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The Medical Society of City Hospital Alumni
President, LOUIS H. BEHRENS, 3742 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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Public Health, R. B. H. Gradwohl, 522 Washington Ave
A CASE OF CANCER OF THE CERVIX AS- On May 3 I performed a radical abdom
SOCIATED WITH FIBROIDS AND OPER- inal pan-hysterectomy. The uterus was ATED ON BY THE RADICAL ABDOM- found adherent to the rectum with several INAL METHOD.*
myomatous nodules upon its surface. In
freeing the tissues about the right ureter, acFRED. J. TAUSSIG, M. D.
cording to the method of Wertheim, a ligaST. LOUIS, MO.
ture was accidentally slipped around this The patient, Mrs. W., aged 71 years, came
structure. The mistake was shortly afterinto my charge at the St. Louis Skin and
wards recognized and the ligature cut, but in Cancer Hospital on April 21, 1906. There
so doing the ureter was necessarily exposed was no history of cancer in her family. Men
for some distance. About one inch of the struation began at the age of 15, and was in
vagina with its connective tissue was removed every way normal until she was 35 years old.
with the uterus and adnexa. The operation At this time she began to notice a decided in.
lasted one hour and fifty minutes. crease in the menstrual flow and the growth
Outside of post-operative urine retention of some tumor in the pelvic region. This her
with a resultant cystitis the patient for the dootor declared to be a uterine fibroid.
first twelve days made a good recovery. On Treatment consisted of ergot given internally.
this day there was noticed the escape of some The tumor remained stationary in size until
urine through the vagina. It soon became the menopause, which set in between the
evident that a partial necrosis of the right forty-fifth and fiftieth year. The tumor
ureter had taken place and the fistula result. rapidly diminished in size after this. Note.
ing in spite of all endeavors, refused to close. worthy is the fact that although the patient
When the patient left the hospital, on June had been married since her twenty-first year,
23, her general condition was excellent. A there had resulted no pregnanog. Every
secondary operation for the relief of the fisthing went well until July, 1901, when she
tula was advised, but the patient refused to began to notice a slight blood-tinged dis
have this done. The last examination, made charge. Soon thereafter she observed upon
two and one-half months ago, showed no re. taking a douche a moderate hemorrbage.
turn of the cancer. From this time she grew steadily worse, but
The further microscopio examination of it was not until October, 1905, a year and a
the specimen removed showed that apparently quarter after the first onset of her trouble that
the excision had taken place in healthy tis. she consulted a physician. He did not advise
sue. . operation, but prescribed a wash. The dis
The special points of interest in the case charge now became odorons and the bleeding
outside of the type of operation, which in this was hemorrbagio whenever the growth now
city has been done only three or four times, felt protruding into the vagina was touched.
are: (1) The unusually slow growth of the In general appearance the patient was
cancer, being operable two years after the on. rather emaciated, appetite, poor but not very
set of bleeding; (2) its occurrence in a nulli. anemio, considering the duration of her bleed.
parous woman associated with fibroids of the ing. A cauliflower mass, the size of a man's
fundus; (3) the necrosis fistula resulting from fist was found obliterating the vagina. Much
undue exposure of the ureter. to my surprise I found that the uterus was still freely movable, and that by recto-vaginal
REPORT OF CASE OF ENCEPHALO-CYSTO-MEN. examination there was seen to be no infiltra
INGOCELE, OPERATION, PRESENTAtion of the pelvio connective tissue.
TION OF SPECIMEN.
The pathologio examination made by Dr. McCon. Two days ago I was called to a confinenell of a piece of the tumor showed a me. ment case. Before delivery nothing abnordullary carcinoma of the cervix.
mal was noted, but the indistinct fetal beart * Read at the meeting of Oct. 4th, 1906.
beat, which was about 115 or 120 per minute.
Dorsett, I made, to take years of
As the head dilated the perineum I noticed a swelling in the region of the posterior fon.
