« AnteriorContinuar »
QUARTERLY REPORT ON MIDWIFERY.
I-HTSICIAN TO THE ROYAL MATERNITY CHARITY.
I. Phy-ology And Pathology Of The Ukimpeegnated Female.
1. Researches on the Erectile Organs of Woman, and on the Muscular Tvbo-ovarian Apparatus, in their Relations with Ovulation and Menstruation. By Charles Ronget. (BrowuSequard's Journ. de Physiol., October, 1858.)
2. On the Functions of the Placenta. By Dr. Cl. Bernard. (Gaz. Hebdom., Jan. 1859.)
3. Note on Haemorrhages of the Fallopian Tubes. By Alrert Purox. (Gnz. Ilebdom., Jan. 1859.)
4. Extirpation of an Inverted Uterus by Ecrasement. By Dr. Mccldstocr. (Dublin Quart. Journ. of Med. Science, Feb. 1859.)
1. M. CnARi.ES Ronget's interesting researches on the anatomy of the female organs are summed in the following propositions:
1. In woman the body of the uterus presents the structure of an erectile organ, of a true corpus spongiosum.
2. That to the ovary also an erectile bulb is attached.
3. That in all the classes of vertebrate, and especially in all mammifera, a special muscular apparatus embraces the oviduct and ovary, and effects their adaptation to each other.
4. That the fasciculi of the ovario-tubal muscular membranes (mesoarium and mesometrium) have such relations with the corpora spongiosa, and especially with their efferent sinuses, that, at the moment of contraction, the meshes of the network in the midst of which run the venous channels, contracting in every direction, these must necessarily be compressed, and the discharge of blood more or less completely stopped^
5. That the contraction of the ovario-tubal muscular apparatus persisting during the whole period of ovulation, the obstacle to the passage of blood and the erection of the corpora spongiosa of the uterus and ovary, which is the result, have the same duration.
6. That menstruation coinciding also, on the other hand, 'with ovulation, it is natural to consider it as the immediate consequence of the erection of the uterus; a true menstrual haemorrhag moreover, never presenting itself but where the uterus possesses a truly erectile structure.
7. That if sexual excitation, as seems probable, can determine the erection of the uterus and ovary, it is easy to account by that fact for the coincidence of the periods of menstruation and ovulation.
2. Dr. Claude Bernard has communicated to the Socifite de Biologie, of Paris, an account of some researches on the function of the placenta. He had some time before announced the presence of glucose in the amniotic fluid. In pursuing his researches into the origin of this substance, ho found that the placenta of certain mammifera contains in the normal state a considerable quantity of glycogenic matter. Ruminants alone seemed to offer an exception; but M. Bernard now finds that in these the glycogenic matter, instead of being met with in the placentas, has its productive organs in certain points of the amnios. The glycogenic matter of frotal age, whatever the species under examination, is formed by cellules, which in nil their histological characters are exactly similar to the cellules of the liver of adult animals. In the rodents these cellules arc formed between the foetal placenta and the maternal placenta. In ruminants, there are seen on the amnios whitish spots, which have either been Completely overlooked by observers, or taken for epithelial pathological productions. These white spots are composed of agglomerations of cellules similar to the preceding. On microscopical examination of these spots, they are seen to be composed of a kind of papillae filled with cells, and cirenmscribed by an amorphous membrane. Iodine gives a rose colour to the cellular contents. The layer of cells separating the foetal and maternal placentas in rodents, and the papillae containing the cells in ruminants, are developed from the earliest epoch of icetal life, and immediately enter upon their functions. I.ike the hepatic cells in form, their function is similar—at least, as far as the production of glycogenic matter is concerned, for the author has not yet concluded his researches relative to the possible secretion of bile by these organs. It is a true liver, absolutely unknown hitherto. Whilst these organs are in function, the internal liver of the foetus is in a rudimentary state; its cells, perfectly embryonic, produce neither glycogenic matter nor glucose. Later they change their appearance, take gradually their normal shape and dimensions, and begin to secrete glycogenic matter. At the same time, the hepatic cells of the placenta or of the amnios become atrophied, and disappear.
