Abbildungen der Seite
PDF
EPUB

The pains just spoken of are peripheral manifestations of irritation near the roots of the spinal nerves as they emerge from the spinal foramen of the diseased vertebra. Unfortunately they are generally accounted for and covered under the broad mantle of neuralgia, rheumatism, etc.; but the fact of their distinct increase by exercise, stooping, missteps, etc., or their distinct connection with an impaired motion of the spine, will generally enable the surgeon to decide upon their origin, and eliminate the almost universal error as to their alleged neuralgic or rheumatic origin. FIG. 13.

K

In Fig. 13 is depicted a brace for Angular Curvature. K and

K and Gare the steel hip bands on which the brace rests. L L repre

sent the steel splint supports for the spine. H the padded points

| almost enable the surgeon to locate the vertebra affected from the pain manifested at the peripheral extremities of the spinal nerves.

In the matter of treatment, constitutional remedies, general or special tonics should not be omitted, and a few neglected cases may occasionally require for a time absolute rest in the recumbent position; but the grand remedy either early or late in the disease, is such mechanical support as will effectually relieve the bodies of the vertebra of a large part of the weight that usually falls upon them. Several devices are well known and frequently used for this purpose; perhaps the most commonly used, and worst of all, is the "plaster jacket" and its substitutes of perforated leather and felt. These are undoubtedly improvements upon the old crutch apparatus, by which futile attempts were made to hold up the spine by pushing up the shoulders, but for many evident reasons they prove quite as unsatisfactory in the treatment of angular curvature as they are in the treatment of lateral curvature.* A steel splint, LL, Fig. 13, applied to the spine, with nicely adjusted pads, H, one on each side of the diseased vertebra, and straps, F, to hold the thorax and shoulders back and prevent the weight falling upon the anterior portions of the vertebral bodies, is perhaps the very best arrangement. The solid vertebral facets thus become the fulcrum and resting point for the weight of the body, and the steel splints are the levers to hold it up. This apparatus is light and effective, is not oppressive to wear in warm weather, is easily removed whenever changing and renewal of the clothing is necessary, and above all does not interfere with the respiratory movements of the thorax. It supports the spine almost perfectly, when properly adjusted, but, like all other orthopaedic appliances, requires continual watching, and occasional re

either side of the diseased vertebra. F the straps to hold the shoulders back. ▲ represents the head rest, and B and C the steel rods by which it is attached to the other portions of the brace. E and D are screw arrangements for elevating and regulating the height and pitch of the head rest. The whole is upon an ingenious double joint, which admits both of rotation and rocking the head backward and forward. The marks [-] are merely elastic tape straps, holding an apron of open meshed cloth adjusting and tightening, in order to get the firmly against the chest and abdomen. best results. These little attentions, however, are easily fulfilled, and require but little time

Thus a positive diagnosis can very often be made in the very incipiency of the disease and treat-after the brace is once properly fitted. Where ment be instituted before any angular deformity is manifested. There is quite universally a clear and positive manifestation of the above symptoms for a considerable time before the occurrence of the angular deformity, the elevation of the shoulder and the peculiar gait, so graphically depicted and described by nearly all surgical authors as important points in making the diagnosis. A good knowledge of the anatomy and distribution of the spinal nerves will

a support for the head is required, the oldfashioned "jury mast" device-an unsightly, rickety concern, extending over the top of the head like a gallows, to which the head is literally swung-should be utterly discarded, and the steady "head rest," depicted in Fig. 13, substituted therefor. The head rest is infinitely less conspicuous, permits of the wearing of an ordinary head dress, any form of hat or

* See page 310.

bonnet,—and, above all, performs its functions | English patients in table A, the forceps were perfectly and well, which the "jury-mast," applied thirteen times, one in ninety-five; -literally a gallows-does not do. This head whilst on 545 Irish they were applied thirtyrest has been known and used for many years past, and it is simply amazing that prominent surgeons should have so long neglected to recognize its merits, or even to become acquainted with its existence.