Dr. Henry Jacobson.—Where it is nec. tanel. It was readily recognized as a menin.
essary to dissect the tissues outside of the gocele. The cbild breathed normally. The
uterine proper it would be much safer to in. opening in the cranium was hardly larger
troduce catheters into the ureters before the than the end of one's thumb. For tbe next
operation and leave them there throughout six hours there was no seepage of the menin.
the operation. Then if the growth extends geal fluid, but after that it soaked the gauze,
around the ureter it can be more readily reand as there was beginning necrosis at the
mored, and there would be no danger of ty. top of the mass I decided after consultation ing the ureter. with Dr. Fry, to do an operation, as leaving Dr. Taussig, in closing.-In reply to Dr. it meant certain death. Yesterday at noon
Dorsett, I found no enlarged glands in this when the child was thirty hours old I cut
ly hours old I cut oase. I made, a search for them. I have away this meningeal sao. The specimen is given up trying to take out normal glands. in tbree pieces. You can see how thin the in an old woman (over 70 years of age) I did
As at the point of beginning uecrosis; not feel like trying to remove the normal Within the meningeal sac was found a sinall
eningeal sac was found a sidall lympbatio glands. As to the use of the piece of brain tissue. This was ligated, a cat.
15 was gated, a.cat. catheter in the ureters, it is very dangerous gut purse-string suture put at the base of the for the reason that we often have to use sac and the skin was closed with interrupted clamps, and if we catch the ureter in the silk-worm gut sutures. The child showed clamo the catheter may be broken. I know
ttle immediate shock. It passed a good Dr. Sampson spoke to me about such an ac. night, taking one or two ounces of milk di- cident at Johns Hopkins. luted with water every two hours as well as Dr. Jacobson. I believe he would be rectal saline enemas. This afternoon there a careless surgeon to say the least, to clamp is a temperature of 102 deg. but it nurses, a ureter when his fingers would so easily retains its food, and there is a possibility feel the ureter with the catheter inside. that the child will pull through.
If he would clamp the ureter, the orushing Dr. Allison, who kindly assisted me in
of the delicate tissues would cause a necrosis, this operation, bas assisted Dr. Lovett, of Bos
r. Lovett, of Bos, and as a result almost surely a fistula, and ton, in two or three similar operations, and
operations, and later if the fistula closes a stricture of the I understand the results are not discouraging, ureter. though none of Dr. Lovett's cases were as large as this one, or done so soon after birth.
PRESENTATION OF SPECIMEN OF DISCUSSION.
FIBRO-MYOMA. Dr. Walter B. Dorsett.-I have had no
HENRY JACOBSON, M. D. experience in meningocele in the new-born.
ST. LOUIS As far as the other specimen is concerned he spoke of a necrosis of the ureter. Were the This was removed last month. The paglands that were taken out along the ureter tient, age 39, never had children, a poor enlarged or attached to it? The question is, woman, bad had severe pressure symptoms, was the ureter involved in the malignant dis which made an invalid of ber and bad been ease? Not long ago I had a oase something treated for soiatica and lumbago. I found like this. The growth seemed to be on the upon examination an enlarged nodular uterus posterior wall of the uterus, and it had as- pressing against sacrum and diagnosed fibrosumed the shape of the pelvis. It went around myoma, and I operated on the 16th of last the ureters like a horseshoe, but I was en month. She made an uninterrupted recov. abled to remove it. Had it enclosed the ery,and is entirely free from pain. You will ureter entirely I doubt if I could have re- see that the specimen is intermural would moved it. This case was of particular in. soon have become subperitoneal. There was terest to me on account of the absence of no hemorrhage in this case, because it was pain while there was great destruction of not growing towards the endometrium. This tissue. While it looked like a fibroid, micro tumor was situated in the inferior posterior scopically it was found almost entirely car wall of the fundus of the uterus; in this cinomatous in obaracter, with very few fibroid situation the growths always call for early reelements. The question has long been dis. moval on account of the distressing pains in cussed whether fibroid tumors become malig. back, and radiating reflex pains down the nant, or whether they facilitate the growth of thighs. It also illustrates that too muob malignancy. This case may throw some light stress must not be laid on uterine hemorrhage on the subject.
in suspected growths of the uterus.
