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very, operate with equal advantage. To these may be added the intimate knowledge of midwifery which the welleducated country surgeons are found so pre-eminently to possess. The most common causes of death appear to Mr. Ingleby to be hæmorrhage, and peritoneal (inflammation, improperly called) fever; and Mr. Robertson, one of the surgeons to the Manchester Lying-in Charity, asserts that more fatality arises from hæmorrhage than from all other causes. The brute creation, in the natural state, from the peculiar economy of the placenta, are exempt from those fatal hæmorrhages; but, when domesticated, some of them have been known to die from this cause. We have also found females of the canine race subject to a peculiar cause of death, namely, mortification of the uterus, before expulsion of its contents has been effected; which fact we have ascertained by repeated post-mortem examinations. In these cases, as soon as mortification commences, the uterine contraction immediately subsides. The remote cause of this extraordinary circumstance has been found by us to consist in a remarkable disproportion between the size of the mother and that of the young; the latter appearing much too large for expulsion by the natural efforts; and a corresponding disproportion has, on inquiry, been found to exist between the male and female parents. The decease of these animals, immediately after parturition has been completed, may probably be owing to some analogous cause.
The premature retirement of the accoucheur after delivery next occupies the author's notice, who makes some very proper remarks on the subject, accompanied by a detail of four cases of sudden death from flooding after delivery. We make it an invariable rule never to leave our patient, until we are satisfied that the uterus has undergone such a degree of contraction as may ensure her safety; and the vascular and nervous systems have recovered from the collapse, which often follows the most natural labour. When consider-able hæmorrhage has taken place, the greatest care should be taken to pre
vent any sudden change of position; as women have been known to die in a moment, while in the act of rising up in bed for the purpose of taking food. In these cases, we are not to be guided by the amount of blood, but by the alarming effects produced from its sudden extravasation; after the constitution has been exhausted by previous pain and hæmorrhage. The best practice, in these cases, is to apply external pressure, which, the author justly observes, should be continued several hours, lest blood should insidiously accumulate within the uterus.
As a means of obviating hæmorrhage, and supporting the pendulous abdomen in the latter months of gestation, the author extols the use of bandages, particularly Dr. Gaitskell's, which he has modified so, that it is equally applicable before or after parturition, as will appear from the following note:
"I allude to the bandage commonly used; but I have modified Gaitskell's, so as to answer for either state, by inserting on each side, for the hips, two pieces of cloth, commonly termed gores, four inches in depth and three in width at the lower edge, and placed one inch and a quarter apart. Two plates adapt it for fitting the back. The bandage has two rows of loops, with corresponding tapes, and averages from 30 to 36 inches in width, and from 15 to 18 in depth at the centre. As buttons are placed at different distances round the lower edge of the bandage, understraps may be used if needful. This answers every purpose, and can be made sufficiently reasonable to be within the reach of the most indigent.”
The application of a bandage having been neglected before serious hæmorrhage occurs, the simple plan of applying three napkins, described by Dr. Blundell in the Lancet, No. 265, page 801, may be adopted; or the following, recommended by the author.
"Rather than disturb a woman at such a moment, it will be better to pass a large towel or broad piece of linen external to the clothes, and draw it as tight as it can be borne. The discharges and wet linen, including the napkin and folded sheets, must be removed from
about the person, as soon as possible, and dry linen substituted. After reposing an hour, or longer if needful, a suitable bandage may be applied. Care must be taken in conveying it round the body, not to disturb the position of the patient. The under garment, which during the last stage of labour ought to be taken away from the discharges, may now be adjusted; and a petticoat, which opens in front, being drawn underneath her, the broad top-band should be pinned sufficiently tight to afford an agreeable support. If the bed has been properly prepared, the patient. may now be placed in it, or if she is already in bed, laid on the opposite side, slowly and without raising her."
"After four or six hours have elapsed it may be necessary to slacken the bandage, agreeably with the feelings of the patient, whose comfort will also be promoted by excluding the atmospheric air from the external parts."
Some useful directions follow, respecting temperature, repose and diet after the completion of the parturient process.
After-pains seldom occur as a consequence of the first labour; and, if our experience with the secale cornutum does not deceive us, we believe that they may be greatly modified by its exhibition before the detachment of the placenta, especially in such individuals, as have been formerly found to labour under a flaccid state of the parietes. and feeble contraction of the uterus. These pains are of two kinds, active and passive: the former consisting of the natural, contractile efforts of the womb, and the latter of a forcible dilatation, occasioned by an influx of blood, often suddenly distending it to an enormous size. In all cases, when the uterus is distended with blood, which either from large, firm coagula or any other obstruction cannot escape, severe pain and tenderness are experienced; and these symptoms in extreme cases continue, until such a degree of decomposition of the extravasated blood takes place, as permits the entire evacuation of the uterus. This process frequently occupies several days, and simulates uterine enlargement, produced by sub
acute inflammation. This kind of afterpains is peculiar to persons advanced in life, or who have had several labours, and is probably that described in the following passage:
" But when severe and long continued, these paroxysms sometimes occasion febrile dirturbance, the uterus becoming large, and highly sensible to the touch; and when attended with a defective flow of the lochia, they may be considered as denoting a congested or inflamed state of the large uterine veins."
