« ForrigeFortsett »
ditions obtainable, the mortality of the cases The parts were relaxed, and the os fully di. reported is very great, being from 30 to 50%, lated, and the child's right hand was presentand no doubt there are many cases never re. ing at external genitals. With shoulder imported that would make the percentage much paoted in pelvis, and the child was alive. greater.
Chloroform was at once administered until With this paper I wish to report two cases all muscles were relaxed. The band and arm of uterine rupture that ocourred within a was replaced, the shoulder disengaged from period of ten years practice in an experience pelvis and child turned by bipolar version of 520 obstetrical cases.
until the head was presenting O. R. A. The
head was flexed and held in position until CASE I.-Mrs. R., age 30; height 5 feet 4.
the womb contraoted and held it so. Labor inches; weight 110 pounds; German, three
continued and the pains grew stronger and children, last child two years old. Previous
position of child was good. The head was pregnancies and labors normal. History of
entering superior strait of pelvis, and the this pregnanoy normal. Labor began at full
pains were very hard and becoming expul. term on Wednesday. Dr. A. was called. As
sive. About two hours after turning the soon as the os began to dilate hemorrhage
child, during an exceedingly strong pain. began and increased with dilatation. There
Apparently somotbing gave way and the was a palcenta previa with central implanta
woman suddenly relaxed and exclaimed: tion. Nothing was done for this condition.
"something broke. There is something flowThe pains were normal, but the hemorrhage
ing." On examination I found about one quart continued severe. Early Thursday morning
freeh blood in the bed. Head still in superthe placenta passed the cervix and was re
ior strait, but loose. Woman showed great moved from the vagina. There was a cross
exhaustion and collapse. There was no signs presentation with left arm down and out, firm
of muscular contraction. An angular procontraction, with the shoulder impacted in
tuberance appeared between umbilicus and pelvis. Dr. Z. was called in consultation on
pubes.apparently an elbow. I suspected rupThursday, but nothing accomplished, and the
ture, and consultation was summoned, and case was given up to die. On reaching the
the diagnosis confirmed. Forceps were apcase early Friday morning I found woman
plied and child delivered two hours after rupin collapse, pupils dilated, could not talk or
ture. There was no sign of uterine contrac. understand; extremities cold, and pulse very
tion or aid from women in delivering. The feeble. No bemorrhage; no pain. Patient
child weighed twelve pounds and was dead. was completely relaxed, and did not complain
There was no signs of life in the child after of pain or sensation. Blood from previous
the rupture. The placenta followed the child. hemorrbage had passed tbrough a feather bed
There was no more hemorrhage and womb and mattress and run across the rooni. I
immediately contracted as in normal labor. pushed the shoulder up and out of pelvis, re.
The woman was carefully cared for and soon placed the arm and turned child by bipolar
recurered from shock. Ten hours later the version. I then grasped both feet and ex.
womb was irrigated with Hgol, solution 1. tracted the child by force, there being no help
5000 with a return flow syringe in order that on part of woman. No bemorrhage followed.
the uterus might not be disturbed. There In examining the vagina found a piece of
was a mild infection following in this case, muscular tissue three inches long and one
involving a part of peritoneum, especially the inoh wide, hanging by a pedicle, and finding
lower part in the pelvis. Paralysis of blad. no pulsation in it, I clipped it off. Only
der followed lasting three weeks. All sympa little capillary hemorrhage followed. This
toms improved, and the patient finally reproved to be a section of the the os with about
gained her former health. Six years have two inches of uterine wall. Tbere was a
elapsed, but there has been no subsequent transverse rupture of anterior portion extend. ing into vagina. The woman rallied slightly
pregnancy. from the shock, but died ten hours later.
CASE II.- Mrs. B.; height 5 feet 5 inches; weight 150; age 35. Six children. Family
VERTIGO FROM BRAIN TUMORS. — Peterson history good, surroundings good. Previous
employs antipyrin, cannabis indica, morphin; labor normal. Was unexpectedly called into
potassium iodid, mercury or mixed treatment case. Labor had been in progress four hours.
for syphilitio growths. On inspection I found child with long diameter at right angles to body of In the presence of a breast infection that mother, head to left. Pains normal and fails to heal within a reasonable time after about five minutes apart. In vaginal exam. appropriate incision and dressings, it is well ination found bag of water had ruptured to think of local tuberculosis.
