THE

AMERICAN

JouEML

OF
A27D

Obstetrics

DISEASES

OF

WOMEN

AND

CHILDREN.

EDITED

BY

B. I
ATTENDIKO PHYBIdAM THE ON HEW OZBEASES OF NEW OF THK TOBK OF TO FBEK CHXLDBEN MEaCBEB YOBK OF OF THE WW

F.

DAWSOX,
YORK STATE FOB THE OF COUNTY XED3ICAL THE NEW MEDICAL STATE

M.D.,
WOMAN'S

H08PXTAI^
;
LATE OF OBiiTETBZCAL

OUT-DOOB CLINICAL THE

DBPABTVEMT;
LECTUBBB

^
*

TO

DISPEK8ABY IS

SICK

CHILDBSX DEPABTMEKT YOBK SOCIETY MEDICAL SOCIETY ETC.

tTKIVEBSITT

YOBK;
NEW

SOCIETY;

COBBESPONDINO

1"fKVWWB

THE THB

CALIFOBNIA OYNJECOLOOICAL OF

SOCIETY;

BOSTON,

ASSOCIATE

EDITOR,

PAUL

F.

MTJNDE,

M.D.

VOLUME

VI.
1873"

May,

August,

November,

February,

1874,

Jfcu)
WILLIAM
WOOD 27
London
:

gork:
CO.,
PUBLISHERS,
Street.
New

" Great
Churchill's

Jones

John

Sons,

Burlington

St.

v^
MAMVMW UMIV"R"rr

APR

1 8 1937

Entered

aooordlng
By

to Act

of

in Congresa, WOOD "

the

year

1874,

WILLIAM
of

CO.,

In

the

Offloe of the LibrariAn

at WaAhington, D. C. OongrRSSi

^0

INDEX

TO

VOL.

VI.

A.

PAGE

Abdominal
M.D

abscess

occnrring criminal,
M.D

after

oyariotomy.
of

By right
H.

Joseph lung.

".

Janvrin,
102 T. G. 103

Abortion,
'*

attempted Thomas,
from
in the

penetration
of. of.

By
M.D

amniotic
third

dropsy, month,
nnrse case

case

By
A.

A.

Smith,
M.D
an

639 632

"

By

Jacobi,
in

Abuse

of

alcohol M.D

by

the

causing
of.

convulsions

infant

By

M. 676

Vemay,
Acardiac
Accident Acute

monster,
from
use

report
of
of the

on

case

By
Wm.
case

Drs.

Lusk M. J.
M.D

and D

Jacobi

629 504

forceps.
after

By

Goodell,
of. By Joseph,

congestion
of
of of Lebert uterine knee the
"

lungs

labor,

L.

Ludlow,

M.

D
.

291
.

.etiology
Affections

flexions.

By
vessels

Ludwig By
in P.

475 525

presentations.
heart
and

Muller,
puerperal

M.D
state.

the

By
chloral.

Prof.

mann Her-

144

Albuminuric

eclampsia
M.D
case dropsy, fluid, effect

and

uraemia

cured

by hydrate By
A. H.

of

By

M. 676

Bouchut,
Amniotic
'^

of

abortion

from.

Smith,

M.D

639

of

complete

By
Amount of
blood in

Heinrich

discharge Lahs, M.D

of, in

preternatural
M.D M.

tions. presenta306 298

breeding

Anatomy
Areolar

of the Fallopian sclerosis and hyperplasia criminal M.D

dogs. By Otto tubes, pathological.

uteri.

Spiegelberg, By
Alex. of
Julius

Klob,
M.D

M.D.
.

83 353

By

J.

G.

Attempted Thomas,

abortion,

penetration

right

Skene, lung.

By

T.

G.

'

103

i
Bailey,
Barnes,
James
Robert.

B.

S.

case

of

lipomata
of chronic

38 inversion
in of of

Reduction

the

uterus

296 509

Baumetz,
Beecher.

Dujardin.
Case of

Hydrate congenital
of.

of

chloral

obstetrics the lower

deficiency
Wm. Wm. A.
and

extremities3

below

theknees

284
ovum,
"*

Blighted
"

case

By By

G.

caseof. caseof. Intermittent

Podalic Albuminuric

Porter, F. Jenks, McCall,

its

M.D
M.D

105 105

ByO.
fever in version

M.D forms

108,
during
cured

284
331

Bohn,
Bouchut,
chloral

Prof.
S.

various

childhood.

Borii^i,

deformed
and

pelves.
urssmia

300

M.

eclampsia
of

by hydrate
death

of 675

Brown, Bulkley,
Burtels.

James L.

L.

Resolutions On

Obstetrical

Society

on

of

267 580 527

Duncan.

herpes

gestationis
of

Intra^uteriue

cicatrization

hare-lip.
in
an

Busey,

Samuel J.

S.

0.

Vaginal
cauteiy
in

hemorrhage
uterine
surgery

infant

five

days

old.
...

46 112

Byrne,

Electric

IV

INDEX.

C.
PAGE

Ccesaxean

section in

Cancroidal
M.D

of nrsemic eclampsia. By M. Mac^, M.D lain, M. Chamberdisease, condition of cervix uteri in. By Wm.
a case

510 101 639

Cancer
**

uterus, specimen of. By Ja^. H. Cathcart, M.D and of uterus, complication of pregnancy parturition with.
Dr. Cohnstein
of Specimen of cancer of the new-bom first inspiration H. cancroidal the uterus

of the

By
646 639

Cathcart,Jas.
Cause

of the

infant.

By

Heinrich

Lahs,
307

M.D
Cervix

uteri,condition of,in
M.D W. M.

disease.

By Wm.

M.

lain, Chamber101 101 634 337

316

Chamberlain,
**

Condition

of cervix uteri in cancroidal

use

disease

Intra-uterine

of nitric acid

in. Children,constipation By A. Monti, M. D Sarcoma uteri Chroback, R. Chronic inversion of six years'standing reduced. By J. P. White, M.D. ** of the uterus,reduction of. By Robert Barnes, M.D.. Circumcision for congenital phimosis with the galvaniccautery. By B. F. Dawson, M.D Cleemann, R. A. Case of puerperaleclampsia of the with cancer Cohnstein. Complication of pregancy and parturition
.

405 296 262 575 641 316 316 78 526

*' "

on on

uterus old primipane the life and and death of the foetus internal and uteri

Combined

external

Compound Complicationof
Cohnstein
Condition of

version. By M. B. Wright, M.D cyst of the vagina. By R. Kaltenbach, M.D

pregnancy

parturition with
in cancroidal

cancer

of uterus.

By

Dr.

646
the cervix disease.

By Wm.

M.

Cham-

101 berlam, M. D of left forearm, 640 M.D case- of. Congenitaldeficiency By W. Sinkler, of the lower extremities below the knees, case of. deficiency 284 By Dr. Beecher ^* double the pelvis in. luxation of the hip-joint, By Ernst 661 Sassmann, M.D *' with the galvaniccautery for. By B. phimosis,circumcision, F. Dawson, M.D 262 ti T. infants. syphilis in six successive Taylor, By Wm.
'*

M.D
**

568,640
of the
sacrum.

tumor

By Dr.

Staude

330

291 Congestion,acute, of the lungs after labor, case of. By J. L. Ludlow^. 337 Constipationin children. By A. Monti, M.D Contributions to phydalogicalobstetrics. 298 By Fred. Schatz, M.D of face into vertex Conversion presentation by external manipulation 657 only. By Frederick Schatz, M. D 675 Convulsions in infant from use of alcohol by nurse. M. M.D. Vemay, By 107 Corpus luteum, fibroma of. By Wm. F. Jenks, M.D Cranioclast, as used and improved by the Vienna school By Paul F. 1 Munde, M.D Ill Craniotomy in deformed pelvis. By Hugh L. Hodge, M.D 525 Cyst of the vagina,compound. By R. Kaltenbach, M.D " 73 of iodine. By H. T. Hanks, M.D ovarian,treated by injection 622 Cystictumor of the uterus, case of. By M. D. Mann, M.D 636 in women. Cystitis By Alex. J. C. Skene, M. D 621 Cysts of the parovarium. By M. Koeberle, M.D

INDEX.

D.
PAOX

Dama^chino.

Dangers
Dawson,

of infantile Pathological anatomy paralysis of dentition. By James Finlayson. 31. D for Circumcision B. F. congenital phimosis with caused

677 6G6 the

galvanic
262

cautery of child Death

Dr. Parrott

by
of

introduction

of

chyme

into

the

air-passages.
knees.

By
528

Deficiency,
Beecher. Deformed
*'

congenital,
;
.

the

lower

extremities

below

the

By Dr.
284
300 J]13 066 150 443

pelves, podalic

version

in.

By

S. Borinski,

M.D

labors in. By Dr. P. R. Osterloh spontaneous Dentition, dangers of. By James Finlayson, M.D "L A. septiceemia Puerperal D'Espine, ovarian of By Prof. Otto Spiegelberg tumors, especially cysts. Diagnosis -* hsematocele. C. M.D C. Lee, By pelvic By Prospero Sonsino on. Digestion, infant, researches in infancy of starch of an osteomalacian Dilatation By Theo. Kezmarszky, pelvis during labor.
,

193
151 153

"

M.D
'*

, OS OS

314

of of

the the

uteri, rapid instrumental

uteri
or

By

'^

at

term.

Diphtheritic Diphtheria.
Diseases state.

nephritis. By Dr. Senator

the

parturition, natural J. C. Skene, By Alex. M.D L. By Litzerich,

incident to pregnancy

in

653 Leopold Ellinger, M.D. and either artificial, mature preM.D

02
338 339

of

urinary
motion organs.

By

Prof.
of

organs Olshausen

and

the

puerperal
821 of
the 326 521 638
. .

Disturbance
female Double

in connection

with

pathologfical

conditions

sexual

ovariotomy,
of the

Dropsy

31. D Mayer, By Louis ^physiological results of. By M. Koeberle, M.D of. By J. B. Ingham, M. D. Fallopian tubes, specimens

E.

Early menstruation,
**

cases

of
Robert

637
571 575

P. Harris, M.D By of. M.D By R. A. Cleemann, case Eclampsia, put-rperal, fluid in abnormal of complete Effect discharge of amniotic Lahs, M. D By Heinrich of maternal Effects impressions on the foetus Electric By J. Byrne, M.D cautery in uterine surgery. of the puerperal poison. Elimination By M. Hervieux of the dilatation Rapid instrumental Ellinger, Leopold. of the umbilical Geo. J. Prolapse cord, its Engelmaun, pregnancy. ment of H.

presentations.
306 641 112 146
os

uteri
and
".

653 treat
"

cause

409,540
639 317

Eigotine
Excessive

in

uterine

increase

use hypodermic of liquor amnii. By Dr.

tumors,

Jungbluth

F.

of. By Julius M. Klob, M.D tubes, pathological anatomy specimen of dropsy of. By W. F. Jtnks, M.D ** M.D specimens of dropsy of. By J. V. Ingham, and cauterization of lamyx Fatal cesophagus, case of. By A. Jacobi, M.D. Feet, seizure of, during version. By Dr. Fritsch Pelvis obtecta in of spinal kyphosis H. Fehhng, consequence

Fallopian

83
109

**

038 633
310 297

VI

INDEX.
PAGE

and Fever, intermittent,

Bohn

its various

forms

dnring childhood.

By Prof.
330

100 By J. V. Ingham, M.D of the utems, incarcerated. tumors By Prof Otto Spiegelberg. 317 of the corpus luteum. Fibroma 107 By Wm. F. Jenks, M.D 6QQ Finlayson, James. Dangers of dentition 316 FcEtus,life and death of. By Dr. Cohnstein effects of maternal 641 on impressions 604 Forceps,accident from use of. By Wm. Goodell,M.D of pelvic haematocele. 642 Formation By Karl Schroeder, M.I) of the placenta 523 Frtinkel, Ernest. Syphilis 320 during nursing. By Louis Mayer, M.D Frequency of menstruation Indications for ovariotomy 320 Friennd, Wm. Alex.

Fibroid tiimor
"

of

rightovary.

"

Fritach.
**

Retro-uterine Seizure

hsematocele

644 310 475

during version of. aetiology Flexions,uterine, By Ludwig Joseph, M.D

of the feet

G. Galvanic
''

cautery in uterine hemorrhage.

Case of excessive
Curious accident
as
an

M.D By A. Jacobi,
in
a

635
294

Goodell,Wm. Gray, Robert.

masturbation from the use

woman

of the forceps

Quinine

oxytoxic

504 507

H.

Htematocele, formation
*' ''

of pelvic. By Karl Schroeder, M.D retro-uterine. By Dr. Fritsch pelvic. By Alfred 'Meadows, M.D
umbilical of the cord

642
644 659 675 654

Haemophiliaof the Hageuiann. Shape

Hanks,
H. T.

Ovarian

cavity of the uterus of iodine cyst treated by injection

73

intra-uterine cicatrization of. By Dr. Burtels 527 Hare-lip, 571 Early pregnancy Harris, Robert P. labor. By Hemorrhage from the cervical zone of the uterus complicating Gustavus C. P. Murray, M.D 296 ^^ S. G. Busey, vagina],in an infant five days old. By Samuel
*

M.D

Hennig, Prof. C. Secondary signsof preg^nancy. of. By Benj.McCluer, M.D case Hernia, ovarian, Bulkley, M.D Herpes gestationis.By L. Duncan Elimination of the puerperalpoison. Hervieux, M. Hodge, Hugh L. Craniotomy in deformed pelvis Human placenta. By F. N. Winkler, M.D of chloral, albuminuric eclampsia and uraemia Hvdrate Bouchut, M.D
"
'*

46 145 613 580 146 Ill 301

cured

by.

By M.
675 677 509 638

of urine cured by nocturnal incontinence in obstetrics. By Dujardin-Baumetz, M.D

use

Hypodermic

in uterine of ergotine

tumors

I.
suture in ruptured perinaeum Immediate of the uterus. Incarcerated fibroid tumors By Prof. Otto Spiegelberg. cured by hydrate of chloraL of urine,nocturnal, Incontinence
...

.520
317 677

INDEX.

Vll

PACE

Indications

for

oyariotomy.
cause

By W.
the

Alex.

Frieund,

M.D
in the.

320 307
1 51

Infant,
"

new-bom,

of

first

inspiration

By

Heinrich

"

Lahs, M.D digestion, researches on. new-bom, shape of body

of
the

Infants, properties
By
"*
'*

Sonslno By Prospero of. By Wilhelm Pfannkuch, pancreatic juice and parotidean

M.D saliva

329
fants. of in-

Br.

Korowin of.
to

528
J.

size

of stomachs

By

L. Ludlow, of alcohol

M.D

040
nurse.

conviilsions nay,

in, due

abuse

by the

By X.

Ver676

MD of.

Infantile Influence

paralysis, pathological anatomy

By
of the
Karl Ketli

By

Dr.

Damaschino

677 079

the of neighboring organs on position and involution the Pfannkuch puerperal uterus. By Wilhelm J. V. Ingham, Specimens of dropsy of the Fallopian tubes Fibroid of right ovary tumor Injection of perchloride of iron in puerperal hemorrhage. By A. B. Steele, M. D Intra-uterine therapeutics. By Prof. Olshausen ** of hare-lip. cicatrization By Dr. Burtels " of nitric acid. use By W. 31 Chamberlain, M.D fever Intermittent its various forms. during childhood, and By Prof.
*'

118 6o8 100

341 324 527 643

Bohn

331
on

Investigation
berg, Iodine,
Irritable

amount

of

blood

in

breeding By

dogs.
H. T.

By

Otto

Spiegel
M.D

M.D
ovarian

208

cyst treated

by injection of.
M.D

Hanks,

73 642

nipples.

By J. L. Ludlow,

J.

Jacobi, A.
**

Septicasmia
Case
" " "

in its relations

to

gynaecology
of the liver month

273 ""31 6'52

of

rachitic abortion fatal monopus

fatty degeneration
in the third of cauterization

*'

"

larynx

and

oesophagus.

633 633

**

'*

Galvanic

cautery
Case
of Abdominal

in uterine
metro-

Janvrin, Jenks,

Joseph
^*

E.

hemorrhage peritonitis abscess occurring after

corpus tied in luteum.
. .

635 275

ovariotomy

102 105

Wm.
* * *' **

F.

Blighted
Fibroma

ovum

of

the

1 tubes

107 K'O 2-^3 475

Specimen
Umbilical

of clropsy of the
cord of
a

Fallopian
knot

square

Joseph, Ludwig. H. Jungbluth,

^Etiology Liquor amnii

uterine and

flexions
increase

its excessive

317

K. Kassowitz.
The F.

Kehrer,
Ketli,

A.

Karl.

unity of variola and varicella Pathogfenesls of the rachitic pelvis of infantile Nosogeny paralysis
Dilatation of
an

334 524 670

Kezmarszky,

Theo.

osteomalacian

pelvis during labor.

314
.

of the Fallopian tubes M. Klob, Julius Pathological anatomy Knee-presentations, aetiology of. By P. Miiller, M. D

"^'^

525
521

Koeberle,
"

M.

Korowin.

Physiological results of double Cysts of the parovarium Properties of pancreatic juice

obtecta in consequence

ovariotomy
and

521

parotidean By
H.

saliva

of

fants in-

528

Kyphosis,

pelvis

of spinal.

Fehling,

M.D.

270

Vlll

INDEX.

L.
PAGE

Labor,
*'

case

of

acute

cong^tion
from the

of

the

lung^ after.
zone

By J. L. Ludlow,
291
uterus

M.D

hemorrhage
labor. dilatation of old

cervical C.

of M D

the

complicating
296

'*

By
of
an

Gustavus

Murray,

"

osteonialacian

pelvis during. By By
Dr.

Theo.

Xezmarszky.

314
313 313

Labors
*"

primiparsc. By Dr. Ahlfeld in deformed pelvis spontaneous.

Heinrich.
''* "

P. JL

Osterloh

Lahs,

Pressure

of of

uterine the

contents

303
in de-

supports
formed effect normal
cause

uterus

during labor, especially

of amniotic

pelvis
of

304 fluid in
ab-

*' *'

complete discharge presentations

the first

306
the new-born infant.
.

'* ' '

of

inspiration of
in the

307
. .

the M.
Case

negative
of

pressure

uterine

cavity
vessels in the

307 205

Lamb.

M.

meningocele
Affections

Lebert, Prof.
"

Hermann,

of
state

the

heart

and

peral puer-

144
disease

Tubercular and the the

of the
of and the

female

genital
of

organs
on

influence

generative

period
tuberculosis

development

progress

323 193 38 338

Lee,

Diagnosis S. Bailey, M.D of. By James Lipomata, case L. Diphtheritic nephritis Litzerich, and its excessive increase. By Li(iuor amnii of rachitic Liver, case fatty degeneration of.
C. C.

of pelvic haBmatocele

Dr.

H.
A.

By

Jungbluth Jacobi, M.D

317

631 640
642

Ludlow,
'* *'

J. L.

Size

of

stomach

of

infants.

Irritable Case of in

nipples
acute

Lung,
M.D

penetration of,
;

congestion of attempted criminal

after

the

abortion.

lungs after labor. By T. G. Thomas, By J.

L.

291 103

Lungs, Lusk,

acute

congestion of,
T.
Case of

labor,
of the

case

of.

Ludlow,

M.D.

291

Wm.

rupture

uterus

628, 632

IVL
of Case Cscsarean of section tumor for of uncmic the
uterus

Mace,

M. M.

Case

eclampsia B;^ Wm. Goodell, M.D.

. .

510 622 294

.

Mann, cystic of excessive, in a woman. Ma.sturbation, case Maternal impressions on the foetus, effects of menstruation Frequency Mayer, Louis.
*^

D.

of.

641

during
connection sexual

nursing
with

320

Disturbance
"

of of

motion the
ovum

in

pathological
326

conditions of of

female

organs

McCall, McCluer, Meadows,

C. A.

Ca.se Case

blighted
ovarian

108, 284
613 and

Benj.
Alfred.
*'

hernia.

Ovarian Pelvic

physiology
ha;matocele uterine M.

pathology By
Prof. B. S. Schultze.

215, 371
659 309
. .

Mechanical

treatment
case cases

of

deviations.

Meningocele, Menstruation,
**

of.

By M

Lamb,

M.D

265 637
320 265

of. early

frequency of, during nursing. By Louis Mayer, M.D of. Metro-peritonitis, case By Joseph E. Janvrin, M. D Metritis and cellulitis caused F. Munde, by steni-pes.sar"'. By Paul
Variola in the female Lothar. Meyer, of. Monster, acardiac, report on case A. of. Jacobi, M.D Monopus, By case
sex

M.D..

635

328
Lusk and Jacobi 629

By Drs.

633

INDEX.

IX

PAGB

Monti, A.

Constipation in children. of paerpend septicsemia treated bj elimination Cases Morton^ T. Morbus bullosus endemic. By Dr. Ahlfeld neonatorum, Muller, P. jEtiology of knee presentations Metritis and cellulitis caused Paul F. Monde, by stem-pessary ^^ and The cranioclast used as improved by the
'.

337 511 520

525 635 Vienna

school

1 296

Murray,

GustaTUS labor

C.

Hemorrhage

from

cervical

zone

of uterus, complicating

Natural

artificial dilatation of the os uteri,either premature or at By Alex. J. C. Skene, M.D New By E. R, Peaslee, M.D stem-pessary. of first inspiration of. New-bom Lahs, M.D. By Heinrich infant, cause '* Pfanukuch, M.D shape of body of. By Wilhelm of. By John use Nitric acid, intrauterine Chamberlain, M.D Normal ovariotomy, case of. By T. G. Thomas, M.D Nosogeny of infantile paralysis. By Karl Ketli, M,D Nott, Josiah C. Resolutions of the Obstetrical Society on the death of. and term.
. .

92
635

307 829 634 634

679

275

O.

Old primiparas. By Dr. Cohnstein *' of Labors By Dr. Ahlfeld of the urinary organs Diseases Prof. Olshausen,
.

311 318
incident to pregnancy
:

puerperal state *' Intra-uterine therapeutics Osterloh, P. B. Spontaneous labors in deformed pelvis Osteomalacian pelvis, dilatation of an, during labor. By marszky, M.D
Os

and

the

321

324 313
Theo. Kez-

314 93
653

uteri, natural
or
*'

and

artificial dilatation

at term. instrumental of and

By

Alexander dilatation

rapid Ovary, fibroid tumor Ovarian physiology

"' *"

of, in labor, either premature J. C. Skene, M.D of. M.D.... By Leopold Ellinger,

106 right. By J. V. Ingham, M.D 215, 371 pathology. By Alfred Meadows, M.D 276 a pedicle. By E. R. Peaslee, M.D tumor, without tumors complicating pregnancy, prognosis ol By A. Wemich,
M.D

321

tumors, diagnosis of, especifdly cyst. By Prof. Otto Spiegel443 berg '* 613 hernia, case of. By Benj. McCluer, M.D ** 73 of iodine. By H. T. Hanks, M.D cyst, treated by injection 521 results of. By M. Koeberle Ovariotomy, double, physiological 634 case of, followed by mania. By E. R. Peaslee " 820 indications Alex. Frieund, M.D for. By Wm. ** 634 normal, case of. By T. G. Thomas, M.D
" '*

'j
if
"

abscess abdominal occurring after. MD " twocasesof. By E. R. Peaslee,M.D G. Porter, M.D Ovton, blighted. By Wm. " F. Jenks, M.D By Wm. ** By 0. A. McCall, M.D

*" '

By Joseph E. Janvrin,
103 102 105 105

108, 284

X
.

INDEX.

P.
PAGB

Parovarium,

cysts of.

By

M.

Koeberle.

