« AnteriorContinuar »
to cure the pains experienced by the patient, and which he attributed to the existing retroversion. The instrument was abandoned, on account of the pain and renewal of hysterical attacks it produced. Concurrently with these hysterical attacks, pelvic pains, and existence of peri-uterine tumours, for which the patient successively entered the wards of MM. Gendrin, Monat, Briquet. The symptoms abated concurrently with the spontaneous cessation of menstruation and the development of pulmonary phthisis. For this last disease she came under the care of M. Bernutz, and died five years after the labour to which she ascribed all her sufferings. The autopsy revealed peritoneal adhesions binding together all the pelvic organs, and these to the pelvic peritoneum. The cellular tissue of uterus and broad ligaments was healthy. The authors infer that the terms “pelvic cellulitis," "peri-uterine phlegmon,” imply an erroneous pathology, and ought to be replaced by peri-uterine peritonitis. It is a return to the old pathology. They cite Andral's authority in support of their interpretation of the last case.
4. The diversity of opinion yet entertained as to the pathology, diagnosis, and treatment of the various forms of pelvic sanguineous effusions, renders it desirable to collect cases throwing light upon this affection. That of Dr. Picifico is interesting. A Turkish woman, aged fifteen, menstruated from thirteen normally; had been married nine months. Three months after marriage, she began to experience bearing-down pains, and sexual intercourse became too painful to be continued. When examined, a large ovoid tumour, with limits well marked, resisting, elastic, painful on pressure, was felt extending obliquely from below upwards from the left iliac fossa to the level of the umbilicus; excessive pain in groins, especially in the left, and in the loins. Examination by vagina reveals a large tumour bulging into the vagina and filling it; the neck of the uterus-very high-was thrown forwards, and to the right. The temperature of the vagina was increased, its sensibility also; fluctuation was very clear. The tumour also pressed upon the rectum; no febrile movement or shivering. An exploratory puncture was made at the most fluctuating point of the vaginal tumour. A dark red liquid escaped in small quantity. À discharge of similar fluid continued for some days. Fifteen days after puncture, the tumour had diminished considerably, but the patient was much exhausted. Frictions with iodine ointment, and steel pills were prescribed. Three weeks after puncture, a severe hæmorrhage suddenly took place: the tumour had opened in the vagina, and discharged a considerable quantity of blood. This ceased on the following day. Great febrile irritation, with shiverings and depression, followed, and fuctuation increased. A second exploratory puncture was made by the vagina, and then ichorous and very fætid pus escaped. The opening was enlarged by a bistoury, and the sac washed out by injections. Instant relief followed. Under quinine and good diet, the patient recovered favourably, the tumour completely disappearing
Dr. Picifico remarks that there appeared two distinct stages in this case : the first, hæmorrhagic, the second, phlegmasic. Was the hæmorrhagic effusion caused by the ovarian irritation produced by early marriage ?
5. Dr. Johns recommends the practice of blistering the cervix uteri in those cases especially in which, after active inflammation has been subdued, neuralgic pains persist. The agent he employs is the following: a strong solution of cantharides in chloroform, in which some gutta-percha is afterwards dissolved. This is applied by a camel-hair pencil. It is said to cause very little pain, either during or after application. Small vesications appear at the time, and a watery discharge sets in within half an hour. This discharge starches the linen, and is in other respects similar to that from blisters externally formed; it lasts commonly for three days, when to it succeeds one of a slightly purulent nature, but not productive of pain. At this stage the epithelium is thickened and raised, and comes off in patches, like bits of chewed paper. Dr. Johns has never seen strangury follow. He relates several cases illustrating the beneficial effects of the remedy.
