THE LOUISVILLE CLINICAL SOCIETY.*

Stated Meeting, Jannuary 28, 1902. The President, William H. Wathen, M. D., in the Chair.

Double Placenta - Continued report. Dr. Carl Weidner: I will simply make a further report upon the case of twin placenta shown at the last meeting of this society. Upon inquiry it has been shown that the twins are of different sex, with entirely different external appearance, etc., one being male, the other female; one having long hair when born, the other short hair. Both are living at the present time. I was astonished to hear this report after the conception I had formed about the case from the discussion before the last meeting. We had the typical appearance of a single, smooth, undivided placenta (we recognize that we may have a coalescing of the membranes), and I looked in this case for typical twins, with similar external appearances and characteristics, same sex, etc. Of course there were two umbilical cords and two amniotic sacs.

Discussion. Dr. T. P. Satterwhite: Unquestionably in this case there were two placenta and they had coalesced. An interesting point to determine would be whether both children were contained in one When there is one placenta and both children are contained in one sac, then they will always be of the same sex, either males or females.

sac.

Dr. W. H. Wathen: In this case there were probably two separate ova, and the union of the two placenta was only by adhesion; this occurs frequently. But so far as the amniotic sac is concerned, even had the twins come from one ovum there would have been, unless something had destroyed the intervening partition, two amniotic sacs, because they arise from each embryo. In the case of twins from one ovum, always necessary in monstrosities, there is a very intimate relation. In that instance we have possibly but a single amnion, but in the case of separate twins the amnion would be separated.

Dr. G. B. Young: In regard to the question of one ovum producing two children: As I understand the matter, this presupposes the presence in the ovum of two nuclei. I believe it is true that the microscope has demonstrated the presence of two nuclei in one ovum ; that ova have been found in the ovary which apparently contained two

* Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.

focal points, and that this is the origin of real twins. In that connection it occurs to me that it is not an uncommon occurrence that we have seen hen's eggs with two yolks, and I would like to ask whether any of the members have seen or heard anything about the development of one of these eggs-have chickens been observed hatched from these eggs where the young were joined together in any way? In other words, is there a case on record where two fowls have been hatched from the same egg?

Dr. John R. Wathen: I have been especially interested along this line. In some biological work which I have been doing I have fertilized ova of the lower biological animals, and have taken the stand that one cell can divide into four centrosomes in the place of two centrosomes. I have written to various authorities upon the subject and they have all denied such a possibility, but I have microphotographs showing that what I have said is true, and just now I am having some cuts made to go in a text-book which I am writing upon the subject showing these four centrosomes, which amply demonstrates the fact, although it is denied by almost every one.

Railroad Accident. Dr. Geo. W. Griffiths: Five weeks ago a railroad man was caught under a car, just exactly how I can not tell; we can not always get the correct history of such cases. When we examined the man we found a fracture of the ulna and radius, and a fracture of the humerus near the shoulder-joint. I dressed the forearm and the humerus by means of narrow splints and put on adhesive plaster, with the usual wedge-shaped pad under the axilla. I saw that I could get no union, and told the man I would probably have to give him a swinging or a false joint, and I could easily remove it afterward if it was not useful to him. The arm went along very nicely, I thought, for some weeks; then gangrene set in. Spots were noticed over the forearm, and the arm wasted away up near the shoulder to the size of a child's ten years old, until I found, of course, that any further attempt to save it would be useless. Five or six weeks after the accident I amputated the arm near the shoulder joint. In all these cases, if I can possibly do so, I always leave a sufficient stump with head of bone, so as not to disfigure the man very much, leaving the shape of the shoulder to hang the coat on, etc.

Ewing Marshall, was with me when I first saw the

My friend, Dr. case, and then

assisted in the amputation. I found a very peculiar state of affairs.

The humerus was fractured near the head of the bone and there made a false joint; we found the humerus fractured near the elbow; the lower fragment (like an old-fashioned clothes-pin) was driven up fully one and a half inches into the upper fragment, so that it could not be pulled out. In operating, I thought if bony union was found I would still try to leave this portion of the bone, but this was found impossible and the arm was amputated as stated. The bone was wedged into the upper fragment as tight as if it had been driven in with a hammer. I have never before seen such a case, in the hundreds of fractures that I have treated.

In fractures of the humerus, especially near the shoulder-joint, it is sometimes extremely difficult to get union; it is one of the hardest bones in the body to get union. I tried the plaster-of-Paris and everything else, but this was the state of affairs found after faithful treatment. The upper fragment was split and the lower fragment was wedged into the upper fragment so tightly that no forceps or anything else could pull it out.

Dr. T. P. Satterwhite: It is a little remarkable that the distal end of the bone should have been driven up between two portions of the proximal end without breaking the bone. I do not believe we could call this an impaction, but if the doctor had measured the arm he would have thought there was an impacted fracture, and had he discovered this he would probably have allowed the impaction to remain. Evidently there was injury of important nerve or blood supply which caused the gangrene.