521 177 677 M.I). 88 268

102

Three of rupture S. of the uterus Parry, John cases of infantile Pathological anatomy paralysis. By Dr. Damaschino " of the Fallopian M. tubes. Klob, Anatomy By Julius to gynasoology Peaslee, E. B. SepticsBmia in its relations " of ovariotomy Two cases ** Ovarian without tumor a pedicle " Case of ovariotomy followed by mania
"

276 634
635 193

New

stem-pessaiy

Pelvic

Pelvis
^^

''

By C. C. Lee, M,D diagnosis of. ** M.D Meadows, By Alfred of k3rpho8is. in consequence obtecta By H. Fehling, M.D labors in. deformed, spontaneous By Dr. P. B. Osterloh of during labor. osteomalacian, dilatation By Theo. Kezmarsky,

hasmatocele,

(i59
297

313 314

M.D
'^

in

congenital
mann, M.D

double

luxation

of

the

hip-joint.

By
M.D

Ernst

Sass651

Penetration

A By Kehrer, rachitic, pathogenesis of right lung in attempted criminal abortion. M.D Thomas, in ruptured sutures Perinaaum, immediate of neighboring Influence Wilhelm. Pfannkuch, on organs involution of the puerperal uterus and with the galvanic cautery Phimosis, congenital, circumcision
the. F. F.

'*

of

524

By

T.

G. 103 ? 520

the

position
148

for.

By

B. 262

Dawson,
*'

M. D

Physiological

obstetrics, contributions
results of

to.

double F.
N.

By Placenta, *' syphUisof. Pleuritis in childhood,

Podalic
version G.

human.

ovariotomy. Winkler, M.D

Frankel,

By By M.
M.D

Fred.

Schatz, Koeberle, M.D

M.D

298 521 301

522

By
and

Ernst

thoracocentesis.

in deformed

pelvis.

By H. Roger, By T. Borinski, M.D

M.D

677 300

Porter, Wm. Pregnancy,

' * ^'

"

*'

105 Blighted ovum twin. 299 By P. Beuss, M.D 145 C. Hennig secondary signs of. By. Prof. of the urinary organs incident diseases to the puerperal state, 571 P. Harris, M. D early. By Robert 321 and. By Prof. Olshausen tumors prognosis of ovarian complicating. By A, Wemich, M.D

321
contents.

Pressure

of the
on

uterine

By

Heinrich

Lahs, M.D

303 311 313

PrimipaWB,

By Dr. Cohnstein. ** laborsofold. By Dr. Ahlfeld and treatment. B. Geo. Prolapse of the umbilical cord, its cause gelmann, M.D Properties of pancreatic parotidean saliva of infants. juice and
Korowin

old.

J. En-

409, 540 By
Dr.

528 affections
elimination of the

Puerperal state,
" "

heart

and

vessels

in.

By Prof.

Hermann ',..,.

Lebert

144 146

"

By M. Hervieux of neighboring uterus, influence organs upon of the. involution Pfannkuch, By Wilhelm septicaemia. By M. A. D'Espine, MD poison,
inversion, spontaneous
reinversion

of.

the M.D

position

and

148 150

"

of

an

old.
iron

By
in.

Prof.

Otto

**

Spiegelbeig hemorrhage, injections of perchloride M.D Steele,

322 of

By

A.

B. 341

INDEX.

jrf
PACK

Paerperal septicaamiatreated by elimination. By T. Morton, M.D eclampsia, case of. By E. A. Kleemaun, M.D
k k

511 575

Quinine

as

an

oxytoxic. By Robert

Gray, M.D

507

B. dilatation of the ob nteri. By Leopold Ellinger, M.D. 653 Rapid instrumental of. 631 Rachitic fatty degeneration of the liver,case By A. Jacobi,M.D. 624 pelvis,pathogenesisof the. By F. A. Kehrer, M.D of chronic inversion of the uterus. 296 Reduction By Robert Barnes, MD. hematocele. Retro-uterine 644 By Dr. Fritsch of. By Samuel B. Wajrd, case Retroflexion of the uterus causingsterility,
, . .

M.D Remarks on Reuss, P. Pleuritis and Roger H. Rupture of the uterus.

fcfc

twin

pregnancy thoracocentesis
cases

Three

of.

in childhood. By John S. M.D

Parry, M.D

By

Wm.T.

Lusk,

529 299 677 177 628, 682

S.

Sacrum, congenital tumor

Sarcoma
*'

Sassmann

of. By Dr. Staude. uteri. By Dr. R. Chroback uterine and vaginal. By Prof. Otto Spiegelberg The pelvisin congenital double luxation Ernst.

330 316 467 of the hip651 54

nal exter-

joint.
Sairlet fever. By Bradford S. Thompson, M.D Conversion of face into vertex Schatz,Frederick.
'"

Schroeder, Karl. Schultzer, Prof. B. S.

of Secondary sigpas

presentation by manipulationonly. Contributions to physiological obstetrics of pelvic haematocele Formation

Mechanical treatment

of deviations of the uterus.

By Prof. C. Hennig pregnancy. By Dr. Fritsch Seizure of the feet during version. On diphtheria Senator. Septicajmia. By T. G. Thomas, M.D in its relations to gynaecology. By E. R. Peaslee, M.D. ** *' *' By T. G. Thomas, MD., 269, 277 " " *' 273 By A. Jacobi,M.D " " '* 277 By E. Noeggerath, M.D. *' 150 puerperal By M. A. D'Espine ** treated by elimination. 511 By T. Morton infant. 329 By Wilhelm Pfannkuch, MD. Shape of the body of the new-bom Case of congenital 640 W. deficiency of left forearm Sinkler, 654 the cavityof the uterus. ''of By Dr. Hagemann 353 Skene,Alex. J. C. Areolar hyperplasiaand sclerosis uteri in women 637 Cystitis
"
.

657 298 642 309 145 310 339 247 268

"

*'

**

'*

^^

Natural
Abortion from

and

artifici^ dilatation of the either

os

premature

or

at term

uteri in parturition, 92
639 151

Smith, A. H.

amniotic
on

dropsy

Sonuno, Prospero.

Researches

infant digestion

M
1

,(

Xii

INDEX.

PAGE

Spiegelbeig, Prof.
''*'

Otto.

Diagnosis of ovarian tumors,. especially cysts. of blood in breedInvestigations on the amount ingdogs
Incarcerated
on

443
.

298
317 319 407

" " "

fibroid of the

tumors
uterus
sarcoma.

of the

uterus

inversion and

Uterine

vaginal

Spontaneous
**

labors

in deformed

of an By Prof. Otto Spiegelberg Starch, digestion of, in infancy of the sacrum Staude. Congenital tumor of A. B. Steele, Injection perchloride of iron in puerperal hemorrhage. of the B. Ward, M.D. retroflexion uterus By Samuel causing. Sterility, M.D Stomachs of infants, size of. By J. L. Ludlow, pelves. during labor, especially in deformed By Supports of the uterus Heinrich Lahs, M.D infants. T. By Wm. Taylor, Syphilis, congenital, in six successive
.

rein version

pelves. By Dr. P. R. old puerperal inversion.

Osterloh

313

322
153

330
341 529

040 304

M.D
"

5()8, G40

of the

placenta.

By

Ernest

Friinkel, M.D

522

T.

T. Taylor, Wm. G. T. Thomas,

** " **

Congenital syphilis in six successive infants 508, 040 criminal of Attempted right lung.. 103 abortion, penetration Case of normal 034 ovariotomy On 247 septicaemia to gynaecology Septicaemia in its relations 209, 277
S. On scarlet fever 54 in childhood.

Thompson,

Bradford

By H. Roger, M.D disease and the influence of the of the female Tubercular genital organs the and of on tuberculosis. development generative period progress By Prof. H. Lebert By J. V. Ingham, M.D Tumor, fibroid, of right ovary. '* M.D a pedicle. ovarian, without By E. R. "Peaslee, By Prof. Otto Spiegelberg. Tumors, fibroid,incarcerated, of the uterus. ** ovarian, diagnosis of, especially cysts. By Prof. Otto berg SpiegelThoracocentesis
**
'*

077

323
10ft

276 317 443

Twin

pregnancy,

prognosis of, complicating pregnancy. nich, M. D remarks on. By P. Reuss, M.D

By

A.

W'er-

321 299

TJ.

Umbilical

^*

cord, haemophilia of prolapse of, its

mann, tied in M.D
a

075
cause

and

treatment.

By

Geo.
F.

J. Engel-

40J), 540

**

Uraemio

eclampsia,

knot, specimen of. By W. square Csesarean section for. By M. Mac(6 of, incident
to pregnancy and the

Jenks, M. D.
state.

283 510

Urinary
By

Prof.

diseases organs, Olshausen

puerperal

321 of, cured

Urine,
Uterine
4k

nocturnal and

incontinence

by hydrate of chloral
Otto

077
407

k(

Spiegelberg in the. By Heinrich Lahs, M.D. pressure of. By Heinrich contents, pressure Lahs, M.D flexions,eetiologyof. By Ludwig Joseph, M.D hemorrhage, galvanic cautery in. By A. Jacobi, M.D

vaginal sarcoma. cavity, the negative

By

Prof.

307
. .

303 475

035

INDEX.

Xlll
PAOE

Uterine snigery,

By J. Byrne, M.D *' tumors, hyi"odermiouse of ergotinein of cystic tumor of. By M. D. Mann, M.D case Uterufl, *' of retroflexion of, causing sterility. By Samuel ease
electric cautery in. M.D
" ^^

113

638
622

B.

Ward,
529

case

of

rupture of
from

By Wm.
cervical
zone

T.

Lusk, M.D

628, 632 By
Gus-

hemorrhage
tavusC.

of,complicating labor.
:

" " ** "

" " '" ti

44

296 of. By Prof. Otto Spiegelberg fibroid tumors 317 incarcerated inversion of. By Prof. CMito Spiegelberg 319 of deviations of. By Prof. B. S. Schultze. 309 treatment mechanical puerperal, influence of the neighboring organs upon the position Pfannkuch and involution of. By Wilhelm 148 316 of. By Dr. R. Chroback sarcoma 654 shape of the cavityof. By Dr. Hagemann Cathcart of. By Jas. H 639 specimen of cancer in deformed pelves. By supports of, during labor, especially 304 Heinrich Lahs, M. D three of rupture of. By John S. Parry, M. D cases 177, 503

Murray, M.D

V. M.D Vagina,compound cyst of. By R. Kaltenbach, Vaginalhemorrhage in an infant five days old. By Samuel M.D 525 S. C.

Busey,
46 467 334 328

By Prof. Otto Spiegelberg. Variola and varicella, unity of. By Dr. Kassowitz *' in the female sex. By Lothar Meyer, M.D
sarcoma.

"

Vemay,
nurse
'^ "

M.

Gonvulsioiis in
external

an

infant intemaL

due

to

abuse

of alcohol

by the
676 78 300 310

combined Version,

By M. B. Wright, M.D M.D. pelves. By S. Borinski, podalic,in deformed seizure of the feet during. By Dr. Fritsch.
and

W.

Ward, Samuel B. Case of retroflexion causing sterility Wemich, A. Prognosisof ovarian tumors complicatingpregnancy White, James P. Chronic inversion of six years, reduced Human F. N. Winkler, placenta
M. Wright,

529 321
405 308

B.

Combined

external

and internal version

71

"i'

ri

THE

^MERICA.N

JOURNAL

OF
AND

OBSTETRICS

DISEASES

OF

WOMEN

AND

CHIIDEEN.

VOL.

VI.]

MAY,

1873.

[No.

1.

ORIGINAL

COMMUNICATIONS.

THE

CRANIOCLAST

AS

IMPROVED SCHOOL.

AND

USED

BY

THE

VIENNA

Bt Master B"T"Tla In Obstetrics ; of th"

PAUL
of the

MUin}E,
Ylenaa

M.D^
; late

Kxw-Tobx.
to Profossor Scanionl at

TTnlTerslty Army
in

Assistant 1806 and

W"nburx.
to the

Sargeon

Bayavtaa

Campaigns
Oerman

of

1870-71 etc.

; Attendiox

PhyBidan

West-Side

Dispensary,

(Pftsentad

before

the

New-Tork

Obstetrieil

Society, March,

1873.)

Instruments

for others
to
a

the for

purpose

of

opening

the

fcetal of the

cranium,

and order

removing
the

various of

portions
the

skull,in
head
as

facilitate deformed the

an

passage

presenting
in use,

through they
were, to

pelvis,have
time of

been

such
first
to

from

Hippocrates.
with
at

The
a

attempt

devise

instrument
value in
was

least in

claim

practical

and

scientific
the younger
to

made
thus

France, by
the firat real and the This

Baudelocque
foundation

1829, and
of

laid

the

operation
of the and

craniotomy
fcetus.

subsequent
contrivance

extraction
was

mutilated

very

bulky

clumsy, however,

weigh-

Munde:

TJve

Oranioclast
in

as

improved

ing eight pounds,

efficient years

thus
; and

itself often

preventing its
the
course

employment ingenuity
was

in consequently,

of in-

the

of

numerous

obstetricians
and latter their

and
more

strument-makers

busy inventing new

which in

elegant and
a

in practicalappliances, number

cular partiobject.
r/Jt/Jw,

good
the
newer

utterly

failed

Among
I

( "e^aA^, head, and cephalotribes,

was

as bruise,)

this instrument

those called,

devised
in

by
many, Ger-

Hueter, Braun, Breisky, Scanzoni,and

and and
are

Martin

Dubois

in

France, deserve
in both

especialmention,
and countries,

still

used principally

by

the

at large. profession

Other
were

instruments

for

the perforatedhead extracting

recommended

Burton, Mesnard, Scheel, by Smellie,

and of and others,
are

Davis, Ritgen, Saxtorph, Busch,

present found
never

at

only in
the

the

museums

lying-in hospitals,
which The their
brated cele-

having had
inventora

practicalvalue
for

vindicated

then^.
Assalini
an

so-called
to

conquasaator
compress
as cle, are

capitiswith
extract

which head
is

proposed by
Kiwisch

and

the

utterlyuseless

arti-

also the tire-tStes of the

a

devised specially after its of

for the

extraction

head

perforationwith
for

his

trephine.
been

Such

variety
the

contrivances

the

diminution,compression,and
have
one

extraction
last

of the foetal head and

invented
as

within

forty years,
to

each
of

praised

superior to

all its

predecessor,most
wan'ant

them claim
been

so differing

slightlyas
with
to

hardly
few

their have

to

that originality,

exceptionsthey
an

utterlycommitted only
be

oblivion, and
There
are,

enumeration
a

would

tedious.

however,
account

few

ventions in-

of later years

which, partly an

of their

Munde:

The

Granioddst
the

as

improved
of

Belgique^
or

in

1869, under

name

spheThotryptear
of
a a

The trwnefforateur.

instrument
a

consists like

long,

straightsteel rod, with

and

point shaped
; this is to
to

pine-cone
the

grooved

like and

screw

be

passed through'
first cranii,

the caJvaria foramen

and like which the that

the
and

brain then

the

basis

magnum

the

sella turcica
; then
a

sought for,
thick

point imbedded
of
a

in the bone

blade,
of

is introduced,into forceps, rod is

the

handle
to

the the

above-mentioned
blade the

brought
then
until the

fit

byis the

placing
driven

and accordingly,

screw

through
the the for

sphenoid
enters

bone into
a

it meets

point of
there

blade

and

little

opening

made of

purpose.
so

The

firm

and

unyielding base
obstacle thus

the skull,which

often

forms

the

chief

to the

delivery of
of the head

the

child and

in deformed

pelves,is
a

ally effectuobtained
to

transfixed

shattered,and
While the

firm I
was

hold

for

extraction.

assistant the
to

Professor

Scanzoni, in
the instrument several

1868,
to

son

of

inventor

brought
and

Wtirzburg
it
to
on

to show

Scanzoni,

I made with

trials with and

the

dead

body,

ways al-

perfect success,
to

my

great satisfaction.

In

order

make

good extractingand
had
a

compressing
and
a

strument in-

of

it,Scanzoni

second the

blade whole

com-

pressing-apparatusadded, lighterand
the
an more

and

thing

made

thus elegant,
"

joining a cephalotribeto
In where pelvis,

rod transforating
extreme uterus
case

transforating cephalotribe."
a

of

deformed been

rupture of
the violent

the

had

already
of the

produced by
to

ineffectual I

efforts
to

organ

expel

its contents,
to

attempted

apply
head
on

this and

instrument, but, owing

before the

the

positionof

the

symphysis pubis,

Ofnd

used

by

the

Vienna

School.
of the

I could within
some

not

get
to

large enough segment

sure

skull after

reach

make

of I had

boring
the

in the

point ;
I

I thought difficulty,
as

succeeded

; the

appeared point dis-

supposed, in began
the

cranium;
to
use

applied the
drawn. slowly withthe

locked, and cephalotribe,

the whole instrument As had and
a

proceeded
to

when traction,
was

and slip,

subsequent examination
child's shoulder be

showed,

point
ear,

simply
entered
such

lacerated the
a one

passed through scalp,

;
a

the

cm'ved in

perforating
with

rod, if

could

devised the

accordance field of
; and

mechanical

and principles

limited
better

action,

would

have

answered
after

the

purpose

doubtless
for-

this case, ceps,

which,

the perforation, cephalotripsis, been the

version, and
was

decapitation had by
been and

successively
of the

employed,
detached
use

finallyterminated
manual could curved
at

repeated perforation, by
the

and

compression and easilyhave trephine

instrument

extraction

head,

concluded
the

of Braun's had A had them

if cranioclast,

we

hand,
was

somewhat

similar

invented

and

used his
or

des hdp. 1867, by Guyon, (^Gaz.

method
'*

No.

145,) who
A

called

intercranienneP cephalotripsie

tire-fond
over

gimlet is
this,and

bored
the

into skull

the

calvaria, a trephine passed

; the

opened

tire-fond

is then
is

duced, intro-

and

bored of
a

into smaller

the basis

which cranii,

perforated tribe cephalobe

pletely com-

by

means

trephine.

The

French
skull
can

being
diameter.

then

the applied, and

whole

crushed The Lollini is

extracted easily

through
of

the smallest

invented forcipe perforatore^

in

by

the

Fratelli
in which

Bologna, consists
movable auger

strong forceps
this the

placed a

; with

base

Munde:
the skull is then

The

Oraniaclast
in perforated crushed

as

improved
and places, with the

of

is to be
to

various

head

be

and

extracted

the

forceps.
In

England, neither
performed

the

cephalotribe nor
are

any

of

the
niotomies cra-

other

just-mentionedinstruments
with
the
or

used, but

most

old-fashioned
hooks

scissors

and

the extraction Braxton Barnes

Hicks

with

sharp
and

blunt

; in later years,

{Obstet. Tr,

vi. p.

263)
ed.

and

Robert p.

{e.I

.p, and

277,

ObsU
the

Op.

2d

1871,

29!9)

use largely

advocate

a craniotomy-forcepSj cies spe-

of

with enlarged and improved bone-forceps, all loose and

which skull
as

they
after
to

remove

piecesof projecting
is so reduced the

the

until perforation,

the cranium

in size

allow

its

being pulled through

in extreme
cases

pelvis. Barnes,
of
off and removal is made

recommends besides, the chain

of of
an

the introduction

6craseur,and

the

sawing
an

portions of

before the basis cranii,

attempt
a

to draw

the skull

through

the

pelvis
"

safe

proceeding
difficult

for the

mother, but, as he himself admits,a

most

thing to perform.*
Of all the instruments

thus far mentioned

in all

and
the

describtion excepbeen
nient, conve-

has ed, the cephalotribe of

with countries, its

England,

maintained
and

and superiority,
as

universally acknowledged
and efficient,

used

the

most

least

dangerous
of

instrument
foetal A

for

the

compression

and
cases

extraction of

the

head

after

in perforation,

deformed

pelvis.
by
uses

brief de-

*It

has

onlj juBt
to

eome

to

my

knowledge,
in

verbal and

communication,
recommends
a

tliat

"idd, surgeon
followed

tlieComb ribbed

Hospital blades, and

Dublin,
Barnes

""rffi^/^

ceplialotribe with

that

in London

has,

in

measure,

his example*

aiid

used

by

the

Vienna

Scliaol.

scriptionof
zoni's, may
is

the
not

one

most

commonly place.
the 3''^ and The

employed,
whole and

Scan-

be

out

of

instrument
8'' to

l7i" long, of handles,

are

which

9i^^ belong to the blades

from and middle the is, middle

the

reckoned broad in the that

of the lock. possess

a

The
jecting pro-

blades

1 V

thick,and
at

ridge
the horizontal

the

borders.

The

pelviccurvature,
V
2'".

elevation

of the

points over cephaliccuras

plane,measures
The lock The

2'' 10''^ ; the is the

one

vature

known the

that

of
can

Naegele-Brueninghausen.
be made
to

points of
2]f'when

handles

approach
The handles

to

within

the instrument
a

is closed.
over

compressive apparatus
and
a

consists of
is very

clamp weighs
from like

both the
two

screw,

and the

simple.

With

compressive apparatus pounds.*

now

instrument

just
those tends

Martin's

cephalotribediffers being fenestrated

makes much it what

all others of
to

in

use

in the blades
"

the

forceps
its

which peculiarity

undoubtedly
its inventor

prevent

and slipping,
an

justly considers
more

advantage,a
than
the any

lighterand
indications
and
to

elegant instioiment
The
manner

of its rivals.

of

using

its cephalotribe,

and be
to

the dangers accompanying contraindications, avoided be taken

by
have

its

and application,

the various

precautions
known their

in its

employment,
occasion
too

are

well sufficiently
use

to

all who

had
me

to

it,and
way

tion descrippresent

would
article.

lead The

far out

of the

in the

advantages,and
use

the particularly

tages, disadvanare

attending the
still

of

the

instrument,however,
different

subjectsof
of

discussion and
"""-""

among it is ray
"" """"""

leading
I I "

tricians obsteto

Europe,
' *

and object,
.1.

necessary
" " "

^^^"^^^""~

""

s^M

"

^.tm^m^^^^^^^m^^^m^^^mmm

Scanzoni, Lehrbadi

der

Qeburtshilfe, ill.Band,

p.

246, 1867.

Munde:

The

Cranioclast

as

improved
the

the

full

understanding
to

of

the

value

of

modified
and

nioclast, cra-

lay

stress

on

these
two

disadvantages
instruments. had
some

show

the

contrast

between

the

who Every practitioner the

has
met

experiencewith
a

cephalotribewill
the instrument The
or

have has head

with

number
means

of

cases

in which his with

not

by
been

any

satisfied

expectation.
the scissors

has

perforated either apply

the

the

trephine,we
to
use

tribe, cephalowe
are

compress,

and the

proceed
instrument and

when traction, and with

a

gradually compelled likelythe

is

feel
to
same

slipping away,
it

remove

apply

again anew,
chance between
or

very hold

until finally result, by neck the other is

firm

caught
blades
to

or

the and

grasped

the
we

points of
have
to

the

extraction instioiment has

succeeds,
or means

resort

some

of

delivery.
a

When
number and look

this

mishap
he for
a

occurred

to

an

operator in
instrument Scanzoni lost

of cases, about

begins to
more

lose faith in the

reliable

substitute.
to

himself

cit. (loc.

iii. p.

