Part 2

Her case was diagnosed “amylaceous dyspepsia,” and she was given Taka-Diastase in eight-grain doses, half of which was to be taken before eating and the remainder during or after, with tr. nux vom. and hydrochloric acid, in moderate doses, _ter in die_.

Despite her determination not to be benefited by “doctor’s medicine,” the improvement was prompt and continuous, and so manifestly due to the treatment that she soon forgot or overcame her antipathy, and with characteristic inconsistency now asserts that it is impossible to get along without it. She eats three meals regularly every day, and suffers no inconvenience whatever in consequence.

CASE 3. W., a white male, aged forty, had never had any serious illness, and digestion had been especially good until about four weeks before consulting me. At that time he, in company with some friends, ate quite heartily of watermelon. He had always eaten watermelon freely and with impunity prior to that occasion. It did not agree with him so well that time, and in a few hours he was seized with an acute gastralgia of the most severe character, and from that time to the present he has had more or less trouble of that kind, even a very small quantity of food, especially if it be of a starchy nature, giving rise to the most distressing symptoms.

The diagnosis of amylaceous dyspepsia was also made in this case, and he was at once put upon the Taka-Diastase in doses of five grains given with the meals, and temporarily excluding starchy foods from his diet as much as possible without too great inconvenience. There was also great torpidity of the liver, and for that he was given sod. phosphate in teaspoonful doses every morning before breakfast, taken in a gobletful of hot water. Under this treatment improvement was satisfactory and rapid, and with the addition of bitter tonics later on he was ultimately restored to complete health.

_Remarks._ Case 1 was an example of that class with which, prior to the introduction of Taka-Diastase, the general practitioner was too often compelled to acknowledge his inability to cope successfully. In them there is difficulty in the digestion of both amylaceous and proteid substances, and the remedies usually recommended were efficacious only so far as digestion of the latter was concerned, and did not reach the former at all. The cure was incomplete, and must have remained so until the substance we have been considering, or something analogous to it, was furnished the physician with which to complete it.

Cases 2 and 3 were examples of the first class mentioned above, viz., amylaceous dyspepsia, and while under treatment with pepsin, etc., they were considered the most intractable of all; under Taka-Diastase they yield rapidly, and are cured in a surprisingly short time.

LIVERMORE, KY.

Reports of Societies.

LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.[1]

Stated Meeting, December 3, 1897, the President, F. C. Wilson, M. D., in the chair.

Footnote 1:

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

_Uterine Fibroma._ Dr. L. S. McMurtry: I present this specimen of uterine fibroma on account of two very interesting features of this class of tumors which it illustrates. The first relates to the morphology of these growths. The tumor is a very large one, and occupied the entire pelvis and the abdomen to the superior limits of the umbilical and lumbar regions. It is a multi-nodular tumor, and its disposition in relation to the fundus of the uterus is unlike any specimen that I have ever encountered. It will be observed that the neoplasm springs from the lower segments of the uterus, and the fundus is not involved in the growth at all.

The second feature of interest, and this is especially interesting from a surgical point of view, is the relation of the bladder to the tumor. It is very common for the bladder to be carried upward with the growth, thus rendering it very liable to injury in operation. This feature is exceptionally conspicuous in this tumor on account of the nodular condition where the bladder was attached, forming a sulcus. In releasing the bladder, after splitting the capsule, the uneven surface of the tumor caused me to inflict an injury upon the coats of that viscus. After dissecting off the bladder I found that I had made an opening in it at this point. It was immediately closed with a double row of catgut sutures. The operation was done six days ago, and the convalescence of the patient has been most satisfactory indeed. The bladder injury has not complicated the patient’s convalescence at all, its function being carried on just the same as if it had not been involved. The convalescence has been afebrile from the beginning, and recovery is assured.

The method I observed in treating the pedicle was to amputate the cervix very low down, leaving a very small rim of the cervix, and suturing the peritoneum over it all the way across the pelvis, making the pedicle extraperitoneal. The conformation of the growth and its relation to the cervix uteri made this method of dealing with the pedicle especially applicable in this particular instance. The patient is thirty-four years of age, and the operation was urgent on account of persistent hemorrhage and marked pressure symptoms.

_Discussion._ Dr. J. A. Larrabee: I would like to ask the reporter for what length of time this tumor had been developing?

Dr. L. S. McMurtry: The woman was thirty-four years of age, and according to the history obtained the tumor was first noticed three years ago. The patient has made a beautiful convalescence. I present the specimen on account of its morphology, and because of the difficulties that might be encountered in performing an operation in such cases by the bladder being impacted in the sulcus.

