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Thus it will be seen that a considerable proportion of the cases were successful, and that this has been so in proportion as the children have been advanced in age. In all the children of less than two years of age, the operation proved fatal ; and the others who succumbed, with two exceptions, scarcely exceeded that age. In the two older children (seven and eight years of age) who died, there were other causes of death independently of the operation. The explanation of this circumstance M. André supposes to exist in the fact that children of four years of age, who recover more frequently than younger children, offer greater resistance to both the accidents of the operation itself, such as hæmorrhage and traumatic fever, to the diphtheritis, and the complicating affections, such as capillary bronchitis and pneumonia. They are also more docile, and allow more readily of the repeated examinations of the wound and canula that are necessary; while suitable diet, so essential, and so difficult of management in very young children that have been operated upon, is more easily regulated. It is probably also due to the greater power of resistance possessed by boys, that the proportion of their recoveries exceeds that of the girls. Another circumstance to be mentioned is the deplorable facility with which children who have not already had the measles or scarlatina contract these affections upon admission into the hospital; and although, usually, eruptive fevers are uncommon prior to the fifth year, scarlatina attacked no less than ten of these little patients, of whom a third part died. M. André agrees in the justice of the opinion long held by the officers of the hospital, that the ulterior success of tracheotomy is much interfered with by the earlier employment of debilitating remedies, such as venæsection, leeches, blisters, &c.
V. A Case of Strangulated Hernia Obturatoria. By Dr. LORINSER.
(Wien Wochenschrift, 1857. No. 3.) As far as the author is aware, there is but one case on record (by Mr. Obré, in the "i Medico-Chirurgical Transactions," vol. xxxiv.) in which this form of hernia has been recognised during life and relieved by operation; and even in that instance, the nature of the hernia was not suspected prior to the commencement of the operation. He now relates a case which occurred to himself, the nature of which was detected, and an operation performed with success.
On July 21st, 1856, a feeble, spare woman, aged sixty-five, while reaching a heavy object from on high, felt as if something burst in the groin. She was seized with pain in the abdomen and vomiting, and was brought to the hospital, and as there was no appearance of a hernia, she was at first supposed to be suffering from simple peritonitis. To the other symptoms were, however, added obstinate constipation, and after a while, fæcal vomiting. The author first saw her on August 1st,-i. e., eleven days after the accident-when she exhibited general symptoms of the most unfavourable description. On examina. tion, the inguinal and femoral canals were found quite free, but the triangular space formed by the adductor longus, Poupart's ligament, and the femoral vessels, was observed on the left side to be level with the surface, instead of depressed as on the right side. When the fingers were passed upwards towards the foramen ovale, a soft swelling, about the size of an egg, and sensible to pressure, was perceived behind the poctineus, stretching from the foramen ovale to the outer border of the adductor. It was placed posteriorly, and somewhat internally to the pectineus, and was yielding rather than tense, the colour and temperature of the skin covering it being normal. Upon percussion, the tumour imparted a deep, full, tympanitic tone. From the vagina, a somewhat tense, very sensitive tumour could be felt at the posterior edge of the foramen ovale. All movements of the thigh caused pain. The diagnosis
was much facilitated by the spareness of the woman, and by the tympanitic tone elicited by percussion over the whole circumference of the tumour.
From the duration of the strangulation, and from the full, deep tympanitic sound, it was concluded that the intestine had become perforated and gas effused into the sac. An operation was, however, resorted to, and the pectineus being brought into view, it was slit up, somewhat obliquely, upon a grooved director, as far as the border of the adductor. Immediately behind it was found cellular tissue filled with exudation, and then the discoloured and softened sac. On opening this, a stinking fluid, partly watery, partly purulent, and containing particles of fæcal matters, flowed out. The finger was now passed into a cavity which was bounded upwards by the obturator ligament, and in a cleft at the upper part of this ligament, and in part adhering to it, lay a relaxed and collapsed portion of intestine, about the size of a walnut. Behind the intestine, at the lower angle of the cleft in the ligament, the pulsations of the obturator artery were supposed to be felt. On account of the great depth of the parts, no ocular examination of the intestine could be made. As the intestine was ruptured, and sufficient egress of the contents was secured, further division of the fibrous cleft was abstained from, in order not to endanger the separation of the recent adhesions, and consequent fæcal effusion into the abdomen. The chief care was employed to secure a free discharge of the fæcal matters, preventing them lodging in the surrounding cellular tissue. To this end the cavity of the sac was well syringed out, linen rags being then applied, and the whole covered with cold applications. A clyster of tepid water was ordered every two hours, and the diet was low.
