« AnteriorContinuar »
For the hard tumours which generally remain, the best application is the iodine or iodide of potassium ointment, and the occasional application of a blister. Several cases are detailed which deserve perusal.
II. Fetal PHYSIOLOGY, On the Anatomy of the Fætal Circulating Organs. By Dr. C. LANGER.
(Zeitschr. der k. k. Gesellssch. d. Aerzte zu Wien, May and June, 1857.)
Dr. C. Langer has made some useful observations on the fætal organs of circulation, especially on the involution of the right side of the heart and ductus arteriosus, after birth. It is known that in intra-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 increasing 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 of 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. Langer finds a marked difference not only in the mature fætus, but in the seven-month fætus 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-inonth fætuses, shows the three layers but very imperfectly defined; and dereloped elastic fibres are not present. 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 exhibits a tissue which can be referred to the connective tissue. In longitudinal sections of the duct, including parts of the aorta, it may be seen that the thick elastic 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 difference of tissne causes near the aorta and pulmonary artery a greater yieldingness of the walls; for this reason, injected preparations are not to be trusted as giring estimates of capacity, since the force of the injection commonly causes aneurismal dilatations. During the first three days, no alteration of the duct is perceptible. On the ninth day, the thickening of the walls has obviously advanced; 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 increases, especially towards the pulmonary artery. It is remarkable that injections pass with difficulty along the arterial canals, eren in children some dars old. This may be owing to the dilatabuity of the walls and the tendency of the inner membrane to be thrown up mlo valvular folds.
That it is not to the altered mechanical circulation-conditions of extra-uterine bife alone that the closure of the ductus arteriosus is owing, is proved by original peculiar structural relations of the duct as compared with the sorta and the pulmonary artery. Through these the way for the late prepared
though these the way for the later involution is
III. PHYSIOLOGY AND PATHOLOGY OF 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. THEODOR KIRSTEN, of Leipzig. (Monatsscbr. 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 primiparæ. 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 anæmia 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 physiological 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 reconvalescence. 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 time, 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 cedema during pregnancy. The examination of her urine revealed copious albumen, which diminished with the ædema, withont disappearing altogether. Towards the end of pregnancy traces of sugar became apparent. She was delivered easily of a badly-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 pyæmia, 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 Medico-Chirurgical Review, April, 1857.
logy. The key, Dr. Kirsten thinks, is to be found in the most recent researches of Bernard. This physiologist has shown that the formation of sugar in the liver is especially apparent when the abdominal circulation is increased, and the temperature rises. The biliary matter chiefly turns into sugar at a temperature of 40° Cent. No time was more favourable for this transformation than gestation, when the abdominal circulation and temperature are always raised to the necessary point for sugar-formation : whence we ought always to expect glycosuria in pregnant women. But as this is not the case, we are obliged to conclude that the greater quantity of sugar produced at this period is wanted for the nourishment of the child, so that it cannot be excreted. It would be interesting, with a view to the verification of this hypothesis, to examine the urine of women whose children may die, as quickly as possible after their death.
During the puerperal week the abdominal circulation is lessened, and the afflux of blood takes place towards the periphery, as is evidenced by the milksecretion and sweats. This condition would not be favourable to the formation of sugar.
IV. LABOUR. 1. Case of Unconscious Delivery. By GEORGE SMITH, M.D. (Indian Annals
of Medical Science. April, 1857.) 2. Retarded Deliveries, probably Caused by Psychical Influences. By ROBERT
ANNAN. (Edinburgh Medical Journal, Feb. 1857.) 3. On a Nero Obstetric Instrument. By Dr. LUDWIG CONTATO. (Wochenbl.
der k. k. Gesellssch. d. Aerzte zu Wien. March, 1857.) 4. On Tympanitis Uteri. By Dr. Alors VALENTA. (Wochenbl. d. k. k.
