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a modification of the luxatio iliaca, produced by violent rotation outwards ; 18. The luxatio iliaca is the rarest of all the forms of dislocation, although it is commonly regarded as the most frequent. The majority of those cases that have been so termed, and a considerable portion of those cases so denominated by Malgaigne, are, in fact, examples of luxatio ischiadica ; 19. The luxatio iliaca essentially arises from rotation inwards, with adduction and flexion of the limb. Its reduction is based upon rotation outwards.
IX. On the Prevention of the Ill-consequences of Operations. By Professor
DEROUBAIX. (Presse Médicale Belge, 1857. Nos. 17-24.) Professor Deroubaix, Surgeon to the St. Jean, Brussels, terminates a series of papers upon this subject with the following summary :
1. If it is the duty of a surgeon to seek, by the improvement of his operative procedures, to obviate the immediate accidents of operations, the endeavour to discover the means of prevention of the secondary accidents, which are far more dangerous, is still more imperiously demanded at his hands. 2. Could the great surgical operations be rendered less dangerous in themselves, the intervention of surgery would be much more clearly and more frequently indicated in cases where the practitioner now often is obliged to remain a passive spectator of disorders which infallibly prove fatal. 3. The danger of great operations is not due to the size of the surfaces concerned, but to the number and volume of the veins divided. 4. When the division of veins proves mischievous, it does so by giving rise, through a mechanism the nature of which it is not always easy to appreciate, to the production of purulent infection, one of the most fearful consequences of traumatic lesions. The great danger and extreme frequency of this complication justify the efforts made for its prevention or removal. 5. There are two directions, both perhaps equally good, by following which we may succeed in rendering pyæmia of much less frequent occurrence. The first of these consists in improving and rendering less uncertain the process of healing by the first intention; and the second in so modifying the divided surfaces as to convert them into a lesion of continuity of far less dangerous character. 6. Metallic caustics, at least in the immense majority of cases, do not give rise to purulent infection; but they are not applicable to certain operations—as, e.g., amputations. 7. It is rational, then, when seeking for substitutive or modificatory means for the prevention of pyæmia, to resort to such as most resemble caustics in their mode of action, and yet are exempt from the disadvantages of these therapeutical agents. 8. The tincture of iodine would seem to possess properties enabling it to fulfil these indications, seeing the deep-seated modification it impresses on the tissues, and the plastic effects it gives rise to. It does not act upon the ligatures, and therefore does not give rise to the danger of secondary hæmorrhage. . When it is applied to bleeding surfaces after an operation, it induces a general hyposthenic effect of short duration, and a local hyposthenic effect, which imparts peculiar characteristics to the granulations and cicatrization. 9. The most remarkable results of this hyposthenization are, the much less indolence of the wound, the slight amount of suppuration, the notable diminution of the general reaction, and the maintenance of a condition approaching that of health. These phenomena offer no impediment to rapid cicatrization. 10. The discharge from the surface of the wound is considerably diminished as a consequence of the application of the tincture; but this does not prevent arterial hæmorrhage, or the loss of blood from the large veins. 11. The putridity of the wound becomes evidently diminished ; and when the tincture is applied to the divided extremities of the veins, these become corrugated and narrowed, and then agglutinated. If phlebitis arises, it is obliterative and adhesive, not suppu
rating. 12. The application of the tincture to the sawn surface of the bones does not lead to necrosis. 13. The tincture imparts no preservative power against pyæmia when an open venous orifice, through which pus may be easily, so to say, mechanically introduced, exists at any point of the surface. 14. In ordinary cases, even the tincture is no certain preventive of purulent infection. When, after it has been applied, we find the vicinity of the wound remaining very painful, we should suspect a commencement of phlebitis, and the course of the pain should be carefully inquired into. 15. It should be remarked that as the general hyposthenization which results from the application of the tincture exhibits itself in symptoms, comparable to a certain point to those produced by chloroform, prudence is required in the simultaneous or successive employment of the two substances. Perhaps this is the principal defect in the iodine. 16. The injection of the tincture into the veins is immediately fatal. It induces an entirely peculiar coagulation of the blood, incapable of being confounded with any other pathological or spontaneous coagulation. 17. Nevertheless, this medicinal substance cannot, when applied to a bleeding surface, be carried in substance into the torrent of the circulation, anless, indeed, venous orifices be maintained open by adhesions. It is absorbed in the state of an alkaline iodide, and may be found in such a state of combination in the blood and urine. The amount ordinarily absorbed exerts no ill effect upon the economy.
