Stated Meeting, December 3, 1897, the President, F. C. Wilson, M. D., in
the chair.
Footnote 1:
Stenographically reported for this journal by C. C. Mapes, Louisville,
Ky.
_Uterine Fibroma._ Dr. L. S. McMurtry: I present this specimen of
uterine fibroma on account of two very interesting features of this
class of tumors which it illustrates. The first relates to the
morphology of these growths. The tumor is a very large one, and occupied
the entire pelvis and the abdomen to the superior limits of the
umbilical and lumbar regions. It is a multi-nodular tumor, and its
disposition in relation to the fundus of the uterus is unlike any
specimen that I have ever encountered. It will be observed that the
neoplasm springs from the lower segments of the uterus, and the fundus
is not involved in the growth at all.
The second feature of interest, and this is especially interesting from
a surgical point of view, is the relation of the bladder to the tumor.
It is very common for the bladder to be carried upward with the growth,
thus rendering it very liable to injury in operation. This feature is
exceptionally conspicuous in this tumor on account of the nodular
condition where the bladder was attached, forming a sulcus. In releasing
the bladder, after splitting the capsule, the uneven surface of the
tumor caused me to inflict an injury upon the coats of that viscus.
After dissecting off the bladder I found that I had made an opening in
it at this point. It was immediately closed with a double row of catgut
sutures. The operation was done six days ago, and the convalescence of
the patient has been most satisfactory indeed. The bladder injury has
not complicated the patient’s convalescence at all, its function being
carried on just the same as if it had not been involved. The
convalescence has been afebrile from the beginning, and recovery is
assured.
The method I observed in treating the pedicle was to amputate the cervix
very low down, leaving a very small rim of the cervix, and suturing the
peritoneum over it all the way across the pelvis, making the pedicle
extraperitoneal. The conformation of the growth and its relation to the
cervix uteri made this method of dealing with the pedicle especially
applicable in this particular instance. The patient is thirty-four years
of age, and the operation was urgent on account of persistent hemorrhage
and marked pressure symptoms.
_Discussion._ Dr. J. A. Larrabee: I would like to ask the reporter for
what length of time this tumor had been developing?
Dr. L. S. McMurtry: The woman was thirty-four years of age, and
according to the history obtained the tumor was first noticed three
years ago. The patient has made a beautiful convalescence. I present the
specimen on account of its morphology, and because of the difficulties
that might be encountered in performing an operation in such cases by
the bladder being impacted in the sulcus.
_Tubercular Testis._ Dr. W. O. Roberts: This patient is twenty-four
years of age; his father and mother are living; father sixty-four,
mother fifty-four; his grandfather on his father’s side died at the age
of sixty-four of what was supposed to be consumption; his father’s twin
brother died at the age of twenty, after an illness of eight months, of
consumption; his mother’s family history is good.
This young man had gonorrhea seven years ago, with orchitis of both
sides as a complication, the left testicle swelling first, then the
right; the swelling lasted in each for about two weeks. Had gonorrhea
again in November, 1896, and says again in December of the same year. At
this time he noticed that his left testicle was getting hard in places
and was swollen, but there was never any pain. The inflammatory process
has never been very acute. However, he noticed after taking a horseback
or bicycle ride the testicle would be somewhat tender. Had another
attack of gonorrhea during the month of September of the present year,
which he says lasted only two weeks, and during this attack the testicle
was also affected.
He now has a swelling of the left testicle, and a hardness about it and
in the epididymis, which I would like for the members to examine,
expressing an opinion as to the nature of the trouble.
_Discussion._ Dr. J. M. Ray: I do not know that the ocular symptoms will
throw any light upon the case. I remember that this young man came to me
some time ago to have his eyes examined. He stated that he had been
under the care of a prominent oculist in the South, and had been fitted
with glasses. When I saw him he had some trouble in the use of his
glasses, and also complained of defective sight of one eye. Upon
examination I found a spot of atrophy of the choroid, showing the
location of a former acute choroidal disease, and there was considerable
diminution in acuteness of vision in that eye, with a defect in
refraction in the other eye. Under mydriatics I fitted him with glasses,
since which time he has been perfectly comfortable so far as his eyes
are concerned.
He states that he remembers I said something to him at that time about
tubercular disease, after looking into his eyes, but I have forgotten
the circumstance; I only remember that I found choroidal disease.
Dr. J. A. Larrabee: Of course we are all led somewhat by the diathetic
history of our cases. Chronic inflammations tend to take on the part of
the diathesis. I did not understand the reporter to say that any test
had been made, by withdrawal of some of the fluid or otherwise, to
determine the exact nature of the condition. I desire to say, however,
that if this were my testicle I would have it removed. I believe that
would be the safest plan. An absolutely positive diagnosis would be
difficult to make without a microscopical examination for the tubercle
bacillus, but I can not help feeling prejudiced in that direction.
Dr. J. L. Howard: I agree with Dr. Larrabee as to what should be done
with this testicle; it should come out. I, too, think it tubercular,
although in all probability the gonorrhea is a factor in the case in
stimulating the growth of the testicle. I do not know that a
microscopical examination would give us much light upon the subject; in
fact I would not wait for that, I would simply remove the testicle at
once.
