Page images
PDF
EPUB

tic dissemination, will cure the disease in by the local treatment of freezing in 1910. from six to twelve months' time. This treatment by the "snow" pencil of compressed carbonic acid gas was tried with success1 by Dr. Lord of Johns Hop

Ferruginous and nutritive tonics, emunctorial eliminants, including hydrotherapy,

[graphic][merged small][merged small][merged small]

, 1913

, Vol. VIII

[graphic][merged small]

MARCH, 1913

Besides the local treatment, Dr. Wayson states that "the main constitutional

treatment consisted of doses of iodid of potash, chaulmoogra oil, anti-leprol, and elix. of iron, quinin and strychnine, together with hot baths and special treatment. Several circumscribed lesions, one especially of subdermal type, with the leper organism present, were successfully treated by the local application of the dioxid carbon pencil."

REPORT OF CASE OF PREGNANCY WITH HYDRAMNION.

BY

S. J. DRUSKIN, M. D., New York City.

I deem this case of sufficient interest from a diagnostic standpoint to warrant the following report:

Mrs. R. B., age 39, para XI, family and previous history negative so far as it has any bearing on this case.

Menstrual history:-Patient first menstruated at eighteen years of age. Catamenia always regular, of three to four days duration, moderate in amount; for the past three years from seven to eight days duration and profuse. Last menses, February Last menses, February 7th, 1912.

Obstetric history:-Eight children at full term, last child five years ago. Patient aborted twice, last abortion six years ago. All previous labors and lying-in periods normal. During all previous pregnancies patient was troubled with nausea and vomiting.

I first saw the patient September 15th, 1912. She complained of amenorrhea, pain in the lower abdominal region, loss of weight (20 lbs. in the last nine months).

In her previous ten pregnancies, without exception, she suffered with severe nausea and vomiting. At this time, however, she did not believe she was pregnant because these symptoms were entirely lacking. Neither did she feel fetal movements whatever. She consulted several eminent

, Vol. VIII

specialists, numerous examinations were made, resulting in various diagnoses, mainly: fibromyoma, abdominal pregnancy with dead fetus, papilloma of the ovary, etc. Several X-ray pictures were taken and these showed no evidence of a fetus. Arrangements for a laparotomy had already been made. Dr. Boldt, through whose kindness the case was referred to me, for observation and treatment, then diagnosed the case as one of pregnancy with hydramnion.

My examination revealed the following: The patient was short and corpulent (180 lbs.) and of healthy appearance; abdoman large, distended, with very thick fat cushions. A large globular mass reaching to within a hand's breadth of the xyphoid could be mapped out. The tumor had a cystic character with irregular thickened portions of its wall here and there, particularly in its lower right pole. Other irregularities could be made out through the cyst wall. These were freely movable, and I took them to be fetal parts. The tumor mass seemed to be continuous with the cervix. A uterus distinct from the mass could not be differentiated. The ovaries could not be palpated. Fetal heart sounds could not be elicited, nor could uterine contractions be excited. External genitals, vagina and cervix were suggestive of pregnancy. Colostrum was present. The acetone test' for pregnancy was positive.

Diagnosis: Pregnancy with hydramnion associated with a associated with a moderate degree of fibrosis uteri,

Following the date of my examination. symptoms of intra-abdominal pressure grew gradually more and more severe. On Nov. 7th, one week before calculated date of labor, I decided to terminate pregnancy. On the evening of that date, I introduced a Voorhees bag into the uterus. After the

1ACETONE TEST. This test is based on the principle that when carbohydrates are excluded from the diet, acetone appears in the urine sooner or later. According to Van Noorden, pregnant women show this effect more readily. The acetone test may be made as follows:Give the patient at 8 A. M. for breakfast, a cup of tea with two lumps of sugar and one roll. Meat and vegetables may be given for lunch, but no carbohydrates. At 4 P. M. the patient empties the bladder, and at 5 o'clock urine will show the presence of acetone.

lapse of seven hours, no labor pains having set in, the bag was removed. On the morning of the 8th, a larger bag was introduced and vagina was packed. After six hours no pain developed. I then gave a hypodermic of 1 cc Pituitrin. Fifteen. minutes thereafter strong and frequent labor pains ensued. Three hours after injection packing and bag were expelled with complete dilatation of the cervix. Fetus in transverse position. Rupture of membranes, followed by combined version on head. Many liters of amniotic fluid escaped. Fetal heart sounds now became very distinct. An hour later, pains becoming weak and of short duration, patient received another injection of Pituitrin; good result. Seventeen and a half hours after the onset of labor, the fetal head was still at the pelvic brim, but owing to development of temperature (102.5) high forceps was resorted to. Extraction of a living baby weighing 11 lbs. 12 ozs. without difficulty. Pituitrin again administered; no atony; no hemorrhage. Lying-in period fever free and uneventful.

Patient discharged November 21st, uterus large and nodular.

