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find on the left side, about half-way from the fundus, a spot that was quite tender on pressure, and also that the womb bulged out at that point, making its contour somewhat irregular. I was unable to satisfy myself in regard to the probable cause of this condition.
The head presented in the first position, and with difficulty entered the pelvic brim. Although the pelvis was roomy and the pains strong, the head advanced very slowly, seemingly out of all proportion to the expulsive force and good size of the pelvic cavity ; but as it did advance, though with extreme labor, I thought it unwise to send for forceps, as my office was at a great distance. The lady complained much of the tender spot on the womb, and I ordered fomentations of hot rum to be applied. The head finally reached the perinæum, and aided by the most powerful uterine and abdominal action it passed into the outer world. Although the expulsive force continued to be strong, the shoulders refused to come. Passing my hand into the vagina I found that the child's right arm was displaced, and lay across the back of its neck; hooking my finger into the axilla I brought down the arm across the chest, when the body was immediately expelled. The placenta came away in the course of an hour after the exhibition of ergot and the practice of considerable traction on the cord. The child's arm was much flattened and completely paralyzed, but as the bone was intact I gave a favorable prognosis.
The cause of the tender spot with the bulging of the uterine wall was now explained. It was evidently due to pressure exerted by some portion of the displaced member. After the os uteri was fully dilated this arm formed a bar which hitched against the pelvic brim, and prevented the head from entering freely, but the expulsive force was so great that the head and arm were pushed on, and the second stage of labor completed after three hours of powerful and continued uterine action. Had the presenting part failed to engage, an examination would have been made, and the offending arm doubtless discovered; but the pains being strong and the pelvis roomy the head was born, and the displaced arm was then revealed, owing to the delay in the expulsion of the shoulders. The child was a girl, weighing twelve pounds.
When in a case of dorsal displacement of the arm the head fails to engage in the brim, an effort should be made to bring down the arm as Simpson suggested, especially if the size of the pelvic cavity and the character of the pains give reason to believe that nature can effect delivery, as she did in my case even with the arm displaced.
The last time I visited my patient was nine days after delivery, when she was comfortable, and as far as I could judge every function was properly performed. I ordered her to be kept in bed several days longer. There was no tenderness of the womb remaining. While in the room I noticed that the child had acquired full use of her previously paralyzed arm.
A month later I was surprised to learn that a few days after my last visit the lady had been seized with some trouble in the abdomen, and through the influence of an officious relative had been suddenly removed out of the city, and put under the care of an irregular practitioner. What this affection was, and whether it had any relation to her accouchement, I was unable to learn.
EMBOLISM OF LEFT FEMORAL ARTERY CONSEQUENT ON
VALVULAR HEART DISEASE; DEATH.
BY E. P. HURD, M. D., NEWBURY PORT.
Mrs. R., aged forty-seven, had been since 1870 under my care for valvular heart disease. There were symptoms of both aortic and mitral insufficiency, and the case was so diagnosticated by me in 1870, Dr. F. I. Knight, of Boston, concurring. The leading features of the case were frequent attacks of pain over the heart, palpitation, and dyspnæa; these were at times most distressing. In 1878 she had pneumonia of right lung, with persistent cough, orthopnea, and prostration. To the surprise of everybody she recovered from this illness, a troublesome cough remaining Mrs. R. was always weak and anæmic, although · her naturally energetic disposition kept her almost constantly at work. There was never any anasarca.
February 22, 1879, nine o'clock, A. M. Mrs. R. was suddenly seized with a violent pain in left lower extremity, which sometimes took the form of cramp of the muscles of the calf, sometimes was like a burning sensation in the foot. Associated with this pain there were coldness and numbness, - anesthésie douloureuse. Above the knee the natural sensibility and warmth were retained. Veins of foot and leg were distended, and there was stasis. There was no pulse in left popliteal, nor was any pulse discoverable in any artery of the member supplied by that vessel. Pulsation in the femoral at the base of Scarpa’s triangle could be felt, but at no other part of its course.
The circulation of the right lower extremity was normal.
Diagnosis. Embolism of femoral or popliteal. The clot had evidently been washed out of the left ventricle ; it might have been formed during the transit of blood over a roughened aortic orifice.