FEVER; WHAT IT IS, AND THE INDICA prove that it may not be found out. To my TIONS FOR TREATMENT.*
mind, the word idiopathio is one of the
most unfortunate in our vocabulary. It is C. A. BOICE, M. D.
such a nice sounding word with which to
salve our consciences when we cannot, or are WASHINGTON, IOWA.
too lazy to make a correot diagnosis. The The advertising pages, and frequently the more we know of morbid physiology the less reading pages, of practically all of our medi. use we bave for such nondescript words. For cal periodicals are replete with advertisements the purposes of this paper, fever as a symp. and laudatory notices of some old drug in a tom only will be considered. Is it scientific new dress. The change in pame bus appar. or rational to treat the fever without reference ently endowed it with wonderful powers. The to the cause? The most important thing to nanie is bigh sounding, easily remembered remember is that we are not treating a dis. and frequently meaningless.
ease, but a patient with an ailment. This or that drug is recommended for fever, High temperature is the outward expression no attention whatever is given to the cause of disordered katabolism, rarely should it be of the fever or to the condition of the patient. treated by direct action, more rarely by direct We are instructed to give this remedy, the depressants. We are entirely too careless in fever will be immediately reduced, the heart regard to applied therapeutics. The trouble will not be depressed(?), and all will be well is largely with medical colleges. Rare is the with the patient. Will it?
college which gives therapeutics a prominent We must draw one of two conclusions from place. Most of them assign to it a very in. such manner of treatment. Either that fever ferior position; some almost entirely ignore is a disease per se, and to be so treated; or it as a branch of medical science. Surgery that there are many, very many medical men and obstetrios are so much more spectacular, who are willing to take any advertiser's word but are they so practical for every day pracas their law of procedure and treat accord tice? ingly. Such men may be doctors, but they The causes of fever may be toxic condi. are not physicians.
tions, infective processes, gastro-intestinal dis. There is certainly a call for such drugs else turbances, beat stroke or purely nervous. The so much money would not be spent in ex. physiology of fever is increased production ploiting them. Practicing medicine along and eliwination of carbon monoxide, in. such lines is a good thing for the pharmacist, creased action of the skin and increased elima poor condition for the doctor and a very ination of nitrogen, and disappearance of bad condition for the patient. It is like the glycogen from the liver. blind leading the blind, and the patient falls High temperature is the result of an at. into the ditob.
tempt on the part of the system to throw off Is fever a disease per se and to be so tbe disturbing factor. There is an increased treated, or is it only a symptom of some other leucocytosis. Why not help, instead of hin. disease? If only a symptom should it be der? treated empirically? If we may, let us learn Fever is probably the most valuable guide what fever is before we treat it.
we have to the severity and progression of Gould defines fever as a "systemic disease, the morbid state, and when we unnecessarily or a symptom of disease whose distinctive
depress the hyperpyrexia, we lose sight of characteristic is elevation of temperature, ac
our index. The indiscriminate prescribing of companied also by quickened circulation, in.
the much raunted antipyretics is to be decreased katabolism and disturbed secretions."
plored. Medicine is not a fixed science, and Aronsohn defines fever as a "result of mor
never will be as long as such methods are bidly exaggerated stimulation or irritation followed. of the heat centres." What stimulates or
It is frequently necessary to prescribe med. irritates them?
icines before a positive diagnosis is made, but Bergel says that the febrile phenomena the case is not rendered any clearer by deare not the consequences of the high tem
pression. perature, but are the direct results of the
Of the various febrifuges the coal tar deriv. infective processes.
atives are the most popular. Acetanilid, an. Fevers have been divided into idiopathic tipyrin, antifebrin and other antis ad nauand symptomatio. Idiopathic fever is one
seum. They reduce fever by direct action on whose cause has escaped detection, but be
the beat centre, but they do not stop there. cause it has not been detected does not
They do not in any manner remove the cause
of the fever. They stop nitrogenous waste ** Read before the second annual meeting of the physicians only while their effect lasts. They depress
the heart and general nervous sensibility. Con
of the First Councillor District of Iowa at Fairfield, Ia., January 26, 1906.
tined or large doses are serious heart depress- Salix nigra and saw palmetto will oure ants. They are seldom indicated, rarely use. many cases of spermatorrhea. ful and frequently harmful. Their chief ad.
