Abrams' method of treatment in aneurysms / by Albert Abrams.

  • Albert Abrams
Date:
[1914?]
Catalogue details

Licence: Public Domain Mark

Credit: Abrams' method of treatment in aneurysms / by Albert Abrams. Source: Wellcome Collection.

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    JULY 8, 1911. j MEDICAL JOURNAG - and may be continued until the membranes are seen to protrude; the scalpel can then be laid aside, and the incision rapidly enlarged with scissors, or the whole incision may be completed by the scalpel;- personally I prefer the former method. If the membranes are already ruptured, care must be taken that the fetus is not injured by the scalpel in making the uterine incision. In two cases I enlarged the incision by tearing with the fingers, and I found that the resulting wound presented no difficulties in suturing. When the mcision is completed the membranes should be opened by scalpel or scissors and the fetus seized, preferably by the feet. If the placenta is encountered in the incision it should be rapidly separated by the fingers. A most valuable manceuvre at this stage is for the assistant to hook up each end of the incision by passing an index finger into it during the extraction of the child; this prevents the uterus falling back into the abdomen as soon as it is emptied, and enables it to be readily brought out through the abdominal incision. lt is well to arrange beforehand that some one shall take charge of the child, otherwise, in the excitement of the moment, it may not receive proper attention. As soon as the child’ is removed the cord should be clamped in two places with long-bladed pressure forceps, and divided between ; this saves time, and the tying can afterwards be done by the person to whom the care of the child is entrusted. The placenta and membranes should be carefully detached and peeled off the uterine wall, and while this is being done the uterus should be enveloped in sterilized hot cloths, and gently kneaded to ensure contraction. This is usually sufficient. to arrest haemorrhage, but if it con- tinues, the assistant should grasp the broad hgament on each side with the finger and thumb whilst the operator continues to knead the uterus. Although the haemorrhage during the uterine incision and the extraction of the child looks very alarming, good contraction usually cnsues as soon as the uterus 1s completely emptied and kneaded by the hand, and I have had no really dangerous haemorrhages - pest ony of ny eadan—— is particularly in cases of contracted pelvis that this question arises, for in cases such as my third, in which the cause of obstruction can be effectually removed, steriliza- tion is, of course, not required. Even in cases of contracted pelvis many authorities are now opposed to sterilization, and several cases have been published in which Caesarean section has been repeated two or more times on the same patient. This is a question in which the wishes of the parents should be allowed to have weight, and the prospects of the offspring from the eugenic point of view should be taken into consideration; this last point of view seems to have been entirely overlooked in a case operated on by Sir William Sinclair, and published in the Jowrnal of Obstetrics and Gynaecology of the British Empire, January, 1904; the patient, who was extremely deformed by rickets and hip-joint disease, was of a low order of intelligence and had spent nearly all her life in workhouse infirmaries. Caesarean section was performed three times, a living child resulting on each occasion. In my own cases the following course was pursued as regards sterilization : In two of the cases, Nos. 3 and 7, the operation was performed for other conditions than contracted pelvis—in No. 3 for labour obstructed by a dermoid cyst; in this case sterilization was not performed, and the patient has since been delivered successfully of a live child, per vias naturales: In No. 7 labour was obstructed by a fibroid; the tumour was situated low down on the posterior uterine wall, and had a wide attachment, and, as myomectomy seemed inadvisable, supravaginal hysterectomy was performed. This leaves eight cases of contracted pelvis. In two, the first and fifth on the list, supravaginal hysterectomy was performed, ‘surely to obtain sterilization; in No. 2 the same operation, partly because there was evidence of commencing rupture of the uterus, Sterilization by excising a piece of each tube was performed in three cases, Nos. 4; 6, and 8, and in the last two cases, Nos. 9 and 10, no sterilization was performed. The following methods of obtaining sterilization have to be considered: Odphorectomy, hysterectomy, ligature of the Fallopian tube, excision of a piece of each Fallopian tube. 3 Odphorectomy is not a method to be recommended. ws i —— ee a 5 —— ——— - Hysterectomy is a method which has the approval of Mr. Bland-Sutton, but in the opinion of most operators it is too severe a proceeding when sterilization alone is aimed at. ‘Tying the tubes has been proved to be quite in- effectual. Excision of a portion of each tube appears to be, on the whole, the method which is to be preferred and most in favour. I have met with a case in which preg- nancy occurred in a patient who had undergone Caesarean section, with excision of a portion of each tube, in Queen Chartotte’s Hospital eight years previously; and other cases have been recorded, though the instances must be very rare. Sterilization is made more certain if the uterine end of the tube is excised and the incision in the uterine wall closed by sutures. . Hysterectomy is indicated in cases in which there is reason to think that the uterus is already infected, or in which there is rupture of the uterus. H the operation is performed, the supravaginal amputation with intraperitoneal treatment of the stump should be considered the operation of selection. For suturing the uterine wall I used silk in all my cases, except the last, in which I used chromic gut for the deeper sutures. I have not met with any ill result from the use of silk, and I prefer it to any other material. I have in every case sutured in two layers, the deeper one including the peritoneum and muscular wall, but not penetrating the mucous membrane, and the superficial layer taking peritoneum only and being applied in Lembert’s fashion. Drainage was not used in any of the cases. The abdominal wall-was closed:in. layers in every case. ‘The abdominal wound healed by first intention in all except one; the case which suppurated was No. 2, the case Which had been longest in labour, and the only one in which prolonged attempts at forceps delivery had been made. The danger of Caesarean section increases enormously with the length of time the patient has been in labour anc the amount of manipulation she hag undergone, and when performed on a patient who has been infected by septic hands or instruments, the death-rate is high, but in un- infected cases the operation gives most satisfactory results. ON THE TREATMENT OF THE EXCESSIVE VOMITING OF PREGNANCY, BY JAMES H. MARTIN, M.D., ASSISTANT GYNAECOLOGIST, GLASGOW MATERNITY AND WOMEN’S HOSPITAL, Durine my term of residence as senior house-surgeon in the Glasgow Maternity and Women’s Hospital seventeen cases of the excessive vomiting of pregnancy or hyperemesis gravidarum were sent in for treatment, and in each case the diagnosis of the family doctor was confirmed by observations at the hospital. All the patients before admission had for several weeks been treated with the usual “stomach drugs,” and in two cases rectal feeding had been tried for some days without any improvement. One case was admitted very ill and died. On admission she could retain nutriment neither by the mouth nor the rectum. She was in that hopeless con- dition described by Dubois, “ characterized by increased prostration, constant headache, impairment of vision, tendency to somnolence, and derangement of the intel- lectual faculties. To operate in these circumstances would only bring obloquy on our art and perhaps hasten the patient’s end.” . On referring to textbooks regarding the treatment of this distressing complication of pregnancy, one is struck by the number and variety of drugs that are all strongly recom- mended. I doubted the efficacy of this drugging, and it seemed to me that other treatment should be adopted. On admission the patient’s history was carefully gonc into. A thorough examination of all the symptoms was made, particular attention being paid to the condition of the alimentary canal, vagina, uterus, and appendages. In view of the recent writings on appendix dyspepsia, this point was investigated, but the result was negative in all. Bad teeth and chronic constipation were found associated in every case. The patient was strictly confined to bed, and was assured
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