X. On the Treatment of Hæmorrhoids. By M. VAN HOLSBEEK. (Presse
Médicale Belge, 1857. No. 22.) Dr. Van Holsbeek recommends the following formula as of remarkable efficacy in the various forms of bæmorrhoids, providing that these are uncomplicated :- B Sulphuri loti, sacchari canarini, of each zj; ext. strychn. pux.vom., gr. vj. To be mixed with a sufficient quantity of tragacanth so as to form twentyfour lozenges. Of these two are to be taken the first day, the number being increased by one every day, until six are taken daily. The patient is then to keep at that number during four days, when he is to diminish it gradually until only two are again taken daily. If a radical cure is not by this time effected, he must follow the same course again. The amendment is, however, usually so rapid that the treatment at farthest lasts a week.
QUARTERLY REPORT ON MIDWIFERY.
By ROBERT BARNES, M.D. (Lond.) LETTSOMIAN LECTURER ON MIDWIFERY, ETC. ETC. I. PHYSIOLOGY AND PATHOLOGY OF THE UNIMPREGNATED STATE. 1. Periodical Dropsy of the Orary. By Dr. Magnus Huss, of Stockholm.
(Archives Générales de Médecine, July, 1857.) 2. A Case of Retro-Uterine Hemutocele, with Rupture into the Peritoneal Sac,
and Recovery. By Dr. B. BRESLAU, of Munich. (Monatsschr. f. Geburtsk.,
June, 1857.) 3. The Constitution of Women, as illustrated by Abdominal Cellulitis, or Infan
mation of the Cellular Membrane of the Abdomen and Pelvis By CHARLES
BELL, M.D. (Edinburgh Medical Journal, 1856 and 1857.) 1. The case of periodical dropsy of the ovary, detailed by Professor Huss, is of great interest in its bearing on the pathology of this organ. Miss C. B., aged thirty-nine, was sent, in the summer of 1855, to be treated at Stockholm. She had begun to menstruate at sixteen; this function had been continued
without interruption or pain. She had enjoyed good health, and had led an active life. The first indication of disease appeared in the beginning of 1852, when she began to suffer dysuria. This state lasted only two days. A month later the same symptom returned for two or three days; the urine during these days was less in quantity, and thicker. In other respects Miss C. B. felt well. From that time similar attacks returned regularly once a month-about midway between two menstrual periods. During Dec., 1852, whilst suffering an attack of dysuria, the patient perceived for the first time an abdominal tumour; this, she said, was of the size of an apple, and was seated in the middle of the hypogastric region, directly above the pubis; it was circumscribed, and was not painful on pressure. The tumour diminished before the setting in of menstruation, and at the end the patient ceased to perceive it. Since then, the tumour returned regularly at the same period—that is, in the mid-interval of the catameniæ, and diminished before and during menstruation, disappearing at the end. Each time the tumour returned, it was a little larger, tending to bear more towards the right side. Its growth was always attended by pain and stretching in the region occupied by it. Since it attained bulk enough to reach the umbilicus, filling the whole right iliac region and the hypogastric region, it has never disappeared entirely. The patient declares she has observed that the more abundant the menses, the less was the subsequent development of the tumour, and vice versa. Latterly the menses have been less abundant. Miss C. B. has never suffered from metrorrhagia or leucorrhea. The increase of the swelling has always been attended by more or less difficulty in micturition. The breasts have never undergone any sympathetic influence, only they have gradually diminished in size.