Dr. Wm. Bailey: The question is not by any means settled as to the exact
nature of the disease in the case before us, whether the patient, having
had repeated attacks of gonorrhea, has not also been so unfortunate as
to have syphilis. With a tuberculous history of course a tuberculous
condition of the testicle seems plausible; but inasmuch as tuberculous
disease of the testicle may remain for a long time possibly without
great danger in affecting the patient otherwise, and knowing the changes
that take place in the testicle from repeated attacks of gonorrhea,
orchitis, etc., I believe if it were mine I would be disposed to keep it
for a while, particularly as the other testicle seems to be somewhat
atrophied, with this one of pretty good size. I think I would keep the
larger one.
Dr. T. S. Bullock: I am inclined very much to agree in the opinion
expressed by Dr. Bailey. I have frequently seen, after repeated attacks
of gonorrhea, a testicle that had become enlarged, without any pain. The
testicle in this case appears to be perfectly smooth, and in view of the
fact that tubercular disease of this organ may exist for a long time
without affecting the general system, I should certainly keep the
testicle until my general health began to show some evidence of
declination.
Dr. F. C. Wilson: The question is a very difficult one to decide. There
is one feature of the case that has not been sufficiently emphasized,
and that is the probable damage to the testicle itself by the repeated
attacks of gonorrhea. We know that the use of the testicle, so far as
any procreative uses may be concerned, has probably been abrogated by
these repeated attacks of gonorrhea, and with this view of the case the
question of removal of the testicle by surgical means would be
simplified; and it seems to me with the tuberculous history, if the
question could be decided even approximately, or even probably, that it
is tubercular, then it had better be removed. But it seems to me I would
first make every effort to solve the question, even aspirating or
removing a small part of the tissue so as to be able to make a
microscopical examination, and in that way possibly throw some light on
the subject.
Dr. W. O. Roberts: It strikes me that this is tubercular, although it
may have been, as Dr. Howard says, excited by gonorrhea. The condition
feels to me nodulated and not smooth, and the disease appears to be
located chiefly if not entirely in the epididymis, and I think the
testicle should be removed. Whether it is tuberculous or not the
usefulness of the organ is destroyed, and I think it ought to come out
if it is tuberculous, especially because the other testicle will become
involved. So far as the cosmetic appearance is concerned, if that is a
feature in the case, we could insert a celluloid testicle. I believe if
the affected testicle is not removed, granting the diagnosis of
tuberculosis to be correct, that the other testicle will surely become
involved.
Dr. Turner Anderson: It is seldom that we have obstetric matters
presented to this society. I have thought perhaps a case I recently
attended might be of some interest. We are aware that the umbilical cord
is frequently found encircling the neck of the child. I delivered a
child four days ago in which the cord was wrapped around the neck twice,
then branched off under the arm, encircling the arm again at its dorsal
surface, then across again, branching over the back. You may better
understand the condition when I say that the cord came up from its
attachment at the umbilicus, encircling the neck twice, branching over
and under the axilla, around the arm, thence to its attachment to the
placenta. The woman was a primipara. As soon as the head was delivered I
detected that the cord was wrapped around the neck. I made an effort to
find the part that led to the placenta. The cord was found pulseless,
and I was in some doubt as to whether it had been so long encircling the
neck as to have produced death of the child. Just as the body of the
child was being extruded the cord snapped, tearing off fortunately from
its placental attachment. The child was delivered and after a little
effort was easily resuscitated. The pressure was so great, the traction
upon the cord was so decided, as to leave a white line across the back
of the child. There was a white mark around the neck, across the
clavicle, around the arm and over the back of the child which did not
disappear for some time afterward.
The proper line of practice, I take it, in those cases where the cord is
around the neck of the child, is to first determine whether the cord is
still pulsating. If pulsating, we are justified in being a little more
tardy in our efforts to deliver the shoulders and release the child. If
possible we would of course draw down the cord and release it from the
neck of the child in this way; but in those cases where we are
confronted with the cord wrapped tightly around the neck of the child,
especially in the primipara, where the length of time which will be
consumed in delivery is uncertain, the line of practice I believe in
should be prompt delivery or division of the cord. As a rule when we are
confronted with a condition of this kind we can meet it satisfactorily
by a little delay and by holding the head of the child well up against
the vulva while the shoulders are being extruded. As the releasing pain
occurs and the shoulders and body are extruded, you can usually by
pressing the head well up prevent undue traction on the placenta and any
accident which might follow rapid delivery and undue traction upon the
cord. This was a case in which there was spontaneous rupture of the
cord; it tore away entirely by the uterine effort. This accident had no
influence upon delivery of the placenta; it came away promptly. It was
evidently not torn loose from its attachment, and there was no
hemorrhage.
_Discussion._ Dr. J. A. Larrabee: The case is not only interesting, but
also somewhat unique as far as I am aware. We are all familiar with the
double wrapped cord, but in this case the acrobatic movements of the
child must have been considerable, in utero, to have produced the
condition described by Dr. Anderson; the child had evidently been
engaged in jumping the rope for some time. When the cord is wrapped
around the neck of the child as described, I think the best plan is to
expedite delivery. Of course in the primipara we must not be in too
great a hurry, we must utilize melting or crowning pressure to prevent
injury, but the management of these cases I think is entirely that of
dystocia, and powerful external pressure upon the fundus of the uterus,
bringing it down as low as possible, is the proper plan of expedition.