243)

confesses

having

good
hold

deal of his enthusiasm and soft but the

for the

after cephalotribe,
a

this firm

slippingaway
of
to

frequent inabilityto get

skull that
a

the

compressed
considers and various
occurrence.

had

repeatedly happened
its

him,

constiniction practical

of the

instrument

precautionsin My
to
own

tion applicalast of

will with

prevent

this

experience
this

Scanzoni's

cephalotribe goes
my late revered in cephalotrypsis,

refute

opinion expressed by
four
cases

chef; for,out
the

of

three
to

instrument,
film

although applied legeartis^failed

the in shattered
one case

get
and

hold

on

head

and

slipped away,
in another

was

reapplied
and

eight times,

twice,

the

and

used

hy

the

Vierma
the

School.
manual

labor and the

was

terminated finally
of the

by
and the

compression
rest

extraction

head,

subsequently the
in the

of

fcBtas ; in the the

third the

case,

forcepseffectually supplied
fourth,the
Hubert's the head of description

place of

cephalotribe ; and
under the

one

mentioned

above

sphenotryptor,the
was

instrument
on

slipped because
and
a

situated

too
not

far be

the

pubis

sufficient segment
blades
to to

of it could firm hold

brought
This

between

the

get

upon.

was difficulty a

owing
which

ficient the insuf-

pelviccurvature,
If of
an

in peculiarity the

the French

is superiorto cephalotribe
we now

German.
to

consider

the instrument
does

slipin
much

the hands

inexperiencedoperator, who
it is easy
to

not

this anticipate

occurrence,

imagine
of the

how

injury the
do
to

rapid involuntary removal

the

cephalotribemay
of the of such
was

cervix, vagina,and
as,

perinaBum
when the The

male, parturient fecases

indeed, post-mortem
even

examinations

frequently show,
the
use

operator

expert in

of in is

the

cephalotribe.
with

instrument, although
one original

nothing locque, ridges

soft

comparison
still

the

of

Baude-

pretty

bulky,

possesses
to

various introduced

sharp
and

and

and projections, with

has
to

be

manipulated
This

great

care,

prevent

inj uring the

restrain

parts of the mother.

same

size and

bulk

will often in its of

cases

prevent
of

or

the free

use

of the instrument necessitates result

extreme

pelvic
verse trans-

deformity, and
the head is

applicationin
is,that
on

the

diameter, the

which

sion compres-

enlarged in

the
as

or antero-posterior gate conju-

diameter

of the

pelvis;

this is the will

diameter

most

generally shortened, the

head

thus

naturally be

10

Munde:

The

Oranioclast

as

improved
soft

pressed againstthe
the anterior
be
more or

already

bruised

coverings
of the

of

and

posteriorpelvic walls, their

and injured, the

tissues will head

less

extraction

retarded. of the

Notwithstanding

the

indisputableadvantages
the

over cephalotribe, especially

complicated and
and

expensive contrivances
and which it is the moderate and applied,

mentioned
the price, its

above, its simple construction

ease

rapiditywith
bility, serviceamore

frequent undoubted
discussed hold
"

disadvantages just
seize

its the

than

frequent inabilityto
head,
the its size

firm

of

mutilated
of

and

bulk, the temporary

of the

enlargement
foetal
can

diameter antero-posterior
ease

head,
be

and

the

with unskilful

which

the

maternal
"

parts

injured
be
"

under

management

all of which

points will
its
use

readilyconceded
these
more

experienced in by practitioners
our

disadvantages,I repeat, warrant

reliable,as
well and
as

looking for
be found

equally effective, simple

to

and

cheap instrument,
contrivance this somewhat which

this I consider the

in the
After

forms

subjectof
order

this paper.

lengthy introduction, which, however,

to
me

appeared
a new

necessary

in

to

show
to

the

want

of its

and

improved
those

instrument,

and

contrast
same

with qualities 1 shall its

now

of its predecessors in the

to

tion, direcand

proceed
from
manner

describe

the cranioclast
to

employment,
form and

its

originalinvention
in which it is at

proved the im-

present used

in Vienna.

In

1860, Sir
a new

James

Simpson
I

described
the the
name

and

mended recom-

under bone-forceps,
Kkao),

of cranioof the into

and clast, (cranio,

break,) for
blade

removal

calvaria

after

one perforation,

being passed

12

Munde:

The

Cranioclast
fenestrated

ds

improved
is V

greatest breadth
of the the solid blade

of the

blade

V'\ that
3'^

9''' ; the

fenestrated

portion is
wood,
and

V'\

correspondingportion of
handles
other of
are

the solid blade notched

2'' 7'^' long. touch

convex

The
each

covered
the solid

with

when the

instiniment
blade with and is

is closed. covered with which the

The
fine

surface

shai'p
responding cor-

points,and
fenestrum

its borders elevations of the other

notches

fit into rim of

depressions in
instrument.

the

blade, thus
of the

adding greatlyto

the

tenacityand
It
was

usefulness

of this

it cranioclast, considering the

as

an

ment instruof

for

extraction, that
and others
was

unfavorable
The former

opinion

Scanzoni
p.

formed.

(loc. cit.,
has
be found

236)
so

says

that,

as

rule, the

which cranioclast,

been useful

warmly only
where the

recommended
there is
no

by Simpson, will
very
on

considerable
the

ment impedivis pelby

Haake

to ; that

passage

of the head has been

part of the

its uselessness
at

demonstrated
that all the

and made alike

Hecker
to

the

bedside, and
bone it. In and

reproaches forceps are

was
an

the

various

excerebration

applicableto
; the

this

opinion
is

Scanzoni than

correct

cranioclast original

nothingmore
somewhat

improved
handles

obstetrical
usual.

with bone-forceps,

longer
clast cranio-

than
on

Relying
was

the renowned trial

name

of

Simpson,

the

subjected to

by

numerous

obstetricians,
but
where no-

and

in various
more

throughout Jhe world, cliniques thoroughly

the in largest than
at

extensivelyand
enormous

Vienna,

where

the

obstetrical material
"

offered

for observation
"

and

experiment

the world

sented ^prein-

admirable

for testing the opportunities

new

and

tiaed

by

tlis Vienna

School. resulted Carl taken

13

strument.

After of

which series of trials,

in

coufirmation

Scanzoni's the the

views,

Professor

BrauD,

having

noticed
of

unusually

firm

hold

by

the thie

iastrument

bones

of the skull, thought that

Y\g.

3.

Improved

Cranloclut.

quality might
otherwise be built

be made

useful,and

and by lengthening instrmnent

the cranioclast, an modifying

up

might

which,by

virtue of its finn grasp,

might sup-

14

MuNDE

The

Cranioclast

as

improved
an

plant the

unreliable

cephalotribeas
Thus

extractor

of the

perforated foetal
was

head. its

gradually
"

the

cranioclast

brought
for in

to

present

state

^not

of

tainly, perfectioncerwe

the

present age

of

invention

cannot

foresee

what

new

improvement
Vienna,
is of

it may

still undergo, but

now

of

undoubted
used very from of

The instrument, as utility.

in

almost

sively excludiflfers

quite recent
the
no manner

date,and
the

in markedly, especially its ancestor

; in

of its employment,
name

it fact,
be

longer deserves
more

but cvaiiio'Cla^t,

should

called

properly craniostronger in all its

whole

(Fig.2.) (ex)ira"tor, parts than

the the lock the

It is

longer and
the ends

the cranioclast, original from

length
the

ing beto

17'' 8'''; the distance

measures

of the handles
to

10^'
; the

7^'';from

the lock
the

tips of
blade is

blade
and 8'^',
measures

7'' V"
that

length of
solid of
are one

fenestrated

3''

of the with

3'' 3''^ old

By comparing
will

these be

those

the

instrument, it
The

seen

that

the

former

considerably larger,the
breadth Attached
pression, com-

blades

being nearly 2^'' longer. especially

is the end
same

of the blades
to

in both handles used

instruments.
is
an

the lower

of the
to

apparatus for
for his

similar
On other

that

by

Hueter
handles
a

tribe. cephaloeach

closingthe blades,the
within
which 9''', the

approach
more

only to
of

insures

energetic
firmer grasp

action
of

compressory
on

apparatus and
the

the blades

the

portion of
firm of hold
a

the skull between instrument.

two traction,

them,
For

and

prevents
of

the

of slipping

the

purpose

a securing

for

lateral
to

hooks, similar
upper

to

those

are forceps,

affixed

the

end

of the handles.
were

These

modifications

suggestedby

the

following

avd
facts It

used
found

hy

the Vienna

School. that the

15

was

by experiment
blades
"

strumen inoriginal

the especially

that
"

part of it which
was

is

introduced
the lock

into the

genitalorgans
of the closure did
a

much of

too

short,
venient con-

lying inside
reach for the

vagina,out

sight and
;

of the blades
not
severe

that further,
secure
a

mere

manual

compression
; that

suffice to
case

firm

grasp with of

of the head
an

in

of

or deformity,

exaggeratedsize
without
more

of the foetal head, the extraction

the latter
for

convenient
as

and

practical pliances apslender and

traction, was
the whole

good

as

impossible; and
too

that lastly,

instrument

was

weak,
The

and

liable

to

feather. may the be used

on

cephalotribe
that is not of the

the
; but

intact
the the

head, cation appliing open-

although
of the scissors. the last

approved
must

way

cranioclast

be may has

preceded by
be done

foetal head. In

This it is,and

with been

the done

old for

Vienna

always

twenty

years, ^vith the

curved

trephine invented
the

by
over

Professor

Carl

Braun,
of

which
a

possesses

advantage
with

the scissors

making
of

clean,round

opening

smooth

edges, devoid being

ragged spiculaeof bone;

Kiwisch's conformance with
the from

and

by
the

its

curvature, surpasses
not

straight trephine,
axis
of ing touchand
sisting re-

which,

built in

is occasionally prevented pelvic cavity,

a

sufficient segment

of

the

head

by

long

perinsBum.
rpvTTfiaigy

After

(cephale,and cephalotrypsis
been blade

perforation) hasout, the

on

performed,
of the

and

the

brain

washed

solid

granioclast is
into
an

introduced
the

the

of guiding fingers

the left hand

in

cavity

of the

cranium,
blade

and

held

positionby
in
on

assistant.

The

other

is then

passed

the side

16

Munde:

Tlie

Craniocldst

as

improved
where
over

of the the

pelvis which
room,

is most

convenient,or
around
This

there the

is

most
or

and

gently brought
child. the

head forebe the

face

of the

will

almost

always
or

possible, except
head skull the offering
as

where

pelvisis
case

very the

narrow,

firmlyimpacted,
firmest the

in which
grasp

portion
The
as

of the

and

the

most

is resistance, solid

chosen
blade

spot for applying the

shifted

blades.
so

is then the

within

the cranium, blades

to lie opposite

external
as

branch, both

are

carefully
act

pushed
will be
the

in

far

as

they
their

will go, and

locked, an

which

much

facilitated
until

by depressingthe
closure has been

blades

toward
The

perinseum

effected.
the

compressive apparatus
are
an

is then

applied,and
the

handles After the

brouglitinto
examination is well

as

close

appositionas
the head

possible.

has

convinced

operator that

strument in-

applied and
traction
of the is the

firmly grasped,
at

slow
to

and

steady
the

made, stopping
head, the
the

intervals
of the The

note

progress

condition instrument.
the

cranial bones, and

tenacityof
it is drawn

empty,
will
to

flaccid found

skull,as
to

through
will
a

pelvis,
itself

be

become

elongated,and instrument,such
more or

adapt
the

the

shape

of the

pelviccanal,thus, as
an

rule, rendering
as

its

compression by
the

cephalo-

tribe,unnecessary.
to

After

less

traction, according
constant

degree
of the in the

of

deformity,and
of the
case

under with

vision superthe

progress

the

of fingers

left hand

vagina, the head, usually elongated to

be and child

twice
may

its
then

length, will
be removed
or, if the

extracted, and
the be
rest

the cranioclast

of the

body
the

extracted

manually,
continued

small, delivered

by simple
instrument.

traction

without

detaching

and

used

hy

the Vienna the

Sclwol.
the

17

It

be niiglit
not

supposed

that

edges
the

of

trephineof
we a

wound,

being protected by
of the

broad

blades

would cephalotribe, find the

injurethe vagina, but trephine:

the

it is here
smooth

advantage
of
case

edges
to

of the

circular the

opening approximate
is known have wounded in which the with
remove

themselves

the

branch
and
no

cranioclast, the flaccid scalp covers

them,
found
to

they

were

protrude, or
has be of the that the the found skull

vagina.
the

If

the

otomy crani-

been

performed
necessaiy
to

it scissors,

will generally

projectingportions
assure

with

the

and bone-forceps, the

one's

self

scalp covers might

that believe the

before edge perfectly,

applying
be liable
tear out

cranioclast.
that the of

One
to

cranioclast would
calvaria this would is and
not
an

or slip,

bones

the

when made refer

now

strong traction
to
to

is made

; and

objection

the the

instrument

by

Scanzoni

others,who
to

originalcranioclast, and
Scanzoni, as

the

one

used

in Vienna.

I know
new

from

personal
or

observation, never
even saw an

operated with
late

the

instrument

operation performed
is
as as

with

it,at

least up

to

1873, which
his
not
over

my

information
a

reaches;
one,
can

sequently, con-

objection is merely

theoretical it

and

valid. the
out

If

applied legeartis^ as
or

usually
never

be,

face,forehead, eye,
; but
or even

ear,

it will

slipor
want
on

tear

if the

from operator is obliged, the

of space
a

unfavorable

positionof
will

head, to seize
ever

parietalbone
to

he instead,

hardly

find himself
to another

compelled
means

reapply the instrument, or

resort

mentions delivery. Rokitansky, Jr.,(loc. cit.,) instances in which the cranioclast was applied in fifty-two of

18

Munde:

The.

Craniocldst

as

i7?iproved
own

Professor in
out
none

Braiin's of which bones

a

clinique,and slippingof
occurred.
cases

six iu his

practice,
or a

the instrument The

tearing
of the 6^'',

of

the

conjugate
from
to 6

diameter
3^'

the

pelvis in
of is
a

these

varied from
3

2"

to

weight (which
I

the

children

pounds
times

Austrian,
Craniomany

than little larger

American
number Professor of

weight.)

clasis has
am

been able

performed
to

(how

not

state)in

Spaeth's clinique,

in both cliniques is about of confinements (the number the assistants assured of their me 10,000 a-year!) and

perfectsatisfaction
instrument

with

its

working.
times
can

myself

saw

the

applied several
with it

in both

with cliniques
my
own

invariably good results,and experiments

deformed
foetal head.
was on

from testify

the dead

body, with grip which

several deliver of

an

ai'tificially
of the
woman

to pelvis,

the vice-like
one

it takes
a

I remember into the made found

instance,where

brought
had It

cliniqueafter
outside
to to
case

ineffectual attempts
her with the

been
was

forceps.
child bones this
was

be

hydrocephalus,the
the and head
as

in the the head and

incipient stage
were

of

and put;refaction, loose

of
cause

extremely
the
m

flaccid from
was

the

hydrocephalus. being
a

The

tapped,
as

the cranioclast

applied to
woman

parietalbone
extremis
"

quickly
the

possible
"

the

and

tion extraccase

completed
cranioclast

in

few

minutes.
been of its

Surely
for skull and

in this

the

might
whole
over

have

excused the

tearingout, but,
it scalp,

grasping the
the head
The last when
to

side

drew

double
can

length,and
when the

retained

its hold. is the

cranioclast
to

be

employed,

the head
same

portion

be

extracted,with

as facility

it is the

presentingpart.

The

curved

trephine is

20

MuNDE

Tlie
Of

Ovanioclast
the

as

improved
died
"

became

apparent.
of

mothers,
of

21

16

of puer-

peral disease, 2
and
1 of

anaemia, 2

rupture

of

the

uterus,

Bright'Sdisease.
uteri, once;
to

The

autopsiesshowed:
spots of the
; in
one

tures Ruplip
responding cor-

of the of the
OS

off cervix,8 times; tearing

of the anterior
uterus
case

gangrenous

the

promontoiy, twice
the

several

perforationsthrough
besides tissues, gangrene
3 two

cervix
into

into the

the
cavum

neighboring
peritonsBi ;
the

openings
;

of the the

vagina,once symphysis, once

suppuration of
; gangrepous

cervix,
of

times, of

laceration
and became

the

cervical of the

mucous

membrane,
Six

once,
women

superficial
affected

erosions

vagina,once.
and
were

with
were

endometritis
not

dismissed The

well; the others

diameters
4

taken

ill in

puerperio.
these

conjugate

varied

fi'om 2^' to

4^' ; the Of

children
43
a

weighed
26
were

between

and with

7J
a

pounds.

cases,

operated on
phalic large ce-

cephalotribewith
curvature,
but large pelvic,

small and 17

but pelvic, with

a

(German,)
very

cephalotribe

with

small

cephalic curvature.
child

(French, Dubois.)
In
52 cases,

the

extraction head

of the

was

performed
the
no

with

the and

the cranioclast,
5

being

47 times
and in
or

ing precedcase

times

the of

succeeding part ;
instrument The

did

any

slippingoff
become for

the

occur,

its

reappli-

cation twice

necessary.

operation was
8 times

performed
for tetanus consequence
; 5

enormous

hydrocephalus;
in 8 resulted

uteri; once
of

in

prolapsus uteri; 17
cases

times from

in

fever,which

endometritis in rupture in
a

times
uterus

for deficient
; 5 times

labor-pains ; 5
in

times

of the frontal of the

in and

face-presentations ; once
once a case

presentation ;

of

enchondroma

and which
to
on

used reduced

by
the
In

the Vienna

8chool.
the

21

sacrum, diameter

length of
cases, the

antero-posterior
version
was

2'' 9'''.
account
cases

four of

podalic

performed
two

pelvic deformity, and through

2" 3''

in

of these

the
out

perforatedhead
from

without extracted, the

having washed
5 times

the brain varied

opening.
normal

The

conjugate diameter
it
was

to the

length,
2"

normal,
2'^

5 times 6

5 times 6''',

3'' 3'", 17

times
and

Z'\

times 2''.

%"\

times

2''

^"\

4 times

?/",
dren chil10

twice

Three

of the

pelves were,
The
ounces

besides,generally
of the
6

narrow,

(funnel-shaped.)
from
2

weight
to 21

varied
ounces;

pounds
from

14

pounds
In
8

their

length
to

16i'' to

J''.
labor

cases, been died

fruitless made
"

endeavors
of the

terminate Of of

the the

had
19

outside of

clinique.

mothers,
of

15

1 puerperal disease, 1 of

anaemia, 2

ruptura

uteri,and
The

Bright'sdisease.* chrcjpic
:

autopsiesshowed
and
once,

Once

suppuration of
to

the

physis, syma

corresponding
a

the

promontory,

necrotic

spot of the size of

of

cent, which

originated in
a

the pressure

the foetal

head, and

in which

minute for
a

opening
slender Four
as

into

the

peritonealcavity, passable only

discovered.
fell ill with
seven

probe, was
puerperae
of the

and, endometritis,
above
well ;
as

as

well sick
were

three

mentioned

taken

before

were delivery,

discharged

twenty-one

dischargedwithout having been In England, (Tyler Smith

*

ill at all. and

F.

W.

Mackenzie,

It

onglit
died
to

to

be

mentioned

tliat

nine

of

the
to

forty paerperse
other the than

recorded

as

haying

after
causes

craniotomj, owed independent

of

their deaths

paerperal causes, employed

for

(that is,

parturitionor

instroment

deliyery.)

22

Muia)E:

TJie Obstet.
one

Oranioclaat

as

improved
the

Transact,

of

the is

Soc, I860,)
of every
1.99 out

mortalityfrom
on

craniotomy
Vienna,
"

out

five of

operated
every of

in

the

mortality vsras
which would

five operations

result of
we

speak

in favor

the

lish Engotomy craniin

mode When is

operating.
consider, however, that
in

England

performed
and

much

more

frequently
a

than

Germany,
Vienna

consequently
whereas the

in

great many

tively comparain of

light cases,
were

operations undertaken by
the the
severest

usually called
results any the

for

forms

the dystocia,
not

published in
so

above

report do

appear

by
the

means

unfavorable. records of the

Comparing
lotribe and
instruments of

above-mentioned

cephathe

the cranioclast,

indications

for which

were

used, their
the various

the reliability,

degree
of the maternal

deformity
the and the

of

pelves,
on

the the the

size

children,
organs,
we

injuries

inflicted

the

mortality following
to

operations,*
favor
of

find

returns

be

most

decidedly in
was

the

cranioclast.

It

performed
terminated

all that in

done way exertion

by

the

cephalotribe,and
severe
cases

every and

equally
to

with less

much

less trouble
to

the

operator

and

danger
"

the

mother.

Rokitansky
occurrences

cit. p. 28) (loc.

says,
use

All

the

unpleasant

accompanying
The

the the

of the

cephalotribe were

found

wanting during building

*

operation with
insti*ument

the cranioclast."
say, that

supporters of the
a

cephalotribemay
all the

by

suitable

defects

mentioned

If craniotomy last moment,

or

were

not

looked

upon

as

last

resort

and

deferred with

until

the

the

mortality

of the

operation, whether
doubtless be much

performed
diminished.

the

cephalotribe

the

cranioclast, would

and
above the
a

used

hy

the

Vienna
such

School. contrivance
To

23

may

be

remedied,
will not
even

and

as

cranioclast

entirelydispensed slipand
when
head

witL
that

produce
us

cephalotribe that firmly grasp

strait of
a

will enable the

to

it is above

rior supe-

the

pelvis and
should and the

restingon
be made

the
a

symphysis
very

pubis,the

instrument

with

slight
almost
of the

cephalic curvature,
at

extreme
to

points bent
a

right angles,like hooks,

and then
us

catch
a

tighthold

head,
to

there follow

must

be

strong pelvic curvature

of the

enable

to

the

axis

pelvic canal
the

; it

be the French must, in fact, bent this

a

with cephalotribe, A and

points
on

little will

more

inward.
a

cephalotribe formed
effective instrument

plan

be

useful

; but

it will also the

too

slipat times, as against,and

of the unfair
uterus.

the Vienna
causes

report show?, and

the

strong pelvic curvature

points to

press the

heavily
wall It would

consequently endangers,
discard the

anterior

be

utterlyto
to

cephalotribe good
the it has
seen

for done how broad

the and

and cranioclast, the

disclaim it possesses introduce

all the
;

advantages
is to

still, having
lock

difficult it often

and

large,
to

blades, how
and

frequently a
how and it is

becomes reapplication of

necessary, be the resorted maternal the

finallyanother
easy

mode
to

deliveryhas
lesions other

to, and
organs,
ease,

produce
the

of nessed witthe
i7
"

having, on

hand,

rapidity,elegance, and
the I cranioclast, the
cannot

safety of
but

operation testimony
The material

with for

give

my

and

preferenceto
in

latter

instrument.
the
can

results of

obtained

Vienna, with
other in school my

obstetrical

which

city no

compete,
any

naturally completely outweigh,

mind,

theo-

24

Munde:

TJie

CraTUOclast

as

improved
without

reticaJ

or

even

practicalobjections offered
in

adequate personalexperience.
Should
cases occur

which
will

it does

not

appear

bable pro-

that the

foetal head the

the

sufficiently adapt
of its

itself to drawn

the

form

of with

pelvis to

allow

being

through

and in which, consequently, cranibclast,

to

the excessive
of

deformity seems
the

call for

an

active

pression com-

cranium,
or

the

built cephalotribe
to

after the

IVench

pattern,
be

according
the

the

given principles
and reliable

above, wiU
instrument.
As

found

most

useful

it is not the

my

object to

write and

an

article
of the

on

otomy, crani-

indications special been

as

details

operation
tions the indicait would
use

have

not

touched

nor

is there

any

difference, except

such
for

have
the

already been
two

spoken of,in
If any, scope and better

using

instruments. of
a

consist in the

existence

wider

for the

of

the cranioclast, owing to

I do
not

its easier

safer than

application. by giving cranioclast,

of

think

can

conclude

Rokitansky's r6sum6
cit. p. (loc.
1. 29

of the

advantages of

the

:)
every diameter the
attended of the

Its

applicationis possiblein
is
never

and pelvis,
to

by

the

difficulties
some

peculiar
cases.

the
2.

employment
a

cephalotribein
field of

It needs

much
to

smaller its

action

than

the

cephalotribe, owing
is diminished is introduced
3.

absolutelysmaller
the fact that the

which size, solid blade

still into

more

by
cavum

the of

cranii. is easy, because

the the

The

action

locking
to the
can

lock

always
in the

remains

external

vulva, and
be

blade

lying

cavity of

the skull

turned, pushed forwai'd

arid U8ed

hy

{ke Vienna

School.

