Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 73

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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That there was an inherent tendency towards this condition was shown by the fact that a number showed a recurrence of

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JANUARY, 1911.]

symptoms if the seemed to produce It was possible patient had been Ľ and it is interesti obtained. Of 16, either cured or gre but if the acidity the acidity was 24 of these figures wc so much due to th of its acid.

In all suffering with arsenic, was g alkalies had no effe free HCI to correc was productive of this would suggest cases the fundamer secretion.

This study seems alkalinization of th sufficiently striking Whether this ben duced are really acid and rendered less ha whether the effect c and alkalies is mai: élimination we cann tainly suggested by : met with by the adr portion of these cases it almost suggests an

AN AN

In view of the fact terior position in the posed to cause conside and to be of more or and child, I have co Keuring in the obst kins Hospital, in orde garded with but little occiput anterior preser Though the figures markedly, occiput post currence. Pinard and 16.23 per cent of their of cases studied by Dr. staller number he attr. wire made late in labo

'me regimen was stopped, though in others it produce entire relief for long periods of time. possible sometimes to examine the urine after the I been under treatment for a certain length of time, nteresting to note the decrease in acidity that we Of 16, whose urine was examined after they were 1 or greatly improved, the average acidity was 21.5, acidity was corrected to a specific gravity of 1.015 was 24, that is practically normal; the closeness tures would suggest that the improvement was not le to the dilution of the urine as to the reduction

uffering from anæmia, iron sometimes combined c, was given (31, 34, 40) while in one case (41) 1 no effect on the pain, but the administration of o correct the functional anacidity of the stomach :tive of almost immediate beneficial results, and suggest that in probably a small proportion of undamental trouble is the disturbance of gastric

ly seems to show that the benefit of the. thorough on of the patient in these conditions was often striking to warrant its trial.

this beneficial effect shows that the toxins pro- eally acid in nature, and are, therefore, neutralized ed less harmful by neutralization with alkalies, or ? effect of increased water drinking, simple diet s is mainly to improve digestion and stimulate we cannot say, although the former view is cer- ested by the very rapid and marked improvement y the administration of alkalies in a certain pro- hese cases, in some, in fact, to such an extent that ggests an elective action.

CONCLUSIONS.

In this article, very brief and fragmentary as it is, we have shown that in a certain group of cases of neuritis, neuralgia and myalgia, which for want of a better term, and in the ab- sence of definite or sufficient etiological factors may be called idiopathic, there is a definite increase in the acid eliminated, although we have not attempted to determine whether this is due to an increase in the acid phosphates, or in the organic acids. We believe, however, that the latter is more likely, and we hope subsequently to investigate this phase of the subject in detail. For want of a better explanation we make the sug- gestion that this hyperacidity is probably the urinary expres- sion of some abnormality or error of metabolism, probably having little or no relationship with the gastric digestion or the degree of acid in the gastric contents, but more probably due to metabolic disturbances arising lower down in the diges- tive tract; and that the pain and other manifestations in the nerves or muscles affected are due to some circulating poison or toxin, the condition thus probably being a form of endo- genous intoxication. Why certain groups of nerves or muscles should be selected in some cases, other groups in other cases, we are unable to say, though in all probability there has been something in the past history of the patient as trauma, ex- posure to cold, etc., which has lowered the resistance of the especial nerve or muscle affected.

Finally it seems certain that in some patients the insistence upon a simple dietary and copious water drinking, and, most important of all, the administration of alkalies in sufficient amount to reduce the acidity of the urine to normal, is fol- lowed by a very marked amelioration of symptoms; and in a few by their complete disappearance without the aid of other remedial agents.

N ANALYSIS OF THE COURSE OF LABOR IN 100 OCCIPUT POSTERIOR PRESENTATIONS.

By CLARENCE B. INGRAHAM, M. D., Denver, Colorado.