Dr. Ewing Marshall: There are two or three points of interest about the case that Dr. Griffiths overlooked, which at least interested me as much as those he related. In the first place the humerus was fractured also below, possibly at the junction of the middle with the lower third, which would imply that this piece of bone between the two fractures was in some marvelous way driven into the upper fragment. I was holding the shoulder for Dr. Griffiths in the amputation, and when what was supposed to be the humerus had been sawn through he still kept sawing bone. In all, three pieces of bone were sawn through in doing the amputation; the split ends of the upper fragment of the humerus and the piece of bone that had been driven in from below. I believe Dr. Bizot, who was present, preserved the specimen, as it was a curiosity and something that none of us had ever seen before.

The essay of the evening on "Cholelithiasis" was read by Carl Weidner, M. D. [See p. 166.]

Discussion. Dr. Geo. W. Griffiths: I remember having been called to see a woman twenty-five years ago who had what was thought to be a cancerous tumor in the right side. I cut down upon the tumor to determine its nature, and if possible remove it, and as soon as I cut through the tissues covering it a gall stone as large as a hen's egg rolled out. It was one of the largest gall stones that I had ever seen.

Dr. Ewing Marshall: In regard to the question of using morphine in these cases, I believe Dr. Weidner said that even large doses of morphine sometimes had to be administered in order to keep the patient comfortable. If the physician is almost constantly in attendance this may pe permissible, but some care ought to be exercised in repeating the dose of morphine, because after relief of pain takes place the patient may be overwhelmed. There is danger in giving morphine in these cases unless the patient is carefully watched and the effect of the morphine already given is carefully noted.

Dr. Peyton (of Jeffersonville, Ind.): First it occurs to me that none of us are warranted or justified in saying to the patient beyond doubt, even in spite of the presence of colicky pains-periodical attacks-—that they have gall stones in the gall-bladder or elsewhere. It may be true, as has been shown by the paper, that the last gall stones have passed. So, speaking to the paper purely from a clinical or surgical standpoint, I would say that in proposing operation to the patient that you are not justified in saying that we are most certainly going to find gall stones present. The last one may have passed, but whether that is true or not we are certainly warranted in advising an operative procedure, even though we find nothing but a severe catarrhal condition, which is as a rule relieved by the free drainage that we get after or as a result of the operation.

In reference to the use of morphine hypodermatically, its occurs to me that we might possibly be safer, if the attack is not too long, in the administration, to the degree of anesthesia, of chloroform. I have used it in one or two instances, and have been much pleased with the result. I have in mind a case, in fact, the last one that I operated upon. The patient was a woman, fifty-five years of age. She had suffered from periodical attacks that had been thought to be attacks of indigestion or acute colic of some kind, and when I opened the gall-bladder I found,

after considerable difficulty, the presence of very minute stones. I found a number of them, but they were inclined to adhere, and by the adhesion of quite a number of these small stones formed a stone of rather large size, but the slightest pressure would break thein apart. This patient was drained in the usual way and did nicely, but after allowing her to go home I find that the drainage has not ceased, the opening has not closed. My judgment is, in this particular case, that there was considerable thickening-almost complete closure—of the cystic duct. I am firmly convinced that the common duct is all right, from the condition of the patient. There is no jaundice and the condition of the stools indicates the presence of bile, but there is still the passage of mucus from the opening in the gall-bladder, and this has continued since the operation. My judgment is there has been a closing of the cystic duct, and if I not able to relieve the condition in any other way I intend to remove the gall-bladder entirely.

Dr. J. W. Irwin: I am sorry I did not hear all the paper, and am also sorry the discussion has not taken a wider range. This is a very interesting subject, especially to the general practitioner, even more so, I think, than to the surgeon, who deals exclusively with the use of his knife, for there are many cases of gall stones that come under the observation of the general practitioner that will not permit of an operation. If we could differentiate between large and small stones it would help us very materially in the treatment of gall stones.

I do not believe that all cases of gall stones require surgical intervention. I have had in the course of my practice a number of cases of gall stones which have been relieved by medicinal treatment. I say relieved, because we are never sure that the patient will not have gall stones again, and even after gall stones are removed by the surgeon's knife they may form again. Therefore, after all, the surgeon's knife is the most radical way of getting rid of the distress, and also draining the bile passages of morbific material that should be carried away.

As to the cause of gall stones: This is an important matter, owing to the fact that so many cases occur in females more than in males. Five females to one male have gall stones. Another remarkable fact is that drunkards rarely have gall stones. Etherized alcohol is a solvent of gall stones, and when a gall stone is in the incipient state— forming-alcohol appears to keep it in solution. This is in favor of moderate drinking. Women, on the other hand, who do not drink like men do, omit one thing that favors the formation of gall stones. Again,