During the last year the patient has suffered from gastric disorder. Seen in June, 1855, by Dr. Huss. The uterus was healthy; it was a little depressed, the fundus thrown considerably backwards. The vagina was distended on the right side by an elastic swelling, evidently due to the tumour which was felt outside. This tumour, perfectly smooth, had the consistency of a bladder filled with liquid. When menstruation appeared on the 1st of July, the tumour had almost completely disappeared. Iodide of potassium was given during the month. No swelling in the hypogastrium took place. During the second week in August the tumour became the seat of sharp pains, with a sensation of great stretching. The volume of the tumour increased rapidly. A blister was placed on the right side, and proto-ioduret of mercury was given internally, so as to produce a slight stomatitis. During its administration the swelling subsided much more rapidly than usual.
The patient returned to the country. The same phenomena continued. She came under observation again at Stockholm in May, 1856. During her absence the periodicity had continued regularly, with the difference that the diminution of the ovary had been less and les3. An exploratory puncture of the tumour was made by the vagina. Several ounces of thick jelly-like liquid escaped. On the next occasion of the growth of the tumour, paracentesis was performed. Two pints of a thick fluid, yellow, like honey, quickly setting in jelly, escaped. There appeared to be three distinct cysts, one portion only being completely emptiod. No benefit followed the operation. The same phenomena continued to recur. The further progress of the case is not recorded.
Dr. Huss, in his discussion of the case, refers to other observations in illustration of his opinion that this was a case of periodical dropsy of the ovary. The only case, he says, he has known which bore any resemblance in the perioaical inflammatory swelling of the ovary, was one observed by himself eight years ago.
CASE II.-A girl, aged eighteen, robust and healthy in appearance, began to menstruate at fifteen. The catameniæ had from their origin been regular and abundant. For the last year she had experienced at each period a painful tension, augmenting each time, with a feeling of swelling in the left iliac region. During the last months she has, three or four days before the appearance of the catamenia, felt a painful weight and fulness in the pelvis. The left iliae region swelled, and became extremely painful to the touch, and the patient says she felt a tumour there. This tumour remained during the two or three first days of menstruation, when the pain- abated, afterwards the swelling was dissipated. When examined in the interval between two periods, nothing abnormal was discovered. Examined again at the advent of menstruation, the left iliac region was found more prominent than the right; percussion gave a dull sound, a tumour, well circumscribed, the size of a hen's egg, was felt by external palpation. Examined by rectum, this tumour was extremely painful, firm, as it stretched, and smooth of surface. During these days the patient had a fever of an inflammatory character. Examined four days after the cessation of menstruation, a tumour the size of a walnut was felt by rectum, softer and less painful to touch, which some days later disappeared. This was a periodical ovaritis.
[This latter case is not a rare one. It is an example of ovarian irritation passing beyond the physiological boundary of periodical congestion into inflammation. It is indeed illustrative of the first case, but is different in character.)
2. Dr. Breslau's case of retro-uterine hæmatocele. N. F., aged twenty: eight, had enjoyed good health till the age of twenty, and had menstruated regularly from sixteen. In her twentieth year she suffered, in consequence of a severe emotion, from convulsions, and a disposition to cramps in the hands, especially at the menstrual epochs. Hallucinations of taste and smell were often present. In her twenty-fourth year she had her first child ; labour natural. The nervous symptoms persisted. The periods lasted three to four days, and returned regularly every four weeks. Towards the end of 1856, the patient was oppressed with pains in the back, but her general health was tolerable until the 21st of January of that year, when, an obstinate form of diarrhæa during a thaw prevailing in Munich, she suddenly fell ill with an intense intestinal catarrh.' Recovered from this, pains returned in the hypogastric and sacral regions. Constitutional irritation followed, and a tumour the size of a hen's egg was felt a little to the left and above the symphysis. The Douglasian space was filled by a tense elastic swelling. Some days later the menses set in. The retro-uterine swelling increased, with the addition of pain in micturition and defæcation. Two days later a sudden sharp pain occurred in the depth of the pelvis, and spread over the abdomen. On examination, no trace of the swelling could now be felt. It appeared clear that the sac containing the retro-uterine hæmatocele had burst into the peritoneal cavity. The patient gradually recovered.
