, 1913 , Vol. VIII, with a history of uterine trouble, hemorrhoids, and constipation since puberty. She took twenty cubic centimeters of hormonal on April 3rd at 7 a. m., and felt, for the rest of the day, some dull frontal headache, some slight nausea, and a faint sensation in the epigastrium. These abnormal sensations disappeared by night. On the 7th of April a bowel movement occurred spontaneously, not a large one. It was not as hard or as painful as usually after several days of intermission. On the 8th the bowels again moved spontaneously, not very much; on the 9th, in the morning, fairly well. While the patient was writing her report she mentioned that she had some colicky pains and had to interrupt her work for the purpose of getting rid of a large amount of feces, the quantity of which astonished her. In a report dated January 17, 1913, nine months after ingestion of the only dose taken, the patient writes to me that it is still active to some extent. "I am not quite as regular as the first half year, but I rarely skip a day. There is a little more difficulty than there was until about a month ago." I intend to give her another dose and hope that this will be sufficient. The fourth patient is a woman of some thirty-six years, mother of two children. She is very short and very stout. Since an operation two years ago when, as far as I can determine, the ovaries were removed, constipation has been very obstinate, no bowel movement whatever occurring without artificial aid. This patient received 201 cc. of hormonal by mouth August 23rd, and derived excellent results from it, which became evident in the course of one week. Under date of April 16th the patient, Her bowels moved regularly daily without who had received no further treatment .for her constipation, wrote me that there had been no movement on the 13th, a good one on the 14th, a small one on the 15th, and two on the 16th; there occurred again a good movement on the 19th, and one on the 20th, so that the action seemed to have settled to one every other day. On the 27th the patient, to whom I had sent a second dose of hormonal, reported that she had not taken this because the first was still acting, a good movement every other day, and that they came very easily, without the former stress and pain. She said that she was very well satisfied so far. On the 28th of May the medicine was still working, except for five days after a trip to St. Louis which the lady undertook, and as railroad traveling always has a constipating effect on her this is not surprising. The important point is that a few days after her return home the bowel movements started again spontaneously and continued since. any assistance until last October, when the effect gradually wore off. At present the patient is as constipated as she ever was. She was to have reported for further treatment, but is one of those persons who cannot bring themselves to obey the orders of a physician, so that I am afraid that a positive benefit cannot be obtained. It will be seen that in these two patients a single dose of hormonal taken by mouth. had a very satisfactory effect which lasted for several months. Although one or two swallows do not make a summer, and although I observed such satisfactory results in only two cases out of four, they have seemed to me sufficiently important to be published, because I believe I am the only one to have administered hormonal by mouth; at least, in the literature at my disposal I have not seen any reports. If it can be established that hormonal can exert its favorable action upon the peristalsis on being introduced directly into the stomach, and if this action persists, at least fairly well, even if it is not as intense or as prolonged as after intramuscular or intravenous injection, our means of overcoming constipation with all its harmful consequences, and with all its immense power to produce injury to the organism, will have been strengthened materially. The important point to my mind is that if hormonal can be established as an efficient treatment for selected cases of constipation, we have in this preparation a physiological remedy, the use of which is a priori far preferable to that of any laxative or cathartic drug. 32 North State Street. CAESAREAN SECTION WITH TION_RECOVERY. BY HOWARD CRUTCHER, M. D., Roswell, New Mexico. the presenting head upward or to apply the The patient was promptly removed to the Parsons Infirmary and preparations made for the Caesarean operation. Chloroform was given by Dr. O. R. Haymaker, and was kindly borne by the patient. With the assistance of Drs. D. H. Galloway and C. L. Parsons, and Miss Lela Wilson, nurse, the abdomen was opened in the median line, when, to our deep surprise, a fluctuating tumor of large size forced its Mrs. B., a white married woman, aged way into the wound. The offending tissue 20, of excellent family history, menstruated last on February 7, 1912, and was taken with labor pains at eleven o'clock in the forenoon of November 30th. Being accustomed to a vigorous out-door life, she had eaten heartily of substantial edibles during her gestation. During the forenoon of December I the patient seems to have had many hard but fruitless labor pains, which continued well into the afternoon, when Dr. C. L. Parsons was summoned. Dr. Parsons soon learned that the patient was making no progress and I was called in consultation at 4:30 the same afternoon. I found a large, firm, immovable fetal head wedged into a bony outlet far too small to admit of possible hope of delivery by natural means. It was impossible to force was quickly identified as an enormously dilated bladder. It was necessary to press the uterus upward before a catheter could be introduced. Something over two quarts of urine was drawn off, when the uterus was brought into the ample abdominal wound and opened in the usual manner. An elastic ligature was for a moment applied to the lower segment of the uterus, a