25

or

withdrawn,

depressed
it is easy
to

or

elevated, more
one

or

less, at
the lock

will,whereby
into the
same

bring
to

portion of
and

plane and

close

the other

effect the

locking.
4. most
5.

The

cranioclast

never

and slips,

consequently is preceding
case

excellent It is

instrument

for extraction.

equally reliable
basis cranii.
the

with

the

as

with
a

the

succeeding head,
of the

in which

latter

it seizes

firm

hold
6.

Injuriesto
can

genitalorgans
much but
sooner

do

not

occur.

7. It tribe
to

be

intrusted of
a

than

the

cephalooperator.
street,

the

hands

moderately
"

skilful Chatham the

Messrs. have

George
the
are

Tiemann

Co.,

67

constructed

several

cranioclasts

after the

one

in

my

with possession, the instrument

improvement

that

steel their

parts of

to prevent nickel-plated

rusting.
to

I should
whom is not
to

be

glad
the

if this article

would

lead

gentlemen

appropriate cases
so

occur occasionally

this (luckily
it is in

much

case

in this after

countiy
the
manner

as

Europe)

tiy the
feel
so.

cranioclast confident

just described
not

and

that

they

will

regret having

done

Appendix,
before
had the

"

Since the
York the

of presentation

the above

article
after it
op

New

Obstetrical

Society,and
No. S. of the

gone

to press,

February
John

Journal paper

Obstetrics, containing Dr.

"

Parry's
in Small
a

on

Craniotomy
to

and

the Cesarean paper

Section I find

Pelves,''
of

came

hand,

in which

corroboration

26

MuNDB

Tlie Craiiioclast

as

improved cephalotribe. My
relative merits
to

the

opinion expressed by
not

me

on

the the

article does

intend

to

compare

of call

craniotomy
attention
over

and the

the Cesarean

but section, the

simply

to

of superiority

improved
do

cranioclast propose and the

more

the draw

cephalotribe ; consequently I
any

not

to

comparison
the

between

the cranioclast
to

the

Cesarean

but section,

merely

desire

make

ment state-

that,if
and where of the

cranioclast

were

employed only
to

ally, genercases

the

cephalotribe reserved mortality from (for which

be Let

for those crush

it becomes

absolutelynecessary
assertion
us

the base would

reasons

skull,the
diminished
been
as

craniotomy only
moderate look
as

be

much have

sufficient upon
soon

given above).
an

otomy cranias

operation to
of the demonstrated and

performed
a

the the

narrowness

pelvisand
its

trial with the

forcepshave
of and its

and necessity, has been

ity feasibil-

podalic version
operation
be

exti'action

discussed,

performance perhaps ineffectually attempted,and performed

exhausted before the mother of has

let the become labor and I

completely
and
see no

by
to

the

duration her

the

the

various

attempts
a

effect

deliveiy,
than

reason

why
have

mined detercraniotomy,rationally
a worse

upon, extraction the

should

termination version.
enormous

an

with

the

forceps or
that is the
to

There

is not of

slightest doubt
been

mortality period at
Dr.

craniotomy hitherto
it has instruments
"

owing
and

the the

late

which

undertaken,
used for its

inefficient and

bulky
says,

performance.
to

Parry

The

great virtue of the latter instrument

is that it enables This
us

(thecephalotribe)
of the

get rid of the vault

! the

cranium

quickly."

is true

cephalotribe com-

28

MuNDE

The

Cranioclast would

as

improved prevented degree of by

of any

the

compressing apparatus Parry's

is all

have

slippingor tearing out.

Dr.
case*
one

in of

which

the

formity de-

precluded
unmutilated
child I
am

hope

delivering a full-grown
way than Cesarean very

in any safe propose

other in

section,

and

asserting that
any other mode

few

obstetricians
after the
an

would

delivery
a

thirtieth week

of

in utero-gestation of
one

pelvis
a-half
.

with

diameter antero-posterior

inch

and

Schroeder

1872, (Geburtshlilfe,
5^ centimetres=2",
of

page

475) gives
as

for
most ut-

Germany English through

as

Paris

measure,

the that

boundary
flat

craniotomy, but
deliver
a a

mentions

the

obstetricians
a

child

by

their

method
as

pelviswith
6'", and
that
to

conjugated
Barnes l". unless be

diameter
to

low in

4 Cm.=l"

hopes
=

succeed these have

reducing
statements

the

minimum

2J Cm.

Of
one

latter
a

Schroeder one's

says
own

that,

"

veiy

high opinion of
the instruments
to

and skill, for the Cesarean

in

possession of
cases,

necessary the

most

extreme
as

it

is better

prefer
mother." which
some

action

the

easier tion opera-

and,

under

the circumstances

also,less dangerous

for the The

paper which which
case

forms

the

subject
a

of

Dr.

Parry's
and in

presents
came

to similarity

very

difficult labor years of A. ago,

nature

under

my

care

several the power

forciblydemonstrates extreme overcoming even

29

difficulties.
came height,

Mehrwald,

years

of age, in of

dwarf

in

into the full

term.

LyingAn

in

Hospital

Wurzburg,
the

in

1863,

at

examination

pelvisshowed

the
5

sions: following dimen-

External

conjugate diameter

J", internal

con-

and

used

hy

the

Vienna

School.

29

jugate 2|"; spines of

The
not

distance ileum of the

arms were

between between

the

anterior

superior
lOJ"
44".
;

the

7i",

the trochanters Her

circumference

pelvis 24^".
walk her

height was
and her
as

legs and
to

slightly bent,
to

she

reported
to

have

been

able

before

fifth year, she

have

"teethed The

through deformity was

legs,"

expressed origin,

herself.
the

therefore

of rachitic

pelvisgenerallycontracted, and
as

the

antero-posterior
consideration
of

diameter of the

usual

the

shortest.

After

due

points of
of

the

case

(Profs.Breslau, large
section

Zurich, and
with

Hecker,
Prof.

Munich,
the

being accidentally present

apparent
of size of

Scanzoni),
the

the

living

child,and

slim the

chances

an effecting was

easy

delivery
While

by craniotomy,
upon, and the

Cesarean

determined

-necessary

preparations made.
reach
a

waiting

for the left the

pains to
the

sufficient
were

the intensity
moned sum-

gentlemen
by
and

hospital,but
of the dead than

suddenly
of the

house-physicianon
descent find
a

account

rapid
arrived

unexpected
time
to

child's of

head,
over

and

just in

child

51b, German bom In in

weight (about
without
came

more

American),
the mother.

ously, spontane1866

any
at

injuiy to
was

she
same

again,
of
a

term, and

delivered

the

manner

male left

asphyxiated child,which parietal bone

was was

died

in

18

hours.

The

fractured;

the

diameter bi-parietal A the year first

3"

3"', the bi-temporal 3".

I had

later,in 1867, she appeared again,and

opportunity to
child

examine

her, having but shortly

assistant bom
to

before

been

appointed junior
was

the

hospital.

The
an

female

again
died

spontaneously, in
hours, after
a

asphyxiated state, and

in three

30

MuNDE

The

Craniocldst

as

improved
child's head: Biof

labor

of

14^

hours.
2'" ;

Diameters

of

parietal,3" glabellaand
In after

2" bi-temporal,

8'" ; circumference

occiput 13". again

labor
5

1869, she
a

entered of nine

the-

and hospital, of
an an

was

livered de-

hours lived

asphyxiated
and
a

child,weighing
The
of the

lb., which
child the and
was

hour

half.

length of
the

the

18J^"; the

circumference

head, 12f";

occipito-mentaldiameter, 5f";
the

3i" bi-parietal,
bone had
a

3^''. bi-frontal,
indentation left the

The

left

frontal without usual In and

deep
The been

lateral mother in the she

came

2^" long,

fracture.

hospital
full

as

without
the

having
become
me

least ill.*

spring of

1870

again, at
by
her
to

term,

having

confident that she the

previous good
get along
out withthe

luck, informed
a

expected
child the in

doctor, and

expel
witnessed

six hours

at

latest.

Having
the of the

extraordinary muscular
the those of the contracted
no

vigor of
diameters

uterus, and
foetal
two

the

gradual adaptation of
to

head former

pelvis, during
she would after that

the

labors, I had
her the

doubt

again

make

good
that

word,
head

and

therefore,

satisfyingmyself
all circumstances in
were

presented,and
left houns
as

apparently favorable, I
Several
not

her

charge
that former than

of

the head

midwife. did

later, I

noticed in the

the

adapt
it

itself

rapidly as
that

labors, and
usual
; but

that

appeared larger and

would

harder the the

*

I still of and the

expected confidently
uterus
overcome

violent

contraction
size

disparityof
Dr.

space.
of his

Visiting her
patient
of
in mode

again,
does

Parry

likewise

reports the
no

delivery
as

1869, at full term,

nor

bnt state

unfortunately
the

gives
and

particulars
the
child

to

the

delivery,

he

weight

size of

in either

confinement.

and

used

hy

tlie Vienna

School
I

3 1

some

eight
the
to

hours

after that

her

admission,
had

was

informed very

by
up

midwife
within almost exhausted

the
an

pains
but

been had

violent

half

hour,

then

suddenly
to

ceased much the

completely,and by
her the

that

the

patient appeared
promote
of the I abdominal
was

ineffectual

efforts

labor

by
On

voluntary contraction
the the unusual

muscles.

examining by
could
was

abdomen,
distinctness
were

diately immewhich
on

struck the the small

with

parts of the child

be
seen

which and

all collected the

left side uteri

whereas felt,
on

hard side

fundus

plainly discernible
There
was,

the

right
small

of the

abdomen. from the

besides,a

moderate very
a

orrhage hemand

vagina, the pulse was

much and prostrated,

rapid,the
of uterine I felt

woman

total

absence

contractions.
a

Judging

from

all these
uterus

signs,
taken

positivethat
hours later. and the

rapture of the
confirmed

had

place,which
a

diagnosiswas
As
os

by

Prof. could

Scanzoni
no

few

the
was

foetal heart

longer
for the easy it

be

heard,

dilated sufficiently

purpose, extraction

Scanzoni, anticipating a
after the former

comparatively
rather than

rapid deliveries, thought

Cesarean section. under

preferableto perform craniotomy

the

subject

patient to

the

perilsof

The and
at

patient was
8 a.m.,

consequently put
6, 1 commenced
the
some

chloroform,
the

June

the of

operation in
Prof. The

presence before
to
a

of, and

with

assistance
120

Scanzoni,
attempt

cliniqueof
Hubert

students.
a

perforate and
to

extract

with

modified

sphenotryptor,
on

according
failed far
on

(described above
head the
was

page situated

4),
so

because and

the

movable,

and
as

before

symphysis pubis

to

present

32

MuNDE

Tlie Crdniodast

as

invp^oved
the

but

an

exceedingly small
the of blades the the
as

portion
of the

to

point

of

the

perforator and
when much

cephalotribe,even
were

handles

instruments

pressed
The the

as

possibleagainst the perinsBum.

Kiwisch then of the
was

straight
same

trephine of
result.

then

applied
use

with

Scanzoni

suggested the
head,
and and

of the

forceps,
seize latter

which
a

by
be

means

their

pelvic curvatm^e
with
fixed the which in
a

could the

firm

hold

of drawn the

migrht

down

convenient and the

position for
been made
me

application of
the

trephine

cephalotribe.
with
to

Vanous

ineffectual

efforts

having again perforate

to

forceps
the child This I

and and

Scanzoni cephalotribe, endeavor

to

advised the

turn

succeeding head.
of the

did, but

owing
the reach

the

traction con-

conjugate diameter
it

and

size of
the sides

the of

child's the

head,

I found
was

impossible to
to

skull, and
the

obliged
of

attempt
which the but

trepanation imperfectly
when ceps forand

through
succeeded. and

roof
After

the

mouth,

traction

by

neck,
been in the

cephalotribe had
least

again
the head

employed
from

out with-

in the of

engaging
were

superiorstrait
further
had

the

we pelvis,

compelled
condition for of about

to desist

manipulation by
been under
as

the

the
two

who patient,

chloroform she

hours,
the

and

who,

exhausted
now

already was
death. child
was

before

was operation,

at the

point of
of the

The

body

removed, rupture

and

the the

head minal abdoof

receded, passing througL

the

into
the

cavity,whence
the

extracted with

it after

death

mother, by perforating it
the crushed organ

Blot's
the

and scissors, my

drawing

through

pelviswith

a7id used hand. The

child

by

the Vierma its

School.

83

without alone

head, weighed 4^ lbs. ;

over one

the

mutilated

head
the
a

weighed
more
was

lb.
were

At

the
firmed, con-

autopsy,

pelvic diameters
fissure man's fist

given
found
on

above

and passage the of

a

than

large enough
at

for the

the

junctionof
spot
all

cervix

and

corpus
to

uteri Prof.
uterus

the

left

side,the

where

(according
ruptures
of
was

Carl

Braun*)
labor

ing perforatplace.
violent

the

during

take the

This

rupture

undoubtedly produced by
the

contractions
which from

of

the upper the

body and fundus portionof the organ

at every

of the
was

uterus, by

torn literally

cervix,which
the

pain was
other

firmlypressed

against by
the 'temal

bony

rim

of

the
No

superior pelvic straight

lesions of the the
ma-

presenting head.
organs and
were

found, notwithstanding manipulations described

would
we

tracted pro-

difficult
easier

above.

How

much

have

been

the

deliveryby performed
us

laparotomy, which
had
not

would easy

have certainly made

the

previous
any
severe

deliveries

inappre-

hensive
Another

of

serious
case

difficulty.
of

dystociacame
and has

under

my

servatio obbeen

in

February, 1868,
Dr. O.
von

already
mentions
case

described Scanzoni's
case

by

Franque (Ueber Stachelbecken,

Dr.

Beitrage,1869).
A short

Parry

it
as

as

53

in his list

sketch
was

of the

is

lows: folthe
tremities ex-

D.

P.,
with
were

20

years

old,

admitted

into

hospital
the

Feb. labor-pains,

21,

1868.

Her

considerably deformed
found

and by rachitis,
external internal

pelviswas

conjugate
*

diameter
from

contracted,the generally measuring 3" 2"' and the

Leotoree

FmateNoteB

dming

the

Sommer

of

1871.

34

MuNDB

Ihe

Cramocla^t
left half
than the

as

improved
the

conjugate 2'' 5"'.

was

The

of

pelvic cavity
On

also

found

smaller
a

right.
the cord

the rupture

of the membranes
the

prolapse of
ceased

took

place,
The

pulsationsof
to return

which and and

after various it above

no

ineffectual head.

attempts
child

keep

the

being dead,
the
was

there

being

apparent probabUiof the

ty of

spontaneous termination

labor,perforation

performed

and

Scanzoni's

cephalotribe applied.
been

This instrumenl, after

having slippedand
diameters it and

reapplied
operators
Dr.

eighttimes (as my
von

in difEerent

by

different

notes

have distinctly

not^cmr times,as

was Franque states),

and podalic version discarded,*

contraction of the antero-pospass the
arm

attempted.
far

Owing
it
to
was

to the

terior diameter
up

found and

impossible to
grasp the had

enough

reach

child's been three

resort

feet made

or

knees, and after

various

five distinct

attempts

in

of positions
were

the

mother, and

by
to

different
to

gentlemen, we
means,

again compelled
think Cesarean

other

and

began seriouslyto
of concluded

of the unfortunate Before

dernier
this

ressort

section.
to

coming

to

extremity we
with

try the various

bonethe

and forceps,

and these, Simpson's cranioclast, in

crotchet, we
skull had cranii

succeeded

removing
on one

large part
the
arms

of the
which

and, aided
been

by

traction
in

of

drawn
the

down,

gradually pulling the

It
was now

basis
sible posand

into
to

superiorpelvic strait.
and crush

seize

the head of

with

the

hand,

finaUy had
*The labor
was

the satisfaction

performing the

manual

therefore

not

at

all finished Br.

by the cephalotribe,not
from the

even

after

protracted

proceedings, as

Paiiy

qnotes

Sydenham

Soa

Beports.

36

'

MuNDE

ITie Crcmiocldst

as

improved
3"
complished ac'

In

minor

degrees
the

of

pelvic deformity (not under certainly

Below becomes the hold

conjugate) easilyand
the

delivery can, doubtlessly,easilybe

the
but cephalotribe, the
more

by

safely still with

and

cranioclast. uncertain

3"
a

cephalotribeby
often is

its size and

dangerous
the Cesarean of is
a

useless instrument, and below

resort

clast cranio-

and preferable, infinitely

2'' at

the most,

section is the

only

for the
that

delivery
Dr.

full-grownchild at taking the certainl]^

he advocates
the

term.

I think view

Parry
of

correct
more

of

the

question

when

frequent performance
cases

gastro-hysterotomy preference
as an

in. extreme

of
the

deformity, in cephalotribe,
performed
favorable
section
at

to

the

employment
customary.
under

of

has

hitherto

been

When

and early period,

the

otherwise Cesarean

cumstances cir-

mortality after
of the is
an

should

be really
or

but

little if any

larger than thigh

in
illustration

after

ovariotomy
third.
an

the

amputation following
most

i^e upper
of how

The

ently apparpectedly unex-

unfavorable

case

can

be occasionally

brought
years in

to

happy
with

termination

J.

K.,

29

old, entered
had

the

Wurzburg place
without
the

Lying-in Hospital
The last

August, 1868,
before.

in labor taken On

her fifth child.

confinement

fifteen difficulty

months
to

examination

pelvis was
it

found formity de-

be

exceedingly contracted, the

and the

character

of the

history of

the

case

making
the

perfectly
of
3"

evident trouble.

that The

mollities

ossium

was

cause
was

the
3'".

diagonal conjugate diameter

the

Deducting

3'" for

pelvic inclination
of the anterior

and

6"' for the

we

bill-shapeddeformity

pelvic wall,

and

used

hy

tlis Vienna

School.

37

have the

an

actual
was

conjugate of
twisted towards
the

2" 6''', The the As

promontory

of the

sacrum

towards left side. of

right, and
there

spinal column
to

seemed

be

very

little chance the natural section

extracting the
all the

full-grown
mother

child
for

through
in

passage,
were

preparations
pains
labor

the Cesarean

made, which, the

being
had
at

good condition,was
a

postponed
the

until the
os

reached
the

sufficient

and intensity of dilatation.

had

arrived

prescribed state

After found
the

the

had head

been
was

going on

for 47

hours, it

was

that

the

gradually adapting
the

itself to
was

deformed

pelvis and, although

was

scalp
the

len, considerablyswolAs
an

advancing
which few

into

pelvic cavity.
harm, it
with the
was

periment, ex-

could

do

no

decided

to to

make
our

gentle tractions
at the

forceps,which,
in The

great surpriseand

succeeded delight,

developing weighed
was

livingchild
oz.

fifth traction. On
the

child

6 lb. 13
a

Bavarian.

bone right parietal

large cephalaematoma, under

the

which

"

the of

child

dying
by

on

ninth
"

day
^was

under
a

the

symptoms

compression of
left the

the brain the

found the
the

caused star-shapedfracture, The mother

pressure

of
on

promontory.

hospital well
The
was

eighth day.
termination that of the
of

unforeseen

fortunate
to

this

labor of the

doubtless

owing
hard

the fact
the process

bones

softened pelvis,
not

during

osteomalacia, had
that the head the
a

yet become

and

brittle

again ;

pressed against them being continually

contractions

by
the

uterine

gradually forced
assisted the
same

them

apart,

procedure
A

which
year

was

and
woman

completed by
was

forceps.

later

again seen

in the fourth

88

Bailey:

Case

of Lipomaia.

montli

of

pregnancy.

The

pelvis was
had
to be
common

still

more

tracted, con-

and This do not

case

artificial abortion is
so

induced.
run,

much

out

of the
other

that

pretend
the

to draw

any

inference
same

from

it than
in
a

perhaps
similar

expediency

of

following the
desire
to

plan
it for

instance, and

only

relate

its

peculiarity.

CASE

OF

LIPOMATA.*

Bt

jambs

S.

bailey,

ILD.,

Albany, K.

T.

LiPOMATA,
connective of the

or

fatty tumors,
may

are

derived
in

from directly
every

and tissue,

occur

almost

part

body. They are

most

commonly
fat
is

met

with

in

the

early
to

periods of
of times
and
can

middle of

the tendency life, when, generally,

development
be

greatest; occurring in the

apparent
to cause, causes,

jority ma-

cases

without

though
as

oft-

traced directly

local

friction

pressure.

Erichsen transmitted

mentions
to three

case

which
a

generationsof

hereditarily family.
was

They

sometimes found

occupy

unexpected locations, though

cellular tissue.
enormous

usually are Lipomata

In
*

in subcutaneous attain

sometimes

and size,
pressure.

sion occa-

great inconvenience
Jones
before

by

bulk

and

and
the
to

Sieveking's Pathological Anatomy,

"

Bead

Medical New York

Sodetj
State

of the Medical

Gotmtj

of Albany,

Febmaiy

26th.

Alao, presented
Febnuoy
4th.

Society, at

its Annual

Meeting,

Bailey mention
to

Case

of lApomata.

39

is made

of and

forty pounds, Vogel

also

specimens weighing from twenty meter. of measuring several feet in diathat that

remarks

they frequently attain they

occur more

an

enormous

weight,and
than appear in
men.

frequently unfrequently
mention

in

women

They
several

most

often

but singly,

not

exist

together.
and

Rokitansky
seated and prone Dr. and in that
to

Jones

and

Sieveking
of

cases

the

abdominal may affect

cavity

considerable
not

size,

they
H.

individuals

otherwise

excessive

fat formations.
in his
recent

T.

Green, anatomy

work

on

pathology
the

morbid of

says, in

reference
grow

to

ment developor

lipomata,

that

they

from

adipose

from
pose

common

connective
must

tissue.

He

remarks:

"Aditive connec-

tissue, it
tissue with

be

remembered,

is

merely
which

containing numerous fat ; and its growth

more an

cells

are

trated infil-

consists
in
a

either in the

infiltration of
of

of

these

or cells,

proliferation newly

the cells and

accumulation

of fat in those

developed.
"

lipoma

in the

same

way
as

by originates they
are

localized come be-

of cells, which proliferation

infiltrated

produced
slow

with
of

fat"
tumors
a

The

growth

these

is very of

they

are

usually encapsuled by
are

layer

fibrous may

tissue ; and
be

usually round
the
The I

and

lobulated, and

separated

'

from

surrounding parts readily.

is
one

followingcase
saw

of xmusual

interest.
was

never

the patient

but during her lifetime,

40

Bailey make

Case

of lapomata.

requestedto
whom
she had

the

lowing autopsy, at whicli time the folfrom

historywas

obtained

her

daughter,with
widow.
gan beAt
to

lived,
aet. ; has

Margaret Remmert,
Has had

sixty-nine, German,
now

eightchildren
at

three

to menstruate

and fifteen,

living.She ceased at forty.

ago, she

the age of

twelve fifty-seven,

years

began
if
a

a experience heavy feelingin

the

bowels, as

men-

stnial
This
on

period was

about
more

to set in.

feelinggrew
side,low
in
seems

decided,and
A
tumor

located

itself
as

the left

down.

appeared,and weight

it grew Mrs. E.

size,the
never

sensation
to to

of

increased.

have

had

naight be
viscera.

attributed

pressure

pain except such as the surrounding upon

on

She the
a

has

complained

very

little of disturbance
very

right side. Her bowels have been being followed period of constipation
Has been
a

irregular,
a

by

watery
wise ; otherbeen

diarrhoea.
was

troubled

with

hemorrhoids Has
never

always
medical
to

healthy woman.
up
to

under

treatment

the time
and

of

her death. October

She

took

her

bed

earlyin June,

died

30th, 1872.
AUTOPSY.

hours after death. eighteen JSxternal Kigor mortis slightly Appearances. Tumor emaciated. of abdomen marked. Body much larly irreguabruptly over the brim of the pelvis, projecting and rounded over reaching up under so as to bulge out the four lower ribs equally on both sides.
"

Sectio cadaveris

Bailbt

C"i8e

of Idpomata.