: the fact that when the occiput occupies a pos- n in the pelvis the condition is commonly sup- e considerable difficulty to the progress of labor, more or less serious consequence to both mother have collected one hundred consecutive cases, the obstetrical department of the Johns Hop- , in order to show that this variety is to be re- out little more anxiety than the more common or presentation.

figures of the different observers vary quite put posterior presentations are of frequent oc- ard and Dubois having found them in 49.8 and of their cases; while in this clinic, in a series | by Dr. Williams, there were 16.8 per cent. This he attributes to the fact that the examinations in labor when anterior rotation had already

occurred. In my series the percentage is still smaller, 12.03 per cent, due probably to the fact that where the least doubt has existed as to the variety of position, the cases have been discarded, and several diagnosed as of transverse variety really belonged in this number.

All the babies in this series were born at term, and those cases with small children were discarded as not being fair examples for comparison in difficult labor. To be sure of the position of the child, in practically every instance, an internal as well as an external examination was made and the variety of position verified.

In looking for a cause of the occurrence of this variety of position, it was found, in this small series at least, that the condition was slightly more common in the contracted pelvis- the number occurring in normal pelves was 85, while in 15 the pelvis was contracted as follows: Generally contracted in

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JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 238

nine, simply flat in two, generally contracted rachitic in one, and funnel pelvis in two cases. The percentage of contracted pelves occurring in the hospital being 13.1 per cent, makes an increase of 1.9 per cent in association with the occiput pos- terior presentation. Forty-eight of the 100 cases were in multiparæ and 42 in primiparæ. Taking into consideration the cephalic measurements, nothing of importance was gained, the average measurements obtained from the 100 heads being :

Cm.

Fronto-occipital

11.73

Biparietal

9.38

Bitemporal

7.90

Mento-occipital

13.92

Suboccipito-bregmatic 9.59

Suboccipito-bregmatic circumference. 31.80

All of which are seen to be practically normal.

Up to this time, the percentage of operative deliveries at term in the Johns Hopkins Hospital, including posterior posi- tions, is 15.2 per cent, which, though high, is due to the fact that many patients are brought in from outside only because complications have arisen. The number of cases requiring operation in the 100 posterior positions was 18, but slightly higher (2.6 per cent) than that of all cases, and of these 18, 11 were due to causes known to be from conditions other than the posterior position, for example :

Cases.

Mitral stenosis (patients not allowed to con- tinue in second stage of labor) 2

Contracted pelves 4

Prolapsus of cord. 1

Eclampsia 1

Dead infected fœtus 1

Ventral hernia and relaxed abdominal muscles 1

Ankylosis of coccyx 1

Of the remaining seven operative cases, the indications given are as follows:

1-Mid-forceps-R. O. T .- P. Poor pains, in second stage 2 hours and 53 minutes with no advance.

2-Mid-forceps-R. O. P. Fœtal and maternal pulse the indication. 3-Mid-forceps-L. O. T .- P. In second stage 2 hours and 10 minutes. Appearance of mecomium and increased rate of fœtal heart.

4-Mid-forceps .- R. O. T .- P. Relaxed abdominal wall and in- sufficient vis-a-tergo. Second stage 2 hours and 45 minutes. 5-Mid-forceps-R. O. T .- P. In second stage 3 hours with no advance. Maternal pulse 110 to the minute. Exhaustion.

6-Low-forceps-R. O. P. (Scanzoni application). In second stage for over 2 hours with no advance.

7-Attempted high-forceps-R. O. P. Maternal pulse 130 to the minute. In second stage 3 hours with no advance. Version and extraction. In this case the dystocia seemed to be due almost entirely to the very large size of the child, which was 57 cm. long and weighed 4110 gm. The head measure- ments were:

O. M.

Cm.

O. F. 14.50

11.00

Bi-P.

9.50

Bİ-T.

S. O. B. 8.00

10.00

S. O. B. circum

32.50

In case four it is doubtful if the variety of position was a factor.

Among these 100 cases, there were seven in which the occiput rotated into the hollow of the sacrum-a condition in which operative interference is quite generally supposed to be necessary; but of these seven, one only required opera- tion, a delivery with low forceps. The remaining six were born readily and spontaneously, the second stage of labor averaging but one hour and two minutes.

In considering the duration of labor for the primipara in whom spontaneous anterior rotation occurred, the average was found to be 18 hours and six minutes-the first stage aver- aging 16 hours and 10 minutes, and the second stage one hour and 42 minutes. For the multiparæ, the average dura- tion was 10 hours and 15 minutes, of which the first stage occupied nine hours and ten minutes, and the second stage 52 minutes.

