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Acute pancreatitis
478
THE
AMERICAN
JOUFtKAL
OF
OBSTETRICS
AND
GYNECOi,OGP
and rigid, we have no means of ascertaining whether the placenta previa is marginti or central. In other words, we are groping in the dark, and in these eases I agree with Dr. McPherson that cesarean seetion is the only operation of choice and by so doing we save the greatest number of mothers and a great number of babies. In addition, I think, every time we do cesarean section for placenta previa the uterus should be packed for possible hemorrhage7 particularly the lower segment. In patients, who are two or three fingers f dilated, we can differentiate whether the ease is one of placenta previa centralis or one of placenta previa lateralis, and we Patients, w-hose hemoglobin goes down to’ 70 can select the method of interference. or 60, due to bleeding, should not be meddled with, and the sooner such patients are delivered the better for the mother and baby. Once a woman has a hemoglobin of 60 or 65, due primarily to bleeding, a second hemorrhage may kill her, even if she loses only a small quantity of blood. DR. OTTO H. SCHWARZ, ST. LOUIS, No.--1 would like to ask Dr. McPherson whether in cases in which he does cesarean section he always transfuses before doing that opera,tion and the use of the bag for the control of hemomhage7 DR. MCPHERSON (closing).-In regard to’ Dr. Speidel’s remarks about the Voorhees bag, I will say that the use of the Vo,orheas bag is a well recognized method of treating these oases. The only objection to it is the danger of its being suddenly expelled with resultant hemorrhage. Theoretically it is claeaner. I have twice had the Voorhees bag expelled before I was able to do anything. The woman had a good hard pain and bled to de’ath before anything could be done. Packing controls hemorrhage until you take it out; if you have such an accident once it is excusable, but if you have the same accident happen twice, it is not so excusable, andi that is the reason I prefer packing to the use of the bag. In answer to Dr. Schwarz about transfusing before doing eesarean section, I do not think it is necessary to resort to transfusion unless there a,re indications for it. If the patient needs transfusion, I have things ready so that it can be given immediately. If she comes into the hospital exsanguinate& it is necessary to transfuse her before operation. I have seen cases that bled straight through, the blood coming out at the other end; in other words, it went into t!m vein and came out of the vagina. I have not made a practice of packing these cases after operation, and I believe that the suturing of the incision is suf!dcient irritation to cause contraction of the uterus. Dr. Rongy is theoretically correct, but these patients have not bled to death after they were operated on. I would rather not pack them after opening the uterus.
DR.
PAUL
DR.
LEWIS
IJ. AXDREWS, of Pittsburgh, Pa., presented A Sudy of Frozen Sections Through the Uteri of During Labor. (For original article see page 896.)
TITUS AND VERNON
(by invitation) Women Dying I?.
(For original
KNEAD,
article
Toledo, Ohio, read a paper on Acute see page 431.) DISCUSSION
DR. FREDERICK S. WETDEREXL, ‘SYRACUSE, N. P.-I should like to report a case I haa recently of acute panereatitis. From an etiologio standpoint, this case was interesting, in that the patient was just eight days over her crisis from
AM.
ASSN.
OBST.,
GYNEC.
AXD
ABD.
SURG.
479
a rather mild lobar pneumonia. She was seen by her family physician because and seen again eight hours after that. of abdominal pain, was given morphine, I saw the case with him, and the clinical picture and physical findings were those of an acute cholecgstitis. The patient was immediately sent to the hospital. There an internist saw her. No urinalysis was made during the attack of pneumonia Furl;her examination with or up to the time of her admission to the hospital. better facilities in the hospital disclosed an abundance of sugar in the urine which led us to think of the possibility of pancreatitis. The abdomen was opened by a transverse incision and extensive white plaques, po’stperitoneally, were seen. An attempt was made to explore the lesser omental bursa through t,he epiploic foramen, and great difficulty was experienced in getting in there, and all the tissues were extremely friable. A large drain was inserted into the omental bursa and the abdomen closed. The patient died in twenty-four hours. At autopsy there was no evidence of any kind of obstruction of the pancreatic ducts, no cholelithia@ but very extensive fat necrosis throughout the abdomen.
