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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 1S52, 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 catamenise, 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 leucorrhnea. 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 couutry. 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 emptied. 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 tliat this was a case of periodical dropsy of the ovary. The only case, he says, he has known which bore any resemblance in the periodical inflammatory swelling of the ovary, was one observed by himself eight years ago.
Cask II.—A girl, aged eighteen, robust and healthy in appearance, began to menstruate at fifteen. The catamenias had from their origin been regular and abundant. For the last year she had experieuced 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 appearanee of the catamenia, felt a painful weight and fulness in the pelvis. The left iliac 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 bv external palpation. Examined by rectum, this tumour was extremely painful, firm, as if stretched, and smooth of surface. During these days the patient had a fever of an inflammatory character. Exammed 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 hsematocele. N. F., aged twentyeight, had enjoyed good health till the age of twenty, and had menstruated regularly from sixteen. In her twentieth year she suffered, in consequenee 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 diarrhoea during a thaw prevailing in Mumch, 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 inereased, with the addition of pain in micturition and defalcation. 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 haematocele 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 experienee. He objects to the opinion entertained 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 inflammation frequently involves surrounding structures. He calls attention to the facts, that it is a disease to which all females are liable, both in the single and married state, from the age of puberty until an advaneed period of life; that it is more commonly met with in early life, and immediately after parturition, especially in primiparae. It appears most usually between the third and tenth day after parturition, corresponding in this respect with the other important inflammatory puerperal diseases, from which it is very difficult to distinguish it in its commeneement. Dr. Bell's observations on the etiology are important. In the married state, he says, it seems in general to be occasioned 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
feneral more distinctly the consequence of mechanical injuries arising from raises, 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 feverishucss and profuse perspirations, which come especially at night. 1'oul tongue, rapid pulse, occasionally constipation, but frequently diarrhoea, apparently arising frum 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 opium, 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 For the hard tumours which generally remain, the hest application is the iodine or iodide of potassium ointment, and the occasional application of a blister. Several cases are detailed which deserve perusal.
IL Foetal Phtsiom)gt.
On He Anatomy of the Fatal Circulating Organi. By Dr. C. Laxgeb. (Zcitschr. der k. k. Gcsellssch. d. Aerzte zu Wien, May "and June, 1857.)
Dr. C. Langcr has made some useful observations on the foetal organs of circulation, especially on the iuvolution of the right side of the heart and ductus arteriosus, after birth. It is known that in mtra-uterine life the thickness of the two ventricles is about the same. Owing to the thoroughfare of the ductus arteriosus, and the placental circulation, the right ventricle has as much work to perform as the left. But after birth, simultaneously with the involution of the duct of Botallius, the relative labour of the left ventricle inereasing and that of the right decreasing, the walls of the right ventricle undergo a comparative thinning. On the third day, no great difference in the thickness ot the walls of the two ventricles is to be detected; on the fifth day it is, however, perceptible, and between the ninth and fourteenth days it is so marked, that complete involution can no longer be doubted. The structure of the ductus arteriosus has been described as similar to that of the aorta and the pulmonary artery; but Dr. Langcr finds a marked differenee not only in the mature foetus, but in the seven-month foetus also. Sections of the aorta show the three layers of the walls plainly developed. The elastic layer is plainly defined. But a cross-section of the ductus arteriosus of five and seven-month foetuses, shows the three layers but very imperfectly defined; and developed elastic jibret are not presext. In mature still-born children there is wanting in the walls of the ductus arteriosus a compact developed layer of elastic fibrous tissue; only fine fibres are seen. The walls of the duct are stronger than those of the aorta and pulmonary artery. Instead of a developed elastic tissue, the duct exhibiu a tissue which can be referred to the connective tissue. In longitudinal sections of the duct, ineluding parts of the aorta, it may be seen that the thick clastic fibres of the tunica media of the aorta diminish as they approach the duct, and quite disappear near the orifice. The calibre of the canal in new-born children is about that of a branch of the pulmonary artery. The differenee of tissue causes near the aorta and pulmonary artery a greater yieldingness of the walls; for this reason, injected preparations are not to be trustee! as giving estimates of capacity, since the force of the injection commonly causes aneurismal dilatations. Durmg the first three days, no alteration of the duct is perceptible. On the ninth day, the thickening of the walls has obviously advaneed; the inner surface is more uneven. The canal is hardly passable by a large needle in the middle; but the nearer the sections are made to the aorta and the pulmonary artery, the larger is the bore. From the fourteenth day the middle stricture inereases, especially towards the pulmonary artery. It is remarkable that injections pass with difficulty along the arterial canals, even in children some days old. This may be owing to the dilatability of the walls and the tendeney of the inner membrane to be thrown up into valvular folds.