OBSTETRICAL EXPERIENCES
WITH OBSERVATIONS.*

BY T. M. DOLAN, M.D., EDIN., HALIFAX, YORKS.
Fellow Royal College Surgeons and Gynecological

I

and Obstetrical Societies London, etc.

PUBLISHED in the Obstetrical Journal of Great Britain and Ireland, June, 1879, an analysis of 1785 consecutive labors attended by me since December, 1866. I now supplement this list by an additional number of cases, arranged in same form, so that two periods of practice may be compared.

The tables shown on page 314 represent two periods of practice. I purpose to make a few observations on the use of the forceps, craniotomy, mortality, antisepsis, and other points arising in connection with these tables.

1. The Forceps.-I use only one kind of forceps, I believe, a Ramsbotham, being of the opinion of the late Mr. Bailey, of Thetford, that if the child is low you can deliver with these forceps; if the child is up a little higher, you have nothing to do but push the forceps up a little higher. I have had them since 1866, and used them in all classes of cases, in high and low operations, and when the os has not been fully dilated, without bad results. As a rule I apply the upper blade first; the patient lying in the left lateral reclining position, the position par excellence for labor. The number of forceps cases will at once strike the eye, and it will also be remarked that I have inserted the nationality of my patients. Whether as a rule the Celtic pelvis is straighter or narrower than the English, or whether Celtic crania are larger than English at birth, I have not sufficient data to determine; but I have found out in my practice that my Irish patients required more aid from art than English ones, and that the application of the forceps were more frequently demanded. Thus on 1240

Paper contributed to Section of Obstetrics, Brighton Meeting

British Medical Association, 1886.

| nine times, one in thirteen. In table B I used
the forceps sixty-three times, once in twenty-
six times. This may seem a large number of
applications of these instruments, but when we
consider the number of labors concluded natur-
ally, the proportion is not excessive. I am con-
servative, but recognizing the advantages of a
timely application of the forceps, I have with
increased experience used them more frequently
in the second than in the first group. In refer-
ence to after results to mother and child, I am
able to report favorably. I have attended the
same women in different labors, and have from
time to time seen the children I have delivered
with the forceps, so that I can speak on this
point. For instance, on December 10, 1866,
I attended Mrs. C-, Southowram Bank, de-
livering her, with the forceps, of a girl. I at-
tended this girl on several occasions, saw her
grow up to womanhood, and delivered her of
a male child with the same pair of forceps on
October 10, 22, 1885, the mother of the girl
being present at the time of birth.
The pres-
sure of the forceps has in no case, that I could
trace, caused idiocy, epilepsy, or any form of
insanity.

2. Craniotomy.-I am convinced craniotomy is too frequently performed, and that the long forceps and turning can very frequently obviaate an appeal to this sacrificial art. I can illustrate this by a few cases.

Mrs. Hin her first confinement had craniotomy performed without a consultation by a medical practitioner, the head being subsequently delivered with the long forceps. This woman has now three living children delivered by me with the long forceps. She will always require the forceps.

Mrs. B, delivered by me in four confinements, including the first, with long forceps. I was away from home in one confinement; craniotomy was performed by the unqualified assistant of another practitioner. The craniotomies I have assisted at have been caused by delay, the children being dead when I was called in. By version I have delivered women who have previously had their children craniotomized. I would emphasise the necessity of the teachers of midwifery laying down stringent dents the great gravity of this operation. Crarules on this operation, and impressing on stu

[subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][merged small][merged small][merged small][ocr errors][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed]

tality is one in 162. In the second group one section. I may here direct attention to the in 333, a result easily to be explained. The first group represents a practice amongst a laboring population, who were unable to regard the best laws of sanitation, and whose surroundings were unfavorable to recovery. The second group represents a better class of patients, who lived in better houses, and who were able to have all the advantages which spring from

paper published by Dr. Mouat (International Medical Congress, 1881, Transactions, vol. iv., p. 392) on "Maternal Mortality in Workhouses.' "In 373 of the provincial workhouses," says Dr. Mouat, "and five of those in the metropolis, representing 25,198 accouchements, there was not a single death in a decade. In 135 others, two of which were in

I in 68

DEATHS.