CORDON HEYD, WARD J. MACNEAL and JOIHN A. KILLIAN presented a paper entitled Hepatitis in Its Relation tal Inflammatory Disease of the Abdomen. (For original article see page 413.)
DRS. CHARLES
DISCUSSION I would like to ask a few questions. DR. GEORGE W. CRJLE, CLEVELAND, OHIO.1’irst, whether during the time these observations were made the temperature ranged high or low. Second, whether the pathologist noted any relation to the changes that take place in the intracellular structures of the blood vessels, the connective tissue, etc. Third, whether he noticed a change in the stainability of the cells of the liver themselves, and whether the acid alkali balance changed. 1 saw many pale areas in the liver which might possibly be thus interpreted. DR. JAMBS E. DAVIS, DETROIT, MWEL-I want to ask one or two questions. First, whether lysis of cells in the liver tissue has been controlled; or, in other words, how long after removal of the tissue was’ complete preservation establishedf It is a common observation in general septic conditions within the abdomen to see not only changes similar to the ones we have had pictured in the liver but in the spleen, in the kidney, and in a lesser degree in other tissues. I should like to ask if any observations have been made as to whether the conditions were primarily in the liver or did they show first in other tissues? DR. W. WAYNE BABCOCE, PITILADELPHIA, PA.-I ‘should like to ask a question with regard to the calcium content of the blood, which usually does not show a reduction corresponding with the reduced coagulation point. Nevertheless, the intravenous use of calcium chloride has been advocated in hepatic and pancreatic disease with a tendency to hemorrhage, and Dr. William J. Mayo had called our attention to the fact that folIowing the use of this drug, operations for these conditions have shown a lessening in mortality of 50 per cent. Is this injection of real value8 In a few cases, using 200 to 500 C.C. of a 2 per cent. solution of calcium chloride, I have seen marked improvement follow, but was the improvement due to the calcium7 In a supposedly hopele% case of hemorrhagic pancreatitis and in a case of sudden collapse after cholecystectomy the patients rapidly revived after the injection. The dilute solution seems safer to use and Iess prone to cause a severe reaction than the concentrated solution usually employed. It is possible that our patients would have improved from a simple saline injection.
THE
AMERICAN
JOUFtKAL
OF
OBSTETRICS
AND
GYNECOi,OGP
and rigid, we have no means of ascertaining whether the placenta previa is marginti or central. In other words, we are groping in the dark, and in these eases I agree with Dr. McPherson that cesarean seetion is the only operation of choice and by so doing we save the greatest number of mothers and a great number of babies. In addition, I think, every time we do cesarean section for placenta previa the uterus should be packed for possible hemorrhage7 particularly the lower segment. In patients, who are two or three fingers f dilated, we can differentiate whether the ease is one of placenta previa centralis or one of placenta previa lateralis, and we Patients, w-hose hemoglobin goes down to’ 70 can select the method of interference. or 60, due to bleeding, should not be meddled with, and the sooner such patients are delivered the better for the mother and baby. Once a woman has a hemoglobin of 60 or 65, due primarily to bleeding, a second hemorrhage may kill her, even if she loses only a small quantity of blood. DR. OTTO H. SCHWARZ, ST. LOUIS, No.--1 would like to ask Dr. McPherson whether in cases in which he does cesarean section he always transfuses before doing that opera,tion and the use of the bag for the control of hemomhage7 DR. MCPHERSON (closing).-In regard to’ Dr. Speidel’s remarks about the Voorhees bag, I will say that the use of the Vo,orheas bag is a well recognized method of treating these oases. The only objection to it is the danger of its being suddenly expelled with resultant hemorrhage. Theoretically it is claeaner. I have twice had the Voorhees bag expelled before I was able to do anything. The woman had a good hard pain and bled to de’ath before anything could be done. Packing controls hemorrhage until you take it out; if you have such an accident once it is excusable, but if you have the same accident happen twice, it is not so excusable, andi that is the reason I prefer packing to the use of the bag. In answer to Dr. Schwarz about transfusing before doing eesarean section, I do not think it is necessary to resort to transfusion unless there a,re indications for it. If the patient needs transfusion, I have things ready so that it can be given immediately. If she comes into the hospital exsanguinate& it is necessary to transfuse her before operation. I have seen cases that bled straight through, the blood coming out at the other end; in other words, it went into t!m vein and came out of the vagina. I have not made a practice of packing these cases after operation, and I believe that the suturing of the incision is suf!dcient irritation to cause contraction of the uterus. Dr. Rongy is theoretically correct, but these patients have not bled to death after they were operated on. I would rather not pack them after opening the uterus.