As soon as a certain amount of fæcal matters had been discharged through the wound, all symptoms of strangulation ceased. For the first few days, the discharges of fæces were pretty frequent, rendering the repeated cleansing out of the wound requisite. The clysters were soon employed but twice a day, a small quantity of fæces being discharged per anum. As these discharges continued, and contained matters of which the patient had partaken since the operation, there seemed every probability that only one side of the intestinal noose had been strangulated, the uninjured portion keeping up the communication between the upper and lower portions of the gut. The wound gradually cleansed and diminished in size, while the woman's strength and appetite increased until the end of August, when she became the subject of bronchitis. This delayed her progress, but by November the fæcal fistula, which had long been inconsiderable, had quite closed, and she only remained longer in the hospital on account of the chest affection.
VI. Ox Bluding from the Ear as a Consequence of Injury done to the Chin.
By M. MORTÀN. (Archives Générales, cinquième série, tome vii. pp. 653-661.)
Bleeding from the ear as a consequence of contre-coup has been accepted by surgeons as an almost certain indication of fracture of the base of the cranium. M. Morran has, however, met with two cases in which injury to the chin gare rise to this phenomenon. The subject of the first of these was a robust lad, five years of age, who had, five or six hours before the author's arrival, fallen on his lace on the pavement from a height of several feet. Immediately after the fall, a large tow of blood took place from the right ear, this being continued, when I Nerran saw him, only in occasional drops, in which condition it lasted for three dars longer. No fracture or dislocation of the jaw could be detected, and the membrana tympani was not ruptured. The child suffered much from pain in front of the right ear, from attempts at deglutition, and Thean any movement of the jaw. In the second case, a very strong man, aged fort y sera Prix & kick from a horse on the chin, which almost deprired, him of consciousness, and gave rise to an abundant jet of blood from the right ear. No fracture or dislocation could be found, but deglutition was excessively difficult. Prompt depletion dissipated the cerebral symptoms, and all went on well, a considerable amount of deafness remaining in the right ear. The membrana tympani was uninjured.
On searching, the author has been able to find only three analogous cases, and these only meagrely detailed, making thus, with his own, five cases. In three of these, the blow on the chin resulted from a fall, and in two was produced by a kick from a horse. In three, the bleeding took place from one ear, and in two from both ears. In the author's cases, thc force acted obliquely, and the bleeding occurred on the opposite side to that of the point of contact. When bleeding has occurred from both ears, the blow has been central. In one only of the five cases did fracture of the jaw occur. In order to produce bleeding by this form of contre-coup, it is probably necessary that the shock should be entirely transmitted to the articulation of the jaw, while when fracture takes place, its force is usually exhausted in the production of the lesion of the bone. In the three cases in which the point has been noted, the difficulty of deglutition and mastication has been excessive at first, and has continued for a long period; and M. Morvan suggests that the lesion which gives rise to this symptom, as well as to the bleeding from the ear, is a fracture across the glenoid cavity, which explains the occurrence of the abundant hæmorrhage, the membrana tympani remaining entire. Some experiments he has made in the dead body, by inflicting blows upon the chin, have failed to produce this form of fracture, but have induced fracture of the base. Thus no doubt can exist that this description of contre-coup may also produce fracture of the base, with bleeding from the ear, and rupture of the membrana tympani ; but when we meet with such bleeding as a consequence of violence done to the chin, and without rupture of the membrane, the hæmorrhage may be regarded as a far less dangerous symptom.