_Tubercular Testis._ Dr. W. O. Roberts: This patient is twenty-four years of age; his father and mother are living; father sixty-four, mother fifty-four; his grandfather on his father’s side died at the age of sixty-four of what was supposed to be consumption; his father’s twin brother died at the age of twenty, after an illness of eight months, of consumption; his mother’s family history is good.

This young man had gonorrhea seven years ago, with orchitis of both sides as a complication, the left testicle swelling first, then the right; the swelling lasted in each for about two weeks. Had gonorrhea again in November, 1896, and says again in December of the same year. At this time he noticed that his left testicle was getting hard in places and was swollen, but there was never any pain. The inflammatory process has never been very acute. However, he noticed after taking a horseback or bicycle ride the testicle would be somewhat tender. Had another attack of gonorrhea during the month of September of the present year, which he says lasted only two weeks, and during this attack the testicle was also affected.

He now has a swelling of the left testicle, and a hardness about it and in the epididymis, which I would like for the members to examine, expressing an opinion as to the nature of the trouble.

_Discussion._ Dr. J. M. Ray: I do not know that the ocular symptoms will throw any light upon the case. I remember that this young man came to me some time ago to have his eyes examined. He stated that he had been under the care of a prominent oculist in the South, and had been fitted with glasses. When I saw him he had some trouble in the use of his glasses, and also complained of defective sight of one eye. Upon examination I found a spot of atrophy of the choroid, showing the location of a former acute choroidal disease, and there was considerable diminution in acuteness of vision in that eye, with a defect in refraction in the other eye. Under mydriatics I fitted him with glasses, since which time he has been perfectly comfortable so far as his eyes are concerned.

He states that he remembers I said something to him at that time about tubercular disease, after looking into his eyes, but I have forgotten the circumstance; I only remember that I found choroidal disease.

Dr. J. A. Larrabee: Of course we are all led somewhat by the diathetic history of our cases. Chronic inflammations tend to take on the part of the diathesis. I did not understand the reporter to say that any test had been made, by withdrawal of some of the fluid or otherwise, to determine the exact nature of the condition. I desire to say, however, that if this were my testicle I would have it removed. I believe that would be the safest plan. An absolutely positive diagnosis would be difficult to make without a microscopical examination for the tubercle bacillus, but I can not help feeling prejudiced in that direction.

Dr. J. L. Howard: I agree with Dr. Larrabee as to what should be done with this testicle; it should come out. I, too, think it tubercular, although in all probability the gonorrhea is a factor in the case in stimulating the growth of the testicle. I do not know that a microscopical examination would give us much light upon the subject; in fact I would not wait for that, I would simply remove the testicle at once.

Dr. Wm. Bailey: The question is not by any means settled as to the exact nature of the disease in the case before us, whether the patient, having had repeated attacks of gonorrhea, has not also been so unfortunate as to have syphilis. With a tuberculous history of course a tuberculous condition of the testicle seems plausible; but inasmuch as tuberculous disease of the testicle may remain for a long time possibly without great danger in affecting the patient otherwise, and knowing the changes that take place in the testicle from repeated attacks of gonorrhea, orchitis, etc., I believe if it were mine I would be disposed to keep it for a while, particularly as the other testicle seems to be somewhat atrophied, with this one of pretty good size. I think I would keep the larger one.

Dr. T. S. Bullock: I am inclined very much to agree in the opinion expressed by Dr. Bailey. I have frequently seen, after repeated attacks of gonorrhea, a testicle that had become enlarged, without any pain. The testicle in this case appears to be perfectly smooth, and in view of the fact that tubercular disease of this organ may exist for a long time without affecting the general system, I should certainly keep the testicle until my general health began to show some evidence of declination.

Dr. F. C. Wilson: The question is a very difficult one to decide. There is one feature of the case that has not been sufficiently emphasized, and that is the probable damage to the testicle itself by the repeated attacks of gonorrhea. We know that the use of the testicle, so far as any procreative uses may be concerned, has probably been abrogated by these repeated attacks of gonorrhea, and with this view of the case the question of removal of the testicle by surgical means would be simplified; and it seems to me with the tuberculous history, if the question could be decided even approximately, or even probably, that it is tubercular, then it had better be removed. But it seems to me I would first make every effort to solve the question, even aspirating or removing a small part of the tissue so as to be able to make a microscopical examination, and in that way possibly throw some light on the subject.