ten pound female child quickly removed and passed to the care of Dr. Parsons and Miss Wilson. The uterus was next cleared of placenta and membranes. The uterine wound was united with a single row of heavy interrupted catgut stitches very closely placed. I saw no occasion to overdo by a second line of stitches what appeared to be a perfect piece of coaptation. New Series. Vol. VIII, No. 2. The mother and child left the Infirmary on the eighteenth day in excellent condition, but it must not be supposed that the convalescence of the former was free from troublesome and even dangerous complications. The necessity for emptying the bladder during the operation caused a vexatious delay of eight minutes. While removing the child from the uterus several ounces of meconium escaped, soiling the tissues over a wide area. The child was not resuscitated without prolonged and determined efforts, lasting nearly half an hour. The protruded rectum proved to be a source of great distress. The bladder, from which trouble had been expected, resumed its regular functions with astonishing rapidity. The operation was completed shortly before nine P. M. of December 1. Thirty-six hours later the patient developed symptoms of acute intestinal obstruction. The pulse rose to 148, the temperature to 103, and bloating came on with alarming speed. The most energetic measures were immediately adopted, the result being the relief of an impacted colon which held more than six quarts of fecal masses of such density that they had to be removed from the rectum by mechanical means. The intestinal storm lasted several days, during which time the patient was relieved of an incredible quantity of hardened fecal matter. There was at no time the slightest Complete Series, Vol. XIX. indication of uterine or of peritoneal infection. The uterine drainage tube was removed at the end of the second day. The amount of blood lost during the operation was somewhat less than half that occurring during a normal labor. The fatty layer of the abdominal wall became infected, but gave no serious trouble. This is my third Caesarean section, two performed for contraction of the bony outlet and one for central placenta praevia, all mothers and children being saved. I have lost sight of my first case, performed many years ago. The second patient was in the last stages of general tuberculosis, but lived long enough to demonstrate the value of prompt and efficient surgery. Whilst the operation presents no great mechanical difficulties to an experienced surgeon, it imposes responsibilities of such a serious nature that its performance should never be undertaken by those who are unprepared by general training and ripened clinical experience to deal promptly and decisively with all its possible details and complications. So far as known, this is the first reported case of Caesarean section in New Mexico. Whilst the conditions were not ideal by any means, the result shows that nothing material to the safety of the mother and child was overlooked in the necessary haste with which our preparations were made. If suppuration at the root of the nail does not soon subside after providing drainage, it may be necessary to remove the nail. This should not be done too hastily, however. Persistence in daily disinfection of the space (iodine, hydrogen peroxide, etc.) and stimulation of the tissues (as by massage) will often be rewarded by saving the nail.-Am. Jour. of Surg. A CASE OF CHRONIC COLITIS. BY J. W. WEINSTEIN, M. D., New York City. Attending Physician to the Department of Digestive Diseases at the Vanderbilt Clinic. It is usually customary in medical societies to present cases the chief interest of which is centered in diagnosis. Therapeutics is usually neglected or omitted entirely. In presenting my patient tonight, I have the honor to present a case the main interest of which hinges on its successful therapeutics, although it is an interesting case even from a diagnostic standpoint. D. M., female, 27 years; married; one child. Habits perfectly normal. Family history. Father and one sister have stomach trouble. Mother suffers with chronic constipation. Past History. At the age of one year she developed suppuration of a finger and it took her nine months to recover from it. As a child she always suffered with cramps. At the age of 11 she developed a very bad form of vomiting and she could not retain anything on her stomach. It took her a year to recover from it. In adolescence she was in good health, but she would spoil her stomach at frequent intervals. She would also belch a good deal most of the time and suffered with headaches. Present History. For the past four and one-half years patient has been very much constipated. For the past three and one-half years she has had constant trouble with her bowels. They would not move, unless she would take a physic and even with physics they would hardly move. She had to increase the doses of the various physics, which would soon lose their effect entirely and would have to change off for another one. Lately she has had agonizing pains in her abdomen and rectum when her bowels would move, so that bad as she felt when her bowels did not move, she would feel worse when her bowels did move. She would go on for two weeks without moving her bowels. Ingestion of food causes a great deal of distress and a variety of dyspeptic symptoms. No pulmonary, cardiac or renal symptoms. Physical Examination. This showed the patient to be fairly well nourished, but rather pale with an expression of suffering and anxiety. Arteries, pulse, heart, lungs, liver, spleen, urine negative. Pelvis negative, except for a retroverted uterus which was free and movable. Stomach normal in regard to size, position, secretion and motility. Rectum rather tender. There was one marked physical sign, namely, the colon was extremely tender to the touch all along its course from the beginning to the end. No part of it could be touched