DR.
PAUL
DR.
LEWIS
IJ. AXDREWS, of Pittsburgh, Pa., presented A Sudy of Frozen Sections Through the Uteri of During Labor. (For original article see page 896.)
TITUS AND VERNON
(by invitation) Women Dying I?.
(For original
KNEAD,
article
Toledo, Ohio, read a paper on Acute see page 431.) DISCUSSION
DR. FREDERICK S. WETDEREXL, ‘SYRACUSE, N. P.-I should like to report a case I haa recently of acute panereatitis. From an etiologio standpoint, this case was interesting, in that the patient was just eight days over her crisis from
AM.
ASSN.
OBST.,
GYNEC.
AXD
ABD.
SURG.
479
a rather mild lobar pneumonia. She was seen by her family physician because and seen again eight hours after that. of abdominal pain, was given morphine, I saw the case with him, and the clinical picture and physical findings were those of an acute cholecgstitis. The patient was immediately sent to the hospital. There an internist saw her. No urinalysis was made during the attack of pneumonia Furl;her examination with or up to the time of her admission to the hospital. better facilities in the hospital disclosed an abundance of sugar in the urine which led us to think of the possibility of pancreatitis. The abdomen was opened by a transverse incision and extensive white plaques, po’stperitoneally, were seen. An attempt was made to explore the lesser omental bursa through t,he epiploic foramen, and great difficulty was experienced in getting in there, and all the tissues were extremely friable. A large drain was inserted into the omental bursa and the abdomen closed. The patient died in twenty-four hours. At autopsy there was no evidence of any kind of obstruction of the pancreatic ducts, no cholelithia@ but very extensive fat necrosis throughout the abdomen.
CORDON HEYD, WARD J. MACNEAL and JOIHN A. KILLIAN presented a paper entitled Hepatitis in Its Relation tal Inflammatory Disease of the Abdomen. (For original article see page 413.)
DRS. CHARLES
DISCUSSION I would like to ask a few questions. DR. GEORGE W. CRJLE, CLEVELAND, OHIO.1’irst, whether during the time these observations were made the temperature ranged high or low. Second, whether the pathologist noted any relation to the changes that take place in the intracellular structures of the blood vessels, the connective tissue, etc. Third, whether he noticed a change in the stainability of the cells of the liver themselves, and whether the acid alkali balance changed. 1 saw many pale areas in the liver which might possibly be thus interpreted. DR. JAMBS E. DAVIS, DETROIT, MWEL-I want to ask one or two questions. First, whether lysis of cells in the liver tissue has been controlled; or, in other words, how long after removal of the tissue was’ complete preservation establishedf It is a common observation in general septic conditions within the abdomen to see not only changes similar to the ones we have had pictured in the liver but in the spleen, in the kidney, and in a lesser degree in other tissues. I should like to ask if any observations have been made as to whether the conditions were primarily in the liver or did they show first in other tissues? DR. W. WAYNE BABCOCE, PITILADELPHIA, PA.-I ‘should like to ask a question with regard to the calcium content of the blood, which usually does not show a reduction corresponding with the reduced coagulation point. Nevertheless, the intravenous use of calcium chloride has been advocated in hepatic and pancreatic disease with a tendency to hemorrhage, and Dr. William J. Mayo had called our attention to the fact that folIowing the use of this drug, operations for these conditions have shown a lessening in mortality of 50 per cent. Is this injection of real value8 In a few cases, using 200 to 500 C.C. of a 2 per cent. solution of calcium chloride, I have seen marked improvement follow, but was the improvement due to the calcium7 In a supposedly hopele% case of hemorrhagic pancreatitis and in a case of sudden collapse after cholecystectomy the patients rapidly revived after the injection. The dilute solution seems safer to use and Iess prone to cause a severe reaction than the concentrated solution usually employed. It is possible that our patients would have improved from a simple saline injection.