Dr. W. O. Roberts: It strikes me that this is tubercular, although it may have been, as Dr. Howard says, excited by gonorrhea. The condition feels to me nodulated and not smooth, and the disease appears to be located chiefly if not entirely in the epididymis, and I think the testicle should be removed. Whether it is tuberculous or not the usefulness of the organ is destroyed, and I think it ought to come out if it is tuberculous, especially because the other testicle will become involved. So far as the cosmetic appearance is concerned, if that is a feature in the case, we could insert a celluloid testicle. I believe if the affected testicle is not removed, granting the diagnosis of tuberculosis to be correct, that the other testicle will surely become involved.

Dr. Turner Anderson: It is seldom that we have obstetric matters presented to this society. I have thought perhaps a case I recently attended might be of some interest. We are aware that the umbilical cord is frequently found encircling the neck of the child. I delivered a child four days ago in which the cord was wrapped around the neck twice, then branched off under the arm, encircling the arm again at its dorsal surface, then across again, branching over the back. You may better understand the condition when I say that the cord came up from its attachment at the umbilicus, encircling the neck twice, branching over and under the axilla, around the arm, thence to its attachment to the placenta. The woman was a primipara. As soon as the head was delivered I detected that the cord was wrapped around the neck. I made an effort to find the part that led to the placenta. The cord was found pulseless, and I was in some doubt as to whether it had been so long encircling the neck as to have produced death of the child. Just as the body of the child was being extruded the cord snapped, tearing off fortunately from its placental attachment. The child was delivered and after a little effort was easily resuscitated. The pressure was so great, the traction upon the cord was so decided, as to leave a white line across the back of the child. There was a white mark around the neck, across the clavicle, around the arm and over the back of the child which did not disappear for some time afterward.

The proper line of practice, I take it, in those cases where the cord is around the neck of the child, is to first determine whether the cord is still pulsating. If pulsating, we are justified in being a little more tardy in our efforts to deliver the shoulders and release the child. If possible we would of course draw down the cord and release it from the neck of the child in this way; but in those cases where we are confronted with the cord wrapped tightly around the neck of the child, especially in the primipara, where the length of time which will be consumed in delivery is uncertain, the line of practice I believe in should be prompt delivery or division of the cord. As a rule when we are confronted with a condition of this kind we can meet it satisfactorily by a little delay and by holding the head of the child well up against the vulva while the shoulders are being extruded. As the releasing pain occurs and the shoulders and body are extruded, you can usually by pressing the head well up prevent undue traction on the placenta and any accident which might follow rapid delivery and undue traction upon the cord. This was a case in which there was spontaneous rupture of the cord; it tore away entirely by the uterine effort. This accident had no influence upon delivery of the placenta; it came away promptly. It was evidently not torn loose from its attachment, and there was no hemorrhage.

_Discussion._ Dr. J. A. Larrabee: The case is not only interesting, but also somewhat unique as far as I am aware. We are all familiar with the double wrapped cord, but in this case the acrobatic movements of the child must have been considerable, in utero, to have produced the condition described by Dr. Anderson; the child had evidently been engaged in jumping the rope for some time. When the cord is wrapped around the neck of the child as described, I think the best plan is to expedite delivery. Of course in the primipara we must not be in too great a hurry, we must utilize melting or crowning pressure to prevent injury, but the management of these cases I think is entirely that of dystocia, and powerful external pressure upon the fundus of the uterus, bringing it down as low as possible, is the proper plan of expedition. In the case reported, however, no amount of external pressure would have accomplished any thing; fortunately the snapping of the cord enabled the doctor to deliver and resuscitate the child, which is about the only thing that could have been done. In this case it would have been almost impossible to have divided the cord. Aside from the anomaly of the case, which is worthy of especial mention, I do not know of any proceeding which would have been equal to that which was followed. It is a little strange that the placental attachment did not give way; if this had been true, if there had been a separation of the uterine attachment of the placenta, then we would have expected the placenta to have been expelled with the child instead of a rupture of the umbilical cord.

Dr. J. L. Howard: I would like to ask Dr. Anderson if usually, when the cord is wrapped around the neck of the child, the cord is not an abnormally long one? I have had this accident happen twice in my experience, but no trouble resulted because of the abnormal length of the cord in each instance.

Dr. J. G. Cecil: This is an accident which as we know happens frequently, as well as many other anomalous things in connection with the umbilical cord. I would have been disposed, if the labor had been delayed in this case, that is, the final delivery of the child, more than four or five minutes, to have severed the cord, fearing that it might have had something to do with the delay. If there was no pulsation in the cord, there would have been little risk in cutting and not tying it; then there would have been no further delay to the delivery; there would have been no danger from hemorrhage, from premature separation of the placenta, or danger from inversion of the uterus. However, as the case turned out so well under the management that was adopted, it does not become us to criticise that management, because the successful issue proves the wisdom of the plan followed.