Gesellsch. d. Aerzte zu Wien. Feb. 1857.) 5. On Tympanitis Uteri. By Dr. MCCLINTOCK. (Communicated to the
Reporter. Sept. 1857.) 1. Dr. Smith's case of unconscious delivery is interesting both in a physiological and medico-legal point of view.
Mrs. S- was daily expecting her confinement. On the 24th April, 1856, I was sent for suddenly, and on reaching the house, found the child'born, and lying under the bed-clothes, close to the body of its mother. The cord was entire, and the placenta within the vagina. The delivery had taken place suddenly. During the night preceding her delivery, this lady had felt quite well. She rose several times to attend to her sick child. About half-past five A.M. she walked from her house to the bungalow in which she was confined. When she reached the bungalow, she lay down upon the cot, and experienced a very slight sensation, as if her bowels were about to be relieved a feeling as if something had touched her body followed, and caused her to ask the ayah to lift the bed-clothes, when, to the surprise and alarm of both, the child was found entirely extruded. Mrs. S- was awake, and yet so little was her notice attracted by her feelings, that the delivery took place unconsciously. This was her second child. The first was born with the usual pains, after a labour extending over six hours. The child—a female—was a little under. sized, but not much.
2. Mr. Annan's cases of retarded delivery serve to illustrate the vexed question of the duration of gestation. A woman, after passing the danger of premature labour, suffered shipwreck, went through excessive physical exer. tion and exposure and mental anxiety, in attempting to save a child, she nevertheless had no pains, and was delivered 332 days after the cessation of the last menstruation. Mr. A- next relates two cases of retarded delivery following psychical exaltation. In one, a woman aged thirty-four, mother of several children, expected, according to her reckoning, labour on the 5th June, 1851; at the end of the seventh month, having attended the exhibition of a mesmerist, she returned home so unwell and excited that she had to seek medical advice, especially dreading premature labour. There were no pains, and in a few days she had recovered. The period of delivery passed over, and on the 20th July, quite six weeks later, she was delivered of a child weighing ten pounds four ounces, by the forceps. The size of the placenta corresponded to that of the child. Her former children had not much exceeded seven pounds in weight. In the second case, a woman aged forty-four was delivered in the beginning of October, 1840, whilst she had had her last menstrual period at the end of December. Shortly before she had heard of the severe labour of an acquaintance, and had been much excited in consequence. Here also uterine contractions first appeared long after the calculated time-namely, on the 20th November; and the woman was delivered on the following day of a dead child, with the forceps. It weighed nine pounds eight ounces. Another case is related, in which no obvious cause of retardation was present. A woman, aged twenty-six, who had aborted three times, which was also threatened in her last pregnancy, was delivered of a child weighing ten pounds eleven ounces, on the 15th February, 1857. Her last period was observed on the 1st April, 1856, so that about 327 days had expired. (The Reporter has also observed cases where excessive weight of the child corresponded with apparent protraction of gestation.]
3. The new instrument devised by Dr. Contato is said to be adapted to decapitating the fætus in utero. The inventor calls it the Decapitator. It is difficult to give a perfect idea of its construction without the aid of figures. The general principle, however, may be said to be the same as that of the guillotine. It consists of two parts. One part terminates in a curved halfring, the inner or concave border of which is grooved, for the reception of a knife, which, fixed to the other half of the instrument, is made to slide along the stem of the first half. The objections to the instrument seem to be, Ist, to discover the cases in which the operation of decapitation is desirable ; 2nd, to apply the instrument. The inventor gives no practical illustration to prove the working capacity of the instrument.