3. M. Albert Paeck, house-surgeon to the H6tel Dieu at Toulon, makes an interesting communication on haemorrhages of the Fallopian tubes. He cites the following cases:
1st. A married woman was attacked with small-pox; when admitted into hospital she complained of acute pain in the lower part of the lumbar region and towards the sacrum, and this although she had menstruated a fortnight before. She rolled about in the bed screaming. Two days later, she was seized with profuse uterine haemorrhage, and died almost suddenly. On examination, the uterus was found full of clots; the mncous membrane was quite healthy, except at the fundus, where it was thickened, violet, infiltrated with blood; at this point a clot remained, which stretched into the left Fallopian tube. The tubes were of a violet aspect, of the size of the little finger, and filled with a large vermicular clot. There was not a drop of blood or serosity in the peritoneum. The right ovary presented no rupture, but had a clot the size of a small walnut on its outer surface. The left ovary, of the size of a hen's egg, was almost entirely converted into a sac containing a fatty matter and hairs. This case was reported by M. Loboulbene to the Society de Biologie in 1853; the conclusion being that it was a case of haemorrhage of the Fallopian tubes.
The next case occurred under the observation of M. Pueck himself. A strong, robust woman, aged thirty-eight, was admitted on the 3rd of July, 1858, and died ten days after, of meningeal haemorrhage. The mucous membrane of the uterus was quite healthy; at the level of the left horn were some sanguinolent mucosities, resembling those contained in the inner half of the corresponding tube. The right tube contained a white opaque mucus, it was fixed to the anterior surface of the ovary; two or three serous cysts the size of a pin's head were on the oviduct; the mucous membrane near the fimbriae was dull red, and pale elsewhere. The left tube was violet, as if ecchymosed; its outer third was as large as the index finger; the fimbriated end was widely open, and connected with the ovary by a tubular membrane continued from it, forming a complete canal to the ovary. This portion was dilated by sanguinolent mucosities, and on pressure escaped from the uterine mouth of the tube; the mucous membrane was dark red, fmely injected. There was no rupture of the ovary; but an apoplectic cavity in its substance. This the author considers to be a case of tubal haemorrhage, partly emptying itself into the uterus.
4. Dr. McClintock relates an important case in which an inverted uterus was removed by linear ecrasement. The patient, aged twenty-two, mother of one child, very anremic, was admitted into the Dublin Lying-in Hospital in September, 1858. For twelve months she had suffered very profuse discharges of blood, always coming on at the menstrual periods, and lasting for fourteen or twenty-one days. A pediculated tumour, of pyriform shape, and of the size of a walnut, was found low in the vagina; the neck of this tumour was embraced, but not constricted, by the thin os uteri; it was quite insensible to ordinary manipulation; its surface was smooth, dark pink, and discharged blood when scratched. The patient had been delivered after a protracted labour, by a rude country midwife, fourteen months before; the after-birth, she says, twice "slipped away" from the nurse, the cord being broken. The tumour being drawn down by a vulsellnm, the os was entirely effaced, the vagina becoming quite continuous with the neck of the tumour. This led to the conclusion that the case was one of inverted uterus. Several attempts were made under chloroform to effect re-inversion, without success-. On the 20th of October, a silk ligature was passed round the neck of the uterus by Gooch's canula; this caused much pain, and some vomiting. In the evening the ligature was tightened, and again on the next day. After forty-eight hours the ccraseur was applied below the ligature, the uterus having been drawn down by a vulsellum. The chain was worked very slowly, the uterus being severed in eight minutes. Pain attended the operation; and febrile excitement followed; opium was given, and turpentine epithems applied. In a fortnight the patient was allowed to get up. Six weeks afterwards, the os uteri presented almost the ordinary appearance; a catheter passed about one-third of an inch up the cervical canal. On the 27th of December, Dr. McClintock was informed that the patient was quite well, but had not menstruated.