I have once or twice encountered some delay in expulsion of the child by reason of a short cord wound around the neck. I have never seen one so displayed around the shoulder as in the case reported by Dr. Anderson. I remember to have seen one case, however, in which there was a knot tied in the cord, and tied so tightly that it shut off the circulation and resulted in death of the child, and also complete atrophy of the cord between the knot and the navel end. This was a very interesting case, and was reported to the Louisville Clinical Society three or four years ago by Dr. Peter Guntermann; it was one of the most interesting cases of accidents to the cord that I have ever seen. How the knot was tied so tightly in the cord can not well be explained; knots in the umbilical cord are not very unusual, but it is unusual to see one tied so tightly that the circulation is shut off thereby. It was thought, I believe, by the reporter on that occasion that the accident was due to a fall which the mother sustained just before the delivery, which was premature.

Dr. Wm. Bailey: Nothing in the management of the case reported by Dr. Anderson can be criticised by me. I am inclined to think that under no circumstances was pressure made on the cord sufficient to interrupt the circulation until after the head of the child was delivered. Then it became a question as to the proper management. I believe it would have been better to have cut the cord, as it might have lessened the difficulty of delivery, and that there would have been no harm done to the child in this case, because there was no pulsation in the cord. The doctor had all the time for this delivery that would have been allowed him if he had a breech presentation with the head making pressure upon the cord, and ordinarily he would deliver such a case in from five to seven minutes, and that would give a chance for resuscitation of the child just as in the case of drowning. The child can be deprived of circulation through the cord, in an accident like this, as long a time as a person can be submitted to water, or drowned, and be resuscitated. I have seen but one case in which there was a rupture of the cord during delivery. I saw one exceedingly short cord, in which delivery of the child ruptured the cord; it was not around the neck, it was simply too short for the child to be delivered without detaching the placenta; just as the child was delivered the cord was spontaneously severed at the umbilicus, simply allowing me a sufficient amount to be caught with the fingers and held until a ligature could be applied. I do not remember the exact length of the cord, but it was so short that it was not possible to deliver the child without either breaking the cord or detaching the placenta. The cord ruptured spontaneously, and there was no further accident or trouble.

I believe if Dr. Anderson had to attend another case under exactly the same circumstances he would prefer to cut the cord rather than to break it off at the placental attachment. Inasmuch as he did not cut the cord and the child was successfully delivered, and also as there was no trouble in delivering the placenta, of course it makes no difference; but I always like to have the cord attached to the placenta so that if it becomes necessary to go after the placenta, in case of retention for instance, I can have the cord as a guide. In Dr. Anderson’s case there was no possible advantage in having the cord intact; as it was pulseless, no injury could have been done the child by cutting the cord before completing the delivery, and by cutting the cord as soon as it was found that it encircled the neck, all possible difficulties as far as the cord preventing delivery was concerned would have been removed.

Dr. T. S. Bullock: I am very much interested in this case; I have never seen one exactly like it. The greatest danger in this particular instance was that alluded to by Dr. Cecil, viz., producing inversion of the uterus. I think Dr. Anderson managed the case in the proper manner, and by his method of expression the only possible danger was inversion of the uterus.

I have only seen one instance of dystocia from short cord; that was a case in which the cord was the shortest I ever saw, and was wrapped around the neck, where it was necessary in order to deliver the child to cut the cord after tying it and then employ instruments, the cord being so short that with each uterine action you could feel the cupping of the uterus from tension on the cord.

I think there would be less danger from premature separation of the placenta than from inversion of the uterus. In the case Dr. Anderson has reported the danger to the child from compression of the cord was obviated by prompt delivery.

Dr. J. A. Larrabee: Will not Dr. Bullock tell us whether the case he refers to, where he could feel a descending or cupping of the uterus by the expulsive efforts, was a primipara?

Dr. T. S. Bullock: The woman was a primipara; the cord was very short, it was tied and severed, then the delivery completed with forceps. I would like to ask the gentleman whether, in those cases where they have employed Crede’s method of delivering the placenta, they have noted a cupping of the uterus from efforts to extrude the afterbirth?

Dr. J. A. Larrabee: I have occasionally noticed cupping of the uterus under those circumstances.

Dr. F. C. Simpson: I remember a certain practitioner in this city several years ago made the statement that he seldom tied the cord after cutting it; that he did not see any necessity of tying the cord. If this is true, then there would certainly be no danger in severing the cord in cases such as Dr. Anderson has reported, and it would not even be necessary to tie it until after the delivery had been completed.

Dr. Wm. Bailey: I want Dr. Anderson to speak to one point in particular in closing the discussion, viz., would there not be great danger if the placenta was separated at a time when the child was still partly in the uterus?