Dr. Phillips praises bryonia in hepatio vantage seems to be that they permit the pa
dyspepsia, with bilious headache and vomtient to die with a normal temperature. It calls to mind a story of the times when bleeding ring was the panacea for all ills. A child was free. Dr. Tuffier concludes that beyond the age ly bled for some slight indisposition and
of 50, all acute intestinal obstruction is due
of 50. all acute intestinal obat death resulted. The mother was comforted to cancer. with the advice that her child had died cured anyway. Many such brilliant results have Dr. Rouget says that inhalations of amyl followed the use of coal tars.
nitrite will relieve hemoptysis when other Alcohol and aconite owe their antipyretio
agents fail. action to their property of causing vasomotor Beale recommends rest, starvation, tea or dilatation and permitting increased radiation coffee, acids, warmth and counter-irritation of heat. They require very careful watching for migraine. and frequently leave the patient in a worse shape than before using. Aloohol lessens
A curious Case of ptyalism.-In one of leucocytosis, checks all elimination and dis. Shali's cases increased salivation persisted turbs proteid metabolism. Aconite is a for six months after a siugle dose of calomel. powerful cardiac, respiratory and circulatory
FRIEDRICH'S ATAXIA, -A. H. Dodge, Phil. depressant. It should not be given in typhoid
adelphia (Jour. A. M. A., March 17), reand other asthenio oonditions.
ports a case of Friedriech's ataxia with nearly Quinine acts as a febrifuge in doses of
all the typical symptoms except the familiar twenty or thirty grains by retarding oxida.
feature. This, however, is not remarkable tion, and thus preventing heat production.
as sporadio cases are not rare. The patient's It does not act on the cause of the fever un father was an alcoholic. In commenting on less it be malarial. Quinine also stops nitro- the case. Dr. J. H. Lloyd, in wbose service genous waste only while its effect lasts.
the case occurred, speaks of the comparative Stevens says that "Antipyretics are only ease of diagnosis of the condition, and mon. indicated when the fever is high enough to tions a type of congenital ataxia paraplegia be in itself a source of danger. They are occurring in children, with some spasticity, all more or less depressing."
increased knee jerks and speech disorders, Cold sponging has a tonic and stimulant with or without nystagmus. This is someeffect; it promotes formation of leucocytes times seen in children who have suffered and assists in overcoming the infection: it injuries at birth and is then of course in quiets nervous excitability, soothes the pa. no sense hereditary or familiar. tient, lessens delirium; restores circulatory THE BLOODLESS PHLEBOTOMIST.-The equilibrium and promotes rest and sleep.
April issue of The Bloodless Phlebotomist If the hyperpyrexia is caused by typhoid contains a grist of interesting original matter, or other intestinal putrefaction and its re- which will appeal to medical men. Among sultant autointoxication, clean all infective the leading artioles are: Proprietary Reme. material out of the alimentary canal and keep dies from the Physician's Standpoint, by W. it clean, and there will be very little use for J. Robinson, Ph.G., M.D., of New York; antipyretics. If the byperpyrexia is from re. The Lesson of the Yellow Fever Epidemic, tained pus (be it appendical, mastoid, empy. by Daniel Lewis, M.D., LL.D., of New York; ema or what not) drain out the pus, sustain Delirium Tremens, by T. D. Crothers, M.D., the patient and the fever will take care of it. of Hartford; The Alkaloidal Treatment of self.
Pneumonia, by W. C. Abbott, M.D., of Chi. The rational treatment of feverish condi.
cago; Otitis Externa Ciroumscripta, by tions has well been summed up by Dr. I. N. Prof. James A. Campbell, M.D., of St. Louis. Love:
The Bloodless Phlebotomist occupies a uni. 1. Prompt, potent purgation..
que position in journalism. It is original, 2. Effective action of all eliminating or. liberal and exceptional. There is no other gans.
journal like it. It is not wedded to one idea, 3. Intelligent nutrition.
nor is it hidebound nor prejudiced. It says 4. High temperature and nervousness best what it means and means what it says. The controlled by cold sponging and rectal flush. Bloodless Phlebotomist circulates 208,000 ing.
copies each issue, reaching practically every 5. Rest.