The deductions that may be drawn from this case are:

I. Absence of positive signs of pregnancy is not sufficient to exclude the diagnosis of pregnancy.

2. In Hydramnion the fetal heart sounds are often absent and the fetus can be palpated only with difficulty.

3. The X-ray picture is valueless in hydramnion and may even be misleading, because experience has shown that amniotic fluid is opaque to the X-ray.

4. In doubtful cases of pregnancy in the latter months the acetone test is of positive value.

5. Pituitary extract is a very useful agent in the induction of labor when combined with a Voorhees bag. It is also of value as a prophylactic against atony and hemorrhage.

FIBRO-ANGIOMA OF THE ORBIT.

BY

OTTO SHIRMER, M. D.,
New York City.

The patient presented, 30 years of age, was operated on one year ago for retrobulbar tumor. Although an absolutely healthy man, he complained of impaired vision of the right eye and occasional diplopia for 6 months and for the past few weeks of increasing protrusion of the eyeball.

There was exophthalmos of about 6 mm., the eye being protruded forward and a little outward, that is, in the axis of the orbit. The eye could not be pressed backward, no pulsations could be felt, no murmurs could be heard. The mobility in every direction seemed to be perfect; nevertheless there was diplopia in the periphery upward and outward. Vision was reduced to 5 but the visual field was normal. There was moderate papillitis.

Though X-ray pictures showed no tumor and though no tumor could be felt, there could be no doubt that there was a retrobulbar tumor situated within the muscle funnel, not starting from the optic nerve. Whether it was benign or sarcomatous could not be made out with certainty. There certainly was a chance to save the eye and I therefore decided upon the temporary resection of the temporal orbital wall by the Kroenlein method.

On March 4th, 1911, a big flap was formed containing skin, muscle and bone. This flap being turned outward I gained access to the apex of the orbit where I felt a round smooth, rather firm tumor of nearly the size of a walnut. It was attached by a small pedicle to the inner orbital wall. I succeeded in detaching it from its sur

Series

roundings and delivering it in toto. The orbital wall was replaced and the wound. sutured. The recovery was uneventful. To-day the scar is scarcely visible, the eye is in a normal position, its mobility nearly perfect, the sight normal. There is no danger of a relapse as the tumor turned out to be a fibro-angioma.

THE ANNOTATOR..

Infection and Immunity.1-G. P. Mueller conditions infection in the following man

ner:

I. The organism must enter its host in sufficient numbers.

2.

nue.

3.

4.

It must enter by an appropriate ave

It must be virulent.

The host must be receptive.

The avenue of infection often determines its severity and type, thus the pneumococcus thrives principally in the pulmonary tissues.

Virulence is a variable quality and depends upon the inability of the microorganisms to produce toxins. The more virulent the microbe the sooner will the host succumb. The very young and the very old are most susceptible to infection.

Hunger, thirst, heat, cold, alcohol, fatigue predispose to infection and so do certain diseases especially those of the kidney, liver and heart.

Certain tissues have a local susceptibility like the lungs, bones and joints in tuberculosis. The infection-producing microorganisms are fission fungi, the most important of them, with reference to wounds, being the streptococcus, staphylococcus, colon bacillus, bacillus of Welch, and tetanus bacillus.

Immunity consists in unusual or complete resisting power to infection and may be natural or acquired.

Natural immunity depends (1) upon the protection afforded by the surfaces of the body, (2) upon internal protective agencies, including the mechanical, bactericidal and

International Journal of Surgery, January,

1913.

, 1913

, Vol. VIII

phagocytic influences in inflammation, and the protective properties of serum and plasma. Acquired immunity may be active or passive and depends (1) upon increased anti-bacterial property of serum and plasma, (2) upon increased phagocytic power of the cells, depending on the formation of opsonins, (3) increased antitoxic power of serum or plasma, (4) habituation of the cells to bacterial poisons. Active immunity may be acquired from infection or artificial immunization; passive immunity is obtained by means of protective or curative serums.

Local immunity is due to the adequate or inadequate supply of blood in a part; an illustration is the use of hot fomentations in treating infections.

From the practical standpoint immunity may be regarded as bacteriotropic and phagocytic.

In bacteriotropic immunity the cells of the body are stimulated to defense, this being the basis of Ehrlich's side-chain theory, when toxins, albuminous substances, cells, or bacteria are injected into or invade the body. In immunity by phagocytosis we have (1) a ferment or nutritional action, (2) resorption of useless cells, (3) protection against bacteria. With all the progress which has been made the study of the processes of immunity is still in its infancy, and our greatest protection seems to lie in the use of preventive measures.

Vasectomy and Public Right,1—The editor thinks it is well to discuss freely the question of the protection of society by the resection of the vas deferens in criminals, and that this is quite as important as the formation of societies for improvement in mental hygiene.

Indiana has carried this subject beyond the experimental stage, and the operation. is now one of daily routine in her state institutions.

It is now unnecessary, at any rate in Indiana, to explain the operation, its harmlessness and the public benefit which has been derived from it.

Everybody in Indiana admits its value. It is believed that a section or a com

'Medical Review, January, 1913.

« PreviousContinue »