Part 3

Dr. F. C. Wilson: The only point I wish to bring out in connection with the case is the possibility of detecting the fact that the cord is around the neck of the child before delivery, and being on our guard for it. Encircling of the cord around the neck of the child ought to give rise to a funic bruit. You can hear very plainly a funic bruit, a bruit which is synchronous with the fetal heart sounds. Where this can be detected at a point where we know the neck of the child lies, it indicates to us that the chord is around the neck.

There are certain other circumstances under which we may also detect a bruit: For instance, the one mentioned by Dr. Cecil, where the cord was tied into a hard knot. I have met with several such cases in my practice, and a bruit can be produced in this way, but at a different place from the location of the neck, and it is a permanent bruit; a bruit that is heard all the time. Where that is the case, of course it indicates that there is some permanent obstruction of the cord, and the likelihood is that it is due to a knot tied in the cord. We know that sometimes the cord slips over the neck, and then the child’s body slips through the cord, thus making a perfect knot; it then may be drawn tighter and tighter, finally producing considerable obstruction. If the bruit that is heard is evanescent, heard sometimes when you are listening and not at others, that indicates simply a temporary pressure upon the cord which may produce a bruit that is fetal in its rhythm, at the same time it is heard occasionally only. Where the cord encircles the neck and is drawn tightly it is apt to give rise to a bruit that is more or less permanent, and always heard at a point where we know from other methods of examination that the neck of the child is located. Where this occurs we ought to be on the lookout and prepared to find the cord encircling the child’s neck, and ought to endeavor to release it in the first place, and where we are unable to do that, then the question of severing the cord will come up. The cord being pulseless in the case reported by Dr. Anderson would have simplified that question very materially. The cutting of a cord that is not pulsating is an easy thing and not at all dangerous. Even where the cord is pulsating I have cut it repeatedly without even attempting to tie it, simply holding one end—of course you have to make a guess as to which end is attached to the child. You can not always tell that, but you can easily see from the continued bleeding or pulsating whether you have the proper end or not, and by simply holding that between the fingers the delivery can be expedited, and then the cord can be tied immediately afterward. Where the cord is pulseless there would be no danger in severing it and leaving it untied and even unheld. I have time and again, after delivery of the child, cut the cord and not tied it, but always waiting till pulsation had ceased. I think there is no danger in doing this. If a cord is cut after it ceases to pulsate and does not bleed by the time the child is washed and ready to be dressed, there will be no hemorrhage from it afterward.

Dr. Turner Anderson: Referring to the point made by Dr. Howard, I believe, whenever the umbilical cord presents anomalies as illustrated by the case reported, that it is as a rule abnormally long. The cord in this case was abnormally long.

Dr. Larrabee made a point to which considerable importance should be attached, viz., that it would not have been an easy matter to have divided the cord in this case. I think practically he presents the case exactly right. When a cord encircles the child’s neck twice, then branches off and goes under the arm, then branches off over the back, it presses the neck so tightly and the conditions are such that it would be a very difficult matter to get one’s finger beneath the cord at the neck and divide it. It is not such an easy matter to sever a cord under these circumstances as one might suppose. I believe the majority of obstetricians content themselves, when they find the cord is encircling the neck, by simply making an effort to stimulate uterine contraction, and to deliver the child as rapidly as is consistent with safety to the mother, and while so doing take the precaution to support the head, to hold it up well against the vulva and prevent undue traction on the placenta.

It is seldom that we fail to resuscitate a child born under these circumstances. The cord as a rule is not encircling the child so tightly so as to prevent our ability to resuscitate it.

Dr. Bailey has correctly stated that arrest of pulsation in the cord does not occur until after delivery of the head, and we have a limited time then to stimulate uterine action and to disengage the body of the child and release the cord from the neck. Contraction and arrest of pulsation of the cord do not occur prior to that time as a rule. I can conceive it possible that it might do so, but as soon as the head is delivered, contraction then is so great that unless the cord is very long there is an arrest of pulsation and the danger commences. Fortunately we have recourse to stimulating uterine action, and have a chance to deliver the child in the manner I have suggested with sufficient promptness.

I am satisfied Drs. Bailey and Bullock recognize all the dangers of premature separation of the placenta in an uncontracting uterus. In the primipara I can not believe that a slight cupping of the uterus, or the premature separation of the afterbirth, would be a matter of any very great moment. We are all agreed as to the dangers which may occur from separation of the normally attached afterbirth prematurely in the absence of uterine action.