That it is not to the altered mechanical circulation-conditions of extra-uterine life alone that the closure of the ductus arteriosus is owing, is proved by the original pecuhar structural relations of the duct as compared with the aorta and the pulmonary artery. Through these the way for the later involution is prepared.
111. Physiology And Pathology Op Gestation, &c.
1. Extra-uterine Gestation, with Rupture of the Cyst, and happy Result. By
Dr. Bertrand, of Schlangenbad. (Monatsschr. f. Geburtsk. May, 1857.)
2. On the Presence of Sugar in the Urine of Pregnant, Parturient, and Puerperal
Women.. By Dr. Tueodok Kirsten, of Leipzig. (Monatsschr. f. Geburtsk. June, 1857.)
1. On the morning of the 4th April, 1853, Dr. Bertrand was called to a married woman, aged twenty-nine. She had complained of acute pain in the side. When seen, her bloodless aspect struck the observer; her pulse could hardly be counted; the abdomen was swelled, and yielded a dull sound on percussion in the right inguinal region and over the pubes. This part was very painful to touch. Frequent vomiting; great thirst. It was now learned that the patient had been eight weeks pregnant, and that blood (but very little) had escaped by the genital passage. Examination revealed that the vaginal portion of the uterus was conical, as in primipara. The examining finger was soiled with blood and mucus. One grain of opium was given every two or three hours, ice-water and acetic ether. Peritonitis followed. But she gradually recovered; the anaemia resulting from great extravasation of blood lasting some time.
2. The researches of Blot on the presence of sugar in the urine of pregnant, parturient, and puerperal women, suggested to Dr. Kirsten the expediency of independent inquiries with a view to the verification of Blot's results. M. Blot arrived at the conclusion,* that the presence of sugar in the urine of women under these circumstances was a phvsiological phenomenon; and that its disappearance was the result of an intercurrent pathological condition. Dr. Kirsten observes, that if this conclusion were true we should possess in the disappearance of the sugar, a tolerably sure measure of the condition of a puerperal woman, since this would indicate a commencing pathological disturbance, whilst its return would indicate reconvalcscence. Dr. Kirsten examined the sugar-relations in two women. His observations do not altogether accord with those of M. Blot: they rather point to the reverse condition—namely, that sugar is present in greatest quantity in the urine of puerperal women when the milk-secretion—whether through a pathological process, or the weaning of the child—is arrested. Thus he observed in several puerperal women whose children had died, that on the second, third, or fourth day after the death the sugar appeared in greatest plenty. After this t ime, the quantity fell in the same degree as the milk diminished; but in four cases it could be demonstrated twelve days later. In three cases in which the patients were seriously ill in the puerperal state, and in whom the milk-secretion was almost null, the sugar was found in greatest quantity. One of these last women had suffered from common oedema during pregnancy. The examination of her urine revealed copious albumen, which diminished with the oedema, without disappearing altogether. Towards the end of pregnancy traces of sugar became apparent. She was delivered easily of a hadly-nourished child. Repeated attacks of peritonitis followed. The milk-secretion was very scanty, and the milk very thin: sugar was present in the urine in abundance. In the second patient, who suffered from peritonitis, followed by pyemia, Dr. Kirsten was able to detect sugar up to the day before her death, this substance having been present in great quantity at the beginning of her illness. The third case was quite similar. On the other hand, he was rarely able to discover more than mere traces of sugar in the most healthy women, who had well-nourished children and a superabundance of milk. It hence appears that glycosuria belongs rather to pathology than to physio
« See Midwifery Report; British and Foreign Medlco-CMrurgical Review, April, 1857.