In the cases in which rotation occurred into the hollow of the sacrum, the labors averaged 14 hours and seven minutes, of which the first stage was 13 hours and the second stage one hour and two minutes. It might be supposed that this con- dition would require a much longer time, but of these seven cases, five were multiparæ; and unfortunately, with the two cases of primiparæ the time cannot be determined as in one case forceps were applied at the end of two hours, and in the other, the first and second stages were not estimated sep- arately, and both together lasted 10 hours and a half. Also three of the babies were under 3000 grams in weight, the only ones in the series below this figure.

When one compares the duration of labor in this series with that of the various text-books, we find that Williams estimates the first stage as 16 hours, and the second one hour and three-quarters to two hours for primiparæ; and for multiparæ, 12 hours and one hour, respectively. Veit gives the duration of labor as 20 hours for primipare, and 12 hours for multiparæ. Varnier, from the records of 2000 cases, one- half of which were primipara, estimates it as 13} and 7} hours, respectively-the second stage 75 minutes in the former and 35 minutes in the latter. It is seen that, as compared to the times of the first two observers, with this series of occiput posterior presentations the duration is short, while with Varnier's figures it is somewhat longer.

The percentage of perineal tears received during these 100 cases was 26 per cent as against 23 per cent in 200 consecu- tive cases of the more common anterior variety. Of these 26 perineal tears, 18 were in primiparæ, and eight in multiparz: 14 of the first and 12 of the second degree. Twelve of the tears were in operative cases, and of these, four were of the first and the remaining eight of the second degree.

Of the seven cases in which the occiput rotated posteriorly there were four tears (55 per cent). This is readily ex- plained when we consider that the vulva, with the more un- usual mechanism of labor, is stretched to admit the occipito- frontal diameter of the head (11.75 cm.) instead of the sub- occipito-bregmatic diameter (9.5 cm.) in the occiput anterior variety. In the three remaining cases, in which the occiput

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JANUARY. 1911.]

rotated posterior! were under 3000 Of the 100 case lived six days wit broncho-pneumonia and lived a few hours after version born; with this chi a funnel pelvis and forceps, by which child died through erally contracted p of the head. Acco with forceps on the ful. Version and became wedged in coming head becan ured 10.5 cm., and i have been pubiotom to operations depen pelvis was general shaped. The poste responsible for eithe Three other babic one there was a pr tracted pelris, and application of force In the series ther died of typhoid fer ing present at the ti delivery, and died fr

In reviewing this presentations, it is s. bnt little more frequ of presentation. Th longed and the perc than in the anterior and child are, howev It is the procedur of position is diagn when, as is shown in In occiput anterior t advocate turning the the hand introduced the patient more lia and while in a certain lasten the labor, in takes place spontaneo 18 uncomplicated. To quote Dr. Willia

"Even when the occip prognosis is not so ver taneous labor usually oc posterior, there is an i

waou posterior, and there were no perineal tears, the babies ere under 3000 grams in weight.

Of the 100 cases there were five fœtal deaths. One baby ved six days with congenital deformity of the viscera and oncho-pneumonia ; one had congenital absence of the pylorus d lived a few days; one with status lymphaticus lived 1} urs after version and extraction; one was practically still- rn; with this child, version and extraction was tried through funnel pelvis and abandoned for a second attempt with the rceps, by which the head was unduly compressed ; and one ild died through perforation of the head ; there was a gen- ally contracted pelvis and a long labor without engagement the head. Accouchement force was done, and an attempt ith forceps on the floating head tried, which was unsuccess- 1. Version and extraction was then resorted to. The head came wedged in the pelvis and perforation of the after ming head became necessary. The conjugata vera meas- ed 10.5 cm., and in this case the method of procedure should ve been pubiotomy. Of these deaths, the last two were due operations dependent upon contracted pelves; in one the lvis was generally contracted, and in the other funnel aped. The posterior variety of position cannot be held sponsible for either one.

Three other babies were slightly asphyxiated at birth. In e there was a pressure necrosis of the scalp from a con- acted pelvis, and in another a facial paralysis followed the plication of forceps. Both recovered completely.