In the primipara we know how very closely the perineum, unless it is lacerated, hugs the neck of the child, and to isolate and cut the cord under such circumstances is a very difficult matter. I do not attach much importance to not cutting the cord, although if I could feel it around the neck of the child and could sever it I would not hesitate to do so.

_Protrusion of the Rectum._ Dr. W. O. Roberts: To-day at my clinic at the University of Louisville a man presented himself complaining of hemorrhoids. I put him on the table on his back, drew his legs up to make an examination, and he strained slightly, had an action from the bowel, and passed out about four inches of his rectum. After examining it carefully to see whether or not there were any hemorrhoidal masses about it, or a tumor of any kind, I started to get some vaseline to assist in replacing his rectum, when he drew it back himself as though he had a string fastened to it. He did not touch it, but simply drew it back. I turned the table about so the class could see the prolapsed rectum, and he shot the rectum out and drew it back four or five times. It is a very peculiar and unique condition to me, and I would like to inquire if the members have ever encountered a condition of the kind in their practice.

_Discussion._ Dr. J. M. Williams: This is undoubtedly a case of prolapse of the rectum with a lax condition of the connective tissue. It may be from continually coming down, and I have no doubt that the bowel comes down after each defecation; there is some kind of an action by which the patient controls the rectum. It may be that contraction of the sphincter muscle starts the rectum upward, and then it simply follows its course. I can offer no other explanation of the condition. Certainly if the bowel comes out four inches there would be considerable tension upon the mesenteric attachment. It seems entirely possible that this phenomenon could be influenced and controlled by the diaphragm and abdominal muscles, and this may be the solution of this unique case. I have never seen a case of this kind.

_Epileptiform Seizures in an Infant Aged Ten Months._ Dr. J. A. Larrabee: I have been considerably interested and I may say annoyed by a case that has been under my care recently. It is in a family which is decidedly neurotic, and in which there is possibly, without history or committal, a taint of specific disease. It is not very unusual to have epileptic manifestations in children at an early age, but the case I desire to report is, I think, somewhat anomalous. There have been, for a period of fourteen days, eleven petit mal seizures in every twenty-four hours in an infant ten months old. These seizures have not apparently concerned or involved the integrity of the child in any respect. The intellectual functions, so far as intelligence is written upon the face of an infant, do not seem to have been affected. The infant is just as well apparently as if it did not have every hour or so an epileptic convulsion. The attacks present the usual phenomena of true epilepsy. The duration of these attacks is from one to two minutes, accompanied by the usual phenomena, flushing, unconsciousness which is perfect, the attack then passes off and the infant is well again.

This condition of affairs having been going on for a period of fourteen days in this case without any impairment in the general health of the infant, or in its nutrition, certainly points, I think, to a specific cause. I have often had cases, not quite so remarkable as this, where the tendency has been neurotic or specific in character, which improved under appropriate treatment; but this case has resisted all treatment, even specific treatment by the inunction of mercurials and the administration of the iodides.

The condition is still in progress, the infant having eleven seizures in every twenty-four hours, not exceeding this number and not falling short. I have witnessed several of them, and they are perfectly characteristic of epilepsy. An older child in the family passed through an ordeal of paroxysms, was unable to walk for three years, and this child has been restored under treatment, and that treatment has been antisyphilitic. One child in the family has been lost, and the history is that it died from scorbutus. The family is decidedly neurotic, and I suspect a specific taint.

The case has been exceedingly interesting and even annoying to me because I have been unable to make the slightest impression upon it by treatment in lessening the number or severity of the paroxysms. I am pursuing the same line of treatment that I did in the case of the older child which recovered, and believe I have sufficient ground for specific treatment, but so far it has not been productive of relief.

The peculiarity about the case is that the occurrence of these paroxysms has not so far interfered with the nutrition or the general health of the infant. In this respect I think the case is somewhat remarkable.

_Discussion._ Dr. T. S. Bullock: I would like to ask if Dr. Larrabee gave the bromides in the case he has reported.

Dr. T. H. Stucky: Have you tried the bromide of gold and arsenic?

Dr. J. M. Ray: In connection with Dr. Larrabee’s case I recall one that I saw several months ago in a child a little older than his which gave a peculiar history. The mother brought the child to me, the history being that the child complained of having something the matter with its ear. I examined the ear carefully. No inflammatory or other disease was present about the structures of the ear; hearing was perfect, and the drum membrane was intact. The child at this time was three years of age. The history that the mother gave me was about as follows: The child had never complained of earache; she had never noticed any defect in hearing, but sometimes two or three times a day the child would apparently be interested in her toys or in something about the room, and all at once she would scream and run to her mother and say that the house was turning over, that there was a bug in her ear, etc. This would happen several times a day, and on several occasions the child had fallen over apparently unconscious, or in a state of partial unconsciousness.

