lime constantly slaking near the patient, both for the steam it creates and the dissolving effect it is supposed to have upon the false membrane. The tube should be attended to, by withdrawing the inner canula and carefully cleansing it every two hours for the first two days; after that, if the secretions are not excessive, once in four hours will be sufficient; but we must be governed in this by the amount of mucus collected in the tube, a neglect of which has proved fatal in many instances. The inner tube should not be left out any longer than is necessary to clean it, as some difficulty may be experienced in reintroducing it if the mucus is allowed to dry in the outer canula. The parts surrounding the wound should be kept clean. If the inner end of the tube should become obstructed by mucus or false membranes, an elastic bougie should be passed through the tube into the trachea; or, if the membrane is large, it may be removed by curved forceps. When difficulty is experienced in breathing, it is sometimes useful to irritate the trachea with a bougie; which provokes a cough and expels the thick mucus or membrane. If we cannot succeed in relieving the patient in this way, and the obstruction seems to, be beyond the tube, we may follow the plan advised by Guersant. "If the trachea is clogged up, he says, with thickened mucus or false membranes, which prevents the child from breathing, it is best to withdraw the canula, and to boldly seize in the trachea, with the cranesbill forceps, everything which obstructs the respiratory canal. For the want of this care, patients, who are almost cured, may die asphyxiated." This attention to the cleansing of the tube, etc., should not be left to the family, but a skilful attendant should always be selected for the duty; a physician if possible, or if not, a competent nurse; for it is a matter of extreme importance that the patient should be carefully watched for a few days following the operation. The introduction of the tube, by admitting air which has not been properly warmed into the bronchia, may produce bronchitis or broncho-pneumonia. To guard against this, as far as possible, the end of the tube is covered with a light handkerchief, and the air of the room kept warm and moist; but the chest should be frequently examined, that any such disease may be detected in time and properly treated. Of the constitutional treatment of those diseases requiring this operation, it is not my intention to speak, except in regard to membranous croup and diphtheria. In these diseases, I would urge the use of chlorate of potassa, in large and frequently repeated doses, 1 Guersant on Surgical Diseases of Children, p. 507. both before and after the operation. Not in the doses recommended in the books, which I consider inefficient, but to give as much as the patient's stomach will bear. I have been for many years in the habit of prescribing a saturated solution of chlorate of potassa, thirty grains to the ounce; and giving, according to the age of the patient, a teaspoonful, a dessertspoonful, a tablespoonful, or even a larger quantity, every three hours in mild cases; but, in cases of extreme urgency, I have given as often as every half hour, and with the happiest results. I will not trespass on your valuable time with details of cases cured in this manner, but would urge you to try it in your own practice. The administration of this medicine does not interfere with the use of other remedies, if the physician prefers to try them, such as emetics, etc.; but, in my hands, the ordinary remedies for membranous croup and diphtheria, after the last has invaded the windpipe, have proved valueless in the majority of cases. When the bowels or stomach are irritated by the use of the chlorate of potassa, a small quantity of opium added to the mixture will often relieve this difficulty; and, as the patient progresses towards recovery, the addition of the tincture of iron to the mixture is of great value. The patient having been happily relieved, and his case progressing favorably, it becomes important to consider when we should remove the canula. This should be done as soon as it can be without risk, as serious results may follow its prolonged use, such as abscesses or ulceration of the trachea. "Two cases have occurred in Guy's Hospital, in each of which, ulceration, so produced, extended through the anterior wall of the trachea into the innominate artery. Fatal hemorrhage, of course, ensued." Such cases are, however, rare, and may have been due to an improperly constructed instrument, or other causes. To determine when this can be done, the end of the tube should be closed with the finger to see if the patient can breathe through the larynx. If we find that this can be done with ease, a cork can be inserted into the end of the inner tube, and allowed to remain for twenty-four hours; when, if he still breathes well, we can remove the canula, and allow the wound to cicatrize, which it does readily; the only attention required being to keep the wound clean and covered with a light dressing. In cases of chronic disease of the windpipe, it is sometimes necessary to wear the tube for years, and even during life. In these cases, the tube should be examined occasionally, as it is liable to become corroded, and cases have occurred where the neckplate has become detached from the tube, and the latter has fallen into the trachea. 1 Holmes's Surgery, vol. ii. p. 505. THE ADDRESS IN OBSTETRICS. BY WILLIAM B. ATKINSON, M.D., PHYSICIAN TO THE DEPARTMENT OF OBSTETRICS AND DISEASES OF WOMEN AND DURING the year that has passed since my appointment to prepare the Address in Obstetrics, many questions have occupied the medical world, a correct reply to which would prove of immense value not only to the obstetrician, but to those who select him to guide them through the perilous ways by which they are surrounded. I shall endeavor to present these to your consideration, as briefly as possible, giving the views of the best and most experienced students in this branch, and closing each subject with a reference which will enable my hearers or readers to study in detail these views as they were originally presented to the public. Post-Partum Hemorrhage.