41

side, right directly of fatty under the parietal a mass peritonseum, tissue, itself covered by peritonsBum, reachingfrom the brim which it crowded of the pelvisto the liver, upward ; divided into a largeand small portion it was to so as resemble a liver, weighing fifteen pounds and two vascular except at its point of ounces, very slightly broad and slightly cated loattachment, which was defined, the brim of the true pelvisand coming about of the uterus. from the posterior ligaments another and over-lapped On the left side, was by this, tumor considerably larger, weighing twenty-two pounds, the most of the remainingabdominal and filling space. covered Its surface was and nodular, by peritonsBiun ferior lyingnext to the abdominal walls ; a branch of the inmesenteric arterypassedinto it. It was composed and had on its under surface a of fattytissue mainly, of fluid. It was tached atcyst, holding about eightounces to the rightposterior ligamentof the uterus,a and a part of the being included, part of the rectum The meso-colon attached to it descending colon was
"

Abdomen.

^Walls very thin. On

seemed

to be

reflected over

it.

Both^umors
Intestines

turned out without

small,and

adhesions. peritoneal to the compressedposteriorly

;
caecum

tumor,

but

otherwise normal
transverse

in sttu^and

what some-

i^erent;
and and

colon, with
the tumor

the

omentum

stomach, crowded

above

into the

tric epigas-

and left hypochondriac region. right Liver one-third in size,displaced upatrophied, ward, bladder the lower edge being above the eighthrib. Gallmuch

distended.

42

Bailey

Case

of Lipomata,

Kidm"ys

small

and

in points granular. flattened, and

Spleen adherent, small,

nodular,

and

with

leatheryfeel.
Ovaru8 the
two

of

normal

size,broad
near

ligament
fimbriated

free.

On

left small

Fallopian tube,
about

the
a

extremity,

cysts the size of

was

pea.

Uterus
woman

the size of that and

of
thick

menstruating
mucous tion? secre-

; flattened

containing a

peritonaeum thickened
Pelvis from
the

posteriorly. inward, large bony projection

from
and

deformed

by

symphyses .knuckle-shaped; measuring

promontory
three

the sacral

inches. three-quarter vis-

T^A^oo?."
cera was

Excepting

old'

adhesion,the pleuritic

entirely healthy.
case,

This been have

could by early surgical interference,

have

relieved,and
been somewhat

perhaps
the

the life of the

patient might
her

prolonged, although period ,allotted to

seems

life-time

nearly embraced
The upper

mankind. derived its

ttmaor

to

only
the
was

have

nourishment
as no

and

support
of
any

from size

surroundingtissues,
observed
to

blood-vessel
tumor.
case

have

penetrated the
Death
of the

in this

seems

to have

resulted

frSm

sure .pres-

lipomata
the

upon

the the

minishi surrounding viscera,distomach

and and

the

capacityof

the vessels

contributingto
food. Ite
seems

absorption

of a-ppropriation

hereditary tendency
in this
case

referred
been

to

by

Erichsen
a

to

have

as verified,

sister
the

three

years

younger,
are life,

and

her

daughter, just passed

affected.

meridian

of

likewise

44

Thomas

Cme

of of EFypertrc^Tiy
as

the Clitoris.

Syphilis being regarded patient was

until
and

the

the primary affection,

x.,

given potass
4.
was

iodid. gr.

three
was

times

daily,
in

January
the tumor

On

that

day by

she
Dr.

anaesthetized,
G.

removed with
and

T.

Thomas,

the

followingmanner,
Dr. B. F. Dawson
stout

the electric

cauteiy, assisted
,

by

the house

staff.

Two
to

silk

were ligatures

passed, at right angles

be
noose

each

to other, through the pedicle,

used of

in

case

of

hemoiThage
wire, with

and

to

aid retraction.

platinum
the

the

usual

handle,
to

was

then

placed around
means

pediclejust anterior
of the
screw

the silk

and, by ligatures,
around the the

in the
was

handle, tightened
connected
connector

part
the

The

handle

then

with

wires The

of

battery and
noose,

the cuiTcnt

closed.

platinum

instantlybecoming
as

red

hot, was

carefully and
the until tissues,

slowly tightened
the
mass

it burnt

through
minutes'
a

was

cut

through and removed,

three
one

without
A

the loss

of any
concave was

blood,

in about

time.

slightly diameter,
For

eschar, about
left,from
which the

and
a

fourth of

inch in

not

drop

blood with

oozed. black
to

several
but

days

stump

was

dressed
on, it was

wash,
ung.

free

suppuration coming
17.

changed

zinci oxid.

January
wound
was

"

^Thirteen

days

after the

operation,the

looking well, and

excellent.
and
a

the

dition patient's general con-

was

At

six

half of

p.m.

she had

well-marked the abdomen.

chill,
At

and
ten

complained
P.M.

intense

pain
of

over

her

pulse was

108, and

the temperature

103i,

and
were

the well

usual

symptoms

acute

general peritonitis

marked.

Removal

with

ike SleclHc

CmUery.
and

45

January
well under
and sinking,

20.

"

Although carefullywatched
influence
at six

kept

the

of
p.m.

morphia,
On

she

was

evidently
abdomen found.

died
21.
"

January
the usual
uterus

Autopsy.
acute

opening

the

signs of
and

were general peritonitis

The

its

appendages being removed,

of
were pelvic cellulitis,

hesions, old ad-

evidentlythose especially anteriorly.

The

found,

Fallopian
eggs,
a

tubes

were

both

distended pus.

to the size

of hens
one

and

filled with

decomposed
its

The

left

had
pus

small

perforation near

from extremity,

which The and

exuded.
a

following Illustration gives

appendages opened.
as

view

of

the

rus ute-

ing they appeared, the vaginahav-

been

1. Bight 2. S. 4. The Lett

FaUopUii
diatended

tube, imopeDed

nnd

filled with

pns.

tube, partiallj emptied

of ita poa.

Bight
Left

0TU7.
OVK17. ia

ngisk

opttwd, ahoviiigprobe

wiOun

cavity of

nteni"

46

Busey:

Qa%e

of Vaginal Hemorrhage
*

CASE

OF

VAGINAL

HEMORRHAGE
OLD.

IN

AN

INFANT

FIVE

DAYS

Bt One of the

BAMUBL
to

0. BTTSBY, OhUdnn*!

ILD., Washington,
eta

D.

0.,
the

H Clinioo-Psthdlagloal

FhyridnoB

the

Hospital,

(Bead

before

BodeCy.)

Mrs.

gave
at

birth to
10

female
p.

child

on

Tuesday, unusually
house the

Jan'y Slst, 1871, speedy

child cord.
On and easy

o'clock

m., after

an

labor.
and

When

I reached

the

was

bom,

the

pulsations had

ceased

in the

Monday, February 6th,

in

at

p.

m.,

was

moned sumnurse

great haste, and

child
The had been

was

informed since

by
the
the

the

that

the

bleeding
worn

previous preceding
I found the

afternoon.

diapers
were

during
with blood
clots

twenty-four
blood labia.
away the

hours

stained
and

blood. stains
on

clots in the The

vulva

ternal ex-

stains

and

having

been oozed No

wiped
from sion abraand

with
vulva could

soft moist trickled

cloth,fluid blood
over

and be

the

fourchette. labia
membrane

discovered.
folds of
mucous

The

external
were

internal
and

and

the

len swolinfant

turgid. During
wat^r

the

examination
and

the

passed
urine
had
was

freely, copiously
and
unmixed

painlessly.The
blood.
and the but The child

normal

with birth

been

perfectlywell
of

from

presentedno
time. I could
The

symptom
mother
no

disease

or

suffering at
was

insisted that it
fact had

premature,
its

cover dis-

confirmatory except
been in

probable

under-

size.

She

feeble

health, suffering from

attacks of intermittent

anaemia, and debility,

occasional

in

an

Infant
at

Five

Days
in

Old.

47 1870.

fever;
Nor

miscarried
I

the

6th

month

February,
Even and with
the

could

recognizeany

circumstance

the justifying

diagnosisof precocious menstruation.

fluid found occasionally
in the nuunmsB,

milky

the precocious

development always
menstruation The and
9th
"

consecutive

precocious
7th and

were

absent

hemorrhage
^thus

continued

through
the
half

the

8th,

ceased

spontaneously during lasting four

examination and
of and
a

afternoon

of the
a

daya
on

During
the

very

careful
was

the

parts

8th, the
on

bladder
an

evacuated,

the

urine, being caught

with
a

oil-silk cloth,was
any

examined, carefully
with

view

to

discover

admixture

blood.

None

was

nized. recog-

endeavored
came

to

determine the vulva

or

whether positively

the

blood
from
mucous

from

vagina;

and

though,
of the

the smallness

of the parts and

I
cannot

tumefaction

membrane,

assert positively

that the

blood
I

poured through
it did.
As

the
I

aperture of the hymen, yet

external and

believe

separated the
over

ternal inand

labia,the blood
was

dribbled

the fourchette
stream

confined

to

single steady
aperture.
continuance No

coming
be

from
seen

the
on

direction the surface

of of

the
the

point could
which of

parts in view, from

blood
and

oozed. for
and
to
some

During

the

hemorrhage,
wasted after
I

days subsequently, the

not

child weeks

much

rapidly,and
artificial

for

several

resorting
the

feeding
deficient

did
and

it

recover.

attributed

emaciation than
to

to

defective

nutriment, rather
Diseases of

loss

of

blood. that in

Vogel
two

(p. 471,

Children)

states

cases,

observed

by him,

48

Busey:

C(i%e

of Vaginal Hemorrhage
and

"profuse
few
not

intestinal

catarrh

atrophy
affirms

ensued
"

in

days,"while
uncommon

Ollivier of in children

Angers*
at

that it is
flow

the

treast, the

ing last-

from

seven

to

fifteen

days, ceasing spontaneously,

the child."

without
This
and

any
case

apparent
is to
me

effect upon
a

novelty., Drs.

Thomas have had

me

Miller,
very

W.

P.

Johnston, gentlemen who

considerable have
on seen

inform experience in obstetrics,

cases
"

they
Bouit

similar

^the latter

several ; it

yet authors
and

obstetrics

forbear

to

mention
to

Vogel
Whence
to

chut

simply

call attention
other vulvar

it,
"

one

denominating
"

vaginal,the
clusion Bouchut
a

hemorrhage,
its relation

the

coa-

is,that
does
so

both

deny

menstruation. from the

in express

words,
that

but

it appears, maintained
of
at
are :

reference

by Bouchut,
which should

Ollivier
'^

opposite view, holding

the function The the
was

that it is
be

sort

prelude to puberty."
1st.

established

inquiries suggested by
of clear the the that

this

case

Was What

hemorrhage vulvar, vaginalor

the
cause

uterine ?
? of the

2d.

hemorrhage
the As
source

It

seems

blood

was

terior pos-

to
were

hymen.
and

the

external

and

visible parts fair that

swollen
and

turgid the
were

inference

seems

the uterus the and v^th

vagina
in

also

congested. Admitting supply

but of the

temporary increased
uterus, which

vascular
are

vagina

infants

slightly supplied
the
mucous

blood, the probabilitywould

of

point to
as

membrane

the
both

uterine from

body
which

the and

of locality

the

hemorrhage,
known
lesser
^

its nature

structure, and
to

resistance
Bouohut

it offers
Children, p.
552.

the

blood

]"iBea8e8 of

in

an

Infant
to

Five

Day

Old.

49

pressure, of
the

and blood
mucous

also

the the

relativelygreater
uterine
in the

pressure

against
blood

than
event

against
of any

the

vaginal

membrane,
to

mination deterThe

of
uterus

the

internal

genitalia.
the

is

supplied

with

blood
"The

through
arteries
;

spermatic
of the its

and

uterine

arteriea
are

(Savage)

uterine
outer

body

flexuous strikingly the

they ramify on
take

cortex
on

beneath

sero-muscular

mediatel implatj'^sma;
a

perforating the
in the become
cortex

latter,some central, more

markably re-

spiral course
meduUa
; others

vascular

straightin making
to
run

their way
the duct

through
tubes the
to

the the and in

inner

between The

capillary trellis-work" vagina

the
a are

arteries
do

of
not

cervix

fewer, less tortuous,

a

terminate

form

of

network The

each

papilla is
the female
ber num-

supplied with
veins

capillaryloop.
that of the is

of disposition
"

corresponds to variety of
of the

ai-teries.

The the

pelvis(Savage)
and surface
"

remarkable especially its

venous

for

collocations." beneath
a

The

entire

uterine

body
with

the of

musculo-serous

platysma
"

is covered
and

plexus
are

veins,

and with

the the
dulla." me-

more

central

finer veins spaces membrane

continuous
erectile

minute

inter-muscular
The

in the

uterine

lining
one
"

of
an

the

cavity

of the

body

is but
an

of twenty-fifth

inch thick

(perhaps large
trellis

less in

is infant),

permeated by
on

innumerable
a

which capillaries,
with very thin

form

its surface
not

vascular

walls,"
; its

easily detached

from

the

subjacent tissue
The

epithelium is ciliated, very

membrane is

loosely
posed. ex-

attached, and when

separated the capillarytrellis is

more

cervical

firmly organ-

50

Buset:

Case

of Vaginal hemorrhage
The

ized and

never

exfoliates.

vaginalis
several

covered of

with
the

pavement

epithelium.
the

These the

considerations

varying organization of
warrant

parts seemingly

probable newly
bom

inference is
a

that

hemorrhage
exudation refers

ring occur-

in

the of

bloody
little
were

from
to

the
two

cavity

the

uterine

body.
two

Bouchut

of autopsiesby Billard,

girlswho
found

died

after

birth,in whom
of the uterus."
of the

"clots of blood

in the
are

cavity
tions func-

Resorption
between
tracts

and

secretion

the

cylindricalepithelium,and
the
on

wherever
gases

the
in the the

osmotic
lumen of
on

exchange
the
the
mucous

fluids and the

one

side,and

blood

other, is active,there
be

the

cylindrical thelium epiepithelium of

the external

is to the

found.
into

The the

pavement

vagina

passes

cylindricalat
blood

orifice of the uterus.

a

Menstrual

escapes

through
Whether
as a

surface
a;

lined

with

cylindrical epithelium.
of

as

hemorrhage through rupture

is

continuityor
as

transudation, manifest, that

resistance
in the

immaterial, inasmuch
the blood pressure

the

fact

is
or

either

is greater

is less in the

cavity of
all the

the uterine

body

than

vagina, though
with blood.
and

internal from
nature

genitalia may
consideration

be
of

gorged
the

Apart
of the

any in

wisdom

purpose
to

adapting the
of

lindrica cy-

epithelium
secretion,the
into the

functions

of

resorptionand
the

sudden

transformation the
external and and

pavement
orifice is tions funcof

cylindricalat
that

uterine

nature's

provision to promote
organ;
to
a

facilitate the this

peculiar to
structure

adaptation
internal

purposes

is illustrated of

in the

unvarying
gen"

result of

determination

blood

to the

52

BusEY

Case

of Vaginal HemorrJuige
holds
that it is
"

observed

number

of cases,

sort

of

prelude
at

to

the

function

which which views

should view
can

become

lished estab-

puberty," from
that such

Bouchut

dissents,
established
or

and

maintains
the

only
the

be flow

by
it

periodical reproduction of
examination trivial affection,without function. the essential
The

by

an

anatomical
as a

of the ovaries.
any

Holmes

regards
with the

connection
in

menstrual

Vogel
of the of

coincides

this
"

opinion. ^periodic

It lacks

quality of

menstruation
is not
a

reproduction. objection.
numerous

age
cases

infant

conclusive
are

The
recur

precocious puberty
even

too
struation men-

to

to, and
and

the

cases

wherein

took the second

place

recurred

regularly prior
to

to

dentition,are
age

numerous sufficiently

lish estab-

the fact that in

a

is not

conclusive.
in the

Dr.

R.

ris, P, Har-

paper pag"

(published 611), asserts

more

third
the

volume

of this of

Journal^
the and
menses

that

first appearance

is
years sixth.
at
one

common

during
than life,
case,
at

the
in

second first,

third
and

of infantile
In year;

the

fourth,
struated men-

fifth

Rowlet's

the

child Sir

Schmidt's,
at

two;

Astley
; De-

Cooper's
Leuhossek's

at

three
at
one

; Susewind's

twelve

months

nine

months.

One

reported by
at

Dieffenyears

bach, and
and

by D'Ontrepout, regular
at

two
one

pregnant
at

eight.

Comarmond
one

reports
at two

lar reguLe

three

months

; Descuret at

years.

Beau's

menstruated

three, and

teen. regularly ti}l fourii p.

Parvin's
case

{American
and

voL PractitioTiery In

126)

at three

six months. and

and

Rowlet's, Schmidt's,
cases were

Cooper's, Le
were

Beau's

Parvin's

the covered

breasts

well

formed

the

pubes

with

in

Child

Five

Days

Old.

53

hair.

In

Flnegers
menstruation with half.

case

(Bayr. began
at

ftrtzL

IntelL-Blatt,
and
a

Nr.

49,
and
at

1871)
continned
five

one

half

years,

tolerable The

regularity
external
and

until

her

death well
roomy.

and

genitals pelvis
child
and
ten
was

were

developed,
Rowlet's Schmidt's Kussmaul's
at

without

hair,
birth
to

the

gave
to
a

living eight
made
"

at

ten,

and

dead

foetus

at

months.

In

case

menstruation and

its first

appearance

two

years,

conception, developed
it

followed

by
took

normal

birth the

of

completely
In

foetus,"
commenced

place

in

eighth.
and

Cummin's

between and

the

eighth
and
from

twentieth
cases,

days

of

life,

in

Kerkring's regularly
{American

Langlade's
the

menstruation

appeared
Parvin's
month and from
case

day

of

birth.

In
at

Dr.

Practitioner)
every

it

began

one

recurred

larly reguto

twenty-eight
the

days,
one

lasting
and
a

four

six and
and

days,
then it has
The

until ceased.
not

child The

was

half

years

old,
age,

child

is

now

four

years

of

returned.

child

referred since its

to

in

this There

paper

has has
been

been

under

observation of remarkable the

birth.

no

rence recur-

bloody
for its

discharge, good
health

and and

the

child

has

been

rapid

growtL

54

Thompson

On

Scarlet

Fever.

ON

SCABLBT

FEVER

Bt Btatifltioil

BAADFOBD of the and New

B.

THOMPBON,
York

M.D., qt Medidne^
of New etc

Becretary

Aoedemy

(Be"d before

the

Hedlcel

VOxaof

Journal

AModatlon

York, Jannaiy 10, 1978.)

By

clinical the

observation, the

comparison
cases

of

statistics,

and
and

of theories analysis infections malady, which of

and

of
off in

this

zymotic

carried

1871-2, the

Bishop
other

Salisbury,Dr.
men,

Thomas
the

Hawkes

Tanner, and
be
om*

renowned

perhaps

gi*ainmay
then

tially parlabor

separatedfrom
will not Dr.
have

the chaff ; if so,

been

in vain.
we

Budd, of England, a writer whom

"

all

respect,

remarks,

that

if science

can

point out practicableconditions

may be

by
is,in
the

which

great maladies
conditions
case

averted, society
but worthy, blame-

highest degree,not
if these

only
are we

unwise

not

realized."
such

cially Espea

is such
as

the

when
year

consider

ease disto

this, which

every persons

slays from England

cause

twenty

twenty-two thousand
There
are

in

alone.

few

diseases

which

greater anxiety,
fever.
^in

suffering,and
where
we

mortality, than
with it and hear in

scarlet of it
"

Every,
in

meet

tutions public insti-

and small

private dwellings;
in
remote

in

large towns,
houses
; in

and villages,
the poor,

country

the

cottage of
"

in the

parsonage the

and

in the

palace

^no

class of

life is

exempt from scarlatina,an

scourge.

Scarlet
first

fever,or

Asiatic

disease, was
d.

accurately described

of Naples, a. by Ingrassia,

Thompson

On

Scarlet

Fever.

55

1500

; it

was

named

by

him
was

jRossdlia. named

In 1565

it
as

was

epidemic
hiola: morbiUi.
he

in

Paris, and

by Ballino
from
as

Utir

measles carefully distinguishes

In

it, as

1580, it is known
in

in

Spain ignei.
measles.

the garo-

tiUo;

in 1680
to
as a

Italy,as

morbilli
was

In

1650,

cording ac-

one

author, it

first

recognized in England
The
late

disease

differingfrom
of
in 1669

Prof. it

Nathaniel

Chapman,
in

Philadelphia,stated
; but

that
view
was

appeared
that
in

in London

Sydenham's
even

was,
more

its appearance than in says

London,
Dr.

in

1690,

name

reality.*
that fever untU this

Richard
was

of Inglis,

Detroit, Michigan,
confounded
the

measles

undoubtedly
for it in
of Dr.
paratively com-

with of

scarlet
cases

and
the

mistaken
appearance

majority

Withering's essay
a

on

fever

in 1793.

It is
A

new

disease in the
the

United

States.

respondent cor-

of

Medical

Record^ November
"

1, 1866,
Connected that it

in

an

interestingcommunication
the
never

on

Laws

with
was

Propagation
known
to 1830
as

of

Scarlet south

Fever,"
as

states

far Dr.
scarlet

North

Carolina

previous

; and

Benjamin
fever
was

Rush, remarked
so

sixty years physician

in

ago,

that
not

rare

that
than

one once

would

be

likelyto
is

see

it

more

in his lifetime.
this

Probably
in

the first record

an

of its appearance
an

country
out

account

of

epidemic
1735. the

which
Dr.

broke

Kingston township, Mass., in

has left
a

Douglass, of Boston,
of the Fever
"

record
a

of it imder

title

Practical with
an

History

of

New

Epidemical
It

Miliary
itself
*

Angina

Ulcuslosa."
colonies

spread
ter-

through

all the New

of
Modidne

England
and

with
1871.

Detroit JBeview

Deoember, Phoflrmacfy^

56

Thompson:

On

8ca/rlet Fever.
the

rible rage, in

to opposition

united

endeavors

of the

profession.
The

disease
seen

is

rare

beyond
San

the

Rocky Mountains,
and other

and

is little

in

Francisco
a

parts

of

California.

It has
to

maintained the

steady foothold
in

since

January, 1869,
Western
and Buffalo.

cities : St.

following Louis,Chicago, Detroit, Cincinnati,

in

present time,

the

It is has it

rarelyfound
occurred

India,and

is not

nor indigenous,

ever

among

the natives of that

country.*

According to Dr. Simmons, of Yokohama, who has had an experience of thirteen years there,scarlet fever is in Japan. unknown There was a severe epidemic of this disease in Philadelphia,in 1869, showing
over
a

large
the

increase

of had

deaths
been

the

previous year,
since the
year

and

highest that
The whole

attained deaths
was

1861. cent, 396

number

of Of

799, or
were

5.9 per

of all the deaths. females

one

these,403
one

males
128

and
were

; 45

were

under
years,
one

year from

of
2 80

age,
to 5

between
4

and and

two

411

years,
90

between

30

40, and

between Dr.
severe

and

years.

Charles

Carroll in

Lee, of New

York, speaks f

of

epidemic
2,765 deaths
all
causes,

pital, 1865, occurringin Blockley Hos-

Philadelphia.
Of

from

1818
one

to
case

1819, in
of

Philadelphia,
is
corded. re-

from

only

scarlatina

J
causes

About
the

one-twentieth

of the deaths

from the

all

in

State

of

Rhode

Island, for
1878.

last

Weitem

LcmMt^ Jaiauay,
Island

t y. t

T. MecUeal

Journal, 1867.
19lih Begistzation

Bhode

Report, 1871.