In the case reported, however, no amount of external pressure would have
accomplished any thing; fortunately the snapping of the cord enabled the
doctor to deliver and resuscitate the child, which is about the only
thing that could have been done. In this case it would have been almost
impossible to have divided the cord. Aside from the anomaly of the case,
which is worthy of especial mention, I do not know of any proceeding
which would have been equal to that which was followed. It is a little
strange that the placental attachment did not give way; if this had been
true, if there had been a separation of the uterine attachment of the
placenta, then we would have expected the placenta to have been expelled
with the child instead of a rupture of the umbilical cord.
Dr. J. L. Howard: I would like to ask Dr. Anderson if usually, when the
cord is wrapped around the neck of the child, the cord is not an
abnormally long one? I have had this accident happen twice in my
experience, but no trouble resulted because of the abnormal length of
the cord in each instance.
Dr. J. G. Cecil: This is an accident which as we know happens
frequently, as well as many other anomalous things in connection with
the umbilical cord. I would have been disposed, if the labor had been
delayed in this case, that is, the final delivery of the child, more
than four or five minutes, to have severed the cord, fearing that it
might have had something to do with the delay. If there was no pulsation
in the cord, there would have been little risk in cutting and not tying
it; then there would have been no further delay to the delivery; there
would have been no danger from hemorrhage, from premature separation of
the placenta, or danger from inversion of the uterus. However, as the
case turned out so well under the management that was adopted, it does
not become us to criticise that management, because the successful issue
proves the wisdom of the plan followed.
I have once or twice encountered some delay in expulsion of the child by
reason of a short cord wound around the neck. I have never seen one so
displayed around the shoulder as in the case reported by Dr. Anderson. I
remember to have seen one case, however, in which there was a knot tied
in the cord, and tied so tightly that it shut off the circulation and
resulted in death of the child, and also complete atrophy of the cord
between the knot and the navel end. This was a very interesting case,
and was reported to the Louisville Clinical Society three or four years
ago by Dr. Peter Guntermann; it was one of the most interesting cases of
accidents to the cord that I have ever seen. How the knot was tied so
tightly in the cord can not well be explained; knots in the umbilical
cord are not very unusual, but it is unusual to see one tied so tightly
that the circulation is shut off thereby. It was thought, I believe, by
the reporter on that occasion that the accident was due to a fall which
the mother sustained just before the delivery, which was premature.
Dr. Wm. Bailey: Nothing in the management of the case reported by Dr.
Anderson can be criticised by me. I am inclined to think that under no
circumstances was pressure made on the cord sufficient to interrupt the
circulation until after the head of the child was delivered. Then it
became a question as to the proper management. I believe it would have
been better to have cut the cord, as it might have lessened the
difficulty of delivery, and that there would have been no harm done to
the child in this case, because there was no pulsation in the cord. The
doctor had all the time for this delivery that would have been allowed
him if he had a breech presentation with the head making pressure upon
the cord, and ordinarily he would deliver such a case in from five to
seven minutes, and that would give a chance for resuscitation of the
child just as in the case of drowning. The child can be deprived of
circulation through the cord, in an accident like this, as long a time
as a person can be submitted to water, or drowned, and be resuscitated.
I have seen but one case in which there was a rupture of the cord during
delivery. I saw one exceedingly short cord, in which delivery of the
child ruptured the cord; it was not around the neck, it was simply too
short for the child to be delivered without detaching the placenta; just
as the child was delivered the cord was spontaneously severed at the
umbilicus, simply allowing me a sufficient amount to be caught with the
fingers and held until a ligature could be applied. I do not remember
the exact length of the cord, but it was so short that it was not
possible to deliver the child without either breaking the cord or
detaching the placenta. The cord ruptured spontaneously, and there was
no further accident or trouble.
I believe if Dr. Anderson had to attend another case under exactly the
same circumstances he would prefer to cut the cord rather than to break
it off at the placental attachment. Inasmuch as he did not cut the cord
and the child was successfully delivered, and also as there was no
trouble in delivering the placenta, of course it makes no difference;
but I always like to have the cord attached to the placenta so that if
it becomes necessary to go after the placenta, in case of retention for
instance, I can have the cord as a guide. In Dr. Anderson’s case there
was no possible advantage in having the cord intact; as it was
pulseless, no injury could have been done the child by cutting the cord
before completing the delivery, and by cutting the cord as soon as it
was found that it encircled the neck, all possible difficulties as far
as the cord preventing delivery was concerned would have been removed.
Dr. T. S. Bullock: I am very much interested in this case; I have never
seen one exactly like it. The greatest danger in this particular
instance was that alluded to by Dr. Cecil, viz., producing inversion of
the uterus. I think Dr. Anderson managed the case in the proper manner,
and by his method of expression the only possible danger was inversion
of the uterus.
I have only seen one instance of dystocia from short cord; that was a
case in which the cord was the shortest I ever saw, and was wrapped
around the neck, where it was necessary in order to deliver the child to
cut the cord after tying it and then employ instruments, the cord being
so short that with each uterine action you could feel the cupping of the
uterus from tension on the cord.