6. The question how far and in what cases iodine injections can be trustel to as a cure of ovarian cysts, is one of great interest in itself, and it has lately assumed a greater relative importance since the operation of ovariotomy has been generally condemned. The question is mainly to be solved by experiment. The collection of authentic cases in which this method has been tried is, therefore, a task of immediate practical utility. In the recent discussion upon this subject in the French Academy of Medicine, M. Caseaux brought forward from Boinet, Monod, Nélaton, Demarquay, Giraldès, Maisonneuve, Simpson, and others, 117 cases of ovarian cysts in which iodine injection had been used. In some of these it was previously determined to close the wound immediately after the operation ; in others, to incite suppuration by leaving a canula in communication with the sac. It appeared that the iodine injection had acted most favourably in all ; for in all the 117 cases, not one exhibited a serious mishap. There were 62 cases of unilocular serous cysts, of which 48 were cured; Il were operated upon without result; in only 4 did death follow. In the 11 cases some improvement was observed.
The experiments with the retained canula were, for the most part, unfor
To this summary we will add some cases recently recorded :
1. M. Dolbeau : A woman, aged thirty-nine, had borne two children. Symp. toms of ovarian disease had commenced seven years back. Two years back the tumour had been apparently spontaneously healed by the bursting and escape of a quantity of fluid through the vagina, but in six months the tumour had resumed its former size. In December, 1855, the sac was punctured, and four litres of albuminous fluid drawn off. The canula was left in the sac. Purulent discharge came after a time. On the eighth day the purulent matter was fated, and an iodine injection was thrown in; but the patient got worse, and sank under profuse diarrhæa on the 19th. Autopsy showed the cyst much contracted: the walls were fibrous, of various thickness, and in three points occupied by fibrous tumours. The inner surface was lined by a yellowish, strong, resisting membrane, pieces of which were found in the fluid, and plainly consisted of a combination of the iodine with the organic substance. It contained small vessels, and was easily separated from the wall of the sac.
2. M. Philipart's case. A woman, aged twenty-three, had menstruated regularly from the age of sixteen. Increase of size of abdomen first observed in 1852. On September 25th the first puncture was made, and twenty-five litres of albuminous water withdrawn. This operation was repeated thirty-five times, down to October 18th, 1855. The condition of the patient had become worse. lodive injection was then determined upon. Thirty grammes of tincture, 4 grammes of iodide of potassium, and 250 grammes of water were injected; no pain. Irritation at first; but in a few days improvement. On October 26th, the injection was repeated; considerable reaction ensued. On January 3rd, 1856, the third puncture ; eight days after this her condition was quite satisfactory. The collection, however, returned, and down to March 6th, three more punctures were made, and the canula left in the wound. The patient is said to have been destroyed by an unskilful washing out of the cyst by a nurse, which caused a fatal peritonitis.
3. M. Pignaut's case. A woman, aged fifty, had recognised a simple cyst for fourteen years, which had latterly become so large as to be unbearable. After puncture, iodine injection; no reaction followed. Cure was complete in fourteen days.
Several other cases have been reported in the British journals, which want of space forbids us from citing. Several cases are known to be under observation. It is hoped that within a reasonable time a sufficient body of experience to determine the application and value of this method will be amassed.
II. PATHOLOGY OF THE FETUS. Case of Double Fætus. By Professor Meigs. (American Journal of Medical
Science, January, 1857.) Dr. Meigs's case of monstrosity is remarkable. It is an example of more or less perfect fusion of two embryos. The two heads present the least perfect fusion. The genital organs are female. The right eye of the right and the left eye of the left fætus are perfect; while the right eye of the left, and the left eye of the right fætus are fused together into one single eyeball, covered by a compound palpebra with three canthi, the fused inner canthus being in the middle of the lower eyelid. All traces of the outer canthi of this compound eye are lost. In the fusion of the heads, the left 'and right ears of the right and left fætuses are lost, with the exception of a small tubercle seen in the middle of the faces. The left fætus has a double hare-lip, and the right one a common hare-lip. The calvaria are deficient in both children, so that they are anencephalous. There was also failure of development of the spinous processes and bridges of the cervical and dorsal vertebræ, giving rise to spina bifida of both the dorsal and cervical ranges, while the lower lumbar and sacral vertebræ are perfectly well developed. This circumstance, Dr. Meigs observes, is interest. ing, showing as it does, that the simplicity apparent in the two well-formed arms and legs, and the single trunk, is nevertheless a real duality of individuals. The dark dermoid excrescence that covers the top of the head is too imperfect to contain any hair-follicles. There was but one navel and umbilical cord. Dr. Meigs however concludes, from physiological reasoning, that the liver was double. The specimen was not dissected, in order not to diminish its value as a museum object.