—A learned discussion has been going on, both in the medical associations and through the columns of our journals, upon the subject of post-partum hemorrhage. This has embraced not only the best means to meet it when present, but how to anticipate and prevent its advent. Dr. R. C. McIntosh, Doncaster, England, having failed in restraining the hemorrhage, after grasping and kneading the uterus, using cold affusions, injecting cold water per vaginam, and also a dilute solution of perchloride of iron, finally resorted to faradism. Stöhrer's portable coil machine was obtained, and an interrupted current directed through the womb, one pole having been placed on the walls of the abdomen over the fundus by means of a curved plate of copper, while the other was applied to the cervix. Firm contraction speedily ensued, which remained after a short use of the current. (Brit. Med. Journal, August 9, 1873.) Dr. Whittle, London, diagnoses the occurrence of post-partum hemorrhage by the pains being strong, quick, and ceasing suddenly. He anticipates the hemorrhage by the use of ergot freely in such cases, as soon as the os is fully dilated. Dr. Lombe Atthill thinks this trouble may be prevented by the judicious and timely use of the forceps. He often gives ergot also, sometimes combining it with strychnia. Dr. Moorman finds the cold affusion of great service, while he agrees in the use of the forceps and ergot. Dr. Bassett gives iron in advance, where, from the condition of the patient, he anticipates this trouble. (Ibid.) Dr. W. S. Playfair, London, is fully satisfied of the beneficial effects of injections of perchloride of iron. When decomposition of the coagula commenced, they were broken down and removed with the fingers. It would be better to examine earlier, and not permit these to remain, lest septicemia result. Antiseptic intra-uterine injections would be advisable. (Obstet. Journal, May, 1873.) Dr. H. Smith, London, has employed this remedy. He used 1 part to 8 of water. He believes that this form of hemorrhage, after complete uterine contraction, is arterial. He believes that the iron does not produce contraction, nor by coagulation, blocking up the arteries, and that it cannot be regarded as innocuous. Dr. Graily Hewitt had seen peritonitis and death after its use. Dr. Murray had succeeded in ten cases where other means failed. Dr. Braxton Hicks had never seen any serious result follow its use. He had employed it a great many times. Dr. E. H. M. Sell, of New York, had seen it employed constantly at the University of Vienna, and with satisfactory effects. Dr. J. J. Phillips had frequently used it, and had never seen a bad result. Dr. Snow Beck had seen death follow its injection into the uterus in nine or ten cases. He believed the usual means to promote contraction of the uterus were all-sufficient, if they were used efficiently. When the local stimulus of cold or the introduction of the hand failed, sponging or swabbing the inner surface with any astringent would induce contraction, expel the hand and coagula, close the arteries and veins, stop the hemorrhage, and prevent any injurious absorption. In secondary hemorrhage, after the first week, where the walls could not be induced to contract further, sponging or swabbing with an astringent was now and then required, but it was necessary to wash out the cavity daily, to remove injurious mattters, and prevent deleterious absorption. Dr. Bantock had seen death follow such an injection in one case. He believed compression of the uterus would suffice in most cases. Dr. Wynn Williams regarded such injections as accompanied with great risk. He emptied the clots, swabbed the interior with a sponge saturated with equal parts of the iron and water, and left the sponge to be expelled by the uterine contraction. Dr. Protheroe Smith, though recognizing the danger, yet felt it to be a valuable remedy when others had failed. He thought the undiluted tincture of matico might be substituted, and thus avoid some of the dangers of the iron. Dr. Holman had seen many proofs of the safety and efficacy of the iron. He always carried it with him to a case of labor, and believed he had thus saved many lives. He exhausted all other methods first. Dr. Edis had failed with equal parts of the iron and water. Death being imminent, he injected an ounce of the pure perchloride, and the patient at once went on to recovery. He had seen Dr. Rogers regarded it only as a dernier ressort. only one case in seven where its use was followed by bad results. Dr. Barnes insisted that it did cause contraction of the uterus and closure of the arteries, and that effectually. He had often had his hand in the flaccid bleeding uterus, and felt the inner surface contracting, corrugating, crinkling under the contact of the iron as it flowed, stopping the bleeding and expelling the hand. The cases reported as having died after its use were either the result of the already exhausted state, or of septicemia, which was certainly not caused by the iron. Flooding predisposed powerfully to septicamic fever. This frequently occurred without the use of a styptic. Those who had seen it used once, condemned it, while it was emphatically approved by those whose experience had been greatest. He was convinced that he had thus saved many lives. He would continue its use, and urge it on others. Dr. H. Smith said that since he had made it a rule to give ergot to every patient after labor was over, he had fewer cases of puerperal trouble. (Obstet. Journal, April, 1873.) Dr. A. B. Steele, Liverpool, after the most careful investigation, speaks from his own experience, that this mode is safe and reliable, and strongly indicated as a means of rescuing a patient from imminent danger. He does not believe that the iron acts so much from its styptic or hemostatic effect, as from its influence as a reflex exciter of the incident nerves of the uterine walls, and by arousing the peristaltic action of the uterus. A class of cases to which this is specially adapted, is where there is recurrent hemorrhage, the uterus contracting and relaxing, and where it is scarcely safe to relax the grasp upon the uterus for hours. Here the iron at once removes all doubt and induces firm and permanent contractions. (Ibid., June, 1873.) |