After looking into the ear carefully and not finding any evidence of disease, I referred the case to the family physician, and in talking the matter over with him he suggested that these attacks were probably petit mal. He put the child upon bromide of gold and arsenic, and a prompt recovery resulted. The last I heard from the case the attacks were few in number, occurring at long intervals and slight in character, although at one time they occurred two or three times a day.

Dr. T. H. Stucky: I have seen several cases of epilepsy in children, but never saw one in a child so young as that reported by Dr. Larrabee. I have followed out the usual routine, giving bromides and other remedies with varying results; and later, following the suggestion of Dr. Buchman, of Fort Wayne, have tried combination mentioned by Dr. Ray, viz., the bromide of gold and arsenic. I believe the latter to be especially indicated and exceedingly serviceable where we have reason to suspect a taint, as mentioned by Dr. Larrabee, getting as we do the sedative influence of the bromide, the alterative influence of the gold, and also the well-known effects of the mercury contained in the combination.

I believe where anemia is very marked in these cases, and there is a feeble heart action, and we are fearful of the depressing effects of the bromides alone, that in the use of the bromide of strontium and gold we gain a decided advantage, getting as we do the sedative as well as the cardiac influence of the strontium salts. Dr. Marvin demonstrated this conclusively before this society in a statement made by him in regard to the action of strontium salts in digestive disturbances, especially those conditions characterized by marked flatulency. If this be true, and we have reason to believe it is, it appears to me that the bromide of strontium and gold would be even better than the bromide of gold and arsenic in cases such as Dr. Larrabee has reported.

Dr. J. A. Larrabee: The case is reported not to demonstrate any unusual manifestation of epilepsy, but on account of the exact regularity and periodicity of the seizures, and the age of the patient, coupled with the fact that the treatment which seems to be indicated has not been followed by relief. In looking up the literature of the subject I find that cases of this character are usually attributed to a specific cause.

In answer to Dr. Bullock’s inquiry: I have used the bromides in this case without any effect whatever. Of course epilepsy in the child is nothing new, but this case presents some peculiarities. There is a decided neurotic tendency in the family, which may have some bearing upon the case. The child is going along having the number of seizures stated each day without any evidence of disturbance of nutrition or impairment of general health, which is rather remarkable. Some of the attacks are almost grand mal, most of them petit mal, and I am convinced that the trouble is due to specific taint.

The next move I make will be to put the child upon the bromide of gold and arsenic.

JOHN MASON WILLIAMS, M. D., _Secretary_.

Abstracts and Selections.

THE INFLUENCE OF THE ORGANISM UPON TOXINS.—Metchnikoff (_Ann. de l’Instit. Pasteur_, November 25, 1897,) has applied the method of comparative pathology to the question of the mechanism by which the animal organism prepares antitoxins, and the laws which regulate their production. By growing bacteria and lowly fungi upon culture media containing toxines he was enabled to show that the virulence of the latter was in most cases diminished and sometimes destroyed. In any case these microbes have no influence in the production of antitoxins, and the idea of preparing them by this means must be abandoned. The animal organism alone being capable of producing antitoxins, the next point was to find out whether this was a property common to all animals, or limited to the superior. Metchnikoff found that the injection of large quantities of tetanus toxin into scorpions and the larvæ of other arthropods produced no antitoxin. The toxin remained for months in the blood or tissues without losing its properties; similar results were obtained when it was taken into the alimentary canal of the leech. It was hence shown that even those invertebrates in which antimicrobic phagocytosis is most marked are utterly incapable of producing antitoxins. Coming next to vertebrates, no power of producing antitoxin is possessed by fish or amphibia; it first appears in reptiles, but not in all kinds. Thus tortoises, like invertebrates, can retain tetanus toxin in the blood for a lengthened period without forming antitoxins; it is in reptiles that the production of the latter is first observed, but in them only when they are kept at a temperature higher than 30° C. If the temperature is 20° C. the results are just the same as in tortoises and invertebrates. The establishment of the antitoxic property in these cold-blooded animals is not attended with any rise of temperature, and the same is true in warm-blooded animals such as fowls. With regard to the last-named animals, whose power of producing tetanus antitoxin was first demonstrated by Vaillard, Metchnikoff has some new and important observations. He finds that practically all the toxin injected into the peritoneum passes into and remains in the blood, none of the organs being toxic after their blood has been washed out. To this an exception is found in the case of the genital organs, ovaries, and testicles, which possess the power of fixing some of the circulating toxin. This they share with the leucocytes, to the toxicity of which that of the blood is due. After a while the toxic power of the blood diminishes, and after passing through a neutral period it becomes antitoxic. It is now found that with the exception of the generative organs, none of the organs when freed from blood possess any antitoxic power. The genital glands are found to be markedly antitoxic, but the author brings evidence to show that the antitoxin is not manufactured by them, but is absorbed from the blood, so that in the fowl the antitoxic property resides solely in the blood. Metchnikoff concludes that it is not possible to accept the idea that natural immunity depends on antitoxic power, and he further points out that the latter is evolved in the history of the animal kingdom at a much later date than the phenomena of phagocytosis.—_British Medical Journal._