SEX.

TWINS. NATIONAL.

26

26

936 861

13

1240 545

Child.

Male.

Female.

English.

Irish.

[graphic]

the metropolis, there was one death in each, 13,110 deliveries in all." The cause of this favorable result, in such a very unfavorable class, appears to me to be in small wards, only used intermittently, supplemented by cleanliness; and here I may speak on antisepsis.

4. Antisepsis.—I think we have got over the day when it would be considered a heresy to question the use of the spray. My patients have not been delivered under the spray, nor are they irrigated in the manner suggested by many eminent authorities. I hold it to be impossible in ordinary practice to guard against germs. I hold it to be unnecessary to inject every woman with perchloride of mercury or any other antiseptic in every labor case. By all this manipulation we are encouraging meddlesome midwifery, and sacrificing the greatest factor towards recovery, physiological rest. have perfect faith in the theory of microbes, and am convinced of the necessity of occasionally resorting to vaginal injections, which should be given by the obstetrician himself; but I strongly protest against all the newer theories and practices with which we are threatened. I hold that absolute cleanliness is a sufficient safeguard, and as we can obtain such results in our workhouses and private practice as those given, I see no reason why we should change.

to express the placenta, but to satisfy myself as to the contractile power of the organ. A tired muscle cannot do its work. When nerve force is exploded an organ requires rest to regain its tone. Expression represents force, and I have only resorted to it when uterine inertia, hemorrhage, or some other cause indicated that it was desirable to empty the uterus. Simple pressure is a useful adjuvant for this purpose.

6. The Perineum.-I am not an advocate for supporting the perineum as I believe much harm may be thereby done. I have seen but two cases of rupture of the perineum; one occurred in my own practice. The bed on which my patient was lying gave way while the long forceps were on, and the instruments tore through the sphincter. The woman made a good recovery. She had three children subIsequently. In another case the forceps were used by a practitioner who was in a hurry. Both cases occurred as far back as 1876, when operations on the perineum were not in vogue so much as they are now. I have saved, I think, many a rupture by delaying delivery by pressing the head back and breaking the force of the pains, my fingers introduced acting as a buffer.

For antisepticism gone mad, I refer to a a paper published in October, 1880, in the Boston Medical and Surgical Journal. It contained an article on "Antiseptics in Gynæcology," with full directions for their use in obstetrics, to prevent puerperal fever by destroying poison-germs which might be introduced by the doctor or nurse. "At the beginning of labor the patient should have a hip-bath, the hair should be cut away from the genitals, the vagina and vulva should be washed with soap and disinfected with carbolic acid. During labor every examination should be preceded by a vaginal injection of a three per cent. carbolic solution, to prevent the examining finger carrying germs lodged at the vulva or in the vagina up to the uterus (which is about to be more or less lacerated). After delivery, the uterus should be regarded an important wound, which may heal by first intention, or in which the secretions may stagnate, become putrid, and be absorbed."

5. The Treatment of the Placenta.--The placenta is, as a rule, expelled without assist I have usually grasped the uterus, not

ance.

7. Heart Disease in Pregnancy. The existence of heart disease in pregnancy forms a complication of a certain amount of gravity. One case I may particularly notice. A lady with mitral disease who had been attended by me in three confinements, during an absence from home, consulted a physician who not only advised her, but instructed her how to prevent conception, telling her she would die if she had another child. For five years she carried out his instructions, but at last, through some inattention to details, she became pregnant. She consulted me; I advised her to make her mind easy and to go on to full time; but not satisfied we consulted Dr. W. Playfair, who agreed with my advice. I delivered her with the long forceps at full time of a fine child, now living. The mother made an excellent recovery. I am of opinion that in all forms of heart disease it is better to wait and then expedite the delivery by version or the forceps. This I think should be the rule, making due allowance for exceptions.