In the series there were two maternal deaths one patient ed of typhoid fever during the puerperium, the disease be- g present at the time of labor ; the other lived one day after livery, and died from chronic myocarditis with dilatation.

In reviewing this rather small series of occiput posterior esentations, it is shown that operative interference need be t little more frequent than in the occiput anterior variety presentation. The duration of labor is slightly more pro- iged and the percentage of perineal tears slightly higher in in the anterior variety. The consequences to the mother 1 child are, however, not much more serious.

it is the procedure in this clinic, when a posterior variety position is diagnosed, to leave the condition to nature, en, as is shown in almost the same percentage of cases as occiput anterior the labor is spontaneous. Many writers pcate turning the head to an anterior variety by means of hand introduced into the vagina. This procedure renders patient more liable to infection through manipulation ; while in a certain number of cases, if successful, it may en the labor, in the majority, rotation to the symphysis s place spontaneously (about 92 per cent), and the labor acomplicated.

quote Dr. Williams from his text-book :

ven when the occiput rotates into the hollow of the sacrum, the losis is not so very bad. as in the majority of cases spon- us labor usually occurs. No doubt, when the occiput remains pior, there is an increased tendency toward perineal tears,

which is particularly marked when the head is born by the less frequent mechanism. But to my mind, the main cause of the dread in which posterior presentations are held is the fact that they frequently escape recognition, and accordingly, if for any reason operative delivery becomes necessary, the forceps is applied improperly-that is, as in occipito-anterior presentations.

" When occipito-posterior presentations have descended into the pelvis, it is my practice to leave them to nature so long as pos- sible, and to interfere only when absolutely necessary. But when convinced that the best interests of the mother and child will be subserved by prompt delivery, forceps should be applied.

"On the other hand, when the head is arrested at the superior strait in a posterior position, version should be resorted to as soon as one is convinced that spontaneous advance will not occur, provided of course, that the operation is feasible and is not con- traindicated by disproportion between the size of the head and the pelvis."

As regards the application of forceps, when the occiput has rotated into the hollow of the sacrum and interference be- comes necessary, the forceps is applied in the usual manner to the sides of the head with the pelvic curve toward the face, and the occiput drawn out slowly over the perineum in a horizontal direction until the forehead or root of the nose engages under the symphysis, after which the occiput should be delivered over the anterior margin of the perineum by slowly elevating the handles. Then, by imparting a downward motion to the instrument, the forehead, nose, and chin sus- cessively emerge from the vulva.

When interference is indicated in an obliquely posterior variety it is attempted to rotate the head to a transverse or even an anterior variety by means of the hands, and then apply forceps in the usual manner. If, however, this cannot be effected the double application of forceps by Scanzoni's method is resorted to and has given such excellent results that it is employed to the exclusion of all other methods.

In the first application, while the occiput is obliquely pos- terior, the blades are applied to the sides of the head with the pelvic curve looking toward the face of the child, and downward traction is made until the head impinges on the pelvic floor, when a rotary movement is imparted to the forceps, by which the occiput is slowly brought into a trans- verse or obliquely anterior position. The forceps, which have become inverted, are taken off, and reapplied in the usual manner for the anterior variety-that is, with the pelvic curve toward the occiput, which is now rotated so as to lie under the symphysis, when the extraction is completed in the usual way.

THE, JOHNS HOPKINS HOSPITAL BULLETIN.

The Hospital Bulletin contains details of hospital and dispen- sary practice, abstracts of papers read, and other proceedings of the Medical Society of the Hospital, reports of lectures, and other matters of general interest in connection with the work of the Hospital. It is issued monthly.

Volume XXII is in progress. The subscription price is $2.00 per year in the United States, Canada, and Mexico; foreign subscrip- tions $2.50.

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JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 238

INVESTIGATION INTO SEVERAL CASES OF POISONING BY VAPORS OF "C. P." BENZOL.

By CHARLES GLASER, Baltimore.

A little over a year ago I was asked to inspect a can-factory in this city and discover, if possible, the causes which had led to the poisoning of a number of the employees. All of the vic- tims were young girls, and four of them had been removed to the Johns Hopkins Hospital, where one had died, another had been reported dangerously ill, while the remaining two were found in less alarming states.

