, 1910 , Vol. V., cells, pavement epithelium, mucus, pus cells, urates and flocculent sediment. The urine varied in amount in the different cases at different times but was always suppressed before delivery. The largest amount voided in twenty-four hours was one hundred and twenty-nine ounces; the smallest twenty-four ounces. The temperature per rectum varied from 99.8 to 104 which was the highest temperature recorded in any of the cases at any time. The highest temperature was always before delivery; in fact there was a little rise in temperature in every case before delivery. The pulse ranged from 120 in the different cases up to 160. The pulse rate was in each case more rapid before delivery than subsequently. Abnormal tension or hypertonia was always present at some time or another in each case. The respirations varied from twentyfive per minute up to thirty-three. The respirations were also highest in each case prior to labor. It might be of interest to compare the foregoing figures with other statistics mentioned from time to time. cases Harrar states that beginning with February, the number of increases during March, reaching the highest point in April and then steadily diminishes, finding the lowest level in November. The curve of this rise and fall nearly corresponds to the curve of the rainfall, which fact he states, might explain the well known theory that climatic conditions have something to do with the disease, although it is not clear why periods of unsettled weather should have the effect of producing a convulsive toxaemia in pregnant women. Regarding the frequency of the condition, McPherson states that it occurred in 1.7% of all labors in the wards of the New York Lying-in Hospital. The high percentage was due to the fact that a hospital is the clearing house for so many of the cases occurring in the city and the probability is that it is about eighteen times as frequent in hospital as in private practice. The condition is twice as common in primiparae as in multiparae, being 64.4 in the former and 35.6% in the latter. Regarding the age of the patient in 250 cases the greatest number of cases occurred between the ages of 20 and 25 years which is in accord with the fact that the greatest number of eclampsias occur in primiparae. The maternal mortality of eclampsia is given by various authors as ranging from five to fifty per cent. The foetal mortality is usually from 33 to 50%. Treatment. The treatment pursued was first the employment of certain drugs to ameliorate the symptoms, and the use of the hot pack. Cathartics were also given but the main idea was at all times to bring on labor and terminate pregnancy no matter what the period of utero-gestation. The idea was always kept in mind that the longer the patient was left in the condition of toxaemia of the convulsive type the slighter were her chances for life with each convulsion. Likewise the child, for the more convulsions the greater are the risks to the life of the foetus. Labor was induced by means of the catheter and forcible dilatation in five cases, two of which were delivered with forceps. In case 2 delivery occurred. without interference shortly after she reached the hospital. In case 3 delivery occurred before the arrival of the ambulance though she continued to have convulsions for some time afterwards. The drugs used in their order of frequency were veratrum viridi, diuretin, morphia sulphatis, atropine, sulphatis nitroglycerin and potassae citratis. In one case, namely No. 7, the tincture of aconite worked well. In case 4 the patient was in a condition of pulmonary oedema; atropine in 1/100 grain doses combined with fluid extract of veratrum viridi appeared to pull her through. She was also given a ten gallon rectal irrigation, and digitalis leaves sprinkled over a mustard plaster were applied over the kidney region. This patient was delivered of her child prior to the attack of pulmonary oedema. Of all the drugs, however, veratrum viridi stands at the head of the list in our experience when given in fifteen minim doses hypodermically every two or four hours till it slows up the pulse perceptibly, sometimes bringing it down as low as seventy per minute. For failing heart conditions consequent upon the toxaemia we have had to fall back on strychnine, tincture of strophanthus, and spiritus frumenti. For the extreme nervousness and irritability bromide of soda was given in almost all the cases. Chloral by rectum was used in three cases but only a few doses were given in each instance. The diet consisted of milk diluted in different forms, cereals, gruels, toast, oatmeal jelly, rice and prepared buttermilk. CONCLUSIONS. From our experience in these cases we are led to believe: I. That there is no expectant treatment in a consideration of Puerperal Eclampsia. 2. That early emptying of the uterus will bring about the best results. 3. That veratrum viridi is a very important drug in the treatment of convul sions due to the toxaemia of pregnancy. 4. That atropine sulphate should be tried in desperate cases especially where there is a tendency to pulmonary oedema. 5. That while careful nursing, hot pack applications to kidney region, and diet, are important, the prime indication for treatment is the early evacuation of the uterus, thus bringing about improvement in the metabolism, improvement in the circulation by reducing blood pressure, improvement in the condition of the urine, improvement in the temperature, pulse and respiration, saving the heart and the cardiac muscle from unnecessary strain, in a word the bringing about of metabolic changes so that the balance between absorption and elimination has been increased in favor of elimination. 