English speaking physician on the globe. It “Study disease not less, but man more" is a journal worth cultivating.
The Medical Society of City Hospital Alumni
President, LOUIS H. BEHRENS, 374! Olive Street Secretary, FRED. J. TAUSSIG, 2318 Lafayette Ave.
CHAIRMEN OF STANDING COMMITTEES :
Scientific Communication, Wm. S. Deutsch, 3135 Washington Ave. Executive. A. Ravold, Century Building
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A NEW PROCEDURE IN TENDON AND method offering better assurance of success MUSCLE TRANSPLANTATION APPLIED was finally devised. This was to interpose IN A CASE OF INFANTILE CEREBRAL the palmaris longus and flexor carpi radialis PALSY.
between the source of power and tbe point of DRS. PHIL HOFFMANN AND SIDNEY I. SCHWAB.
its application. These muscles are superfic.
ial, and being long avd slender, approximatST. LOUIS.
ing a tendon in shape, offered a good medium Read before the Medical Society of City Hospital Alumni, through which to transmit the biceps' pull. St. Louis, February 1, 1906.
They being paralyzed, were used simply as DR. HOFFMANN.-In presenting this case passive structures to connect the tendon of I shall limit my remarks to its orthopedic the biceps, where it crossed the elbow, with aspect, leaving the neurologic side to Dr. the tendons of the finger flexors, where they Schwab, with whom I have been associ. crossed the wrist. After the biceps tendon ated in its care. The patient, a boy of had been detached from its insertion at the seventeen, was afflicted with a left bemi. radius, it was sewed into a longitudinal slit plegia of cerebral origin, dating from a in the bellies of the flexor carpi radialis and few days after birth. He had entire loss palmaris longus, which had been previously of power in the flexors of the band and detached from their common origin at the wrist, and barely enough in the extensors to inner condyle of the humerus. Next, the extend the fingers, but not the wrist. The tendons of the flexor carpi radialis and pal. little extensor power present offered no possi. maris longus were out from their insertions at ble chance of success from the ordinary the wrist and sewed, en masse, to the tendons method of tendon transplantation, i.e., at- of the deep and superficial finger flexors, intaching the tendons of the paralyzed muscles cluding the long thumb flexor. Now, the bi. to contiguous healthy ones in the same seg. ceps in contracting pulls primarily on the ment of the limb. The extensor muscles' flexor carpi radialis and palmaris longus, and were so weak that it was useless to try to di. secondarily, through them, on the tendons of vide their power with the flexors. There was, the flexors sublimis and profundus digitorum however, fair power in the flexors and exten, and flexor longus pullicis. The operation was sors of the elbow. The boy had never used performed at the Jewish Hospital, September his hand, and there was no possibility of in. 1,1905, and the splint removed November 10. juring its function by any procedure, as the No sign of flexor function was observed until hand could not have been worse functionally. November 26. Since then there has been The thought occurred that possibly we might gradual improvement. He is now able to draw upon the intact upper arm for power grasp a fork or spoon and carry it to his with which to supply the paralyzed segment mouth; and can lift a five-pound Aat-iron below. The first thought was to cut away and hold it for thirty or forty seconds. In tbe biceps from its insertion into the radius order to prevent the biceps from also fexand insert it directly into the central ends of ing the elbow when it is flexing the fingers, the deep and superficial flexors of the fingers. he must synchronously contract his triceps. This idea was abandoned because the great None of the fingers have independent movebulk of the muscle bellies of the finger ment but all, including the thumb, are flexed flexors would afford but a poor medium together. Having no power in his wrist ex. through which the biceps could exert a pull tensors, and the finger extensors being too upon the fingers, and because the dissection weak to extend the wrist by a continuance necessary to detaoh the origins of the superfi. of their action, he must wear a splint to cial and deep flexors from the bumerus, bold the wrist in the lextended position, so radius and ulna would result in such exten. that his new finger flexors can act to good sive scar formation as to probably altogether advantage. He will later be relieved of the prevent transmission of the biceps' pull. A necessity of wearing the splint by an oper
ation to anchylose the wrist in the extended cal method of treatment, and that is surgical. position, a so-called arthrodesis.
