Charles A. Gordon

Respiratory emphysema in labor

Summary 1. Subcutaneous emphysema is a broad term for a rare complication of labor which needs further classification. 2. Respiratory emphysema of labor is suggested as descriptive of the form studied here. 3. Its etiology and pathology are not definitely known, but it may originate in any part of the air passages. 4. Its prognosis is generally good, and its treatment obvious. 5. One hundred and thirty cases are now available for study and the appended bibliography, with the abstracted cases above, includes all the references except textbooks.

Osteogenesis imperfecta Congenita

Summary 1. Muscular action on cartilage probably accounts for the deformityof bone, and may increase the size of the marrow cavity. 2. Failure of subperiostral bone formation, with marked decrease inthe number of trabeculae and peristence of embryonal cartilage constitutethe essential lesion. 3. No evidence of disproportionate breaking down of bone was seen. 4. if any conclusion were to be drawn from this isolated study. itwould seem that the condition is due either to defective function ofthe osteoblasts or possibly lack of suffieient preparatory calcificationof cartilage.

The reduction of mortality in ectopic gestation

Abstract The impression that the mortality of ectopic gestation is well under control is erroneous. Nearly 6 per cent of the maternal mortality of the City of New York is due to ectopic gestation; equally high figures, with a large percentage of deaths due to sepsis, and many patients never operated upon at all, are reported elsewhere. Even gynecologists have published inconsistent results. The outstanding fact is failure of diagnosis. Our textbooks disagree on treatment and for the most part fail to emphasize and discuss thoroughly the importance and value of supportive treatment. It should be possible to rationalize teaching at least. It should not be said repeatedly that diagnosis is especially difficult, nor should it be unqualifiedly stated that every patient should be operated upon at once no matter what her condition, no matter who may be the operator. In the presence of intraperitoneal blood only the simplest operative procedure should be carried out. It is perfectly proper and wise to defer operation in many serious cases, not indefinitely, but until transfusion and other supportive treatment lessen the risk of operation. A comprehensive survey of the whole problem should be undertaken.

Studies in pelvic iontophoresis

Abstract 1. 1. Pelvic iontophoresis of a choline compound was given to 58 patients with subacute and chronic pelvic infection, all severe enough to warrant hospitalization; 37 were cases of tuboovarian infection and 21 were cases of cellulitis. 2. 2. Subjective improvement was generally marked, and often out of proportion to objective evidence of decrease of the infection. 3. 3. The results of therapy in tuboovarian infections, while often good, were not sufficiently remarkable to warrant routine use of this method of treatment. It seems clear that we cannot hope for resolution of old inflammatory tuboovarian masses, since fibrosis and multilocular cysts are a prominent part of the pathology. It may, however, be given a trial in persistent tuboovarian infections, when operative treatment is not indicated and other methods of treatment have been ineffective. 4. 4. The best response to iontophoresis was seen in cases of massive cellulitic infection of recent origin which had failed to yield to ordinary treatment. Pelvic iontophoresis is recommended for this type of infection.

Regional ileitis as a problem in pelvic diagnosis

Abstract X-ray would have established the diagnosis in all three cases. The intractable fistula, in one case, was typical of regional ileitis, yet that diagnosis did not occur to us, because the mass was pelvic. In the other cases a tumorlike mass was thought to be of adnexal origin, because it was deep in the pelvis. Chronic illness in a young woman, with weakness, loss of weight, dull abdominal or pelvic pain, cramps or diarrhea after eating, and a history of repeated remissions suggests regional ileitis. An abdominal mass to the right of the umbilicus or a fistulous opening near an old laparotomy scar is excellent confirmatory evidence. This mass may be mistaken for adnexal tumor, because of its proximity to the uterus or because of possible coincidental gynecologic symptoms. The x-ray will establish the diagnosis. Resection well beyond the involved area is indicated, for unless excision is radical the disease will spread. The two stage operation is the procedure of choice, as the mortality for primary anastomosis is high. Careful diagnostic study will protect the gynecologist who is not prepared to perform intestinal resection.

Rupture of the uterus

Abstract 1. 1. Rupture of the uterus during pregnancy or labor is the most serious obstetric complication. If untreated its mortality approaches loo per cent for the mother and undelivered fetus. 2. 2. The obese multipara with a pendulous abdomen and scarring of the cervix is predisposed to rupture of the uterus. 3. 3. No patient should be permitted to continue long in labor with the presentation unknown. Obstructive dystocia from malpresentation may cause spontaneous rupture of the uterus. 4. 4. When pituitrin is used for the treatment of uterine inertia, the intravenous drip method is advised if certain contraindications are not present. 5. 5. The symptoms and signs of rupture of the uterus due to separation of a cesarean section scar may vary greatly from the usual picture. In an occasional instance the dictum “Once a cesarean, always a cesarean” may be violated. 6. 6. Internal version is by far the most common cause of rupture of the uterus. It is a dangerous procedure. When indicated certain prerequisites must be met. 7. 7. The diagnosis would be made more frequently if it were thought of; shock during labor is significant. 8. 8. The uterus should be explored in every case in which shock and persistent bleeding follow a major vaginal operative procedure. 9. 9. The cardinal principles of good treatment are massive transfusion and immediate operation. Shock is no contraindication to operation.

Puerperal morbidity without disinfection of the vagina

Abstract We have presented 2016 average cases of labor, with a morbidity of but 3.6 per cent. These patients were delivered by interns with but our routine preparation of the outside field, and without any attempt to disinfect the vagina. For our iodine we hold no brief, but I believe that conservative obstetrics, with minimal interference, is the best protection against puerperal infection. Our series is small; possibly more figures would increase our morbid rate, perhaps not. I feel sure that somewhere lies the irreducible minimum. The whole question of vaginal antisepsis is still an open one. Although excellent results have been unquestionably obtained, coincident with the use of merenrochrome, there is grave doubt of its value as a sterilizing agent. The widespread use might give a false sense of security to those whose obstetric judgment is outdistaneed by their desire for rapid delivery.