by frequent micturition. Finally Dr. Hearn of the Jefferson College performed a suprapubic operation, opening the bladder and removed the piece of catheter It was cov

« ÎnapoiContinuă »