428 47th St., Brooklyn, N. Y. SURGICAL HINTS. In the medicinal treatment of acute intestinal obstruction, atropin is often of great value. Enlargement of the tubercles of the tibia is not of unfrequent occurrence in football players. Anesthesia in women, as a rule, requires more time than in men, but less ether is needed to induce and maintain narcosis. Cholecystitis and pyelitis sometimes closely resemble each other, and a thorough analysis of the urine should never be omitted in doubtful cases. As Reginald Harrison has said, "it is very easy to spoil a stricture and so lose the way through." In exploring the urethra for a suspected stricture the greatest care should be exercised, as any neglect in this respect may render subsequent passage of sounds more difficult. -Int. Jour. of Surgery. New Series, Vol. V., No. 3. CORRESPONDENCE. LETTER FROM THE PHILIPPINES. OBSTETRICS UNDER DIFFICULTIES. To the Editor American Medicine: Physicians in city practice, where it is always possible to get nurses or hospital care in emergencies, have no realization of the difficulties of practicing among the pioneers on the frontier. It is generally supposed that the pioneer days are over, but in reality they have just begun. For a long time to come, those physicians who think of casting their lot with the soldiers and civilians upholding American civilization in the Philippines, will be compelled to practice in most primitive conditions, often without the slightest aid from "the neighbors," or even the simplest conveniences supposed to be essential. The following letter was the result of an inquiry of an American officer serving with Malay troops, as to whether any of the swarms of native women in the camp, could be obtained to nurse his wife in her expected confinement. Incidentally it is a rare instance of "English as she is spoke" by races who are learning it for the first time. There is a distinctive tone to the frivolous seriousness of the Hindoo attempts, and now our Malays are furnishing a new type of these delicious misuses of words. Incidently, too, a word might be said about the courage of the American woman, who, in spite of dangers, will go anywhere on earth where duty sends her husband. The stories of heroism in English East Indian literature are now being silently repeated over and over again in out of the way places in the Philippines and we all take it as a matter of courseall in the day's work, with never a Kipling to sing it. Very truly, (Complete Series, Vol. XVI, that the most depest of sorrows to tell you that I have used the best influence I can find to some woman among the soldier's family in our company, for the purpose of taking care of your wife for a week; but no one of the said families desirous to comply such combination. But should you be away or detailed as an officer of the day, they can favor you to accompany your wife while you are absent. It is hard for us to coincide then to a combination as these, as they don't want to make any negligence to their duties with their husbands. I hope that this reasons will please you. I remain, Respectfully yours, Ist Sgt. -Co. Phil. Scouts. ETIOLOGY AND DIAGNOSIS. Gastroptosis and Its Causation.1-Bonniger in a recent address called attention. to the normal fixation of the stomach, to which, along with the suspensory ligaments and the cardia, the intestines belonged, which on their own part were supported by the abdominal wall. It was entirely due to this arrangement that the stomach did not fall lower when the diaphragm sank when emphysema was pres ent. Gastroptosis was always accompanied by lengthening of the stomach, as Mainert and, later Holzknecht had pointed out. This was not simply a distension of the stomach, as the lengthening could be demonstrated by the Röentgen rays even when the stomach was empty. It was rather brought about by a longitudinal growth of the body. That the length of the stomach varied greatly even in healthy individuals was shown by examination of 300 healthy adults, where the length varied between 14 and 28 cm. The longer stomachs were in women with a paralytic habitus. The speaker did not doubt that there was a relation between the length of the stomach and the body growth. Lengthening of the stomach was not a sequence of the gastroptosis, with its attendant stretching, otherwise shortening 1 Med. Press and Circular, Feb. 23, 1910. would take place on prolonged rest in bed, and there was no question of that. Lengthening of the stomach was also met with in the cadaver, although the majority of people died after a lengthened stay in bed. Before the twelfth year of life lengthening of the stomach was not met with. From that time on, the condition was met with with increasing frequency. If the lower thoracic aperture was small, as in the habitus paralyticus, the stomach grew in length and downwards, according to the law that the form and position of an organ were dependent on drawing and pressure. As the lower limit, before speaking of gastroptosis, he took the level of the umbilicus in his Röentgen examinations, and found gastroptosis in 26 per cent. of the men, but in 63 per cent. of the women, and as frequently in nulliparæ as in those that had borne children. Antecedent labour, therefore, could not be looked upon as a contributory cause. Gastroptosis was not a disease, for many people had a low-lying, lengthened stomach without any symptoms. If symptoms did appear, improvement was brought about by good food, strengthening of the abdominal muscles, and gymnastic exercises, tending to enlargement of the upper thoracic aperture. More important, however, than all this was prophylaxis, a healthy bringing up that did not neglect bodily exercises in childhood and youth. TREATMENT. rec The Stem Pessary.1- Carstens ommends the stem pessary in indicated cases calling attention to the fact that the introduction of the stem requires dilatation of the uterus. As this is very painful, it is necessary to give an anesthetic, although it may take only five minutes. Then the absolute cleaning of the vagina is necessary. Carstens uses the Chambers hard rubber stem, although he admits others may be as good. That everything be aseptic he boils the stem with the instruments, but, as the two arms of the stem come together 'J. H. Carstens, M. D., Detroit, Jour. A. M. A., Nov. 20, 1909. while boiling, he immediately, when taking them out of the hot water, separates them and dips them in cold water so that they will stay open. Generally the patient is on the back; with vulsellum forceps the operator catches a lip of the uterus, pulling it down somewhat and straightening it out as much as possible. A