I think there would be less danger from premature separation of the
placenta than from inversion of the uterus. In the case Dr. Anderson has
reported the danger to the child from compression of the cord was
obviated by prompt delivery.
Dr. J. A. Larrabee: Will not Dr. Bullock tell us whether the case he
refers to, where he could feel a descending or cupping of the uterus by
the expulsive efforts, was a primipara?
Dr. T. S. Bullock: The woman was a primipara; the cord was very short,
it was tied and severed, then the delivery completed with forceps. I
would like to ask the gentleman whether, in those cases where they have
employed Crede’s method of delivering the placenta, they have noted a
cupping of the uterus from efforts to extrude the afterbirth?
Dr. J. A. Larrabee: I have occasionally noticed cupping of the uterus
under those circumstances.
Dr. F. C. Simpson: I remember a certain practitioner in this city
several years ago made the statement that he seldom tied the cord after
cutting it; that he did not see any necessity of tying the cord. If this
is true, then there would certainly be no danger in severing the cord in
cases such as Dr. Anderson has reported, and it would not even be
necessary to tie it until after the delivery had been completed.
Dr. Wm. Bailey: I want Dr. Anderson to speak to one point in particular
in closing the discussion, viz., would there not be great danger if the
placenta was separated at a time when the child was still partly in the
uterus?
Dr. F. C. Wilson: The only point I wish to bring out in connection with
the case is the possibility of detecting the fact that the cord is
around the neck of the child before delivery, and being on our guard for
it. Encircling of the cord around the neck of the child ought to give
rise to a funic bruit. You can hear very plainly a funic bruit, a bruit
which is synchronous with the fetal heart sounds. Where this can be
detected at a point where we know the neck of the child lies, it
indicates to us that the chord is around the neck.
There are certain other circumstances under which we may also detect a
bruit: For instance, the one mentioned by Dr. Cecil, where the cord was
tied into a hard knot. I have met with several such cases in my
practice, and a bruit can be produced in this way, but at a different
place from the location of the neck, and it is a permanent bruit; a
bruit that is heard all the time. Where that is the case, of course it
indicates that there is some permanent obstruction of the cord, and the
likelihood is that it is due to a knot tied in the cord. We know that
sometimes the cord slips over the neck, and then the child’s body slips
through the cord, thus making a perfect knot; it then may be drawn
tighter and tighter, finally producing considerable obstruction. If the
bruit that is heard is evanescent, heard sometimes when you are
listening and not at others, that indicates simply a temporary pressure
upon the cord which may produce a bruit that is fetal in its rhythm, at
the same time it is heard occasionally only. Where the cord encircles
the neck and is drawn tightly it is apt to give rise to a bruit that is
more or less permanent, and always heard at a point where we know from
other methods of examination that the neck of the child is located.
Where this occurs we ought to be on the lookout and prepared to find the
cord encircling the child’s neck, and ought to endeavor to release it in
the first place, and where we are unable to do that, then the question
of severing the cord will come up. The cord being pulseless in the case
reported by Dr. Anderson would have simplified that question very
materially. The cutting of a cord that is not pulsating is an easy thing
and not at all dangerous. Even where the cord is pulsating I have cut it
repeatedly without even attempting to tie it, simply holding one end—of
course you have to make a guess as to which end is attached to the
child. You can not always tell that, but you can easily see from the
continued bleeding or pulsating whether you have the proper end or not,
and by simply holding that between the fingers the delivery can be
expedited, and then the cord can be tied immediately afterward. Where
the cord is pulseless there would be no danger in severing it and
leaving it untied and even unheld. I have time and again, after delivery
of the child, cut the cord and not tied it, but always waiting till
pulsation had ceased. I think there is no danger in doing this. If a
cord is cut after it ceases to pulsate and does not bleed by the time
the child is washed and ready to be dressed, there will be no hemorrhage
from it afterward.
Dr. Turner Anderson: Referring to the point made by Dr. Howard, I
believe, whenever the umbilical cord presents anomalies as illustrated
by the case reported, that it is as a rule abnormally long. The cord in
this case was abnormally long.
Dr. Larrabee made a point to which considerable importance should be
attached, viz., that it would not have been an easy matter to have
divided the cord in this case. I think practically he presents the case
exactly right. When a cord encircles the child’s neck twice, then
branches off and goes under the arm, then branches off over the back, it
presses the neck so tightly and the conditions are such that it would be
a very difficult matter to get one’s finger beneath the cord at the neck
and divide it. It is not such an easy matter to sever a cord under these
circumstances as one might suppose. I believe the majority of
obstetricians content themselves, when they find the cord is encircling
the neck, by simply making an effort to stimulate uterine contraction,
and to deliver the child as rapidly as is consistent with safety to the
mother, and while so doing take the precaution to support the head, to
hold it up well against the vulva and prevent undue traction on the
placenta.
It is seldom that we fail to resuscitate a child born under these
circumstances. The cord as a rule is not encircling the child so tightly
so as to prevent our ability to resuscitate it.