VII. On Secondary Syphilitic Affections of the Lachrymal Passages. By M.
LAGNEAU, Jun. (Archives Générales, cinquième série, tome ix. pp. 536–555.)
M. Lagneau, after taking a review of the scattered observations which have been made upon this subject by various authors, and narrating the particulars of four cases that have come under his own notice, arrives at the following conclusions :
1. The syphilitic nature of certain affections of the lachrymal passages seems sufficiently proved; 2. There is usually more or less complete obliteration of one of the lachrymal points, which is generally caused by an osseous lesion (periostitis, exostosis, caries, or necrosis), having its seat in the os unguis and the ascending apophysis of the maxillary bone-sometimes in the angular apophysis of the frontal bone. Sometimes the closure seems to depend npon swelling of the inflamed mucous membrane, arising from chronic blephoritis, and at others upon a lesion analogous to and accompanying naso-palatine syphilitic affections. 3. The symptoms which enable us to distinguish syphilitic from other affections of these parts, are the existence of a hard, resisting tumour,—the chancrous appearance of the cutaneous surface of the fistula lachrymalis, when this is present,—the co-existence of syphilitic affections of the mucous membrane, or bones of the palate and nasal fossæ,—the presence of syphilitic eruptions of the face, and the co-existence of supra-orbital cephalalgia and exostoses,-together with the history of the patient, or the discovery, on inspection, of the marks of syphilis on other parts of the body; 4. The progress of the affection is usually indolent, although sometimes there is a certain amount of erysipelatous inflammation; 5. The prognosis of syphilitic disease of the lachrymal passages and of adjoining parts (ancholops, ægilops) is less serious than when the same affections are not induced by a specific cause, for, when it is employed in time, they are usually curable by appropriate treatment; 6. When the obliteration is due to only a lesion of the soft, in place of the osseous parts, we may sometimes, as a palliative treatment, re-establishi the channel for the tears by means of catheterisın; 7. Most of the cases recorded have been successfully treated by mercury; but the author thinks, with M. Tavignot, that the iodide of potassium may be usefully employed when the bony parts are affected.
QUARTERLY REPORT ON MIDWIFERY.
By ROBERT BARNES, M.D. (Lond.)
I. PHYSIOLOGY AND PATHOLOGY OF THE UNIMPREGNATED STATE. 1. On Amyloid Degeneration of the Female Sexual System. By VIRCHOW.
(Monatsschr, f. Geburtsk. April, 1857.) 2. Case of Artificial Enucleation of a Large Fibroid Tumour of the Uterus. By
T. F. GRIMSDALE, Esq. (Liverpool Med.-Chir. Journal. January, 1857.) 3. Clinical Researches on Peri-Uterine Phlegmons. By G. BERNUTZ and E.
GONFIL. (Archives Gén. de Méd. March, 1857.)
Méd. d'Orient. May, 1857.) 5. On Blistering the Cervix Uteri. By Dr. Johns. (Dublin Quart, Journ.
May, 1857.) 6. On the Treatment of Ovarian Dropsy by Iodine Injections. The discussions
in the French Academy of Medicine. (Union Médicale; Gazette des Hôpitaux. 1856 and 1857.-M. DOLBEAU: Gazette Hebdomadair. Oct., 1856, M. PHILIPART: Gazette des Hộp. January, 1857.—M. PIGNAUT:
Moniteur des Hôp. January, 1857.) 1. Virchow has related to the Berlin Obstetrical Society a case exhibiting a form of disease of the female generative organs not hitherto described, which he calls “Amyloid Degeneration.” It was that of a woman who had sunk under amyloid degeneration of different organs, and who exhibited the entire sexual system affected by this peculiar process, which of all diseases is that which has the widest extension throughout the organism. The degeneration extended over the ovaries, tubes, and uterus, the last being in consequence enlarged, transparent, clear, and remarkably anæmic. The deposition of the amyloid mass had here particularly followed the organic muscular fibres, so that scarcely one of these did not present the characteristic iodic reaction. The disease had in this woman, as commonly happens, run its course concurrently with the symptoms of Bright's disease.