orthopedio interference. The sooner this is Dr. Hoffmann then exhibited the patient understood the better the results are bound
to be. In this case the result does not apDR. SCHWAB.-My interest in this case is pear to be unusually brilliant. The patient chiefly concerned with the pleasure I have still has his deformity and the restoration of had in working with the ortbopedist. There function bas been slight, comparatively speak. are several points in coppection with this ing. The grasp of the band has been in a case that are of importance. It is one of in- measure restored. This case, however, may fantile cerebral palsy in which the mentality be taken as an example of the way we should is almost normal. In the greater number of go and the method of attacking the problem, these cases there is some mental involvement. The thing is to get these cases early before but in a certain small percentage there is no joint changes have taken place and before the apparent mental defect. In such cases the atrophy and succeeding contractures of the presence of a physical deformity will neces- muscles have produced a deformity too exag. sarily tend to interfere with the patient's gerated for easy correction. In a case of an. success in life, and we are, therefore, moved terior poliomyelitis, if in a year a full restor. to greater efforts to aid in the removal oration of function is not obtained, then it is betterment of this deformity. Therapeutic the duty of the physician to call an ortho. measures in the usual acceptance of the term pedist to consider the advisability of surgical such as strychnine, electricity, etc., are of no interference. In the very old cases it is avail, and dependence upon them alone is uphill work to get good results. Spiller, nothing short of a therapeutic crime. If this Frazier and Taylor have in this country patient, some years ago, had been placed un- worked out the nervous-surgical aspects of der the care of an orthopedist who under these cases, and they and others have ob. stood fully the mechanics of the arm and bad tained good results by tendon-muscle nerve been willing to make use of tbat knowledge, transplantation and suture. Dr. Schwab, in the results might have been much more grat. closing, insisted that great care be taken in ifying tban is the case now. The sad feature making the differential diagnosis. Oppen. of the case is that the boy has been allowed beim last year had called attention to cases to reach nineteen years of age without the of progressive muscular atrophy which had attempt being made to afford him any logical been operated upon with the idea that an. sort of relief. The boy is sufficiently bright, terior poliomyelitis was present, of course no but any position that he may apply for he improvement had taken place. It was ab. will have to overcome a prejudice created by solutely necessary in all these cases that a his deformity. He is able to write fairly well differential diagnosis be made, and in some and has received a good enough education, cases this might be a hard task and at times but in spite of this any chance of advance. 'ins possible. ment is practically denied to him. An at
DISCUSSION. tempt should be made in this class of cases first to correct deforwity and then to restore. Dr. Norvelle Wallace Sharpe thought the function. If by any chance the two together results were quite encouraging, for the boy can be obtained a most gratifying result will was, certainly, a great gainer by what had follow. The results in tendon work which been done. It was, as Dr. Schwab had said, Dr. Hoffmann has done in cases we have an object lesson for all of us. The profession seen together have been on the whole encour. was derelict in tbis olass of cases; as an exaging, and we have felt that even in this ap- ample he mentioned à colleague who had parently hopeless case an attempt was justi. himself bad a congenital deformity. Some fied. The great trouble that we have found years ago Dr. Sharpe had tried to induce this is that cases hopeful in the beginning for gentleman to have something done by tendon surgical interference are kept under treat. or nerve transplantation, but found that he ment for years and years until the plastic was strongly opposed to such treatment, at period of youth or childhood is passed, and least for his individual case; and Dr. Sbarpe then it is frequently too late to obtain the believed that this man's view-point was the. best results. An example of this sort of result of his training in college years ago therapy is the common custom of treating and the additional fact that the profession as spastic types of paralysis with electricity, at- a whole, fails to realize the actual possibili. tempting apparently to increase the muscle ties, for this unfortunate class, by an intelli. tone in an already hypertonic muscle. There gent intervention. It seemed, too, almost a is one thing that can be positively asserted, crime to fill these patients with the convenand that is, that when such a condition exists, tional therapeutics of the neurologist. He as in the present case, there is only one logi. wondered if something might not be done in