The attending physician of the hospital joined me in the inspection of the factory, and at the same time examined 14 girls, aged 14 to 18 years, and employed in the same building from which the four victims, first mentioned, had been re- moved. A number of the men were also examined. All were found to be highly anemic.

The principal work carried on in the building where these people were employed, consisted in preparing the tops of the cans for sealing. Four machines, each one attended by four girls, carried on this operation. The tops, carried by mechan- ical means, were passed under a brush, and this, also mechan- ically, provided each disc near its outer edge, with a rim of rubber dissolved in benzol, and thickened by means of bole and ground asbestos.

Two of the girls were employed at this work, whereas the other two spread the tops, after they had passed out of the machine, on racks to dry. Upon evaporation of the benzol there is left a thin rubber ring near the margin of cach top, and this makes possible an hermetic closure.

Although all the windows were open, the air in the building, particularly in the vicinity of the machines, smelled strongly of benzol. Upon inquiry it was stated that about 10 gallons of the rubber solution had been used daily for the preceding six months. During this time several large lots had been con- sumed without detrimental effects of any kind, and it was not until a certain drum marked No. 36 began to be used, that sickness appeared.

A small sample of benzol from drum No. 36 was tested, with the following results :

Specific gravity at 153 ° C. = 0.880.

Sulphuric acid gave a distinct straw-yellow color.

Carbon bisulphide was found present in small quantity by the xanthogenate test.

Anilin and nitrobenzol were shown to be present in traces by Jacquemin's test.

A larger sample of benzol No. 36 was thereupon obtained from the factory, and of this 200 cc. were carefully fraction- ated with the aid of a Le Bel head.

The initial boiling-point was 80° C. which rose gradually to 853º C., when 190 cc. had distilled over. The remaining 10 cc. were tested for aniline with negative results, and for nitro- benzol, which gave a strong dark blue coloration by Jacque- min's test.

The first death (that of patient W.) had occurred a few

days before I was called in, and this case was out of reach of a chemical examination. The attending physician, however, sub- mitted samples of urine from two of the other patients. C., who was critically ill, and died soon afterward; N., who was not so seriously ill, and who finally recovered.

The examination of these urines was conducted as follows: they were distilled in a current of steam, the distillates were exhausted with ether, and the aqueous residues discarded.

To the ether 5 cc. of n 10 sulphuric acid was added, and after shaking, run off. After this the ether was washed ser- eral times with small quantities of water. The united acid liquids were then neutralized with solid sodium carbonate. One drop of phenol, and several drops of a sodium hypochlorite solution were added. Case C. gave a strong blue color reaction for aniline.

The ether from which the sulphuric acid had been ab- stracted was tested for nitrobenzol with negative results in the following manner: it was allowed to evaporate spon- taneously until only a little remained; upon the addition of alcohol the liquid was transferred to a flask with a long reflex tube ; sulphuric acid and zinc were now added, and the mixture in the flask left in a warm place, usually over night. After neutralization, the aniline formed was extracted with ether, and treated as before described.

Case N. gave a faint blue color reaction for aniline. The ether in this case gave a distinct, but not clean blue color re- action when tested for nitrobenzol. This effect may have been due to a small remnant of aniline, a trace of nitrobenzol, or to the presence in the urine of some other substance capable of giving imperfectly and deceptively a test more or less blurred for aniline after reduction.

The urine of another patient, who had nothing to do with the benzol cases, was submitted by the attending physician, and gave, after steam distillation, and further identical treat- ment, a negative test for aniline, but a faint brown reaction turning slowly to a faint dirty green when tested for nitro- benzol.

The two cases, N. and C., seem to show an interesting con- nection between the severity of the cases and the strength of the reactions obtained for aniline.

After the death of patient C. her brain was submitted for analysis. About one-fourth of its was pulped, acidulated, and subjected to distillation in a current of steam. Four hundred cubic centimeters of distillate were obtained.

The distillate was exhausted with ether and the latter ex- amined as before described. Only a trace-reaction for aniline was obtained, and a very faint apparent reaction for nitro- benzol, which could not be positively identified by a control test for isonitril. For this reason the latter reaction was con- sidered as probably due to the same substance that gave a

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 73

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189