On the Diagnosis of Pregnancy. By Professor Hejkeb. (Monatsschr. f. Geburtsk.,
Professor Hecker, of Marburg, has published the result of extensive investigations into the prognostic value of the penetrability to the finger of the os internum uteri in pregnancy. It is generally known that shortly hefore the onset of labour the os uteri internum opens. Dr. Heeker has endeavoured to give precision to the indications of this phenomenon. Since 1833, when he succeeded to the charge of the Marburg Lying-in Hospital, records have been kept of the date on which the os internum was ascertained to be open, and of the lapse from that event to labour. He of course points to the difficulty, that the time when the opening of the os internum was felt was not necessarily that when the os first opened; but he believes that the results of a large number of observations compensate for this source of error, although, since all the error is always on the same side, it is not easy to see how the multiplication of cases can tend to its neutralization.
Dr. Heeker remarks that he has several times observed, in the case of women who had walked along distance to come to hospital, or who recently had undergone violent exertion, that the inner os uteri was penetrable on admission, but closed again after a few days' rest.
His general results are as follows:
Out of 2593 persons examined between 1833 and 1858, there were 946 in whom the inner os uteri was penetrable to the finger. Of these 946,723 were pluriparis and 223 primiparae. Of the 723 pluriparae,
366 were delivered within 7 days of ascertained penetrability.
586 " "21"
638 " "28"
85 " after 28"
Of the 223 primiparae,
138 were delivered within 7 days
189 " 21"
209 " 28"
14 went over 28"
Thus it appears that in primiparae, penetrability of the inner os uteri was followed by labour in seven days in 62 per cent, of the cases, and in pluripane in about 50 per cent.; that labour followed within fourteen days in 75 per cent, of the primiparae, and in 70-o per cent, of the pluriparae.
1. Four Deliveries by Caesarian Section in extreme Contraction of the Pelvis. By Dr. G. Pagensteoher. (Monatssch. f. Gob., Aug. 1858.)
2. Canes of Casarian Section, with Successful Res8t for Mother and Child. By T. J. FheeRiors and J. A. Groesrecr. (Nederl. Tijdschr, ii., Jan. 1858; and Schmidt's Jahrb., No. 8, 1858.)
3. On Perforation and Cephalotripsy. By Dr. Charles Hejtnig. (Monatsschr. f. Gebnrtsk., Jan. 1869.)
4. Obstetrico-Medical History of a Woman in twelve Labours. By Dr. Perrlv. (Gazette M&licale, Jan. 1859.)
5. A New Obstetric Forceps (called I.eniceps). By Dr. A. Mattel (Gazette Me"dicale, Jan.
6. On the Inflammation of the Fallopian Tubes and Escape of the Purulent Secretion into the Cavity of the Abdomen, as a cause of Peritonitis in Puerperal Women. By Dr. A. Martin. (Monatsschr. f. Geburtsk., Jan. 1859.
1. The four cases of Dr. Pnjrenstecher illustrate various conditions which are held in Germany to be motives for resort to the Carsarian section.
Case I.—Rupture of the uterus during labour, in a pelvis contracted from osteomalacia; escape of the child into the abdominal cavity; Casarian section.—On the 9th November, 1857, Dr. Pagenstecher was called to a woman, aged thirty-eight. She had borne a first child three years before, and had been unable to move for four months after. During this second gestation, she had suffered from pains in the bones of the pelvis and hips, and during the last three months had been unable to walk or lie down, being reduced to sitting on the edge of the bed. During stormy and painful contractions, repeated vomiting set in, after which the child's head, which had been before felt, suddenly disappeared, and all pain ceased. Dr. Pagenstecher found the patient an hour and a half after the catastrophe much prostrated, cold at the extremities, cold sweat on the forehead, pulse imperceptible. The belly, very tender, was hanging over the symphysis; below the navel he felt a hard ronnd lump, filling both sides of the abdomen; above this, to the left of the navel, a foot was made out The pelvis presented a strong curvature of the lumbar vertebra forwards, and to the right a considerable curvature of the sacrum, it being compressed from above downwards. The conjugate diameter was 2£ inches, the symphysis was pointed to the right, and the rami of the pubes formed two nearly parallel lines, running to the tubera ischia. The tubera were scarcely two fingers'-breadth across. The os uteri could not be reached. When the abdomen was incised, the uterus was seen pale and contracted in the lower half of the wound, the right shoulder-blade of the child in the upper. The child extracted, much thick dark blood flowed from the abdomen. The incised wound yielded hardly any blood. There seems to have been no reaction. Death followed twenty-six hours after the operation. On dissection, numerous coagula were found in the peritoneal sac, but no peritoneal exudations. The uterus was tolerably thick and contracted at its fundus, and very distended and thin below. Its posterior wall was rent in an oblique direction, from the os uteri to the insertion of the right broad ligament The fist could be passed through the wound, and onwards into the vagina through the open os uteri. The walls of the uterus at fundus were pale, but sound and thick; ' the lower parts, and especially around the rent, were discoloured, very soft and thin. Dr. Pagenstecher is unwilling to declare that the uterine walls were in a diseased state prior to the rupture, He thinks that possibly the long pressure of the uterus against the projecting point of the pubes, and the sharp ridge of the last lumbar vertebra, favoured the rupture.