THE TREATMENT OF TUBERCULOSIS WITH TUBERCULIN R.—Dauriac (_Progrès Médical_, December 4 and 11, 1897,) reports the results of the employment of Koch’s tuberculin R. in various cases of tuberculosis; fourteen of these presented local affections, such as suppuration over the sternum, enlarged cervical glands, ulceration of the skin, etc. All of the patients were satisfactorily cured. In a second paper he describes the results in fifteen cases of pulmonary tuberculosis in various stages of the disease; all were greatly improved, and many are described as cured. One of the cases was insufficiently nourished and clad, had no fixed residence, and, when the treatment was commenced, large cavities were found at the apices of both lungs. A case is also described in which, in addition to pulmonary tuberculosis, lesions were present in the kidneys and the bladder. This patient also made a complete recovery. The treatment, in spite of these brilliant results, is supposed to be most applicable to the earliest stages of the disease, and it is suggested that it would be advisable to detect the presence of tuberculosis by injections of minute doses of the original form of tuberculin. The treatment is usually commenced with a dose of 1/500 mg. This should be increased daily until a dose of 10/500 mg. is reached; this then should be increased 1/50 mg. daily until ⅕ mg. is reached, and this increased ⅕ mg. daily until 1 mg. is given. This can then be further increased if considered desirable, the maximum dose being about 20 mg. The immediate effects of the injections are usually _nil_. With doses in excess of ⅗ mg. a slight elevation of temperature is occasionally observed. Local reaction is extremely rare. The subsequent effects consist in reduction of fever, cessation of sweats, increase in appetite, and disappearance of tuberculous lesions. As none of the patients reported in this paper was admitted to the hospital, but simply came three times or less frequently a week to the dispensary for injections, improvement could not possibly have been due to any alteration in their hygienic surroundings.—_The Philadelphia Medical Journal._

CESAREAN SECTION BY TRANSVERSE INCISION OF FUNDUS.—Braun (_Centralbl. f. Gynak._, No. 45,) has had experience of Fritsch’s cesarean section, the operation being the second of its kind ever recorded. Fritsch bases his practice on the course of the secondary branches of the uterine arteries which run horizontally, so that a longitudinal incision down the front of the gravid uterus can not fail to cause free hemorrhage. He is accustomed to extirpate diseased fallopian tubes completely, snipping a wedge-shaped piece out of the uterine cornu. Bleeding is always free, but the tying of a suture passed antero-posteriorly under the bleeding vessel stops it at once. The ligature lies at right angles to the vessel, the most favorable position. Hence Fritsch conceived the idea of making an incision straight along the fundus from cornu to cornu, in order to extract the fetus in a cesarean section. Braun publishes full notes of his own case. The patient was a rachitic primipara with a universally and irregularly contracted pelvis. The conjugata vera was two and three-quarter inches. Labor pains had set in. Care was taken to antevert the gravid uterus sufficiently, the upper part of the wound being held together with forceps during delivery of the child. Then the transverse incision was made. Braun found that it bled as much as the longitudinal incision in cesarean sections where he had operated during labor at term or in relatively early pregnancy. The placental site did not lie near the fundus. The delivery of the fetus, which was living and weighed six pounds, was neither harder nor easier than through a vertical incision. The wound in the fundus was under four inches long after the fetus had been extracted. The sutures had to be placed close together, fifteen deep and eight superficial being applied. Ergot was given after the abdominal wound was closed, as there was hemorrhage. The patient made a good recovery.—_British Medical Journal._