4. Dr. Valenta's case exhibits one form of a rare affection-tympanitis of the uterus. A woman, aged forty-three, who had borne twelve children, was brought to the Obstetric Clinic at Vienna, on the 15th October, 1856, from a country district distant two hours' journey. Labour had set in on the 13th. The midwife, not feeling any presenting part, sent for the surgeon, who ruptured the membranes ; upon this the left hand came down. On the 14th, attempts were made to extract the child by the sharp hook; this failing, another surgeon being called, replaced the arm, and prescribed ergot. On the following day she was taken to Vienna. The uterus was then found unusually but equally distended, so that it was impossible to discern any part of the child; the fundus reached to the xyphoid process, and was very painful; percussion in the circumference of the uterus gave a remarkably clear-sounding tympanitic resonance. The child's left hand, bare of epithelium, was felt in the vagina. No sign of rupture was discovered. Great febrile irritation, shivering, pulse 160, bilious vomiting. Exploration of the position of the child revealed the cause of the distension of the womb and the resonance, for suddenly a rush of stinking gas escaped from the uterus, followed by loosening of the distension. Delivery by turning was effected. It was found that the brain had escaped through the opening made previously by the perforator.
The patient sank on the following day under symptoms of acute peritonitis.
Autopsy revealed adhesions of the right Fallopian tube and ovary to uterus and psoas muscle; the left tube distended with gas; the uterus itself very flabby, easily moveable, its anterior surface pale-red and smooth, its posterior surface bluisb-red and covered with flocculent deposits; the substance of the uterus in the highest degree lacerable; the inner surface covered by a loose, knotty, delicate, dirty-brown, very foul-smelling mass.
The conclusion of Dr. Valenta was that the tympanitis was due to the evolution of putrid gas from the decomposition of the child, the gas being prevented from escaping by the closure of the mouth of the womb by the child. (It is probable that early delivery by turning on the 13th would have obviated this process, and averted the fatal result.-Reporter.]
'5. The case of tympanitis uteri, with which the Reporter has been favoured by Dr. McClintock, is especially illustrative in juxtaposition with the preceding. The case occurred in the Dublin Lying-in Hospital, during the present year. A primipara passed nine hours in the second stage of labour. At 8 P.M. the os was mostly dilated; the membranes broken; pulse 112; tongue getting furred. The symptoms indicated the desirability of completing delivery. At 9 A.M. the irritation had increased; pulse 120; complains of constant pains in uterus; head partially in pelvis; no tumour on head; fætal heart inaudible. The entire uterine tumour anteriorly is quite resonant on percussion. When finger was passed up between head and pubis, a discharge of fætid air came away from the uterus. Craniotomy; no blood came from head. Rigor at 6:30 P.M.; and another on the second day; tongue white, dry, rough; belly tympanitic; no abdominal pain or tenderness, Opium, quinine, and wine administered. Sloughing of vagina followed—the result partly of pressure during protracted labour, and subsequent poisoning of the blood from absorption of foul air. The child was putrid.
It seems a necessary condition for the production of tympanitis uteri, that the child should be dead and the membranes broken, so that air may enter the uterus, and give rise to the ordinary putrefactive process.
THERAPEUTICAL RECORD. Guano in obstinate Skin Diseases.-Récamier (Gazette Médicale de Paris, No. 4, 1857), in the latter portion of his life, prescribed baths of guano in the treatment of some skin diseases; and a Belgian practitioner, M. Van der Abeele, has recorded six cases where this plan has been adopted with success. Three were cases of ecthyma and three of eczema. The baths employed contained 500 grammes of guano in solution.
Valerianate of Atropia.-M. Michéa (L'Union Médicale, January, 1857), who has for many years devoted great attention to the therapeutical virtues of the Solanaceæ, publishes a case in which the valerianate of atropia proved to be more efficacious in asthma than stramonium, and some other previous remedies. He employs the valerianate in the form of pills, as being most convenient and most certain, and the dose is from half a milligramme to two milligrammes. In asthma, he advises the discontinuance of the remedy, and its renewed use alternately, every week in persons under twenty-five years of age, and every fortnight in persons above that age.
Nitrate of Silver in Ozæna. The remedy proposed by M. Galligioli (Raccoglitore Medico di Fano, 1857) is the fused nitrate of silver, but employed in &