3. Dr. Charles Bell's papers on Pelvic Cellulitis form a valuable contribution to the pathology of this affection. After a careful historical survey of the subject, the author gives his own experience. He objects to the opinion enter tained by some, that the disease is of a chronic character. He insists that the pelvic cellulitis, when proceeding to suppuration, is an acute disease ; and that the mflammation frequently involves surrounding structures. He cas attention to the facts, that it is a disease to which all females are liable, bonus the single and married state. from the age of puberty until an advanced person of life: that it is more commonly met with in early hife, and immediately aber parturition, especially in priminare. It appears most usually benetaan third and tenth day after parturition. corresponding in this respect other important inflammatory pnerperal diseases, from which it is YOS
mit in its commencement. Dr. Bell's observations on the etiology
In the married state, he says, it seems in general to be oc
casioned by exposure to cold soon after parturition ; but if we were to inquire minutely into the circumstances of the case, we should probably find that this cause is more apparent than real, and that there is strong reason to believe that the disease is the result of pressure, arising from constipation, or from the Womb itself, during pregnancy. This opinion is fully supported by the numerous cases preceded or attended by constipation, as well as by the fact that cellulitis is more common in the primipara, in whom the muscles of the abdomen have a less tendency to yield. But the effect of constipation is also seen in the single state. In the unmarried state, however, cellulitis is in general more distinctly the consequence of mechanical injuries arising from bruises, falls, blows, and operations on the uterine organs, especially the hazardous and often rashly-performed operation of slitting open the os and cervix uteri.
Diagnosis.-In consequence of the incidental or contingent diseases, but more particularly peritonitis, its symptoms are at first usually complicated and obscure; as the disease advances, certain symptoms assume a more prominent and permanent character, and may almost be considered as pathognomonic. It is necessary in many cases to examine both by rectum and vagina. Sometimes, from the thickness of the parietes of the abdomen, and the deep situation of the inflammation, the pain from common pressure is scarcely perceptible; in such cases M. Broussais advises lateral pressure. Early in its progress, cellulitis often resembles an aggravated form of after-pains. The spasms may at first extend over the whole abdomen, and gradually concentrate, until at last they are fixed in one place, generally in the iliac fossa of either side. The lochia are not always suppressed, nor the milk permanently interrupted. It is not always preceded by rigors, nor do they occur early, unless the peritoneum sympathises extensively in the inflammatory action; but they invariably come at a more advanced period, when they indicate the formation of pus. They return more or less frequently, and are followed by feverishness and profuse perspirations, which come especially at night. Foul tongue, rapid pulse, occasionally constipation, but frequently diarrhea, apparently arising from the irritation produced by the tumour. Great difficulty in passing urine, which seems to arise from a displacement of the bladder. As the disease advances, the limb of the affected side becomes stiff, and so bent that the patient cannot stand straight, or walk without great pain. Although the tumour is not invariably situated in the iliac fossa, it is most frequently met with there; but it always conveys a peculiar brawny hardness to the touch, and it is often long of being dispersed after the inflammatory action has been overcome. It is a striking characteristic that it is liable to have sudden and alarming exacerbations, attended by increase of pain and fever, indicating those occasional attacks of peritonitis which, if not attended to, may prove fatal. If the pus is not artificially evacuated, it almost invariably makes an outlet for itself, generally into the bowels or vagina; it may burst into the peritoneum, which is always fatal; more rarely into the uterus; it occasionally perforates the parietes of the abdomen at the iliac fossa, but sometimes near the umbilicus. [The Reporter has recently seen a case, under Dr. McClintock at the Dublin Lying-in Hospital, in which the abscess has burst in this latter unusual place). When it bursts into the bladder it is less fatal than when into the peritoneum.
Treatment.--Dr. Bell thinks general bleeding rarely necessary. Leeches are useful, applied repeatedly; a full dose of calomel and antimonial powder and Dover's powders-i.e., five grains of each, followed by a dose of castoroil; then small doses of calomel and opinm, or, what he has found most beneficial, small doses of calomel and James's powder-one-fourth to one-sixth of a grain of each--minutely triturated with white sugar, to be taken every two hours until pain and fever are subdued. Blisters and narcotics are useful.