Dr. Bailey has correctly stated that arrest of pulsation in the cord
does not occur until after delivery of the head, and we have a limited
time then to stimulate uterine action and to disengage the body of the
child and release the cord from the neck. Contraction and arrest of
pulsation of the cord do not occur prior to that time as a rule. I can
conceive it possible that it might do so, but as soon as the head is
delivered, contraction then is so great that unless the cord is very
long there is an arrest of pulsation and the danger commences.
Fortunately we have recourse to stimulating uterine action, and have a
chance to deliver the child in the manner I have suggested with
sufficient promptness.
I am satisfied Drs. Bailey and Bullock recognize all the dangers of
premature separation of the placenta in an uncontracting uterus. In the
primipara I can not believe that a slight cupping of the uterus, or the
premature separation of the afterbirth, would be a matter of any very
great moment. We are all agreed as to the dangers which may occur from
separation of the normally attached afterbirth prematurely in the
absence of uterine action.
In the primipara we know how very closely the perineum, unless it is
lacerated, hugs the neck of the child, and to isolate and cut the cord
under such circumstances is a very difficult matter. I do not attach
much importance to not cutting the cord, although if I could feel it
around the neck of the child and could sever it I would not hesitate to
do so.
_Protrusion of the Rectum._ Dr. W. O. Roberts: To-day at my clinic at
the University of Louisville a man presented himself complaining of
hemorrhoids. I put him on the table on his back, drew his legs up to
make an examination, and he strained slightly, had an action from the
bowel, and passed out about four inches of his rectum. After examining
it carefully to see whether or not there were any hemorrhoidal masses
about it, or a tumor of any kind, I started to get some vaseline to
assist in replacing his rectum, when he drew it back himself as though
he had a string fastened to it. He did not touch it, but simply drew it
back. I turned the table about so the class could see the prolapsed
rectum, and he shot the rectum out and drew it back four or five times.
It is a very peculiar and unique condition to me, and I would like to
inquire if the members have ever encountered a condition of the kind in
their practice.
_Discussion._ Dr. J. M. Williams: This is undoubtedly a case of prolapse
of the rectum with a lax condition of the connective tissue. It may be
from continually coming down, and I have no doubt that the bowel comes
down after each defecation; there is some kind of an action by which the
patient controls the rectum. It may be that contraction of the sphincter
muscle starts the rectum upward, and then it simply follows its course.
I can offer no other explanation of the condition. Certainly if the
bowel comes out four inches there would be considerable tension upon the
mesenteric attachment. It seems entirely possible that this phenomenon
could be influenced and controlled by the diaphragm and abdominal
muscles, and this may be the solution of this unique case. I have never
seen a case of this kind.
_Epileptiform Seizures in an Infant Aged Ten Months._ Dr. J. A.
Larrabee: I have been considerably interested and I may say annoyed by a
case that has been under my care recently. It is in a family which is
decidedly neurotic, and in which there is possibly, without history or
committal, a taint of specific disease. It is not very unusual to have
epileptic manifestations in children at an early age, but the case I
desire to report is, I think, somewhat anomalous. There have been, for a
period of fourteen days, eleven petit mal seizures in every twenty-four
hours in an infant ten months old. These seizures have not apparently
concerned or involved the integrity of the child in any respect. The
intellectual functions, so far as intelligence is written upon the face
of an infant, do not seem to have been affected. The infant is just as
well apparently as if it did not have every hour or so an epileptic
convulsion. The attacks present the usual phenomena of true epilepsy.
The duration of these attacks is from one to two minutes, accompanied by
the usual phenomena, flushing, unconsciousness which is perfect, the
attack then passes off and the infant is well again.
This condition of affairs having been going on for a period of fourteen
days in this case without any impairment in the general health of the
infant, or in its nutrition, certainly points, I think, to a specific
cause. I have often had cases, not quite so remarkable as this, where
the tendency has been neurotic or specific in character, which improved
under appropriate treatment; but this case has resisted all treatment,
even specific treatment by the inunction of mercurials and the
administration of the iodides.
The condition is still in progress, the infant having eleven seizures in
every twenty-four hours, not exceeding this number and not falling
short. I have witnessed several of them, and they are perfectly
characteristic of epilepsy. An older child in the family passed through
an ordeal of paroxysms, was unable to walk for three years, and this
child has been restored under treatment, and that treatment has been
antisyphilitic. One child in the family has been lost, and the history
is that it died from scorbutus. The family is decidedly neurotic, and I
suspect a specific taint.
The case has been exceedingly interesting and even annoying to me
because I have been unable to make the slightest impression upon it by
treatment in lessening the number or severity of the paroxysms. I am
pursuing the same line of treatment that I did in the case of the older
child which recovered, and believe I have sufficient ground for specific
treatment, but so far it has not been productive of relief.
The peculiarity about the case is that the occurrence of these paroxysms
has not so far interfered with the nutrition or the general health of
the infant. In this respect I think the case is somewhat remarkable.
_Discussion._ Dr. T. S. Bullock: I would like to ask if Dr. Larrabee
gave the bromides in the case he has reported.
Dr. T. H. Stucky: Have you tried the bromide of gold and arsenic?