without inflicting pain. It was thus the most easily traced colon that I have ever seen. In fact the colon was almost visible, for it was spasmodically contracted over its contents. and it thus slightly protruded through the abdominal wall in a sausage shaped manner. The diagnosis was therefore plain enough, namely, an inflamed, eroded, probably in spots ulcerated, colon, or a colitis caused by a constipation of long standing. This is a very common disease picture and sequel of chronic constipation. In any case of chronic constipation the colon at first readily adapts itself to the residual feces. The colon readily stretches and the patient, except for a slightly bad taste in his mouth, some headache and his consciousness that he has not moved his bowels, experiences no ill effects. As time goes on however the clinical picture changes. As a result of the constant pressure on the mucous membrane of the colon by the feces which from long standing loses its water, gets dried out and assumes a shape of the hard scybalae, pathological changes take place within the bowel. The bowel becomes inflamed, eroded and often ulcerated, the well known stercoral ulcers as a result of decubitus, form. The peritoneum becomes involved and adhesions form. The large numbers of chemical irritants formed by the decomposition brought about by the numerous microorganisms and especially by the numerous drugs introduced as physics, play an important role in the causation of the pathological changes. bowel of this type behaves differently altogether from the ordinary constipated bowel. Here the presence of even a small quantity of feces within the bowel causes considerable suffering. These patients must A , 1913 , Vol. VIII, move their bowels every day or even oftener, else there is considerable suffering. Treatment. This consisted in putting the patient temporarily to bed. This was not carried out faithfully on account of the care that the patient had to take of her baby. The baby was on mixed feeding. On account of the wretched condition of the mother it was considered too much of a strain on her to nurse a baby and in spite of the warm weather the baby was taken away from the breast. The patient was put temporarily on fluid diet, milk, zoolak, buttermilk, fermilak, clear chicken broth and water. Hot compresses were to be applied to the abdomen. All physics were to be stopped once for all. The patient received a pill of Extr. of Belladonna and Extract of Opium aa. gr. 4 three times a day. To move the bowels the patient was advised to take one tumblerful of cotton seed oil, make it lukewarm, put in an agateware irrigator and have it injected into the rectum in the evening. The patient was to lie flat during the injection for at least 25 minutes and the injection was to be retained over night. On the next morning should there not follow a movement, a water injection of five glasses of lukewarm water with the patient again in the recumbent position, the irrigator not to hang higher than 3 feet above the level of the patient, the enema to be retained for from ten to fifteen minutes. The improvement at first was slow. As the bowels started gradually to move better the water injections were gradually withdrawn and the bowel movements depended more and more on the oil. A habit was gradually cultivated in the patient to move the bowels daily at the same time, and the oil was being withdrawn. Six weeks after the commencement of the treatment the bowels started to move spontaneously, but the injections of the oil were still employed twice a week.. An increase in the diet took place two weeks from the beginning of the treatment when some light cereals and other foods that leave very little of a residue were added. Meats and fruits and vegetables were the last foodstuffs added. It would have been very imprudent to give vegetables and other foods that leave an abundant residue to a bowel that was diseased and spastically contracted as this one was. The belladonna and opium were kept up for two months, when on account of fear of contracting a habit, the opium was dropped and the belladonna kept up for another month, when it was discontinued. Each and every step of this treatment was of vital importance to the successful issue of the case. The stay in bed and milk diet alone would have never done the work. The patient was kept in bed and on a milk diet for six weeks in a hospital before without any result whatsoever. These procedures including the injections would have been of no avail. For the oil and water would have never reached beyond the ampulla of the rectum, since the bowel was so spasmodically contracted that it held on to the column of feces with a vise-like grip. Here came in the salutary effect of the belladonna and opium which caused the bowel to relax and loosen its hold on its contents. The hot compresses were an adjunct to attain the same object. The patient gained flesh and strength, eats anything she pleases now without any discomfort whatsoever and moves her bowels regularly without physics or any other artificial aids. The tenderness of the colon persisted for several months. On December 8th, 1912, the tenderness disappeared, the patient having come first under observation on August 5th, 1912. A few words on the diagnosis will not be amiss. The patient is a resident of another city and, strange enough, her malady was diagnosed by the physicians who treated her there on the strength of alleged radiographic examinations, as an organic stricture of her bowels and the patient was sent to this city to a prominent surgeon for an operation. She came however to me for an opinion. I have pooh-poohed the idea of there being any obstruction and did not deem it even advisable to take an X-ray picture. It was evident that a colon so tender to the touch could never mean an obstruction. An obstruction could give one point of tenderness and not a tenderness all along the course of the colon. Moreover |