sound is now inserted to get the exact length of the uterine cavity. Then he selects a pessary a little shorter ( or inch) and have it ready for insertion by fixing it into the introducer. Now dilate the uterus. As this is often small it is necessary to start with a fine-pointed dilator. Use the Notts dilator. This generally is not sufficient and Carstens then uses the Goodell-Erlanger dilator or any other kind, thoroughly opening the uterus. If there should be any endometritis or discharge from the cervix thoroughly curette the cervix only and swab it out with pure phenol, wiping it dry. The stem can then be inserted. The button at the end must be on the cervix. The stem is kept in place by a finger on the button; then the introducer is pulled out and the thing is done. If indicated, a Thomas-Hodge pessary is inserted. The physician must see that the button is in the center of the retroversion pessary. There may be a little blood lost from the dilatation; therefore phenolized douches are given twice a day for a day or two while the patient remains in bed. Some can get up the next day, but, as a rule, they are kept in bed for forty-eight hours. Then they can get up and go about their usual vocations. They can do anything and everything, as they always did, and never know that they are wearing stem pessaries. Once in a great while in women who are very constipated the pessaries may be forced out by straining. This sometimes also occurs in cases of relaxed vaginas. In the latter the soft rubber inflated pessary will often help to retain the stem in place. The Treatment of Constipation.1— Verbrycke says that it should be insisted upon that the patient go to the closet at a certain time each day, preferably just after breakfast, whether he have the desire J. R. Verbrycke, Jr., M. D., Washington, D. C., Med. Record, Mar. 12, 1910. , 1910 , Vol. V., or not. The mind should be concentrated upon having a movement for at least five minutes, and should not be occupied by other matters as in the habit of reading at stool. If an evacuation does not result no further attempts should be made, unless there is a distinct desire, until the following day at the same time. Impress the patient with the efficacy of this, as the results of concentration of the mind are quite remarkable. To show how easily habits are formed in many cases I will relate the instance of a man I know, who used to have several movements a day. It was inconvenient, so he disregarded as far as possible all sensations coming at other times than after breakfast, with the result, in a couple of weeks, of having the desire only at that time. Later he tried, as an experiment, to see if he could produce two movements a day at will, and found on going to stool morning and evening for a week the desire came at these times. The diet in simple chronic constipation is not rigid. Usually too much of the following should be barred: proteins leaving little residue, dry foods, eggs, thick soups. Forbid strong tea, cocoa, chocolate, huckleberries, and anything else which contains tannic acid. Plenty of the following foods, which are somewhat laxative, are to be eaten: oatmeal, cornmeal, buttermilk, cream, butter, olive oil, maple syrup, molasses, and nearly all the fruits, raw and cooked, except bananas, huckleberries, and gooseberries. As a rule it is only necessary in arranging the diet to take out the most indigestible things the patient has been eating and add the laxative fruits, oatmeal, etc., in sufficient quantities. If the patient has been gluttonous and the bowel has been dilated restrict the amount of vegetables containing cellulose. if, as is usual, not enough food containing residue has been eaten, give a diet containing both meat and vegetables with the latter, and fruits in preponderance. Of nearly equal importance is the frequent drinking of cold water, in small amounts. For But its tonic and stimulating effect a glassful should be taken every morning immediately on awakening and a half glass at intervals during the day. Outdoor exercise when possible should be recommended. It will not only serve to improve the general condition and nerve tone, but will strengthen, among others, the muscles entering into the act of defecation. Walking or any of the mild sports are beneficial. If business or other reasons prevent this, ten or fifteen minutes morning and evening devoted to indoor physical exercise will help to take its place. When exercising the window must be open and deep breaths be taken. A cold sponge bath in the morning followed by a brisk rub is a great stimulant. For those who can stand it a cold plunge may be substituted. Usually all of the preceding lines of treatment are to be instituted with or without the addition of one or more of the procedures about to be mentioned. Deep abdominal massage in the morning before breakfast often does good, or the same result may be obtained by rolling a croquet ball over the course of the colon for five minutes before going to stool. Vibration by a mechanical vibrator or faradic electricity with slow interruptions are useful. Irrigations may be given of ich'nyol, I dram to the quart, using them daily for a time and then every other day for a while longer. After a short treatment with the irrigations oil enemata of 6 ounces of olive oil, with or without a little ichthyol, may be given at night, to be retained and passed the next morning, when a movement will usually result. Or again, small cold water injections, 75° to 65°, powerfully stimulate the musculature of the intestines. It is occasionally necessary to clear the bowel out by a purge in some cases, but this should not be repeated any oftener than is absolutely necessary. As regularity becomes established the artificial aids should gradually be discontinued, the diet and personal hygiene still being observed to make the improvement permanent. A course of several weeks or months of judicious treatment is usually followed by the most encouraging results. Treatment of Haemoptysis.1- What is to be done in a case of profuse hæmoptysis? By far the most important thing is to remember the natural way in The London Practitioner, Mar., 1910. |