Lecturer on Pediatrics, University and Bellevue Hospital
tal and Nursery and Child's Hospital. The Seaside
SELECTED ARTICLE could in any way be modified to impart auff.
oient knowledge without impairing the
health of the child, and with less liability THE PHYSICAL CARE OF SCHOOL of exposing the child to contagious diseases. CHILDREN.
Let us Girst consider what are the essen
tials of the preservation of good health in ROWLAND GODFREY FREEMAN, M, D.
First, they need ample rest. They should NEW YORK.
have ten or twelve hours in bed at night, and often with advantage a nap after the
midday meal. Hospital of St. John's Guild, New York.
Second. A proper diet: A moderate breakIt is probably the opinion of most physi. fast, a substantial but digestible dinner, and cians of this city who have the care of child. a simple supper. All these meals to be eaten ren that almost all school children are over- slowly and well masticated. worked, and that this is true in all grades of Third. Fresh air. A child should be out. school life, in the kindergarten, the primary of.dvors several hours a day, and when in school, the secondary school; and the same the house should be in rooms well ventilated is true of young men in the professional and provided with at least 1,500 cubic feet of schools. This overworking is a natural tend- air space per person. ency, because children are sent to school to Fourth. Freedom from dust and exposure learn certain facts and to receive mental to disease. Infections due to dust and the training, and each institution is striving for direct exposure to contagious diseases cause a high standard of scholarsbip. Such a prao- a large part of the siokness of school children. tice is apt to cause some physical wrecks, as Fifth. Freedom from worry and fatigue. we know is the case in New York, through a Neurasthenia exists in earliest infancy and is straining of the nervous system or on account common in sobool children. It is induced of the lack of physical exercise caused by by anxiety, and particularly in children by continuous application to studies, while in- prolonged application. The child can exert directly by overworking the teachers who are itself intensely for short periods without apt to become neurasthenic, there is set up a harm, but prolonged application produces reflected nervous irritabiilty in their pupils. marked fatigue.
Under good surroundings that can be regu. Our experience tells us that when these five lated, the care of obildren, both by parents essentials of good health oan be maintained and physician, is a source of considerable ample rest, proper diet, fresh air, freedom satisfaction and pleasure until they enter the from infection and freedom from worry—there kindergarten or school. Until that time they is usually little difficulty in securing promay be troubled occasionally with slight longed good health. Our problem, then, is colds, with oonstipation, or with adenoid by. to ascertain whether such conditions are pracpertrophy, but as a rule they may be kept in ticable for our school children. They are good health. As soon as the child is en certainly not offered now to any school child. tered in the kindergarten infections are more ren. Can private or public schools be organapt to oocur. Colds recur more frequently, ized that would afford them? and the ordinary acute infeotious diseases of The first condition, ample rest, may be ob. children are apt to break out. Whooping. tained with our present school arrangements, cough, mumps, chicken-pox, and measles usu. except that with most classes no opportunity ally occur within a few years after the en- is allowed for a nap after dinner. This is not trance at the kindergarten. As the child necessary in all cases, but is always desirable. leaves the kindergarten and enters the prim. The diet is also a matter for home regulation, ary school this liability to contract conta. except in publio school cbildren, but this opgious diseases persists, while the prolonged portunity for the children to take their hearty concentration required in the school regime midday meal at leisure is often prevented by produces frequently, toward the end of the too small an allowance of time for the noonschool year, certain nervous disorders, of day recess. In some of our best schools but which chorea and bysteria are the more com forty-five minutes are allowed for the child mon varieties.
