CharlesD Musgrove
1899 The Lancet  
o which I had to entrust to the woman in attendance, while I first made an attempt to apply forceps. This failing I tried -version and brought down both legs quite easily but -could not get the body to budge an inch; neither by ,pressure on the abdomen nor internally, on the head, could a single movement be got. At 9 A.M. I returned home (three miles) to fetch a perforator and a cephalotribe returning about 10 A.M. I again chloroformed the patient as before .and perforated easily. Crushing was,
more » ... however, much more difficult owing to the height of the head in the pelvis ; and though I made several attempts to drag down the head with -the cephalotribe in order to get at more distant parts the blades slipped off every time. Finally, at 11.45 A.M. I sent !for assistance and Mr. Scudamore kindly came at 1.15 P.M. The cephalotribe, however, was not more useful in his -hands than in mine, so that we decided upon embryotomy, for which purpose I was forced to go home again to fetch instruments; among these I brought a -scalpel and bistoury but no artery forceps or silk. Embryotomy was, we found, extremely difficult owing to the tightness of the uterine contraction now getting tonic; and as the patient's condition was growing very bad (she had already required three injections of strychnine ;and brandy) immediate Cassarean section was decided on, and this I did at 3 P.M. Without waiting for any ritual observance as regards cleansing the abdominal wall, but merely hastily swabbing over with a 1 in 40 carbolic solution, ,I opened the abdomen. There was, luckily for me, no hsemorrhage from abdominal wall or uterus ; the placenta we had noted to be on the posterior wall. The child was rapidly and -easily extracted, the placenta peeled off readily without any loss, and as the liquor amnii had already drained away there was no soiling of the peritoneum. Introducing a carbolised marine sponge into Douglas's pouch I found that there was practically nothing there, so I at once sutured the uterine ;and abdominal walls, using silkworm gut sutures and my perineum needle for each. A cyanide dressing was then .applied. The patient, who had till now been resting on the mattresses of her bed, was carefully lifted up on to the bed .and surrounded with blankets and hot water-bottles ; and she slowly rallied again. The operation had lasted almost twenty-nve minutes. From the commencement of cephalo--tripsy the total period of anesthesia was five and a half hours (from 10 A.M. to 3.30 P.M.), added to which she had had .about one hour in the early morning (from 7.30 to 8.30 A.M.). The foetus, a finely-developed female, weighed fully 9 lb. without brains, and was over 20 in. in length. The after-progress of the patient was slow but on the whole satisfactory; constipation and flatulence were the chief 'drawbacks. The stitches were removed from the wound on Nov. 2nd and it then appeared soundly,healed, but on Nov. 6th the lower angle reopened to give vent to a quantity of broken down, foul-smelling blood-clot; this discharged for :a few days only and then the opening slowly closed up. The 'highest temperature throughout was 1006° F. The patient -on Nov. 29th was downstairs and getting about again, 'though not of course performing her household duties. I have to record my grateful thanks to Mr. Scudamore for his kind and able assistance. Kingsbury, near Tamworth. THE above title is one which I have adopted to designate ' , 'certain attacks which have come under my notice as I -occurring in individuals who are liable to be called upon to write against time "-this latter phrase implying more than simply writing rapidly, for, as will be explained shortly, it is when a given amount of writing must be completed in a limited space of time that the factors which are efficient in disturbing the cardiac mechanism are brought into play. I have selected the above title because it signifies both the cause and the character of the disturbance thus induced, and I have felt justified in the use of the term " angina" from the close resemblance which these seizures bear, not only in their outward manifestations but, which is infinitely more important, in their intrinsic nature to the malady known as " angina pectoris." It is the accepted use of the latter term which constitutes one of the chief difficulties in the discussion of cardiac phenomena. It would simplify matters considerably were a writer able to state in a paper of this kind that he intended to regard angina pectoris as a symptom merely; but the term has acquired such an individuality as representative of a distinct clinical entity that for the present it is hopeless to attempt to divest it of this significance, and we must content ourselves with regarding angina pectoris as a malady characterised by certain classical symptoms of which pain in the region of the heart is a predominant one, and having an importance due mainly to its liability sooner or later to end fatally. When, however, we approach the discussion of allied seizures, such as those forming the subject of the present paper, some form of title must be sought which will serve to indicate their nature. "Angina-like attacks " is too clumsy and "angina" suggests itself as at once the most suitable and convenient. If this be prefixed by a term expressive of the conditions under which the attacks occur these latter are furnished with a title which not only indicates their character but also makes clear the distinction between them and angina pectoris properly so called. This distinction is one of vital importance to the safety and comfort of the patient-for his safety in that the cause of the seizures being removed he may avoid the ill-effects liable to ensue from a frequent repetition of the same; and for his comfort in that he may be assured that the attacks from which he suffers are of a curable nature if he will but follow out the directions given to him. It is only by a minute inquiry into the circumstances under which the attacks take place and the discovery that they occur solely at times when the patient is engaged in hurried writing that we are able to assure him as to the nature of his complaint. The symptoms correspond so closely to those of angina pectoris that it is impossible by a consideration of these alone to eliminate the latter from our diagnosis, and if in addition the patient be at or above middle age the difficulties are still further increased unless the above-mentioned fact in the history of the attacks is inquired into. Observe, however, that I have used the word "solely," for, of course, in a patient who is undoubtedly the subject of angina pectoris genuine angina pectoris may be induced by the effort of writing hurriedly just as by any other form of exertion (which is an entirely different matter). To take a typical case : a business man finds late in the afternoon or evening that he has, say, an hour's correspondence to get through in half that time, and makes a spasmodic attempt to finish it, hurriedly scrawling off one note after another with anxious glances at the clock meanwhile. He is suddenly alarmed by finding himself seized with a pain in the region of the heart, behind and to the left of the sternum, with a feeling of tightness and oppression about the chest and a sensation as if the heart were going to burst, followed by a number of violent pulsations which one patient graphically described as his heart " turning somersaults," while in some cases the face is covered with a cold sweat. He throws down his pen, leans back in his chair, takes a number of deep breaths, and in a few minutes is comparatively well again, but on resuming his work is again alarmed at finding sooner or later the same train of symptoms repeating themselves. Before considering the nature of this disturbance, it is necessary to discuss the causes which bring it about. These may be considered under three headings-(1) the concentration of the mental faculties ; (2) the posture, and the cramping of the muscles ; and (3) the state of the respiration. To take the last first, a man who is engaged in hurried writing seems to discover, almost unconsciously it may be, that he has not even time to breathe properly, and his respiration tends more and more to consist of short breaths confined to the upper part of the thorax. This condition is further aggravated by the position which he tends to assume, twisting himself round until the left side of his chest is almost in contact with the desk, so that abdominal or deep thoracic respiration is an impossibility. Meanwhile his fingers have become rigid and this rigidity has communicated itself to the muscles of the forearm and thence to those of the upper arm and chest, whilst an observer may soon satisfy himself that even the muscles of the lower extremities have been called upon to contract in the same useless manner. It is evident that as a consequence of the abnormal state of the respiration the right side of the heart must tend to become more or less engorged, while at the same time, owing
doi:10.1016/s0140-6736(01)62913-1 fatcat:2q22tox5gvf2zh4viwjbmpiyoa