Dr. J. M. Ray: In connection with Dr. Larrabee’s case I recall one that
I saw several months ago in a child a little older than his which gave a
peculiar history. The mother brought the child to me, the history being
that the child complained of having something the matter with its ear. I
examined the ear carefully. No inflammatory or other disease was present
about the structures of the ear; hearing was perfect, and the drum
membrane was intact. The child at this time was three years of age. The
history that the mother gave me was about as follows: The child had
never complained of earache; she had never noticed any defect in
hearing, but sometimes two or three times a day the child would
apparently be interested in her toys or in something about the room, and
all at once she would scream and run to her mother and say that the
house was turning over, that there was a bug in her ear, etc. This would
happen several times a day, and on several occasions the child had
fallen over apparently unconscious, or in a state of partial
unconsciousness.
After looking into the ear carefully and not finding any evidence of
disease, I referred the case to the family physician, and in talking the
matter over with him he suggested that these attacks were probably petit
mal. He put the child upon bromide of gold and arsenic, and a prompt
recovery resulted. The last I heard from the case the attacks were few
in number, occurring at long intervals and slight in character, although
at one time they occurred two or three times a day.
Dr. T. H. Stucky: I have seen several cases of epilepsy in children, but
never saw one in a child so young as that reported by Dr. Larrabee. I
have followed out the usual routine, giving bromides and other remedies
with varying results; and later, following the suggestion of Dr.
Buchman, of Fort Wayne, have tried combination mentioned by Dr. Ray,
viz., the bromide of gold and arsenic. I believe the latter to be
especially indicated and exceedingly serviceable where we have reason to
suspect a taint, as mentioned by Dr. Larrabee, getting as we do the
sedative influence of the bromide, the alterative influence of the gold,
and also the well-known effects of the mercury contained in the
combination.
I believe where anemia is very marked in these cases, and there is a
feeble heart action, and we are fearful of the depressing effects of the
bromides alone, that in the use of the bromide of strontium and gold we
gain a decided advantage, getting as we do the sedative as well as the
cardiac influence of the strontium salts. Dr. Marvin demonstrated this
conclusively before this society in a statement made by him in regard to
the action of strontium salts in digestive disturbances, especially
those conditions characterized by marked flatulency. If this be true,
and we have reason to believe it is, it appears to me that the bromide
of strontium and gold would be even better than the bromide of gold and
arsenic in cases such as Dr. Larrabee has reported.
Dr. J. A. Larrabee: The case is reported not to demonstrate any unusual
manifestation of epilepsy, but on account of the exact regularity and
periodicity of the seizures, and the age of the patient, coupled with
the fact that the treatment which seems to be indicated has not been
followed by relief. In looking up the literature of the subject I find
that cases of this character are usually attributed to a specific cause.
In answer to Dr. Bullock’s inquiry: I have used the bromides in this
case without any effect whatever. Of course epilepsy in the child is
nothing new, but this case presents some peculiarities. There is a
decided neurotic tendency in the family, which may have some bearing
upon the case. The child is going along having the number of seizures
stated each day without any evidence of disturbance of nutrition or
impairment of general health, which is rather remarkable. Some of the
attacks are almost grand mal, most of them petit mal, and I am convinced
that the trouble is due to specific taint.
The next move I make will be to put the child upon the bromide of gold
and arsenic.
JOHN MASON WILLIAMS, M. D., _Secretary_.
Abstracts and Selections.
THE INFLUENCE OF THE ORGANISM UPON TOXINS.—Metchnikoff (_Ann. de
l’Instit. Pasteur_, November 25, 1897,) has applied the method of
comparative pathology to the question of the mechanism by which the
animal organism prepares antitoxins, and the laws which regulate their
production. By growing bacteria and lowly fungi upon culture media
containing toxines he was enabled to show that the virulence of the
latter was in most cases diminished and sometimes destroyed. In any case
these microbes have no influence in the production of antitoxins, and
the idea of preparing them by this means must be abandoned. The animal
organism alone being capable of producing antitoxins, the next point was
to find out whether this was a property common to all animals, or
limited to the superior. Metchnikoff found that the injection of large
quantities of tetanus toxin into scorpions and the larvæ of other
arthropods produced no antitoxin. The toxin remained for months in the
blood or tissues without losing its properties; similar results were
obtained when it was taken into the alimentary canal of the leech. It
was hence shown that even those invertebrates in which antimicrobic
phagocytosis is most marked are utterly incapable of producing
antitoxins. Coming next to vertebrates, no power of producing antitoxin
is possessed by fish or amphibia; it first appears in reptiles, but not
in all kinds. Thus tortoises, like invertebrates, can retain tetanus
toxin in the blood for a lengthened period without forming antitoxins;
it is in reptiles that the production of the latter is first observed,
but in them only when they are kept at a temperature higher than 30° C.
If the temperature is 20° C. the results are just the same as in
tortoises and invertebrates. The establishment of the antitoxic property
in these cold-blooded animals is not attended with any rise of
temperature, and the same is true in warm-blooded animals such as fowls.