Thompson:

On

SooHet

Fever. from

57

eighteen years,
malady
years The York
in the

were

from
of

this fever. Illinois for

Deaths eleven

the

State

consecutive
cent.

previous to 1867, averaged nearly mortality

for the

4 per

from

the

disease
was
as

in the

cityof
:
"

New
cases

subjoined years
24

follows
2 in

in 1819, 5 in 1820, 3 in 1821, 1 in 1822,

1823, 1828,

3 in 188

1824,

10

in

1825,

in 1826, 4 in 1827, 11
258

in

in 1829, 5J46 in

1830,

in 1831,

224 202 391

in in
in

1832, 179 1836, 579 1840, 517

in in
in
668 928

1833,

408

in in

1834, 174 1838,

158

in in

1835, 1839,

1837,

257

1854, 1,052 in 1855,

in 1858,
in
840 903

1,263 in 1856, 1,325 in 1857,

in in

1859, 1,929 in 1860, 1,278 in 1861,

1863.

1862,

During
were

the

27

months
deaths

ending
from
a

December
scarlet

26,
fever
"

1868, there
and city,

1,757
in

in this
1

966

Brooklyn,
under
or

total
in

of

2,723

or

death, in 1867, to 1,039 inhabitants; 1

Of

1,049 in
age.
In

1868. 1869

these, 2,100
were

were

5 years 1 death
were

of in

there

1,314 deaths,
of
were

1,065 of the
5

population;
1870
or

these, 1,050
975

under
in

years.

In

there death under

deaths

New

York
of

City,

in

1,025
of

of the
age.

population; mortality

these,753

were
was

5 years

The

in this year
Of

greater than
from

any
1866

year
to

since 1861.

the
were

5,271 deaths
under
5 years
were

1870, inclusive,
above
2
were one

3,908
years
one

of

age ; 8

only were
35,
under two

30

; of

these, 2
2
were
one

30

years
; 445

old, one
were were

40,
year, old.

45, and
between
over

60

years

878

and years in

two, and
of
age
were

918

years

Those
Our

30

females.
home and

researches

reports
deaths

at

abroad

show

that the

majority of

reported from

the age of 25

58

Thompson:

On

Scarlet

Fever.

years

and

upwards,
males

are

among

females.

Statistics also its

tality, mor-

exhibit

the
in

preponderance
over

of the
In

and disease, the

year year

females. this

1871, 796 2,850

cases

deaths
were

occurred

in

city; in

that

reported.
The
three
most

fatal

epidemics

of

the

year

1872,

were

scarlet Charles

fever, small-pox,and
P.

fever. cerebro-spinal Statistics of

as

Dr. New
our

Russell, Registerof Vital

last

York,
most

in his

report, regards scarlet fever

its

constant

and epidemic,'

mortality in
not

1872
to the ; 725

(990),although greater than in 1871, was Its mortality approached 32 average.

of its deaths age,
84 193
over

up
cent.

per

occurred between
15 5

among and

children

less than
10

5 years

of
and
40

10,

38

between
a

and

15

years, the oldest Of

of all its

being

male

between in the

and

45.

deaths, 667

took

place

first six months In

the year.
the
ten

Boston, Mass., in
deaths
1831
to

years
were

from
30

1811 ; 1821

to to

1820, 1830,

the

from

scarlet

fever
1841 to

48;

1840, 972;
of

1849, 1,468.
a

Dr. London

Ballard,
Fever
and

London,*
of Medical its

read

paper

before

the
on

Association
and

Officers

of

Health,

"Scarlet

Fatality,as
his in his

affected

by Age,
based of

Sex, Season,
upon
a

Epidemics,"
diseases the
12

remarks

being

of registration
over

parish

ton, Islingand

extending
three

years

1857-1868,
gave
a

cluding in-

epidemics.
cases
"

His

tables

total

of of
count, ac-

2,375 pauper
calculation
;

making 10,000 living his

the whole

basis into

and

taking
showed
Medioal

population
5 years 4, 1869.

his tables
*

that under
Jw/moSL,
Dea

of age

there

BrU^

60

Thompsok

On

Soa/rlet Fever. fever of

5

General's

returns

of scarlet
two

for and

the
16

whole
years
1838

of

England,
1842, and

include

periods period
from

spectively. re-

The the
21

first

extends
to

from

to

second
years

1847

1862,
from

inclusive. disease
was

During
were

these

310,720 deaths
average annual
was

the

registered; the
The death
more

mortality
174 per

14,796.

rate

of

1863

100,000
average off in

population,being
of

than

double

the

annual

the 26
year

years
1864

1838-64.

Scarlet

fever

carried

in

the

in

England, 29,700
The
was

persons;

land, Irethe

2,653 died in that year.

fever in

mortality from
or

1868, in England,
or

21,912,

in

990;
1 in

Scotland, 2,253,
2,048.
Fever
more

in

1,416; Ireland, 2,707, or

Annual

Dr.

Murchison's

Report
that

of the London disease

was

Hospital

for 1869,* shows

London and

the

prevalentin
year

throughout England
confirmed

than the 12th

in any

since

the

publication of reports by
is

Registrar-General. This
Annual

by

the of

Report
in

of

Mr.

Simon, medical
the

officer

the

Privy Council, who

year

asserts
was

great epidemic of the

fever.
total
not

1869

England
in

scarlet alone. The

There deaths
less

were

5,803 deaths
the disease
in the

London

from than fever

throughout England epidemic

than of

were

those

1863-4,

when
A
to

scarlet

destroyed more
of

60,000 persona
were

large
the

tion propor-

these
and

deaths
of

ascribed authorities.
from

neglect

of

individuals Of
18

local

1674

persons

dying
Oct.
cent

this

malady during
and
19 5 years May 21,

the

weeks

ending
64

1, 1870, in London
died under
9, 1870"

other

large towns,
*

per

of age, and
1870.

BrUith

Medieal

JmrruO, ApxU

Thompsok

On

Scarlet

Fever.

61

33

per

cent

died
cent

between of adult

the ages
deaths
to

of 6 and

20, leaving

only

3 per

from

this

cause.

Geo.

Rigden,* Surgeon
says that from

Canterbury (England)
years have
1839
to

pensary, Dis-

the

1865

sive, inclu-

epidemics of
with
years.
mean

this disease

occurred
once

in Canterbury

considerable death-rate

regularityabout
was

in four
of

The of the

about

1.7 per

cent

the

population. epidemics of
of Salf
second
to

Two Dr.

distinct

the

fever

are

recorded
occui*red

by
in

Arthur

Bansom,
and the

Manchester,
first in

which

Manchester

ord, the

attainingits height in

Oct, 1863,

Oct,

1868.
mary sum-

According f
for Britain

the

annual Registrar-General's

1872, the
was

death-rate

of

the

fever

in

Great The

low, although small-pox was

considered
it that satisfactory
to

high.

Begistrar
were

fever-deaths

declining from
he accepts
of the
as a

3,689 in 1864,

1,746 in 1872.

This

sign of
infective

the Next

improved sanitarycondition
to

metropolis.
the

typhus fever, the

which
occur

most

fatal

o"

diseases

in

England
In

is scarlet

fever.
years
was
or

North
a

Holland, during the

from
In

1866,
on

7, 8
an

and

9,

with
192

population of 570,742,
this
cause

there year,
a

average

deaths

per

1 in

habitan 2,900 in-

Amsterdam,
deaths per

with

population of 266,681,
or

there

were

146

year,

1 in

1,900.
were

South

Holland, with
deaths
per year,
a

679,950 inhabitants, there

or

only

16

in

42,374
of

inhabitants.
8 deaths

Botterper year,

dam, with

population
*

116,650,

BriUih,

Medical Medical

Journal, April 17, 1869. Journal,

Jan.

\Bntuh

21,

1872.

62

Thompson
1 in

On

Scarlet

Fever.

or

14,511.
per

The
year,

kingdom, 3,576,382 inhabitants,

or

1,094 deaths
The
A. M.

1 in

3,270.

and important communication interesting

by

Dr.

Ballot,* relative

to the

"

Epidemics
1815 to to

of

Small-pox,
shows

Scarlatina,and Measles, in Rotterdam,"

the year
1778
to

Holland, from 1870,

1811, and

from

that in the and

third
were

period, from

1841

1870, small-pox
that
to

scarlatina
was

measles
"

Why

is the

diminishingfrom increasing. In answer for measles susceptibility

diminished
the ?
"

while city,
his

inquiry,

increased, and
an

that

for scarlatina

we

find, from

tended ex-

research,etc.,that

climate
to

during
usual,

greater
the

portion of

the

third

period,1841 diyer

1870, in which

was epidemics prevailed,

than

or, in other

words, there
which
may also

was

less local

moisture

in that

section,
of scarlet the
in

account partially

for the decrease

fever,
last that

the
years

small
more

number

of deaths. has

During

twenty

attention
and

also been

paid

cityto
there

cleanliness
and
seems

scarlet fever

measles
to

fumigation. Although both tious, communical^e and infecare

great difference
in

be

their

tagiosity. con-

Dr. Elisha

Harris

truly

says

"

Taking

the

ence experiand

of cities and

the contagiousvirulence villages,

epidemic
in about the

ravages

of this foe of childhood

local

will be found
and

greatest force where

moisture

impurities
"

dwellings and neighborhood

where

are

greatest in
conditions

other

words,

general unhygienic
Dr.

prevail."
The

great experience of
*

Ballard,f of Islington,

Medical British

Times

cmd

Medical

QaeeUe, May 6, 1871. Jtmmal, Deo. 4, 1869.

Thompson

On

Scarlet

Fever.

63

teaches
are

ns,

that in alike
cases

regard to
in

seasons,

spring and
the

summer

nearly
of attains

the

to liability

disease; the
the
summer

nnmber and
more

increases maximum

considerably in
in
autumn.

the

The

disease

is

disposed to spread
66^ to 60^.

when

the fatal

mean

temperature is
summer

from winter.

It is less

in

than

in Dr.

During
there
the

the

twelve
to
was

years

recorded the

by

Ballard,

appeai*ed
disease

be,

on

whole,

most

fatality when dampness

That clinical

least

prevalent;
even
a

and low

promoted
fever

fatality more
be
to

than

temperature.
scarlet
may due
to

blood-poisoning,
all the premonitory
nervous

facts would

seem

corroborate, as

symptopas indicate malnutrition system.

the
Dr. disease be

of the

Carpenter, of Croydon, England,*

to
common

believes
and
a

among and in into

slaughtermen
districts
sewers,

butchers, and

their families ;

where
and

great quantity of blood

passes

comes be-

putrid, the
out.
^

fever

will

almost

invariablybreak
asserted

Whether of
our

vegetable parasites
"

^as

by

bury, Salis-

own

country,
a

and

man, Schurtz, Hallier, Hoff-

etc.

"

^have kindred
on

part

in

the

development
for

of scarlet gation investiname

fever

and

diseases, remains
clinical is

further

based tUletia
spores

observation.

The
to

of

scarlatinosa of which
were

given,by Hallier,
in the blood

fungi,the
of

observed

patients
which

with been

scarlet fever. found

Micrococci, in great numbers, have

in the

by Hoffmanf
*

linen

wrappings
1872.

British ZeitBchz.

Medical
1

JaumcU,

Feb.

4,

voL Pttras,

iii. p. 106.

64

Thompsok:

On

8ca/rlet Fever. treated

had

been

used

as

coveringsin
and been

cases

by

cold

affusions. Acute

observers,at home
of the fever
have of

abroad, show
traced
to
use

that outbreaks of

milk. St

Dr.

Bell, Professor
has recorded

Medicine, University of
an concerning

Andrews,

the facts
was

outbreak

by

this medium

which

infected

by

the

ing desquamatAnd Dr.

cuticle thrown
persons,

off from of
a

the hands

of scarlatinal

milkmen
W.

particulardairy.

cases Taylor, of Penrith, recites many in this occurringin various houses,which originated He brings irrefragable proof showing that the way.

Michael

milk-carriers had
been

not themselves

the fever.

Cases have

published by during the journals,

American

observers, in medical

agreeingwith the observations of Drs. Bell and Taylor. and In regard to the arrest, prevention, propagation valuable of scarlet fever, instruction has been particularly given by Dr. W. Budd, Physicianto the Bristol Dr. Peter Hood of London, Dr. Aldis, Royal Infirmary, parishSt. George,London, Robt. Renfrew, of Glasgow, and Dr. John Harley of London. does not attach much Dr. Budd gating importanceto fumithe sick-room with chlorine or sulphurous acid, advocates He of the fever. during the whole course basins the importance of having in the sick-room for the recepcharged with chlorides or Condy's fluid, tion of bed and body linen immediatelyon its removal from the body of the patient. Renal Bpithelium, which he is cast off so believes performs the plentifully,
,

last five years,

same

eliminative

function

as

that

which

is cast off in

Thompson stm

On

Scarlet

JFever.

65

greater profusion by
Hood's

the

outer

surface

of

the

body.
Dr,

experience
the
course

shows

that

free

use

of

chlorine, during
will confine
coarse

of the fever,in the sick-room

to

the

contagion hung

that with

I'oom.

He
of

causes

large
sheet

towels, saturated
be
over

chloride of

limea

solution, to
to be

the backs

chairs ; also

suspended
evidence

in front of the

door

of the sickroom.

Valuable
that

is afforded
even

in

favor
the
use

of of

the view tion, disinfec-

ordinary washing,
is not
sufficient the
to

after

deprive

the linen of

the power

of

communicating
in

poison. Experience
been

has

shown

that,
when

American

and

English hospitals especially,

sent

the soiled
to

clothing has
new
cases

away

from

pital hosbeen

be

washed,
and

of scailet fever

have

rare.

For fumes

rooms

bedding
is
one

the

popular disinfectant,
is

of

sulphur,
The

that

cheap, speedy,
of

and

effective.

periodical fumigations highly

the

crowded

houses, and
carbolic

the saturation
are

of drains,closets, etc., with beneficial

"

acid,

as

commended reparticularly now

by
carried
Health. In and
cases a

Dr.

Druitt, of London, jnd main, by various

fully success-

out, in

Boards

of

paper

recently read

before
Dr. the

the

Royal
28

Medical valuable

Chirurgical Society, by
were

Harley,*
formation

detailed,showing
common

following pathological
of fibrinous
a

changes
clots in

to all

1st. The

the

heart
*

and

great

vessels

during
28,
1871

pyrexial

BriUth

Medical

Journal,

Dea

66

Thompson

On

Sca/rlet Fever.

condition

at

any

period
the the

of

the

disease.

2d
3d.

Marked General
was

derangement
inflammation

of
of

hepatic

function-

lymphatic glands, which

be

ways al-

present.
The conclusion
to

drawn

was,
an

that

the

logical pathocase

changes
scarlet

accompanying
all

ordinary
of the from
first
one

of

fever

included that but

a

those

stage of
disease

enteric
to

fever, and
other
was

the

transition

the

natural any
cause

pathological sequence,
which
of

readily detennined
and
scarlet

by

might

increase

the intestinal irritation. fevers The submits of

to
were

His
not

cases

enteric co-existing
to

attributed

accidental

occurrence.

term

"abdominal

scarlatina," Dr.
the

Harley variety

the

profession,for
after

contagious
for

enteric

fever,

sufficient evidence

conviction. Prof. Virchow has

pointed
The

out
"

the

followingforms
of

of

after Tddmsy-affectioThB scarlatinosa

:
"

scarlatina

forms ^viz.,

ritis nephin

1st.

catarrhal the

ized form, characterthe

by
tubes

the

proliferationof
catarrhal

cells epithelial
to

of the

medullary substance, similar pneumonia.

elements
,

that which The

no

takes
known

place in
"

2nd.

form

as

nephritis parenchymatosa,"in
the cellular and
takes

which

liferatio pro-

of which
The

place,but
"

in

change

degeneration of
down

the cells is the rule.

croupous
was no

form, formerly laid

could
no

by himself,

he nephritis,"

as longer recognize,

there

disease

of

the

kidneys

which
casts.

was

characterized

by

peculiarkind
That

of fibrinous

Pabula/r

nephriticmay by

be the
a case

only symptom reported by

oj
J.

sca/rletfever^ is illustrated

68

Thompson

On

Sca/rlet Fever.

affusions the year

may

afford

relief

"

in especially

delirium. of

In

1825, Dr.

Gregory,
the

Prof, of Practice carried

of
out

cine, Medito

University of Edinburgh,
such
an

this idea

extent

that, in
his
of
a

presence

medical

friends,

he immersed in the
course

own

child

in

tub

of

cold water, and

few

minutes

it

expired.
and

Py"mic

flammat in-

of

joints,delirimn,
scarlatinal Kent

cervical

abscess,
ing accordthe

called
to

by Trousseau,
Dr.

huboj demand,
of

John of

Spender,
of hot

London,*

ministra adand

quinine,comp.
to

scammony

powder,
fluid to baths.

fomentations locally,

medicated

joint or
That

joints,blisters quinine is
the
an

the

scalp,and
and

hot-air

and antiseptic of Binz pus

is supported by antipyretic^

experiments
of the the
lancet

Cohnheim.

In

cervical

abscess,to prevent the

muscles with
cause

from

burrowing
should

among be

the
made

neck, early punctures

laid
of the flat
on

the

skin.

Delay

might

gangrene Graves
and

connective

tissue, as

mentioned

by
is

Trousseau.
most
our

One

of the

serious

evils

followingscarlet
that the

fever sheetwith

dropsy;
in

and

experience shows

anchor

cases

with

congested kidney, associated

combined chloridi,

dropsy, is
as

the

tinct. fern

with
and Dr.

talis, digiW.

advocated

by

Dr.
to

Robert
St.

Renfrew,
and

B. Dr.

Cheadle, Physician
S. T. Hubbard
a

Mary's Hospital,London,
York,
to
a

of

New

others. and
a

Dr. of

Cheadle

gives from
of

drachm
a

drachm
of

half

the infusion
old far

to digitalis

child with the

from

2 to

3 years

for
as

considerable

time
of

perfect safety. drug

is

As

the

diuretic action
*

concerned, the

BriUsh

Medieai

Jmmal,

July 16, 1870.

Thompson:

On

Scarlet

Fever.

69

mfusion tincture.
Dr.
use

is

far

more

reliable

preparation
the

tlian

the

Chapin,
of
ether

of

Michigan, is partial to
acid combined

internal of

carbolic and
as
*

with
account

tinct of its

opii,
Dr.

chloric

on glycerine, an

antiseptic
; and

also qualities,

applicationto
of

the

throat
an

H.

T.

Cleaver
in which

speaks
relief
was

70

cases,

in

epidemic
of

in

Iowa,
of
cases

ajfforded

by

the In
as

application
none

this
were

acid

to

the any

inflamed

throat.

his

there

dropsicaleffusions dropsy, varying

is in doses

sequel.
Dr.
a

Croton

oil,in

scarlatinal

given by
and

Liddell, of England,

from

|^to J of
water.

drop,
The

rubbed

up

with

mucilage,
he avers,

syrup

dropsicalsymptoms, patients are

Chas.
to
not

subside the

quickly,and
in

the

debilitated

by
New

purgation.
ring referphia, Philadelof chlorine

Dr.

Carroll

Lee, of
in

York,f

the

epidemic
to

Blockley Hospital,
that the internal
use

in
was

1867, remarks
resorted
in the

connection

with

milk

punch
seemed

and

beef

tea, when

ordinary
almost
two

treatment

the anginose symptoms incapable of arresting

; and

the

ratio of

of

recoveries chlorine
reference

was

to

one were

in

favor

the

treatment;
to the

the

cases

selected

without

severityof
a

the

symptoms.
of the eases disand

Statistics
of

show
ear,

that

large percentage by English origin to

their

the

tabulated

American fever.

aural
In
393

owe statisticians,

scarlet

cases

of

ear

disease, attended

with

otorrhoea,

I'eported by

W.

C.

Williamson, P.RS.,
Medical York

Prof. Natural

lowk Jf$u

Journal,

1869. 1867.

Medieal

Journal,

70

Thompson:

On

Scarlet

Fever.

History in
be the

Owen's

College,*this
cause

disease The

appeared
in

to

proximate

in

171.

there, propriety,
our

fore, of

guarding against these complications

Geo.

treatment, is apparent.
Drs. of

Johnson, of London, Chas.

late the Prof.

T.

Thompson,
others,
the

England, the
inculcated

Geo. of

T.

and Elliot,

have

importance

in ordering, A

early
for

hot baths. stages of the disease,

an

daily packing
sheet
covered

hour

or

more

in

warm

wet

with the
to

blankets

for

the

promotion
We
all know

of

rash, etc., is advisable

bear

if the

outcoming of patient is too feeble

the

the

the batL
for

the value

of Konochetti's ness usefulthe

invention of

and promoting perspiration, and

Richardson's the throat

other

spray-producersfor
Dr.

of palliation

symptoms.
the

Chas.

T.

son Thomp-

impierses his patientsvery

stage, or allow,
more
as

often

as

frequentlyin the early strength of the patient will

prevent the
the
to excreta

to particularly
"

dissemination the skin

as

of the fever
soon
as

^byremoving deposited
"

from

it is

and
done
to

promote

cuticulaf years.

des-

quamation.
One minute from This of the

This

he has

for the last 15 aim

the
at

first

things
are

is, to prevent the

which particles,

carriers of the
can

poison,
surface

being
can

disseminated

until

they

be

disinfected.

be

effected by anointingthe perfectly

a

of the

body, scalp included, twice

oil,as
recommended

day
Both

with
or

ated camphorcold
cream

by

Dr.

Budd,

"

^the latter

being

more

effective. relief from

are

agreeable
ing itch-

to

and patients,

give

the

troublesome

attending the
*

disorder.
Medkaland

MamxhetUffr

Surgical BeporU, 1870.

Thompson:

On

Sca/rlet Fever.

71 habit
tion. erup-

Dr. of

John

C.

Peters, of New
from the
the

York, is
first

in

the

ordering
He

inunction for

day

of the

employs
rose

purpose

simple cerate,
cerate,
uses or

ment ointam-

of moniated
of

water,
To

camphorated during
to

weak
an

oiL

he prevent contagion,

unguent
whole this
to

carbolic

acid, and

convalescence

the

body, scalp included, is

is
go

be

scrubbed

; and not

until

accomplished
out

the

patient should
for

be

suffered

The

following by
Dr.

combination

gargle
York

is
:

mended recom-

F. A.

Burrall, of New
a

Bromoa

chloralum, glycerine,each
of water.
"

teaspoonful

in

bler tum-

As

contribution
note
at

to
on

the

history of tracheotomy,* it
8, 1834, Dr. the Hunterian

is well

to

that
a

January
of

of

London,

meeting
a

Whiting, Society of
M. Mack-

London,
murdo,
two

related
in
a

case

of

tracheotomy by
scarlet
took

patient
in

of

his, with
recovery

fever, aged
At

years, he

which of
no

place.

that
tion opera-

time

knew been

other

case

in which

the

had
In Best and

performed
would

for

etc." glandularswelling,
remark

concluding, we
V.

that

the

case

of

Staff; recently mentioned

after
to two

in the Medical trials remains

Times turbed, undis-

Gazette^ which
is
a

warning
would

young

and

inexperiencedpractitioners
the propagation
one

who

guarantee
diseases.
a

patients from
The
case
was

of infectious which
the
owner

in

of

at Eastbourne, lodging-house,

brought an action against a gentleman who brought their children from London
*

and

his

wife,
con-

during

Ozation

of Tbo"

Biyant, F.ILG.S."

before

Hnnteriau

Society, 1870.

72

Thompson:

On

Scarlet

Fever.

valescence

from
the

scaxlet landlord

fever,
any

into

the

lodgings,
of
the

out with-

giving
which
dren died.

intimation Two
took

danger
the chiland

his of
In

family

were

incurring. keeper
the

of

the
the and

lodging-house
first
at

the

fever substantial

trial the

jury
trial relied

awarded the verdict

damages,
aflBrmed.
of

second

was

re-

The his
in

defendant who

greatly
that The from

on

the

vice ad-

physician, carrying
the

stated

there

was

no

danger
marks:

infection.
to to

editor
the the

thus

re-

"The it is

moral

be

drawn

case

is,

that
in

impossible
when

determine

exactly
can

period
in their

convalescence

persons

be

exposed

presence."
The

following
were

journals,
consulted

not

previously

mentioned this

by

foot-notes,
Reports
BritiBh St. of the

in

preparing
Biitam.

paper.