In conclusion, I may say I have, in the desire to be brief, omitted reference to many practical points which spring from this paper, as laceration of the cervix, puerperal convul

[ocr errors]

On making an examination, I found the transverse colon very much distended with hardened fecal matter. My patient being in a very precarious condition, I was as brief as possible in my examination. Being informed that her bowels had not moved for three weeks, I immediately ordered an ointment composed of—

R. Belladonna ext.
Adeps

sions, placenta prævia. It deals with rather a | also vomiting fecal matter.
prosaic subject, and after listening to so many
papers dealing with operative procedures and
rare forms of midwifery complications, it may
seem rather commonplace, but after all I think
that the useful routine of daily practice in
dulged in by thousands of medical men all
over England possesses some degree of interest.
This contribution illustrates the work of the
general practitioner: it differs from the prac-
tice of the schools, because in the latter the
student has to be taught, and all the newer
methods have to be explained. In our practice
we have to be self-reliant, to be prompt in
action, to accommodate ourselves to our sur-
roundings, to be content with nurses of varied
attainments not always of the highest character,
and in other ways to have "to labor" under
difficulties.

The role of accoucheur, then, though it may not be so brilliant, yet withal it may be useful, and though we may not gain such a degree of praise as falls to the lot of the operative gynæcologist, yet it is something to be rewarded by the mother's smile and the father's thankfulness, when we have completed a process which has, from the earliest days, ever been regarded as a period of peril. We can never rob it of its dangers; we have to receive "a poor spark snatched up from a failing lamp, which went out therefor." In too many cases the weight of maternity is too great, and as Elizabeth Barrett Browning describes "Aurora Leigh's Mother," so we have to attend such mothers.

[ocr errors][ocr errors][merged small]

To be applied over the entire abdomen. Internally, I ordered 1⁄2 gtt. pills of oleum tiglii every two hours. After a lapse of six hours, patient had two copious evacuations of black, fetid matter. I then allowed her to take an occasional milk punch. When I called the next day, I made a very thorough examination into the history of the case, and learned that she did not have a regular movement for twenty years; had constantly been under medical treatment, and had exhausted every known means in the way of medicine, and finally resorted to the fountain syringe, daily washing out the bowel. At the time of my being called, even this procedure had failed also. I asked her if she had any trouble with the head and spine, at first she said no, but after continuing in my examination, I found that she had suffered from hysteria, and that the entire lower half of her spine was extremely sensitive to pressure. Upon examination of the abdominal organs, the liver and spleen were ascertained to be very much enlarged. I proposed a course of electricity, employing the faradic current, placing the positive electrode over the ileocæcal valve, and with the negative passing over We can reduce our mortality down to a lower each portion of the bowel down to the sigmoid degree, but we cannot overcome qualities in-flexure; each sitting lasting from twenty minherent in the mother. How we may render the process safe appears to me to depend on adhering to some of those laws which were laid down by some of the older obstetricians, and foremost among these is a reliance on nature, "more wise than we are," as Madam Bovin says.

"She was weak and frail;

She could not bear the joy of giving life;
The mother's rapture slew her."

[blocks in formation]

utes to half an hour.

After continuing in this way for about three weeks, I reversed my treatment, using a rectal electrode (negative) for the bowel, and passing the positive along the spine and over the abdomen. A marked improvement has since taken place in the patient's condition. Not only do her bowels move naturally, but her liver and spleen are very much reduced in size, and she has gained several pounds in weight. 31 GARDEN STREET, POUGHKEEPSIE, N. Y.

BULLETIN WANTED. Any subscriber sending a MARCH (1886) NUMBERS OF THE MEDICAL copy of this number to 1217 Filbert St., Philad'a, will have his subscription advanced two months.

« ZurückWeiter »