2. Mr. Grimsdale's case of artificial enucleation of a large fibroid tumour of the uterus is a valuable illustration of the pathology and therapeutics of this affection. The tumour occupied the posterior wall of the uterus and cervix : an incision was made in the posterior cervix, forming a sort of artificial os for the tumour; through this the tumour was gradually projected by the contraction of the womb, ergot of rye being repeatedly given, and on the fifteenth day it was wholly severed by breaking down adhesions with the finger and the scissors. A good deal of irritative fever accompanied the extending process. No hæmorrhage attended the final separation. Mr. Grimsdale contends that the operation for enucleation is occasionally not only justifiable, but desirable. 3. Drs. Bernutz and Gonfil have contributed a valuable clinical contribution to the history of peri-uterine inflammation, an affection which, under different names, has lately attracted particular attention. They first relate in detail two cases of peri-uterine inflammation, in which swellings, taken to be symptomatic of pelvic cellulites, had been recognised during life, but which, terminating fatally through intercurrent diseases, were found on dissection to present evidence of peritoneal inflammation only.
Case I.-Absence of previous uterine affection, blennorrhagia occupying the urethra, vagina, and uterus; the twelfth day after the commencement of this blennorrhagia, general illness and acute pains in the inferior part of the belly. On the twentieth day, when admitted into the l'Ourcine Hospital, very acute pain was manifest in the hypogastric region, especially on the left, and the touch revealed a tumefaction surrounding three-fourths of the uterine neck. An acute pleurisy supervened, which destroyed the patient. Peritoneal adhesions were found uniting on the median line the bladder and the anteflexed uterus, and fastening the uterus to the ligmoid flexure and rectum; on the right, adhesions united the sigmoid flexure, which was much “elbowed” to the broad ligament; on the lest, adhesions united the parietal peritoneum to the broad ligament, the sigmoid flexure, and rectum. Between these organsthat is, placed behind the broad ligament, in front of the ligmoid flexure, was an intra-peritoneal collection of pus in contact with the left ovary, the proper tissue of which was healthy, as was that of the opposite side. The cellular tissue which surrounded the uterus and broad ligaments was healthy.
Drs. Bernutz and Gonfil are of opinion that the blennorrhagic inflammation extended along the Fallopian tubes, leading to an ovaritis, in a manner analogous to the extension of blennorrhagic inflammation along the epididymis to the testicle in the male. They remark that the dissection which revealed the healthy state of the cellular tissue of the uterus and appendages compelled them to renounce the conclusion they had arrived at during life, that the cellular tissue was the seat of the peri-uterine induration. This was in reality formed by the peritoneal adhesions binding the pelvic organs together in an irregular manner.
Case II.-Regular menstruation; pregnancy; labour and puerperal stage normal; vaginitis cured without having caused any morbid disorder of the uterus; syphilis. During the treatment of this disease, the catamenia, heretofore regular, were suppressed after two days. Shortly afterwards, development of a retro-uterine phlegmon; malignant small-pox, rapidly fatal. The antopsy revealed uterine deviation; peritoneal adhesions between the posterior surface of the uterus and rectum; the peri-uterine cellular tissue healthy; inflammation of the Fallopian tubes. Drs. Bernutz and Gonfil make a similar cominentary upon this case They remark that in them and in another (cited in a previous Midwifery Report), peritoneal adhesions binding together loops of intestine, may so closely simulate a tumour containing a liquid as to deceive even skilful exploration.
The next case exhibits a peri-uterine phlegmon, originating in a more usual way-namely, in labour.
CASE III.-Hysteria ; dysmenorrhæa; cessation of hysterical complications when the patient became pregnant; laborious delivery, followed in a few days by metro-peritonitis, which persisted in a latent form for five months. At this period the catamenia returned, and at the same time the acute symptoms. She was admitted into the wards of M. Valleix, when the existence of a purulent collection, which soon emptied itself by the rectum, was recognised. Scarcely discharged from the hospital, the symptoms returned. Admitted under M. Nélaton, who recognised peri-uterine phlegmon. Relieved, she returned to the care of M. Valleix, who after some time applied his uterine pessary, in order 39-XX.