BegiBtiar"Qexieial
Journal for

of

Great

Medical

18684872. vol. 1870.

Geozge^B
Record

Hospital
toI. L

Reports,
yii

z.,

Medical American

Journal
Times

Medical and

Sciences,
1867-1872.

1870-1872.

Medical
London

Gazette,
1865-1873.

Lancet,
York Medical

New Health

Journal,
of
New

1867-1872.

Reports
of St.

York and

City
St.

and

Brooklyn. Hospitals.

Reports

Thomas'

Bartholomew's

Hanks

Case

of

Ova/rian

Cyst

73

CASE

OP

OVARIAN

CYST

TREATED

BY

mJECnON

OP

IODINE.

Bt

H.

T.

hanks,
to the

M.D.,
Demilt

Phpddan

far DlaeaaeB

of Women

Dlapeiuaiy,

New

York.

Mrs.

K., aged 36,

past five
;

married

eight years, livingsingly

;

for well

the

never

pregnant
;

skin

pale, body
mind
;

developed
she each

and

nourished Has

active intelligent, from

of several

industrious
of

habits.
teims

suffered

attacks and But

been

what

"inflammation

the

womb

bowels,"
for the
a

attack

followinga
during
has had in

menstrual

epoch.
she has
illness

past
of

four

years,

which
no

time

patient of mine,
attack

she

serious

except

an

malarial
"

fever
called

July, 1872.
oflSce

Oct. 6, 1872.

She

at my

complaining
I found

of
a

pain in
cervical nitrate October
Nov.
an

the

pelvicregion. Upon yielded

her

examination
to

catarrh, which
of silver.
31. 5.
"

the for

treatment

of

saw

last

this

difliculty
than

She

had

severe

chill

for lasting which

30.

more

hour, followed
was

by high fever, in
Pulse
130.

the This

ture temperawas ceeded suc-

105^.

Resp.

by
and

short

sweating stage.
very

The

temperature
6,

pulse

remained

high during
and of

all November

when
over

pain, tenderness,

swelling were
touch

developed
revealed the
;

pelvicorgans.
pain
in

Complained
; the os-uteri

frequent paroxysms

of

this

region. Vaginal

parts hot and

dry

tipped forward slightly

74 the cervix
in The

Hanks

Ca%e

of
down

OvaHcm
in the

Oyst firmly fixed pelvis,

the median line.

and

body

low

positionconsiderablyto
disease

the the

rightof
of

passed through
the
use

regular stages of pelvic

pus. in

without peritonitis,
accustomed
to

formation

Having
her

been

the
now

of
treated

morphine
with with

former

attacks,

she

was

unusually large and

some

frequent
Nov.

doses

hypodermically,
and

aconite;
bark. be

and, during convalescence, iron

25.
"

Peruvian
as

She

was

so

far recovered

to

able
in

to

sit up, but

suffered
the

considerable and

pain

at times
use

the
phine mor-

region
Dec.

of

womb,
doses.

continued

the

of

in smaller
1.
"

She

called my
On

attention

to

slight swelling
I found
a

over.left iliac fossa.

oval tumor, in
its

examination
two

small

apparently about
the left ovary. it

by

three

inches in size,
of

regionof
nature, but

I did

not

satisfy myself
to blister,

feared

might
I

be pus, the result of

pelvic
be

and cellulitis,

accordingly
a

applied
On

dressed
December
or

with

starch found

poultice.
no

the

followingday,
pulse,temperature,
vinced con-

2, 1

change
a

in the

respiration,and
me

vaginal
was

examination
a

that

the tumor
an

not

cellular Dec.
two
saw

abscess,
a

but

undoubtedly
Dec. 7.
"

ovarian

cyst.
continued L. Brown

3, she had

slightmenstrual
with
Tumor and

flux, which
James

days only.
the the

^The late Dr.

patient
walls
of
to
as

me.

felt through distinctly

the abdomen,
press

by vaginal examination
the

discovered

close

upon

fundus held

of

the

uterus, which,
to

previouslystated,was
the median the line. the
We

by

adhesion
to test

the

right of
of
I

decided

the

character

fluid with

hypodermic syringe. Accordingly

76

Hanks

Ga%e

of

OvaHcm

Oyst performed by
and but Dr.

Jem.

5.

"

This
the

operation
presence
ounces

was

Brown,
About

in

of
of The

Dr.
was

Thomas

and

myself.
the

thirteen

fluid

removed,

cyst entirelyemptied.

patient suffered
in the
severe

little
In

pain

and

was

very

comfortable
had
a

evening.
I

the
in

night, however,
regular course
to

she

chill,followed
was

by

fever

and

sweating.
doses of

obliged
hypo^

give large and

Jan.
6.

frequent
much

morphine
Pulse
over

dermically.
"

She

was

improved.
extended the

105

to

111.

Temperature
fossa,but
no

102^.

Slight tenderness
of
or

left iliac
were

symptoms
this

inflammation

developed during
Pulse and continued the cyst

three
on

succeeding days.
the

temperature
to

diminished
up
to

9th,

and

she

improve

the 13th, when

I discovered

filled again. partially Tumor

was

Jaifi. 20.

rapidly. filling
of from

It was,

indeed, patient
she
was

nearly as largeas
had suffered that
so

at the time

aspiration.The ovariotomy patient with

the
to

much
the

pelvic pains,that
of

anxious

operation

should

be

performed.
Feh. sudden
counsel
"

13.

"

^Dr. Thomas of Dr. Brown

saw

the

me

"

the

death ^and

depriving us
of iodine, so
of

of his valuable
sac

proposed again emptying

tincture
chance
as

and

then

injectingit with
still another

give

the patient of

escaping the
the

operation

ovariotomy.
he
was

This

proposal impressing me operation.

the

favorably,
drew

requested to perform
15.
"

Feb.
twelve

Dr.

Thomas

tapped
He then

cyst and

out

ounces

of fluid. and

reversed
ounce

the action of tincture

of

the

instrument

one injected

of

Ideated

by Injectionof
a

Iodine.

77
then

iodine, mixed
withdrew

with

pint
No

of

warm

water, and
or

this solution.

enlargement
but

tion tumefac-

remained.

Patient of
a

suffered

little

pain.

minister Ad-

two-thirds

grain
90.

of

morphine

hypoder99^.

mically.
Feb.

16, 10
18.

A.M."

Pulse

Temperature
and

piration Resno

Slept
one-half

since

operation
of well

suffered

pain.
Feb.

Gave

grain
Rested

morphine hypodermically.
;
no

17,

A.M.

"

change

; took
no

light
terial ma-

nourishment

; one-half

grain morphine.
Pulse
100.

7 p.m.,

change.
Feb.

18,

10

A3I."

Temperature
tenderness
of

100^.

Respiration20.
over

Some

pain

and*

parts
and the

and

adjacent to
discovered

left ovary.
on

Slightinduration
Increased condition.

swelling
dose

examination.
same

of

morphine.
Pulse
No

8 p.m.,

Treatment

continued. Feb. tion around Feb.

some

19."

96.

Temperature
of

99

i^.

Respiramorphine.
nonnal
;

normal.

spreading
Continued
and

local

inflammation
of

left ovary.
22.
"

full doses

Pulse

temperature

nearly

tenderness,induration, and

thickening
date
took

discovered

in

region of April
5.
"

left ovary. ^Patient from

time last less and

less
over

morphine,
90.

and
is

at
no

no

since has the of the tumor, in

date

pulse been
but
some

There and

return

tion indura-

thickening remain
14.
"

region of
the
a menses

left ovary.
have
amount

April
blood down

Since for The

last three

again
of low

appeared;

and

days

normal

escaped
in the

uterus

is still

firmly

fixed

pelvisto

the

right of

its normal

position.

78

Wright:

(m

Comhined

IJxternal

The

patientis
attributed

able to

oversee partially

her

household
can

duties,and
be

suffers
to

only occasional
disturbance
uterus. to

pains.

These

all the

the the

consequent

upon

displacement of
Thus

far there

appears

be

no

tendency
every
a

to

reaccu-

mulation

of fluid in the sac, and

a cure

I have

reason

to

hope

that

has

been

effected.

It is
a

well-known
cure

fact,however, that, even

to have

long

after such

appears
occur.

been such

accomplished,
an

reaccumulation

may

Should
fail to

occurrence

take

place here

I shall

not

report it

ON

COMBINED

EXTERNAL

AND

INTERNAL

VERSION.

Bt A

V.

B.

WRIGHT,

1C.D., Cindxinati, Ohio.

HIoIcb^b Letter
in

Beply

to

Dr.

J. Bxazton

No.

IV., YoL

Y.

Editor
called
to

Am.
a

Jour,
letter
on

of

Obstet.

"

My

attention

has

been

the

above

subject in

this

year's
been

February
Hicks.
make
as an

issue

of

your

Journal, and
the

signed J.
to

Braxton
to

The issue
to the

object of
between

letter

seems

have

himself
"

and The

Dr.

W.

S. Richardson,

of originator

Combined

External
a

and into

Internal
a

Version

"

plan
I

of

converting
this

shoulder

vertex

presentation.
seen

It will that Dr.

"

be

before
was

close

communication,
the

Richardson

right in using
and that

expression,
not

Dr.

Wright's Method,"
detract

it does Hicks.
an

in And

any

way

from

the

claims
I

of Dr.
now

it

gives me

great pleasure that

have

opportunity

and of

Internal

Version.

79

meeting
but

Dr.

Hicks,
calm

not

in

jealous or

angry

sion, discusfessional pro-

in the views.

and

of friendly interchange

My
"

"

Prize
was

Essay

on

Difficult Labors for vain

my

and
nor

ment their Treat-

not

written
to

show,
mite

for

self-

but glorification,

contribute
to

to the

demands

of

obstetrical

and science,

dischargea
of the
to the

duty justly

claimed is far
amount
more

by
of

the

junior members
attached

profession.There question.What
definite
was

importance good
as Still,

is to be realized

from

plan
it

of

action ? than
? of the

to the other
a

question, By
of

whom

gested sug-

discussion
not

the latter
a

is the

order it.

day, I

must

shrink
Dr.

from

in participation has
a

It is apparent

that

Richardson
"

taken

one

standpoint.Dr.
their conclusions.
on

Hicks The

another latter has of

hence

difference

in

predicated his
whose
had

criticisms
was

the

reported cases
to

gentlemen,

object
been

mainly

show

that

cephalic version
to describe

fully success-

performed by myself, as deeming

its Dr. it necessary

their counsellor,without
the

precisemanner

of

accomplishment.
Richardson,
on

the

other

hand, relied for

of the

rect cor-

judgment paragraph
my taken

on

the
from reads

language
pages
as

essayist.
seven

twenty-sixand
:
"

of

originalessay "Suppose
the

follows have her

patient to
be
"

been

placed
its

on

her
"

back,
the

across

the bed, and

the

with

hips near
have

edge

presentationto
into

right shoulder, with

to

the been

head

in the left iliac fossa

^the right hand the arm,

may be

troduce in-

the

and vagina,
as near

if

prolapsed,to
posioriginal

have

been

placed

as

in its

80

Wright:

on

Combined

External

tion

across

the the

breast.

The

fingers axe give greatest apply of

a

now

to

be

applied to
or axilla,

top of the shoulder, and the thumb

in the of

such

part
enable

as

will
us

command
of

the force.

chest, and
The the

to

degree

lateral

hand left

is also to be

applied to

men the abdo-

of
pressure way
as

patient^ over
be made

the breech
vpon

the foetus. Lateral in

is to
to

the shoulders of the

the
to

such

give
At

to the

body

foetus left

ciu*vilinear

movement.

the

same

time
so as

hand, applied as breech, as

the
the the the

above,
it were,

makes and The

pressure
move

dislodge the
centre to
assume

it towards is thus
made

the

of

uterine

cavity.
bent

body

original
are

the points of position,

and
a

contact

with

uterus

loosened
in action
on

perhaps diminished,and
overcome.

force
any

hesion of ad-

good degree
into
as a

Without

direct

the

head, it gradually approaches the superior

the

falls strait,

opening, and
vertex
as

will in all

probability
of positions into
one

adjust itself
the head the may

favorable
acted upon be

presentation. If not,
the

be
or

in deviated

vertex,

it

may
in

grasped,,brought
with

and strait,

placed

correspondence

of

the

oblique diameters."
Can any
one

say, after of

his

own

powers of

to reading the above, in justice perception,in view of his professed

knowledge
of
internal

language, and
"

with

just claim only

the
Hicks
use

to

esty honthe the

purpose,

that
even

Dr.

Wright
did Dr.

used

hand,
one

not

mentioning
eyes

of
use

external
"

"

Whose
Dr.

when,
failed

on

reading over
see

Wright's original paper," he

The of

to

the

points so distinctly presented?

years my

truth

is,

during

the many

lecturingupon

obstetrics,

a/nd Internal

Version.

81

never

failed,when discussion,to

cephalic version
enforce hand. the

was

the

subject

nnder action To Hicks' in

absolute

necessityof
and "Dr.

by
my

the external

mind,
"

*'Dr.

Wright's
"In

method" in

plan

are

different essentially

and principle I need

practice.
one or

Dr.

Hicks

says,

my the

plan
head

only
ternal ex-

pass

two

and fingers, and the until

new

bring

by
to

the the

pressure, and have be retain

internal
the

fingersdown
In this

os,

it there the the is

gentle uterine
is*the

contractions

confirmed

position."
of the foetus
to

plan, it

will
on

observed,
action of

head

only point
to

which method

brought

bear. head
cases.

According
acted
on

the

Dr.

Wright,

the

is not

at

all,

in except incidentally
to

some

Internal

force is applied

the shoulder, external

the

force to the breech.

the

Again,
directions.

force used with

to

change
two

position of
is in Dr.

the

in harmony foetus,
The

the hand Dr.

plans, by
to

opposite
to

outside
"

is used

Hicks
up

push
hreech. The

down

the head

by

Wright
is
"

pv^h

the

language
the
are

of Dr. I have

Hicks

Now,
was

the

distinctive

point of
hath hands
in "Dr.

plan

introduced
Are The

just this,that
both

used

^ together Method?"

not

hands
cannot

used
be

Wright's

turning
without

speedilyand Every
at

performed skillfully
is not the

it.

experienced practitioner will

a

testify that,
In

best, turning
cases

desirable

task. escapes

nearly
an early,

all the

in which of

liquor amnii
is
to

adequate degree
as

force

be

skillfully applied
I not

ternally in-

well
we

as

externally. May
most

ask, by which
the directing

process

can

secure

efficient aid in

82

Weight

External

and

Internal

Version.

movements two

of

the

foetus,
to

the

introduction

of

"

one

or

fingers
full power

down
of

the hand of
"

os,"

or

by
the
to

applying
shoulder know

nearly
?

the Is

the

against
interest

it

still
his

question
views in
on

who
and If

fii'st

presented
Version"
refer
to

Combined

External
?

nal InterI

shoulder that dates

presentations
my
as

so,

may of

the

fact,
version
the

experience early
soon as

on

the

utility
and

combined lectures

1847,
afterwards.

my
A other

on

subject
in

occurred the

case

was

published
1851.

Lancet

in

1850,
a

and

cases

in

My

essay

containing
in his
1854.

description
1860

of

the for

process, the Dr. first

was

published presented
strike ? the the

In
to

Dr.

Hicks

time

views

the

profession.
us

Will he

Hicks

difference have
value

and

show

how

reverses

time
of

The

profession

now

an

tunity oppormethods
to

testing

comparative

of
And

two

of

rectifying
that the the

shoulder
two

presentations.
may have
rest

it

seems

me

disputants they
may

their
to

exultation the

upon

good claiming

secured
for

sufferer,
or

without

special

praise Very

ingenuity

skill.

truly

yours, M. B.

Wright.

84

Klob

The

Pathological Anatomy
such

velopment
attachment orifice
seems

may in
to

occasion
the
me

occlusion.

Placental
the uterine in

immediate
to

vicinity of
still

be

of
cases.

greater importance
uterine

the

explanation of
the

such

In

so-called

interstitial
may

or

portion
an

of

the mescence intu-

Fallopian tube,
of
from

stricture

be

produced by

the

surrounding growths
find the

uterine

tissue, especially
Not

adventitious
we

(fibrous tumors).
of

unfrequently
tortuous

canal

the

tube upon
a

ingly exceedcareful

in this latter
we

portion,and
will
notice

external tumefaction

examination of that

either
or

irregular
numerous we

portion of
more

the

uterus

prominences.
will
find that

Upon
the of tube.

thorough
so-called

examination
is due
to

irregulartumefaction
the

the

tortuous

condition

interstitial

portion
that

of

the

Fallopian

Such

an

anomaly

is

generally
at least state ; it

bilateral,confirming,therefore,the
we

presumption
or

are
one

dealing with
that
as

congenital anomaly,
the duct

with

originatedduring
the in

puerperal My

appears twisted
was

in if, bent

foetal state, MuUer's

numerous

had

been

and

directions.

attention

called to this latter of

one

anomaly by Rokitansky.
also be

The

walls

tube

may

considerably thickened
coat, and
thus

of by hyperplasia be
more
or

its muscular

its canal

less contracted.
of

yicerative affections
rare,

the

Fallopiantubes
from
a

ai'e

ceedingly ex-

consequently strictures rarely

and

contracting
has been upon

cicatrices
di'awn down

are

observed.

If

tube

fastened of the

by

false

membranes

either

surfaces

broad

ligament, then, besides

also be

being bent

at its uterine

it will portion,

partially

of
twisted, and
canal will be
in

the

Fallopicm
the

Tabes.

85

consequence

permeability
from
in

of its

considerablyimpaired.
of the

Impermeability
occurs

Fallopian tubes
may
occur

traction
any tion porplete com-

in various of

degrees,and Rarely
; it is

their

course.

does

traction

cause

obliteration
affects the middle

generally partial,and
orifices of the tubes
and atresisB,

chiefly
is the arises

portion.
of

Occlusion
most

of the abdominal

frequent
from

the

accidental

either
or

from
the

involving the peritoneum, peri-uterine oophoritis or pelvic peritonitis.

abdominal orifices
rolled
are

tubal

catarrh

When
are

occluded towards

the

fimbriae
canal

generallyfound
the

inwardly

the

of

tube, their
the

peritoneal surfaces
the tube
assumes

being
a

adherent.

Thus

extremity of
It of

funnel-shaped
of the the of

appearance. extremities
lesion the is

is

possible that
is in
many abnormal later.
cases

the

inversion

the tubes

cases

primary
tubes,

arisingfrom
occumng

contraction At

the

adhesion

least this

explanation
of any adhe this

in all those possible other anomaly of the sion. In

no exhibiting

trace

peritoneum beyond
find

old

women

we

sometimes of

more

extensive
must

imbe

of peiineability attributed
The
to

the canal

the tubes, which

senile

atrophy. of
strictv/res and
as

consequences
vaiy

occlusions the

of

the
fects af-

Fallopian tubes
either the Strictures
due

accordingly
or

anomaly

entire tube
to

only
of

limited
tubes

portions.
may
or

flexions

the

either the
to

wholly

hinder

the

reception of
to

the ovum, thus

arrest

latter in its passage

the

uterus, and

give rise

86

Klob:

The

Pathological Anatomy
same

tubal the have

pregnancy.

The

may the

occur

in occlusions which
case

of
we

interstitial
the
occurrence

portion

of

tubes, in

of so-called of the uterine

interstitial pregnancy. orifices may

the also lead of ovary
as

Partial

occlusions

to

similar

results, the

of possibility
the

passage
to

the
of
doubted. un-

spermatozoa
the affected

through
side

opposite tube
at

the

being

present

conceded

Complete impermeability
the

of

both

tubes

of

coui-se

moves re-

of conception. possibility and the

Kiwisch
of have
never

Forster
tubes

mention

the
and

occurrence

of
mucus.

clusions oc-

from such
a

thick

viscid

I sions occlu-

observed the abdominal from

condition.

Partial rise
to

of

orifices may accumulated

give

tion disten-

of the tubes

secretion.

DISTENTION

OF

THE

FALLOPIAN
: HYDROPS

TUBES

WITH

MUCUS

OR

SERUM

TUBARUM.

Distention
consequence

of

the

Fallopian
the

tubes

is

generally
mucous

the

of catan*hal
to

inflammation

of their

lining extending
extremities,and
in the their
manner

peritoneum
to

of their fimbriated of the latter

same

giving rise already

be

the adhesion If at the

described.

time

uterine

orifices

partially or
uterine
mucous

wholly

occluded
an

by

tumefaction
of the

of
the

the

membrane,

accumulation of membrane the muscular

secretion,and
will
a

tention correspondingdisensue,

tubes in

be

apt

to

the

mucous

being

condition
a

of

and hypersecretion,

walls

in

state
occur

of

inflammatory paralysis.
without
and

However,

distention
the

will

inflammatory
orifices
are

if hypersecretion

abdominal

uterine

of
closed, and
its normal escape. the
mucus,

the

Fallopian
membrane

Tubes.

87

mucous

continues

to secrete

its secretion

in such

cases

having

no

According
either be

to

the location entire canal

of

the

stricture

or

sion, occlumay

the

of the

Fallopian tube
The be
to
more

distended, or
of the

only its extremity.

latter

frequent
to

distention

portion is
the

to

attributed the
wall

its

larger calibre, and slighterdevelopment

The natural

perhaps
of

also

fact
of

of

the

muscular

this portion.

attachments

of

the

Fallopian tubes explain the

affected.
course

and

their relations to the ations

of the form
a

peritoneum
of
tubes is

will

alterIf

thus

the
be

entire canal

of

tube and

distended, its

will

acutely
the

tortuous

twisting,which
of elasticity
to

latter, however,

consideringthe
tube,
of
must

limited

the

peritoneum
Above
one or

of

readilygive rise
the tube in

flexiona into

the
more

points
sacs,

flexion

distends

thus

producing,

highly developed
each other

cases,

like cyst-

cavities

separated from
latter wall. be
are

by
of
cases

the the

ning interve-

walls, which
of the tubal

composed
recorded

tions duplicaIf

The

of alveolar

tubal
the

sacs

must

explained
which

in this

manner.

only

outer
sac

third

of the tubal

canal

has been

distended,an anteriorly

oblong
or

is formed

depends
been

either

unless posteriorly, false membranes.

it has

otherwise

displaced
the very

by

Very rarelythe
half of
the

distention
which
case

is limited it is
tubes
never

to

uterine
erable. considmous, enor-

tube, in

Distention
and I have
seen

of

the
cases

is sometimes
the
sacs

in which

attained

88

Klob:
a

The

Pathological Anatomy Althoughwe

distention may
cannot

the size of
but

child's head.

deny

that in isolated cases

be still more of other been taken mis-

if we consider the statements excessive, still, it is evident that ovarian cysts have writers,

for tubal found having

dropsies.Thus
a sac

Muniker
tubal

mentions
Mu-

110 lbs.of fluid in

dropsy ;

walls of the rat,112 lbs. (the

beingthe thickness and Cyprianus, of the finger). 150 lbs. Harden,140 lbs., The walls of the Fallopian tubes undergo various of their muscular chiefly atrophy changesfrom distention,
walls. I have often searched in vain for musculai' folds between in the flexed portions or
even

fibres;

the

brane memtheywere also absent. The mucous also degenerates into a thin serous membrane^ is covered with a single which in marked cases layer Thus the polymorphous ated striof pavement epithelium. of the tubes has been metamorphosed epithelium cylindrical in a manner observed in the excretory similarly On opening the outer ducts of other organs. of a distended tube we will abdominal extremity or sometimes find the fimbriae projecting flower like small cauliinto the distended cavity of the excrescences also we with papillary meet tube. In some cases crescences exof connective tissuefrom portions of the mucous membrane (Rokitansky), has made the interesting observation that Rokitansky of a tubal sac is membrane in rare the lining cases transformed into osteoid scales. I have onlyonce met

distentions

with such of

case, in which

there

were

several groups

ossified scaly, particles. yellowish, In excessivedistentionof the Fallopian distinct tubes,

of separations
whicli
are

the

Fallopian
between caused

Tubes.