With regard to the last-named animals, whose power of producing tetanus
antitoxin was first demonstrated by Vaillard, Metchnikoff has some new
and important observations. He finds that practically all the toxin
injected into the peritoneum passes into and remains in the blood, none
of the organs being toxic after their blood has been washed out. To this
an exception is found in the case of the genital organs, ovaries, and
testicles, which possess the power of fixing some of the circulating
toxin. This they share with the leucocytes, to the toxicity of which
that of the blood is due. After a while the toxic power of the blood
diminishes, and after passing through a neutral period it becomes
antitoxic. It is now found that with the exception of the generative
organs, none of the organs when freed from blood possess any antitoxic
power. The genital glands are found to be markedly antitoxic, but the
author brings evidence to show that the antitoxin is not manufactured by
them, but is absorbed from the blood, so that in the fowl the antitoxic
property resides solely in the blood. Metchnikoff concludes that it is
not possible to accept the idea that natural immunity depends on
antitoxic power, and he further points out that the latter is evolved in
the history of the animal kingdom at a much later date than the
phenomena of phagocytosis.—_British Medical Journal._
THE TREATMENT OF TUBERCULOSIS WITH TUBERCULIN R.—Dauriac (_Progrès
Médical_, December 4 and 11, 1897,) reports the results of the
employment of Koch’s tuberculin R. in various cases of tuberculosis;
fourteen of these presented local affections, such as suppuration over
the sternum, enlarged cervical glands, ulceration of the skin, etc. All
of the patients were satisfactorily cured. In a second paper he
describes the results in fifteen cases of pulmonary tuberculosis in
various stages of the disease; all were greatly improved, and many are
described as cured. One of the cases was insufficiently nourished and
clad, had no fixed residence, and, when the treatment was commenced,
large cavities were found at the apices of both lungs. A case is also
described in which, in addition to pulmonary tuberculosis, lesions were
present in the kidneys and the bladder. This patient also made a
complete recovery. The treatment, in spite of these brilliant results,
is supposed to be most applicable to the earliest stages of the disease,
and it is suggested that it would be advisable to detect the presence of
tuberculosis by injections of minute doses of the original form of
tuberculin. The treatment is usually commenced with a dose of 1/500 mg.
This should be increased daily until a dose of 10/500 mg. is reached;
this then should be increased 1/50 mg. daily until ⅕ mg. is reached, and
this increased ⅕ mg. daily until 1 mg. is given. This can then be
further increased if considered desirable, the maximum dose being about
20 mg. The immediate effects of the injections are usually _nil_. With
doses in excess of ⅗ mg. a slight elevation of temperature is
occasionally observed. Local reaction is extremely rare. The subsequent
effects consist in reduction of fever, cessation of sweats, increase in
appetite, and disappearance of tuberculous lesions. As none of the
patients reported in this paper was admitted to the hospital, but simply
came three times or less frequently a week to the dispensary for
injections, improvement could not possibly have been due to any
alteration in their hygienic surroundings.—_The Philadelphia Medical
Journal._
CESAREAN SECTION BY TRANSVERSE INCISION OF FUNDUS.—Braun (_Centralbl. f.
Gynak._, No. 45,) has had experience of Fritsch’s cesarean section, the
operation being the second of its kind ever recorded. Fritsch bases his
practice on the course of the secondary branches of the uterine arteries
which run horizontally, so that a longitudinal incision down the front
of the gravid uterus can not fail to cause free hemorrhage. He is
accustomed to extirpate diseased fallopian tubes completely, snipping a
wedge-shaped piece out of the uterine cornu. Bleeding is always free,
but the tying of a suture passed antero-posteriorly under the bleeding
vessel stops it at once. The ligature lies at right angles to the
vessel, the most favorable position. Hence Fritsch conceived the idea of
making an incision straight along the fundus from cornu to cornu, in
order to extract the fetus in a cesarean section. Braun publishes full
notes of his own case. The patient was a rachitic primipara with a
universally and irregularly contracted pelvis. The conjugata vera was
two and three-quarter inches. Labor pains had set in. Care was taken to
antevert the gravid uterus sufficiently, the upper part of the wound
being held together with forceps during delivery of the child. Then the
transverse incision was made. Braun found that it bled as much as the
longitudinal incision in cesarean sections where he had operated during
labor at term or in relatively early pregnancy. The placental site did
not lie near the fundus. The delivery of the fetus, which was living and
weighed six pounds, was neither harder nor easier than through a
vertical incision. The wound in the fundus was under four inches long
after the fetus had been extracted. The sutures had to be placed close
together, fifteen deep and eight superficial being applied. Ergot was
given after the abdominal wound was closed, as there was hemorrhage. The
patient made a good recovery.—_British Medical Journal._
LABOR IN MATURE PRIMIPARÆ.—De Koninck (_Revue Medicale_, Louvain,
October 30, 1897,) has compiled an instructive memoir on labor in
primiparæ married for some years and relatively mature (twenty-eight
years Bidd and Pourtad, thirty-two Ahlfeld). De Koninck gives thirty as
the earliest year coming under “maturity,” the “_primipares agees_” of
French authorities. He sets aside as curiosities certain cases of
primiparæ almost “aged” in the English sense of the term, such as
Cohnstein’s two women aged fifty and Steinmann’s woman aged fifty-two.