The active species of after-pain, particularly when proceeding from a partial contraction, will often require the aid of opium; the other is most effectually relieved by ergot of rye, assisted by an open state of the bowels.
The sub-acute inflammation, the seat of which is in the fibrous structure of the uterus, makes its appearance from the fifth to the tenth day; and, when it has attained its height, the organ acquires a magnitude fully equal to that, which it possessed at any period before the commencement of labour. It is accompanied with extreme tenderness, fever, thirst and a pulse at 102. The blood, when coagulated, has a thick buff on its surface, but is not cupped. The treatment consists in the abstraction of blood in small quantities, followed by the application of leeches and gentle mercurialism.
The customary period for decumbiture after parturition is five days. We agree, however, with the author that, after a severe labour or hæmorrhage, a much longer time should be enforced; and, where prolapsus is apprehended, it should be extended to several weeks...
"This plan has been attended with complete success, even in cases in which the uterus in the early months of gestation had fallen completely through the vulva. Very recently I was called to reduce, at the fourth nonth of gestation, a gravid uterus, which lay completely without the os externum. By means of the largestsized globular pessary and the horizontal position, it was prevented, after its reduction, from again descending, and thus the ascent in the abdomen would
be accomplished almost as early as in
By attention to position alone after confinement we have uniformly found prolapsus, occasioning the greatest distress before pregnancy, which of itself in the latter stages is a temporary cure, have been entirely obviated.
In the chapter on menstruation occurring during pregnancy the author states that the menstrual secretion rarely ap, pears in the last six or eight weeks of utero-gestation in these cases, and believes that it proceeds from the uterus in opposition to the opinions of Denman and Hamilton. This however is not an original sentiment; for Cruikshank long ago supposed the secretion took place from the exhalant arteries of the uterus, which experience a periodical enlargement for this purpose.*
To evince the fact of the absence and termination of the decidua at the orifices of the fallopian tubes, the author relates the appearances observed in a fatal case of extra-uterine pregnancy, Occurring in the practice of Mr. Bellamy.
fifth month her size was prodigiously large. The fluctuation was as distinct as in a case of ascites, and the legs threatened to burst. Indeed, had she not experienced aggravated symptoms of pregnancy, no one would have suspected it. At the sixth month the patient, who had then abandoned the idea of pregnancy, was delivered of twins, and a deluge of water reduced her to a state of imminent peril. In the third pregnancy the same symptoms recurred, but earlier than in the preceding. At the fifth month, she was as unwieldy as though she had reached the ninth. Small bleedings, abstinence from liquids, mild purgatives, diuretics, with the horizontal position, carried her on to the sixth-at this period the membranes unexpectedly gave way during the night, and twelve napkins were saturated with the fluid prior to my seeing her early in the morning. The singular part of the case is, that every second or third day the waters escaped, affording relief in proportion to the quantity discharged, being from a pint to a quart each time, so that fresh secretion must have been going on. I can vouch from frequent examinations that the fluid proceeded from the uterus. Either from the thinness of the uterus, or the small quantity of liquor amnii contained within the membrane after these discharges, almost every part of the child could be felt through the parietes of the abdomen; the knees could be distinguished from the elbow, and the head could be brought from the inguinal region to the hypochondrium, and vice versâ ; just as the sutures of the foetal head have been distinguished through the abdomen without lesion of the uterine parietes. Indeed, if the fluid had not been unequivocally passed through the os uteri, I should have regarded the case as an extra-uterine gestation. I scarcely need say that the fluid was not urine. Urine I am aware is not unfrequently mistaken for the liquor amnii in those discharges, which on muscular exertion are passed in the latter weeks of gestation. On one occasion the bladder was quite empty; on another, when the discharge Cruikshank's Anatomy of the Ab- was flowing away, I introduced a ca
In females of a plethoric habit a hemorrhagic tendency is sometimes acquired by pregnancy, which, neglected or allowed to proceed, usually occasions such a detachment of the placenta, as is inconsistent with the life of the embryo or fœtus. Hence arise most of the abortions in such constitutions. The most effectual treatment consists in adequate depletion, temperance and abstinence from violent exercise. There is a passive kind of hæmorrhage, the author observes, which arises from constitutional weakness; and to this class may be referred that which proceeds from a mechanical obstruction to the circulation.