III. PREGNANCY AND LABOUR. 1. Account of a Case in which Impalement of the Uterus occurred in the Produc.
tion of Criminal Abortion. By. F. BROUGHTON, Esq. (Transactions of the
Medical and Physiological Society of Bombay, 1855, 1856.) 2. Case of Ruptured Uterus. By M. REYNOLDS, M.D. (Charleston Medical
Journal, January, 1857.) 3. Rupture of the Uterus. Gastrotomy successfully performed. By John H.
BAYNE, M.D. (The American Journal of Med. Science, Jan., 1857.) 4. Report of Seven Cases of Transfusion of Blood, with a Description of the In
strument invented by the Author. By ALFRED HIGGINSON, Esq. (Liverpool Med. Chir. Journ., Jan., 1857.)
1. Nursingua was fifty years old. Her husband having died two years, she formed an intimacy with a goldsmith, and pregnancy was the unexpected and undesired result. To obviate discovery and evade the punishment inflicted in this country upon both parties when convicted of adultery, she was as usual tempted to submit to measures for the induction of abortion. A five months' fætus was expelled. Slight hæmorrhage but considerable pain followed. The pain increased, and she was sent into hospital. She died in a few hours.--Autopsy : The abdomen was immensely distended with serum. Bands of coagulable lymph passed in every direction, of recent formation. The peritoneum fieryred, the whole mass glued together. Upon lifting up the bowels some difliculty was experienced in exposing the uterus, owing to the presence of a rod, which passed through the fundus and projected three inches into the bowels, which were lacerated, and hanging upon its extremity. The other and broken end occasioned the abrasion of the internal membrane. The uterus was firm, and tolerably contracted, and would appear to have been more passive under such fearful injury than the intestines. It is remarkable that the patient was fifty years of age, and that she survived this injury ten days.
2. Dr. Reynolds' case of ruptured uterus is referred to because it illustrates the conservative behaviour of the uterus in certain cases of this injury. A negress, in labour with twins, suffered rupture of the uterus during the expulsion of the first child. The second escaped into the abdomen. She died shortly afterwards. On autopsy, the fretus and appendages were discovered in the abdomen. The uterus was so firmly contracted as to efface all visible mark of laceration until it was distended by passing the hand into the cavity. The seat of the laceration was the cervix ; it ran somewhat obliquely, and measured in the contracted uterus three inches. A little coagulated blood was found in the cavity, and very little effusion of blood into the peritoneal cavity. There had been no hæmorrhage during labour. There was slight inflammation of peritoneum. The viscera were all in a state of integrity. It may be assumed that this poor woman died of shock, since the strong contraction of the womb prevented all hæmorrhage. The Reporter has witnessed a case of recovery after rupture of the womb, in which powerful contraction of the womb was the conservative agent. The rupture occurred during the delivery of triplets. The children and three separate placenta were expelled per vaginam. A large loop of intestine was felt and seen protruding between the thighs. This was spontaneously retracted, and the woman completely recovered. This tendency of the uterus to contract being an essential element in the process of recovery, should not be frustrated by attempts to drag the child back through the rent, in order to deliver per vias naturales. If the child has been cast into the abdomen, gastrotomy seems to be indicated by nature.-R. B.]