Case II.— Casarian section in contracted pelvis from osteomalacia.—A woman, aged forty, had borne eight children, the last four dead. Labours, tedious, with forceps. Since the second pregnancy she has suffered from pains in the bones, and can only walk with difficulty. Labour began on the 2nd of December, 1857. The external conjugate diameter measured six inches. The symphysis was strongly beak-shaped, and the pubic arch, down to the tubera, so sqneezed u\i( that these were scarcely an inch apart. The pubic arch assumed the shape of a key-hole. The promontory was easily felt by the finger. The foetal heart was distinctly heard. The Caesarian section was performed under chloroform. The incision had to be extended upwards above the navel, on account of the rising of the bladder so high above the pelvis. The extraction of the child was rendered difficult by the extremely energetic contraction of the uterus. The placenta had to be detached from a strong adhesion to the anterior wall. This occasioned great haemorrhage both during the operation and in the following honrs, when contractile pains entirely ceased. The child lived. The after-treatment consisted in small draughts of cold water and cold compresses; one-quarter grain doses of morphia every three hours. Pains and distension of the abdomen continued for the next four days, then a discharge of thick coagulated blood. At the end of the first week a normal lochial flow. The sutures were removed on the seventh and eighth days. At the end of the second week peritoneal symptoms appeared, with vomiting and constipation, and painful distension of the belly. Small doses of opium with castor-oil, and lavements, allayed these conditions, and in four weeks' time the patient was fully restored. The child lived.
Case III.— Casarian section in contraction ofpelvis from rachitis.—Primipara, aged thirtyseven; 8th March, 1858. The patient is scarcely three feet and a half high; her skull was very flat and low, with very angular parietal bones. Labour began last night; the water flowed about midnight; the child was alive. The conjugate diameter was estimated at two inches and a quarter; the pelvic outlet very narrow. The head, with large caput succedaneum, presented. The patient was narcotized, and an incision carried from the navel to two fingers'-breadth above the pubes; this was afterwards extended above the naval. The peritoneum opened, the very fat and redematous omentum lay behind the abdominal wall. This was pushed aside, and the uterus was opened. On account of the incomplete anaesthesia and the restlessness of the patient, the protrusion of some folds of intestine could not be prevented. The left shoulder presented first; the left arm, then the right, were freed, when the breech was brought forward, and the child delivered by the legs. It was very cyanotic; it breathed, however, after a slight loss of blood and cold aspersions. The placenta lay below and to the right; it was removed without difficulty. Free bleeding of the uterus was stilled by ice. The wound was brought together, a small plug inserted at the lower angle, the belly properly supported, and an ice bladder applied for twenty-four hours. Internally, morphia and ice. The sutures were removed on the sixth day; the entire wound heale I by the first intention, with the exception of a small spot. The patient was quite well in the third week, suckling her child.