Treatment. Whatever could make the patient most comfortable, a fatal issue being foreseen. The limb was wrapped in warm flannels; these, assiduously renewed, brought back heat.
The heart's action was weak, rapid, and tumultuous, as if that organ were becoming paralyzed from shock. It was a condition of asystolie. Tincture of digitalis in ten-drop doses every hour, in a tablespoonful of
brandy. Gilman's chlorodyne in teaspoonful doses every half hour for pain. Two o'clock, P. M. A little abatement of pain. Pulse has improved somewhat under digitalis. There are two large patches of gangrened integument, of dark brown color and parchment feel, six or eight inches square, on the front and lateral aspect of the left leg ; there is also a dark, “ mummified" patch as large as the palm on the dorsum of the foot. The integument of the entire leg and foot is of purplish color, mottled here and there with streaks of livid extravasation, and for some distance above the knee punctiform petechiæ are abundant. Six P. M. Pain has been relieved by the chlorodyne. Brandy and milk have been freely given. Tincture of digitalis in fifteen-drop doses every two hours. February 23d. A very feeble attempt at collateral circulation; the
; whole limb threatens to become gangrenous. Mrs. R. has slept a few hours. Pulse 100, weak and compressible ; it is sudden and jerky, without any prolonged swell of the artery. There is a soft murmur, heard at base and apex, with both sounds of the heart. Complexion purplish and sallow; veins everywhere distended and prominent; pulsation of right jugular well marked.
February 24th, nine o'clock, A. M. Mrs. R. has vomited at intervals all night; medicine and nourishment have been necessarily suspended. Patient is prostrate, and apparently sinking. Digitalis, in twenty-drop doses of the tincture, caused her to rally somewhat, but at ten P. M. she died.
An autopsy was performed the next day, Drs. Howe, Healey, and Hurd being present. Only the thorax and abdomen were examined. Abdominal organs were healthy, with the exception of the liver, which was hyperæmic and hypertrophied; from incisions made with the scalpel venous blood flowed freely. Gall-bladder greatly distended. Heart enlarged and encroaching on left lung ; pericardium full of Auid. Right side of heart hypertrophied and dilated; no valvular lesions. A firm and partly organized clot was attached to the musculi pectinati ; it extended into the infundibulum of right ventricle. Left auricle was enormously enlarged, and the four pulmonary veins entering it looked like huge aneurismal pouches. Section of the auricle disclosed hypertrophy and dilatation ; the mitral valve was contracted to a mere chink, firm and resisting, which the index finger could hardly be made to enter. This, when the ventricle was opened, was found to be due to agglutination of the segments of the valve by old inflammatory deposits, and to subsequent contraction and induration. The sigmoid valves of the aorta were rigid and indurated, opposing obstruction to the efflux of blood. Their incompetence to prevent regurgitation was shown by the usual test of
1 For the formula of Gilman's chlorodyne I am indebted to a former number of the JOURNAL
pouring water into the aorta. There was also thickening and dilatation of left ventricle, and general pulmonary congestion.
In this patient we had aortic constrictive, aortic regurgitant, mitral constrictive, mitral regurgitant, lesions, and a striking example of how much serious heart disease may be tolerated for a series of years, with a fair degree of general health and comfort, and ability to perform the ordinary duties of life.
Embolism of large arteries of the extremities in heart disease is generally if not always fatal, the patient dying from shock, or from inability of the heart to establish a sufficient collateral circulation.
The good effects of full doses of digitalis in this case were very manifest, and there is probably no other remedy that would have proved equally efficient.
ANNUAL MEETING OF THE MASSACHUSETTS MEDICAL
The usual initial meeting of the Massachusetts Medical Society was preceded during the forenoon by medical visits of the Fellows, and surgical operations before them at the hospitals. At the Massachusetts General Hospital Dr. H. J. Bigelow performed his operation for litholapaxy; Dr. C. B. Porter excised a parotid gland and exhibited surgical cases, among which was one of extrophy of the bladder, in which Dr. Porter had performed a successful plastic operation.