to go to his home, eat the most substantial The question naturally arises whether these meal of the day with meat, and return to disadvantages of our present scbool system school. One hour would seem to be too litare due to any defect in school methods, or tle for such a recess. The question whether whether they are only an accompaniment of our public school system should not provide a system of education that is necessary for one nourishing meal a day, at least to those each generation, and whether school life children who are poorly fed at home, is a matter that we cannot discuss here, although same time the children would enjoy the fait is evident that the best work cannot be ob. cilities for outdoor play which are such an tained from the underfed.
advantage to our boarding school obildren. When we consider the laok of facilities of The effort to protect school children from obtaining fresh air by our school children, we disease has brought about many improvefind one of the most potent elements in the ments in our publio school system, but has production of disease among them. The de- not as yet effected many changes in private fective ventilation of school buildings is in schools, although some inspection exists in common with all public buildings, and the many of the latter. The excluding of sick popular fear of a draught often interferes with children has never been as rigidly carried out a sufficient opening of windows.
As it should be to protect those that are well. In the consideration of outdoor play, it is so far as I know children with colds are necessary to separate the private sobool child. excluded from only one private school in ren from the public school children, and we New York City, wbile it is well known that must also remember that it is not sufficient to so-called oolds are often an evidence of influ. give all children an opportunity to get into enza, which is a very contagious disease; fresh air if they will, but that it is necessary that they exist for three days preceding the to force some children of natural sedentary eruption of measles, while what is known as habits to play out of doors.
& cold is the common phenomenon of the Children go to school in the morning, re- first two weeks of whooping-cough before the maining until noon; return at one, remain characteristic cough develops. If children ing until perhaps three,after wbich some will with colds were absolutely excluded from our play in the streets and others return to their schools measles epidemios would not travel homes, having had practically no out-of-door so fast, whooping-cough would be much less play during the day.
prevalent, and through the diminution of inNew York has previously offered few fa- fluenza echool attendance would be markedly cilities for outdoor play for sobool children. improved. It seems to me that the provision for this I was recently called to see a boy sufferoutdoor play, which is essential to their ing from sore throat, who was attending a health, and thus must be obtained if they kindergarten class of eight children. I asked are to do good school work, should devolve him whether the children had all been in atupon the educational authorities.
tendance on the preceding day. He said no, This problem may be solved to some extent that he was the only child there. I visited by the public school, which could keep the the school the following day and found no children under supervision during the whole member of the class present, and on inquiry day, having a supervisor of physical exercise learned that one of the children had come to remain with them before and after school school with a slight cold the week before. hours, when they could play in enolosed Had that child been excluded it is not likely oages on the roofs or in adjacent public parks that the other seven children would have under supervision.
been absent at that time. The important influence that such super. Next to colds, the piost common evidence vision would bave, not only upon the physi. of contagious diseases in children may be cal condition but on their moral development, said to be eruptions; so that no cbild with an would be worth to the city far more than the eruption should be allowed at sobool until expense for the suppression of crime when the eruption has been pronounced by a comthese children grow up.
petent person is not an indication of a conIn some of our best private schools provi. tagious disease. The presence of dust in sion for play under supervision is made, but school rooms as naturally a source of danger, such play is too often carried on in closed and should be reduced to a minimum by care
rooms, and not out of doors, so that a large ful and proper cleaning of the floors and fur. - part of the advantage that might accrue from niture.
it is thus lost. My own feeling is that the Fatigue in school children was well demon. time will soon come when our best private strated in a scientific manner by Dr. Christoschools will move to the suburbs of the city, pher of Chicago, who supervised some excelwhere, instead of occupying a plot fifty by lent work on the public school children of one hundred, they can bave several acres of that city. By means of the ergograph, which land. The obild could sleep at home, go to tests motor activity in the middle finger, he the school in the morning, obtain the out- examined a number of children in different door play there, and return to his home late schools. In each case he found their activity in the afternoon. The parents would thus greatest wben entering school at nine o'clock; remain in touch with their children in a way that it diminished rapidly during the morn. not possible at boarding schools, while at the ing session, reaching its lowest point at noon,
when they were dismissed. At one, after re- There can be no question but that proper turning, it had reached about the same maxi. physical development is more important for mum as at nine in the morning, and during our school children than any knowledge that the afternoon diminished even faster tban can be imparted to them. The acquirment during the morning. He found the same re- of knowledge accomplished by physical in. sults in all the children tested, except in one jury is harmful, not beneficial. group of four boys in one of the schools, who It is usually the case that when little showed no deterioration in physical activity children of five years, who have previously during the day. On investigating these cases been kept out of doors all day, and bave had it was found that the teacher of these boys
no concentration on any subject, enter kinhad been absent, and while they had been in
dergarten classes, where a session of one school all day they explained that they had hour should be sufficient, you will find two been having a good time. It, therefore, ap and one-balf hours required, during which peared that this deterioration in physical ac.