3. Dr. Bayne's case of rupture of the uterus occurred in a woman aged twenty-five, of robust constitution, in her fourth labour. When seen she complained of having experienced some hours previously an excruciating pain in the epigastrium, accompanied with a peculiar tearing sensation. There was then an entire cessation of pain and of all expulsive uterine efforts. Pulse 130. Difficulty of respiration, and prostration. Coma, and tendency to collapse. The head of the fætus felt at first presenting, seemed to be rapidly receding; and in a very short time the entire contents of the uterus had escaped into the abdomen. Child then felt very distinctly through the parietes of the abdomen. An extensive laceration had taken place in the anterior portion of the fundus. Gastrotomy was immediately performed, without anæsthetic agents; as soon as the abdominal cavity was opened, there was a sudden gush and escape of at least one quart of sero sanguineous fluid. No hæmorrhage. A very large fætus was removed. Womb at the rupture thin, and the laceration jagged and irregular. Peritonitis set in on third day. A dark grumous, offensive, purulent discharge continued per raginam for several weeks. She recovered. Dr. Bayne observes that the antero-posterior diameter was less than the standard, and the capacity of the pelvis less than usual. Her labours had always been protracted. He does not refer to the condition of the womb as regards contraction.
4. The cases of transfusion reported by Mr. Higginson are of extreme interest. We cannot extract the description of the author's instrument. It is
ingeniously contrived to keep the blood used for transfusing warm, and to prevent the injection of air into the vein.
The following is a summary of the cases :
CASE I.-Extreme prostration from protracted suckling of twins.—The exhaustion was extreme; the patient fainted when raised from her pillow; it was considered she would die during the night. Twelve ounces were injected from a healthy female servant; a state of quietude succeeded; pulse improved; she seemed sleeping; but in a few minutes a rather severe rigor came on. This did not last ; reaction occurred; the patient sang a hymn in a loud voice. She steadily recovered.
Case II.-Hemorrhage after birth of child, on expulsion of placenta.—Complete prostration from sudden loss. The lady's sister supplied the blood, and between ten and twelve ounces were easily injected. The benefit was immediate and striking, and no bad symptoms retarded her recovery.
CASE III.- Hemorrhage from Placenta Prævia. Fætus retained.--Sudden and exhausting hæmorrhage. The placenta had been removed; the child's head occupied the os uteri, and hæmorrhage was over. The skin was of a livid hue, as in the asphyxiated stage of cholera. A female servant gave the blood, and six or eight ounces were injected, when a sudden jactitation jerked the pipe from the arm; coagulation impeded the operation. She died within half an hour, undelivered. Case IV.-Hemorrhase from adherent placenta. Uterus empty; hæmorrhage
-Twelve ounces were injected. The patient lived seven days, but gradually sank. Uterus found internally purulent and offensive. No disease of the veins, either in the uterine region, or in the arm where the puncture had been made.
Case 1,-PartisPlucenta Preria. Hemorrhage before delivery.- Partial Separation; great hæmorrhage. Woman appeared sinking, neither placenta ar fitus explied; hæmorrhage bad however ceased. The blood injected was "dark and sluggish," and produced scarcely any effect, not more than five or Sit ounces having entered Warm water with a little common salt was then in cated to twelve ounct's slightly improving the circulation. Delivery was then seur etreted, but life was extinct before this was fully accomplished.
Toe Reparter would observe, that although the delivery was here, according to mirrave ruke, foned, yet this operation was precisely calculated to extinguish the patient. Whr was it held necessary The hæmorrhage had ceased. Bisit us at returu. This fear is not altogether justified by the true physiohele pisutata preria, nor by clinical experience. The natural hæmostatic Sim Okku mached; the labour had truly become a natural labour.]
Case 11 - V ip i be found; erhaustion ; approaching collapse. - Nis sed din
from the radial arteries. A good supply of rather Art Niki w* diny a female Pulsation returned at intervals, the breit, **** , d e pression of the countenance became much better. Tway *****er are were kated. The following day she appeared better,
out, she died in forty hours. The heart contained dark tant North
Case 11.-e s posering l ed); delivery, and subsequent draining ; away and the use arat ; nens of fooding; death.