At the City Hospital, Dr. Thorndike amputated a breast, Dr. H. W. Will. iams operated for cataract, and Dr. Ingalls removed a fatty tumor and operated on a case of necrosis.
At Carney Hospital, Dr. Arthur Cabot applied Sayre's plaster jacket for the benefit of one of the Fellows.
During the afternoon of this day the Warren Museum at the Medical Col. lege, the Warren Museum of Natural History on Chestnut Street, Children's Hospital, and Museum of Natural History Society were visited by the Fellows.
The initial meeting was called to order promptly at twelve o'clock, in Horticultural Hall, on Tuesday, June 10th, by the president, Dr. George H. Ly. man, who at once introduced the readers of papers, namely, Dr. Rollin C. Ward, of Northfield, who read an essay on The Physician's True Position in Society ; Dr. James B. Ayer, of Boston, whose subject was Cases of Insanity following Acute Diseases; and Dr. George K. Sabine, of Brookline, whose paper was entitled Intestinal Catarrh of Infants.
In our report of the last annual meeting of the society the criticism was made that not one word of discussion was elicited by the papers ,then read. On this occasion, however, the president called upon the Fellows by name and asked for remarks. The result was a most interesting discussion upon the very excellent papers of Drs. Ayer and Sabine, in which many gentlemen took part. We trust the precedent thus established by Dr. Lyman may be followed by future presidents on similar occasions. At the close of this meeting the president announced that since the Medico-Legal Society wished to occupy the afternoon he would adjourn until the following morning at nine o'clock.
At three P. M. of Tuesday the Medico-Legal Society was called to order by its president, Dr. Alfred Hosmer, who introduced the members appointed to read papers having a medico-legal bearing. They were as follows: A Digest of Returns from Members of the Society for the Year ending December 31, 1878, by Medical Examiner F. Winsor, M. D.; Duties of Officers under the Present Law of a Medical Examiners, and the Relations of the Community thereto, by associate member Hon. Asa French ; Report of a Committee on Expert Testimony, What it is and what it should be ; Report of a Committee on the Use of the Metric System of Weights and Measures in Forensic Medicine ; A Medico-Legal Case of Abortion followed by Conviction, by medical examiner J. C. Gleason, M. D.; on Pathological Changes in Pyremia and Septicæmia, by associate member E. G. Cutler,M. D. ; Evidences of Abortion derived from Clinical and Post-Mortem Teaching, by Medical Examiner C. C. Tower, M. D. ; a paper on Death by Lightning, by Medical Examiner J. L. Sullivan, M. D., was deferred on account of insufficient time. Meeting then adjourned.
At a private meeting this society, save in one instance, reëlected its entire board of officers, the exception being the substitution of Medical Examiner Abbott, of Wakefield, in the place of Medical Examiner Winsor, as corresponding secretary
At seven o'clock, P. M., the annual meeting of the councilors of the society was called to order by President Lyman in the hall of the Medical Library Building The records of the last annual meeting were then read by the secretary, Dr. F. W. Goss, and were accepted. The nominating committee was next announced, and consisted of one Fellow from each district. On its return to the hall the chairman, Dr. Bronson, announced the slate for 1879-1880 as follows:
President, Dr. George H. Lyman, Boston. Vice-President, Dr. David P. Smith, Springfield. Treasurer, Dr. Frank W. Draper, Boston. Corresponding Secretary, Dr. Charles W. Swan, Boston. Recording Secretary, Dr. F. W. Goss, Roxbury. Librarian, Dr. David H. Hayden, Boston. These officers were all elected by ballot. Following which the president nominated as
Orator, Dr. Thomas H. Gage, Worcester.
Committees : Of Arrangements, Drs. Robert Amory, C. J. Blake, F. C. Shattuck, W. L. Richardson, J. O. Green, E. G. Cutler.
On Publications, Drs. G. C. Shattuck, R. M. Hodges, B. E. Cotting.
To procure Scientific Papers, Drs. H. W. Williams, Calvin Ellis, F. K. Paddock, G. S. Stebbins, J. R. Chadwick.
On Ethics and Discipline, Drs. Charles Howe, R. L. Hodgdon, G. J. Townsend, G. E. Francis, A. H. Johnson.