period not more than twenty-five minutes of tivity, when present, was the result of pro
recess is allowed. As they grow older, at ten longed applioation, and not of the confine
years four hours will be required, with no ment in school.
more recess than the kindergarten child had, The relief of school children from worry
and with more time devoted to the preparaand from fatigue from prolonged application tion of lessons of the following day. can best be secured by shortened school
It is my opinion that for obildren between hours, by short periods devoted to any one
five and ten years of age not more than ten or subject, and frequent recesses devoted to phys.
or fifteen minutes should be devoted to any ical exercise. Such a scheme should be so worked out that, when controlled by some in
one subject, and that this period should be strument such as that used by Dr. Christo.
followed by five minutes of active exercise in
the open air or with the windows open; that pher, school work would result in no appre
but one hour should be devoted to work by ciable deterioration Through the kindness of Miss Carse, the .
ohildren of five years, and that not more than principal of the Charlton school, I have tested
one-half hour should be added each suoceed
ing year up to ten years; and that a part of for fatigue certain children under her care.
school day should be out-of-door play in the I choose for the test children wbo were for the first time undertaking work that required
afternoon under supervision. concentration—that is, children of about seven
To summarize, then, our ideal private years. I applied the Crampton test for fa
school should be out of town, but within easy tigue, the comparison of pulse rapidity and
e rapidity and reach of the homes of its patrons. It should
resol blood pressure, taken standing and lying
have short periods of study, separated by fre
have short periods of study: sepa down, and the test with the ergograph.* The
quent recesses, and ample time allowed for a children were tested just after coming to
substantial midday meal, taken at leisure. school at nine o'clock and just before leaving
The harder work should be given during the at half-past twelve. In none of the children
morning hours, the lighter work in the afterexamined was any marked fatigue shown. noon hours, to be followed by play out of Most of the tests Average as good at twelve. doors, in whioh all the children must take thirty as at nine o'clock in the morning. The reason for this striking absence of fatigue The ideal publio school should take the may be found in the examination of the daily children as many hours a day as practicable. program. The school day lasts only from
They should come to school as early as eight nine to twelve-thirty. The session consists
in the morning and enjoy an hour's outdoor of periods of but fifteen minutes devoted to play under supervision before undertaking any subject, and each fifteen minutes the
their tasks. The periods devoted to each sub. children are alternately standing and sitting. ject should be short, with frequent recesses. The middle of the session is interrupted by
At noon a nutritious but simple meal should a fifteen-minute recess out of doors, and an
be furnished them. In the afternoon the hour later by a five-minute recess spent in
easier subjects, the manual work, and the jumping through the seats. These observa
preparation for the lessons of the next day tions of mine are too limited to base large
should be taken up. Opportunity for outconclusions upon, but the unusual absence
of-door exercise under supervision until late of fatigue in most of the obildren examined in the afternoon should be provided. would seem to indicate that the program was In both private and publio schools a much very successful.
more severe examination for any evidence of contagious diseases should be made than at present. All children with colds should be absolutely exoluded from sobool, and child.
The writer is indebted to Professor E. S. Lee of the College of Physicians and Surgeons, Columbia University, ror many valnable suggestions and for the apparatus loaned to him for the experiments.