Hydrops Amnii, a preternatural secretion from the amnios, next engages the author's attention; and in a note is recorded the following extraordinary case. "A lady, subject to uterine hæmorrhage, was afflicted with dropsy of the ovum in her second gestation. At the
theter, and drew off the urine. As the
ninth month advanced, the head rested permanently on the pubes, and could no longer be moved about freely. She attained the full period, and was delivered of a child unusually large. At the second pain the secundines were spontaneously expelled, my hand receiving the mass, when at the outlet, lest its weight should tear the membranes. I then carefully examined the whole, and in addition to the aperture in the centre of the membranes, made by the passage of the head, there was a circular one very distinct just at the edge of the placenta. From this aperture the fluid had doubtless from time to time escaped, the patient prior to each evacuation being sensible, by a kind of passive contraction of the uterus, that it was about to come away. The situation of the rent accounts also for my not being able to draw off the liquor amnii with a catheter, though the attempt was frequently tried with a view of accelerating labour. The longest period I had known between the rupture of the membranes and the accession of labour was eight days. A respectable surgeon, formerly of this town, knew a case, in which a month intervened."*
[To be continued.]
Analysis of the BLOOD AND URINE
OF DIABETIC PATIENTS.†
We need scarcely inform our readers that the labours of Dr. Prout have thrown considerable light on the various alterations of the urine coincident and connected with alterations of the system in general, or the urinary organs in particular. It has been stated, and
We regret that the late period at which we received Mr. Ingleby's important work prevents us doing much more than commence the analytical review of it. In our next number we shall give a full account of the remainder of the publication.-Ed.
+ Dublin Journal, No. I.
apparently proved, by that able chemical physician, that in diabetes the highly-animalized principle urea is not to be detected in the urine, its place being supplied by sugar, a principle eminently vegetable. Prior to the appearance of sugar, in other words, before the diabetic condition is established, Dr. Prout asserts that albumen is found in the urine, and thus a regular series of changes is observed in that secretion, from its state of health to diabetes, and from diabetes back to its state of health. But it seems that chemistry has its fallacies as well as physic, indeed animal chemistry will, we fear, be for ever an uncertain branch of an uncertain science. For this gloomy notion we might offer several powerful reasons; but two will at present be sufficient-the varying character of the animal fluids, and their necessary alterations under the chemical re-agents to which they are exposed. Sure it is, that no two chemists will agree in their finer analyses of the animal solids or fluids. We do not intend to throw cold water on chemical investigations in connexion with physic; we think that they have already effected much good, and that they will yet effect much more. we have seen enough to render us distrustful of the conclusions of this or that particular chemist, more especially if he deviates far from the ordinary track.
Mr. Kane, professor of chemistry to Apothecaries' Hall, of Dublin, has published a paper in the Dublin Journal, contradictory of the belief in an absence of urea from diabetic urine. He asserts that it is not even diminished in quantity in that disease. We shall not relate the manner in which he detected the error of Prout and others, but merely shew the method which he adopts to procure the urea. Before doing this, we may mention that he discovered that, if nitric acid (the re-agent by which the presence of urea is deter mined) be added to diabetic urine under ordinary circumstances, a considerable increase of temperature takes place, and urea is not obtained, a cir. cumstance probably owing to some chemical combination between it and the acid. If the urine, on the addition of
the nitric acid, be plunged into a freezing mixture, urea is procured in the quantity shewn by the following tables. "A given quantity of the urine was desiccated cautiously as long as it lost weight, retaining the temperature constantly below 212°, the residue gave the relative proportions of water and of solid matter in the urine. To determine the quantity of sugar, an excess of solution of acetate of lead was added to the urine, and the precipitate separated by the filter. The lead in the filtered liquor was then thrown down by sulphuretted hydrogen, and the sulphuret. of lead having been separated by the filter, the liquor was evaporated on a water bath to dryness, and the residue weighed; in some instances the confused crystalline mass was dissolved in spirit, and crystallized, but this part of the process was not found necessary.
The quantity of urea was determined by the process by means of which it had been first obtained in quantity; the mixture of acid and urine was immersed in a freezing bath, and the nitrate of urea deposited, separated, dried, and weighed, and the quantity of urea calculated from its known composition. The nitrate thus obtained, is slightly tinged, but being weighed in this state, it gave a closer approximation to the truth than if it had been purified and decolorized; in which case, a portion of it would infallibly have been lost. The quantities of urea given, are those actually found, and I consider that they are less than actually existed in the urine, as I only succeeded in diminishing very much the action of the acid on that principle, without, however, by any means putting a total stop to its
A man in the Meath Hospital, May 27th, 1831.
Urine, Sp. Gr., 1050.5.