It appears that in a genuine uncomplicated case of delayed impregnation
the advent of the catamenia is always found to have occurred late in
youth. Out of 401 such cases menstruation was retarded till twenty in
39, till twenty-four in 4, and till twenty-six in 1. As to the retarded
first pregnancy, abortion, ectopic gestation, twins, and special renal
mischief are relatively frequent. Above all, lingering labor is
specially common, statistics even exceeding guesses and _a priori_
reasoning in this respect. In 12 out of 17 noted by De Koninck labor
lasted from forty to fifty hours, the remaining labors being yet longer;
1 exceeded ninety hours. Feebleness of uterine contraction is absolute
from first to last, and independent of any obstetrical combination. They
also cause far more physical and mental exhaustion than the vigorous
contractions of a young uterus, and at the same time are more painful.
There are discrepancies in the “pains” seen in mature primiparæ of the
same age, probably homologous with the great variations in the age of
menopause observed in otherwise normal women. The uterus may be older in
one woman aged thirty-five than in another of the same age. The forceps
and other obstetrical operations are often required in the mature. Most
of the above facts are easily explained. The excess of male infants
borne by mature primiparæ (thirty per cent) is a less explicable
phenomenon. Hecker considers the predominance of male infants as a
speciality of all primiparæ, but Rumpe turns attention to the fact that
in a family of children the predominance of males is commoner the
further the mother is from her first menstrual period.—_Ibid._
KINESITHERAPY IN HEART DISEASE.—Colombo (_Gazz. Med. di Torino_, 48, N.
39, 40, 1897,) pleads for a more general use of kinetic treatment in
heart disease. Even in advanced cases he seems to think such treatment
is very advantageous. Milder forms of treatment, for example, the
Swedish method of gymnastic exercise, should be started at first, and
afterwards more active methods, for example Oertel’s, can be tried. The
action of the Swedish method is most marked upon the peripheral vessels,
while Oertel’s system acts more directly upon the heart itself, so that
dividing heart disease into disease of central or cardiac, and that of
peripheral or vascular origin, the different methods could be applied
accordingly. The Swedish method, moreover, has this advantage, that it
can be applied in severe cases which can not leave their beds. Barie
(_Sem. Med._, November 12, 1897,) advocates the treatment of heart
disease by Swedish gymnastics. The aim of the exercises is to facilitate
the work of the heart by increasing its contractile power and by
lessening the peripheral resistance. The exercises are a series of
regulated, combined, or alternating movements of resistance or
opposition. The movements employed fall under the main groups: (1)
Kneading, rubbing, or stroking of the muscular masses in the limbs and
abdomen; (2) movements of circumduction which facilitate the circulation
in the main venous trunks; (3) movements which favor respiration. The
exercises are very varied, and accomplished by means of passive and
active movements, numerous different manipulations, and by special
apparatus. The average duration of the treatment ought not to be less
than an hour a day during three months of each year. The treatment is
suitable for cases of dilatation, hypertrophy, fatty degeneration,
chronic myocarditis, and various neuroses and functional affections of
the heart. Such symptoms as shortness of breath, palpitation, insomnia,
cephalalgia, giddiness, gastric phenomena, edema, ecchymosis, cyanosis,
improve or disappear under treatment. The pulse-rate is lowered, but
rises again as soon as treatment is interrupted. Rational application of
the treatment does not exclude internal treatment by ordinary medical
means, and the two methods may often be employed simultaneously with the
best results.—_Ibid._
LIVE FROGS AS AN ANTITHERMIC.—An English practitioner of Constanta,
Roumania, writes: On the evening of October 19th I was called to visit a
Roumanian boy, six years old, suffering from typhoid fever. I found him
_in extremis_, almost pulseless. The child’s head was completely wrapped
over with a large white sheet, and as I looked at it this enormous white
envelope seemed to be on the move, and while I was surveying this
covering there crept from under it a small frog, which quietly sat over
the child’s left arm. It seemed quite content. I immediately called the
mother’s attention to it and requested her to take the animal away,
thinking it had crept there as an intruder. “Oh, no!” said the old lady,
“a doctor recommended that a lot of them should be kept to the head to
keep it cool.” Seeing the head covering still on the move, I raised it
for curiosity, and in a second out jumped about twenty other frogs and
hopped away in all directions. I have often heard the expression “as
cold as a frog,” but this was the first time I had seen a frog applied
as a head-cooler.—_London Lancet._
TREATMENT OF ENDOMETRITIS IN BROMINE VAPOR.—Nitot (_La Gynecologie_,
October 15, 1897,) maintains that the correct prophylactic treatment of
parenchymatous metritis and chronic salpingitis consists in rapid cure
of recent endometritis, which is the starting point of those troublesome
diseases. To insure cure a remedy is needed which can penetrate to the
deepest recesses of the muscosa, and even the tubes, without dangerous
effects. Caustics and fluid preparations do not possess such properties.
A gas is required, and it must be freely diffusible, antiseptic, and
capable of acting on the epithelium so as to modify without destroying
them (“anticatarrhal action”). Bromine emits gas with the necessary
qualities; a saturated aqueous solution should therefore be placed in a
bottle with double tubing like an ether spray or the chloroform bottle
in a Junker’s inhaler. A hollow sound, connected with one tube, is
passed into the uterus, while the solution is made to bubble by pressure
on a ball connected with the second tube. Thus vapor is propelled into
the uterus. Nitot claims the best results, and notes that the advantages
of gaseous diffusion over intra-uterine injections or other medication
are self-evident.—_British Medical Journal._