Case IV.— Casarian section in pelvic contraction from osteomalacia, performed for the second time on the same teoman.—On the 28th of March, 1858, a married woman, whom Dr. Pagenstecher had delivered by Caesarian section in 1852, came again under his care. In the first year the patient had suffered frequent relapses of osteomalacia, and was now in a state of marked marasmus. With extreme muscular atrophy, the abdomen had undergone an enormous development, reaching to the knees; and its walls, thin as paper, were necrosed in several places. For months the patient could neither walk nor stand; the pelvic bones were in the highest degree painful, much thinned, and the diameter, as far as could be determined, considerably narrowed. Labour began with strong pains in the morning; at six P.m., when seen, the pains had ceased, and with them the foetal movements. The foetal heart could not be heard.
The incision was carried to the middle of the abdomen. The transparent uterus was exposed and opened. It had, notwithstanding the extreme thinning of its walls, maintained the compression of the pains; the membranes protruded uninjured; they were much thicker than the uterine walls. It was ascertained that the placenta was fully detached, so that the intra-uterine labour was completed. The removal of the dead child and placenta followed without trouble, and the uterus contracted into a hard fist-sized ball. The abdominal wound was united; the haemorrhage was very violent; morphia and ice-bladder were unable to allay it. The belly became distended, so that on the next day it had attained the same size as before delivery. Vomiting set in, and death followed eighty hours after the operation.
2. Case I.—A woman, aged twenty-nine, with short and crooked legs, had been delivered in her first pregnancy of a (lead premature child; in her second pregnancy, of a child at full term by craniotomy; in her third pregnancy, of a dead child in the eighth month, also by art. Her fourth pregnancy seemed at an end on the 9th of July. The sacrum was much curved, the promontory easily reached. Tho conjugate diameter was two inches and a half. Cresarian section performed. The details are not related, but the patient is reported to have completely recovered.
Case II.—A primipara, aged twenty-one, was in labour. The promontory projected greatly; the upper pelvic strait was narrowed to a fissure two inches across. The abdominal incision was made a little to the side of the linea alba, on account of the lateral position of the uterus. There was little loss of blood; the uterus contracted well. Slight unpleasant symptoms were removed by morphia. In the eighth week complete recovery.
In neither case is the fate of the child recorded.
3. Dr. Hennig has made an analysis of a number of cases of cephalotripsy, with the view of comparing the results of this operation with those of perforation. The cases are arranged in three scries: 1st, Those in which the mother recovered; 2ndly, Those in which the mother's life was saved, but the structures injured; 3rdly, Those in which the mother died. 64 cases are collected; of these 41 mothers recovered completely, 6 imperfectly, and 12 died. The result of the remainder is unknown. [The detailed examination of the cases is cot decisive in favour of the operation. The collection, like most others of the kind, is worthless as an element of statistical comparison. Some of the operations were performed in hospitals, and the deaths might be, at least in part, ascribed to puerperal fever; and other circumstances vary, especially the indications taken by different physicians to call for the operation. Thus one case is quoted from Dr. Crode" in which this physician waited three hours in order to let the child die. It is quite clear that no trustworthy comparison can be made between the results of operations performed on the Continent and in hospitals, and of operations performed in this country.—Rep.] •
4. The obstetrical history of a woman in twelve labours, related by Dr. Perrin, is of extreme interest, as showing two points—1st, The presumed increasing pelvic contraction; Sndly, The application of turning to delivery as a substitute for craniotomy. The first seven labours passed without remarkable difficulty ; the seventh, however, required the forceps. The children were all living, and some of them showed symptoms of rickets during infancy. Id the remaining five labours none of the children survived. In the eighth labour the head remained at the brim without being able to enter, from projection of the sacral promontory. The forceps failed, and turning was performed; the head was at length disengaged by the forceps. The child's heart was beating, but it never breathed. In her ninth pregnancy, the proposition to induce labour at seven months was not carried out. The feet presented; extraction was effected; but the child, born asphyxiated, did not breathe. In the tenth labour the head was lying on the brim. Turning was effected, and the head was extracted by forceps. The child's heart pulsated, but it never breathed. In her eleventh labour, by version alone, without forceps, a still child of average size was delivered. In the twelfth and last labour the head lay again at the brim; child was alive. Turning was quickly effected immediately after rupturing the membranes. The diminution of the antero-posterior diameter, caused by the projection of the promontory, arrested the entry of the head until