89

found

the

different

tions, disten-

are

either

by pseudo-membranous
to

adhesions, or

are

due, as
tubal

I presume, resisted he has

were

the fact that such distention.

cases

portions
Scanzoni which

of the

walls that

the

mentions

observed found into

no

in

fi'om

five to six occlusions

in

one

tube,

which, consequently,was
and may small be
sacs.

distended
met

several
case,

large
and

have that

with

such

it

supposed apparently

deep

indentations
each

separating
have

cavities been

distinct

from

other, may
is

considered the

occlusions,although it
such
an occurrence.

impossible to they

deny
As

of possibility

regards the
consist of
in the

contents
a

of
it is

such

tubal

sacs^

erally gen-

clear

yellowish limpid
rare

serum,

and

even

sacs lai'ger

to

find other
are

contents.

In

many

cases,

crystalsof
In the
or

cholesterine

found

in the

large quantities.
contents
are

slighter degrees,however,
a

brownish,
the and

greenish brown,
of
source

or

ink black the

same

color,from
time from
extreme

admixture ropy.

blood,

and

at

thick the

The
of

of the

hemorrhage

is in

blood-vessels
cases

the

tube, which, however,

are

of
that

distention
in

also the

atrophied.
blood is
at
an

The

circumstance

dropsy
of

of

tubes, almost

out with-

exception, only metamorphosed pointsto period of

we an

found,

occurj^ence

the

hemorrhage

early
that

the

disease.
meet

It is only in aged females

with chocolate-colored of rigidity
forms of

frequently
with

contents,

coincident

considerable

the arteries. tubal

two Froreip distinguishes

dropsy

"

dropsy
ai'e

in which

both

the

abdominal
in which

and the

uterine uterine

fices ori-

closed,and

dropsy

orifice

90

Klob

The

Pathological Anatomy quite

convinced
to

is

permeable.
not

am

that

the

uterine

orifice need and that

be

occluded fluid is

produce
a

tubal
certain
contents

dropsy,
amount

after the
a

subjected to
may make

of pressure
sac

slightcause
the
uterine

the This

of the
has

flow

into

cavity.

condition

been did

termed
not

projluent dropsy of
such
cases

the tube.

Kiwisch him
as thentic, au-

consider and

published before
expresses
a

Forster But and

was

likewise

distrust in older
this process the

observations.

Rokitansky
the
sac

considers
a case

undoubted,

Scanzoni

describes

in which
*

right
and

tube

to di'opsical

size

of

goose'si^o^ig^
a

the

left

forming *a loose
few
the lines drachms of

the

size

of

hen's

egg,
necting con-

containing a
with

and sanguineous fluid,

a

uterine

cavityby
I

canal

about

1^ inch
found
the

long, and
similar
contents

in width. in

have

repeatedly
in every mixed

conditions of the the

:

aged females, and

tube
were

case

distended

with the
the

blood.

I presume
manner

hemorrhage
evacuation walls

originatedin
of the sac, and

following
excessive

After of the the

pressure semia

being suddenly removed, hyperoccurred in consequence and

of

blood-vessels

of

diminished from From

cases

followed resistance,
of rigidity the

by rupture
that

rhage hemor-

vessels.
it is evident in many

these

conditions
of
occur

evacuation
sacs

the

sanguineous

contents

of

the
to

tubal

may

and periodically, of

am

inclined

consider
years, tube.

statements
a

menstruation

occurring in
in which years,

later
the

after
Thus

as profluentdropsy long cessation,

of

Heyf

elder relates
a

case

ation menstru-

reoccurred

in

woman

aged
observed

78

after

sation ces-

of 26 years.

Braun

its occurrence,

after

92

Skene:

Nat/wral

and

Artificial

NATURAL

AND

ARTIFICIAL EITHER

DILATATION

OF OR

THE AT

08

UTERI

IN

PARTURITION,

PREMATURE

TERM.

Bt

ALEXANDER

J.

C. SEEKS,

M.D., Long
Idand

Professor

of Gjiuecology

and

Clinical

ObetetricA N.

in

the

College Hospital,

Brooklyn,

Y.

In other

times in that

past, writers

and

teachers of
"

so

vied

with

each

their the process

denunciations

meddlesome
dared all
to

ry," midwifeinterfere of natural tedious

of
til un-

practitionerhardly
of

with

the

until parturition abandoned.

No how

hope

delivery had
and

been

matter

how

painful
"Natui'e

the

labor, or

little the advised

her

prospect
to wait

the physician was speedy delivery,

had exhausted all

resources." upon,
out

This

rule

of had

so practice,

strongly insisted
It

has

less doubtwant

its

uses.

naturally grew
artificial
means

of the

of

knowledge
labor the could

of be

any

whereby
that reiterated,

natural

safely
is,or

aided
so

; and

also,from possibly,
"

dogmatic statement,
"

often
to

dling medtion," func-

with

what

ought
or

be,

"

natural

always
Now those
we
are

involves
free
to

more

less
we

danger.
should
of
to
not

am

confess
maxims

that and

disturb

time-honored

rules

practiceunless
offer,in their
both

quite sure

we

have

something

stead, that
and
In

promises greater security to

of

mother

child. the progress

discovery

and

opinion, valuable

Dilatdtion
have
;
so

of
been
at

the

Ob

Uteri

JParturition. of

98

resources

added the
so

to

our

means

assisting
is
ly naturalfrom

labor

that

present time

the

obstetrician

taught
and

to

wait

only

long

as

labor

progresses

with

reasonable

speed. Any
is

deviation

ordinary
the the

natural mother without be

labor, which
or

likely to jeopardize
the
as

life of

child,or
reference

of protract the suffering

even

mother,

to

question of
resources

danger, should
of the

promptly met,
enable him
to

so

far
so.

the

obstetrician

do

The has led

acceptance of these views, in

to the

more

modem

times,
of

discoveryof
of

new

means

for the purpose

overcoming
The
resources

the

difficulties and
our

dangers of child-bearing.
in the

art

are

rich specially
"

ment depart-

of
the way

"

operativeobstetrics

"

and

that

great gain,in
sulted re-

of from

and avoiding death, has relieving suffering these

improvements,
obstetrician

there

can

be

no

doubt.
.

What

well-informed
think had the

of the

present

day, for
more,

instance,would
after before
the head

of

waiting
to

for six hours, or

the floor of would

descended

the

pelvis,

using

forceps?
for the
os

Or
to

who

delay forty-

eighthours, or
in the
mean

more,

while the patient, dilate,

most

time^was

the suffering

pain ? distressing
the latter in the

It is for the
"

purpose

of

overcoming

culty diffifirst

one

of
"

the

most

important
some

elements

stage of
prooesa The

labor

that I submit of the

os.

points regarding the

of
cause

dilatation

of natural the

dilatation

of the

os

uteri is

traction con-

of

longitudinalmuscular
on

fibres, which, by
or

making
waters.

traction

the os, has

more

less influence the

in

producing

dilatation

sufficient

to

admit

bag

of

94

Skene The

Natural

and

Artificial
in

most

important agent, however,

the
to

directly
dilates
one

is dilatation, effecting the

OS

bag

of waters, which
of two and

either

or fully,

the

extent

half

to three

inches,before
the the

the
waters

membranes has child

rupture.
its useful
os, and

When purpose, thus

bag
head

of

accomplished
engages

of the
process.

ip

the

completes the
of

This, briefly stated,includes

the the

various several

steps in the

firststage
in normal There

labor, ie,^when
of succession.
many progress,

stages follow

order
are,

however,
the add

circumstances
and the

which

may

conspire to
labor, as
Prominent mentioned

retard
as

thereby prolong delayed labor

A

the

well

greatly to
the
causes

patient's suffering.
may be

among

of

irregularmuscular
of the
causes os

auction.

rigid, unyielding
of the All

condition
most

is undoubtedly one itself, of

important
may
not

delayed
to

dilatation.

the

conditions

be favorable

dilatation ; but

the parts

simply

do

yield.
rupture
the

Again, premature
occur,

of
most

the

membranes

may in

and

we

lose Or
a

thereby
tense

important agent
the
os, and

dilatation.

condition

of the membranes

may

prevent
the
cases
were

their

bulging down
as

into
"

forming
In
as

wedge
the

known
membranes
across

the

bag
to

of
the

waters."
touch do
case, os, not

such

appear the
os

if

they
in of vent pre-

stretched
:

but uteri,

engage head
as

it

or, what

is not

unfrequentlythe
over

the
so

the

child
the

may

lie close down

the

to

liquor ananii
os.

from

down forcing

the membranes

into In

the

such

cases

the

liquor amnii

is

usually scanty.

Dilatation

of

the

0%

Uteri

in

Parturition.

95

Another
in child in

cause

which
cases,

prevents the completion

is obstruction
into the
to the

of of

latatio di-

some

head

the

down settling
os

pelvis.

The
a

membranes

dilate the
up,

the

sufficiently, perhaps, to
or

admit

segment of

foetal and It is

head,

breech

; but

the child

remains

h^h

hence

dilatation necessary

is
to

delayed.
state, in this connection,that
the

hardly
suffer time

patients
loses of

long
and

and

severely,and
I risk

physician
cases

both

patience waiting
; and

in all such in
can

slow

dilatation

nothing
this

the be

further

statement, that
and the

very

much

of

time

saved,
of

suffering alleviated, by
"obstetric
our own

the it may

judicious exercise
be
more

art."

And
are

fairly claimed
prompt
to
even lieve re-

that, in

time, we
than ago.
were

far
the I
am

such decade that the

cases

obstetricians
far from

of years
resources

And
our

of
the

art, in this
am

believing direction, are fully

satisfied that the
os

exhausted.
means

On the be

contrary, I
retarded
to

for may

relief of

dilatation
an

of

the

uteri

safely employed
is the

extent

altogether
the

greater
time.
The
more

than

general practice
do
not

of

present

reason

why

we

employ
the

artificial dilatation
at

frequently is
difficulties

doubtless

due, in part

least,
The the

to
two

the

attending
of is known

manipulations.
are

principalmethods by
what
or first,

dilatingat present
as

by
in be

and finger, The

"Barnes'

dilators." its
complished ac-

manual

is quite limited dilatation,

reason

application;
admit
at least

for

the

that has and

little

can

until
two

the

os

dilated
even

to sufficiently

fingers ;

the

pressure

which

96

Skene

Natural

and

Artificial
from inefficient,
effect

can

then
that

be

made

is

irregularand
a

the

fact
to

it takes

longer,as
to

rule, to
the
two

dilatation,
to

the

extent

sufficient

admit

than fingers,

complete
Manual

the process
dilatation be

afterwards.
is

rarely
two

called

for;
"

indeed

it

ought

to
"

limited

to but

conditions.
livery de-

Fi/rstj When
;

there

is

for rapid urgent necessity

and,
"

Second^
.

^When

the

os

has

begun

to

dilate

and

is

quite dilatable.
The

hand

can

then

be introduced into

into the the

os.

vagina,and
method

the

carefullywedged fingers
well when
when the version
os

This

answers

is called

for in haste.
branes mem-

Again,

is
a

considerably dilated,the
head
on or

ruptured, and

segment of the
can

breech

engaged
or

in the os, traction

on

be made

the anterior

pressure

the

posteriorlip of
will often

the

os,

according

to

circumstances.

This

facilitate the

tion comple-

of dilatation.
The however filled with
most

important agent
"

for

artificial dilatation
The rubber

is the

hydrostaticdilator."
as

bag
the

water,
and

used
means

by

Dr.
at

Barnes, is undoubtedly
our

the

safest
in

surest

command

for

purpose There

question.
however,
"Barnes'
some

are,

objections to

the I

practical
desire
to

working
It has

of

dilators,"to which

call attention.
been
as

observed,
a

for

instance,that
corrmiencement
so

the

greatest
tion, dilatadilator

delay
cannot

occurs,

at the inile,

of that
a

while
be

the

opening

is still

small
to

easily introduced.

Owing

the

size and

Dilatation

of

the

Os

Uteri

in

Parturition.

97

shape

of

Barnes'

dilator,I
it until
and for
a a

have

found
os was

it

exceedingly
at least

difficult to introduce
an

the

dilated this the

"

inch, or

an

inch

half.

Before exists The

the
"

when

the
lator di-

greatest

demand
be

dilator
ease.

Barnes'

cannot to

used

with

principal objection
on

its use, at this

stage,is
if it is into

pocket

the outside
it takes up

of
too

the

bag.
room

If

it is made
;

of thick

rubber,

much
to

and

thin, the

uterine
tear

sound,

used

guide

the

dilator

place,will
in

through
is

it
The

introduction under

of
the

the dilator
most

ordinary keep
uterus

use

difficult, even and,

when in the and up,

favorable

circumstance^
the instrument

introduced,

it is difficult to when the

out

placa
is very

Moreover,
liable to be

contracts,
;

bag
it

pushed
the

into the vagina

is carried
uteiais.

to guard against this, if,

dilator the

well The

frequently slips entirely into

is

latter accident
head
or

likelyto

do In

damage by displacingthe
short,the
dilator in is troublesome

presentingpart
introduce, and

to

difficult to

keep

place when

introduced.
In and I order
to make
remove

the dilator
an

more

easilymanipulated,
its use, and

thereby

important objection to
for

recentlydevised
in It is

plan

introducing the
answers

bag,

retainingit

place,which

all

practicalpurposes.
It consists of

simple,easy
tube, about
knob
at
to
one

of use, and

will,I think, commend

itself to my
a

brethren. professional
ten

hard
a

rubber
or

inches
a

long, terminating stop-cockat

the axis

in

bulb

end, having

the the
re-

other, and

curve

correspond
tube

with

of is

pelvic

excavation.

The

(which

is all that

98

Skene

Natwral the

cmd

Artificial
well
presented re-

quired

in addition
in the

to

dilators)is original

accompanying figure.
Fig. 1.

It

is

about

the

size of
tube

No.

catheter, and
into the rubber

is

slightlyflexible. bag,
and
"

This three

is carried

answers

important
introduction

purposes.

Firsts Second^
Third,
" "

It

guides the

of the the
os

bag.
uteri,and
with
the

^holds it in
makes
a

place within bag

tube

convenient with when

connection
water.

syringeused
Figure bag
and

to fill the

2 shows

the
use.

introduced line shows

into the

the
line out-

ready

for

The

dotted

of the

bag.
Fig. 2.

By
be used

this

arrangement much
those of Barnes than the
:

smaller-sized

dilators
are

can

than

indeed,there
on

several

sizes much instrument.

smaller

pocket

the outside

of his

Figure

3 shows

the smallest

full dilator,

size.

100

Skene

Dilataiion

of

the

Os

Uteri.

In

such

cases

artificial

dilatation do
not

is

cult. occasionally diffito

When

the

parts
we

yield readily
to

the
os

drostat hyat

dilator,
several devised

are

advised
I

incise
a

the

points
for
a

:"

For

this purpose scarificator. divided which

use

knife

which
an

uterine

Its

shape

is like

ordinary
two

uterine

sound,
one

longitudinally
is
"

into and ^is

"

equal
into
at
are

parts,
the

of
; the
a

probe-pointed
a

fixed made

handle end

other, pointed
the

little

shorter,
The
a

the

like

bistoury.
blades
are

two

halves

held

together, like
when the sound

of

scissors,
it looks

by

button, and,
like
4
a

blades
or

closed,

exactly

uterine
a

probe.
of

Figure

is

good

illustration
Fig. 4.

this

instrument.

When
into the for

the the

blades
cervix

are

closed, it

can

be

easily
in the

duced introend of

uteri,and, by pressing
its

cutting blades,
the The purpose

sharp point
the this There

is thrown

forward

of
can

making
be, by

necessary

incisions. with

rigid

os

instrument, incised
is
or no

convenience
the and the the

and

safety.

danger

of the

ing wound-

parts while

introducing

removing

knife, control,

cutting blade, being

can

under

complete
desired.

incisions

be

made

to

any

depth

New

York

Ohatetrical

Society.

101

TRANSACTIONS OBSTETRICAL

OF

THE

NEW

YORK

SOCIETY.

Repobted

bt

CHARLES

S.

WARD,

M.D.,

Sbcbetabt.

Stated

Meeting

of

Dec.

24, 1872.
IN THE

Dr. Chair.

James

L.

Bbown,

President,

CONDITION

OF

CEBVIX

UTEBI

IN

CANOROIDAL

DISEASE.

IJR. Chamberlain
The

related

the

followingcase

of

epithelioma :

last summer in patient,a young lady,was under treatment of cervix for ulceration the from which London, uteri, reputed her the Contiand then continued she soon nent. tour on recovered, On had the rational signs of her return to this city she

malignant
mass
on

disease. canal.
the
cer\nx

the anterior cervical

caused The

discovered Physical examination of the which extended lip uterus,

villous

upward
nitrate of surface

in

the

mercury
healed.

application external mass to disappear,and then was dilated,and one or

made acid
to the
was mass

The

of

the

acid

the
two

tions applica-

of the acid which

the
at intervals
no

nitrate

in

the

cervix,after

As

applied two or three times a slough followed,and further to be detected. trace of the cancroidal growth is now it is impossible to pass a probe through the interval os, Dr.
mono-chlo of
acetic week. A considerable

Chamberlain

thinks resulted.
a

that adhesion
the
mass

of

the cervical

walls

at

that

point has
In
cervical

reply to
canal

questionby

President

as

to how

the cancroidal

extended, Dr.
the
case

up the C. stated about

far

of an inch. three-quarters Dr. Brown said,supposing

to
to

Question disease has

le

is,whether
gone
the

it would
so

be

wise

far. asked

It would the

be

epithelioma, the delay, in a case where better, in his opinion,

be

to

amputate
Dr. often
any

cervix.

Chamberlain the

experience
of the has occurred

of

members

as

to

how

portion infra^vaginal
process

cervix in

is absorbed dia-

before
ease.

ulcerative remarked

malignant
is

Dr.

Brown

that where

the

cervix

destroyed or

102

Trcmsactiona
is true in

of

the

absorbed, it

cancer,

while

epitheliomathere

is

great

proliferation.
ABDOMINAI.
ABSCESS OCCUKRING AFTER

OVARIOTOMY.

Dr.

Janvrin Dr. of

related
in
an

the

following case
at

Last

July

he

sisted as-

Peaslee
the

ovariotomy
and small

Patterson, N. J.
were

The

tumor

was

The
the

rightovary punctured. During

tumor^
a

left ovary, contained some the

tnere

cysts

many which the of

adhesions.
were

simply
of
to

first three weeks

weeks

days

after

removal wound

tent

was

left in the
Five of
was

lower

angle (being
a

the

insure
was

drainage.
able
to

Three

after the

operation

the
over

patient
four

be

months from

from exposure, the

up. time and

ago operation),the taken with she

little

during me
days after

following
attack

week she

chilled patient became in the left iliac pain region ; had and nine repeated chills,
a

discovered

tumor,

and

sent

for

her

her. who Abdominal to see requested Dr. Janvrin physician, three or four times as large palpationreadily detected a tumor the uterus fist. On examination the found was as high vaginal and up lower
tumor

fixed

from of

local

which peritonitis
at

occun^ed

at the

angle
could
were

douches
at

the

lower

operation, but no be reached. Quinine, fomentations, and vaginal abscess pointed an ordered, and, on Saturday last, of the which was wound, opened by her angle
; from

the womid

the

time

of

Dr. Terry benr physician.

this

was

discharged from
Janvrin occasioned remarked

one

pint
he from Emmet
an

to

pint
of
once

and

halt

of

pus.
nave

Dr.
been

that

thought
one

the abscess the had

might of ligatures
a case

by

irritation

the

of abscess

and stated that Dr. pedicle, after occurringeightmonths the

; had

ovariotomy.
Dr. Brown
must

doubted been
an

if the iliac

operation influenced
or

abscess.
it

This

have

abdominal

abscess

nated origi-

in the have been

broad

touched

the ligatureswere ligament where It been an might nave per vaginam.

it could

encysted

peritonitis.
OVARIOTOMY.

ovariotomy : 1st of difliculty account in arresting on case, interesting especially of the obligocystic was hemorrhage. This tumor variety,and twice burst had spontaneously during a period of two years.
After

Dr.

Peaslee

reported

the

following cases

of

rent found ^adhetne tumor making the abdominal section, was above tlie everywhere except at the top, and posteriorly enucleated. was Ilemorrhage from a vein pelvis. The tumor
in the

pelviswas

the

point of specialinterest

; the vein

was

so

New

York
be

Ohstet/rical

Society.
was

103

situated

that it could
with

not

the hemorrhage ligated,

until
were

trolled con-

by pressure when incision,

the sponge,

a sponge the intestines

ready
crowded

to close

the abdominal
in

down

place of

and

their

after the closure

not

press comby an pressure augmented of the wound. The subsulphate of iron was

external

employed,
irons

as

it has

occasioned

peritonitis. There

were

no

hand, and it is doubtful if he could have used them. After operation the patient was pulselessat tlie she conscious and was wrist, though spoke. Injecperfectly tions of brandy, with fifteen drops of tinctiire oi cantharides^ stimulant. The hour a were as given every patient died from hours the shock after the operation. At thirty-four autopsy of blood Peaslee found in the pelvis. Dr. two ounces were
cautery
at

the

once

had
not

case

in which

could
use

ligatecontinued
connection

he vessel which a hemorrhage from the daily for ten days,necessitating wash
out

of abdominal
In this

injectionsto
Dr.
consists
a

the

cavity.
a

Peaslee
in

exhibited it
a

modification left
curve

of
or

his

needle, which

giving

right and
so

twist, and
The

having
case a

jointin tne angle.

related

shaft

that

it may

duced be intro-

at almost

any

second

showinghow
The

by Dr. Peaslee emptied itself cyst partially

was a

was

as interesting,

after
not

minute above

ture. punc-

tumor

small

one

and

did

reach

the

patient'sstrengthwas rapidly failinghe to operate. days previous to the operation,he of the hypodermic syringe,a small quantity withdrew, by means of fluid which appeared like that from a cyst of the broad ligament, thus tiated but it coagulated by heat, and was readilydifferenfluid The fix)m that condition. so was limpid that it the flow the into of continued out to peritonealcavity,so cyst Thomas and Dre. Emmet that when the patient was seen by umbilicus,
decided but
as

the

Two

resonance

was

found
the

over

the

tumor

which
was

was

diflicult to
into

d^

termine.

At

operation
in the could

the

cyst
seen

found
oozed

lapsed, partiallycolout

and abdominal
made

lying
by
the

fluid which
be

had

the

cavity,and

stilloozing from

the puncture

hypodermic syringe.
ABORTION OF
RIGHT WTrH A LONG ^DEATH. WIRE
"

ATTEMPTED

OBIMINAL

^PENETRATION

LUNO

Dr.
he
a was

Thomas

related
see a

the
woman,

following case
the wife
two

:
a

A
man

short

time

ago,
to
oe

called to

of

claiming
as

physician.She
another

had

had each

children,and
to
a

she

had
never

fered sufto

greatlyduring
have

she gestation,

determined

child.

Owing

deferred

menstruation, she

104

New
herself

York
six Veeks she

Oh%Ut/incal

Society.
;

believed
former
fitrument

preOTant

and, acting npon

her

her
an

determination,
witli which
to
room

appealedto
a

husband upon
into

for

in; he

acceded
to

her she

an procure and request, gave her

to

abortion wire.

herself

her

passed

one

end

of the wire
until

Having the vagina,and

wire
was

retired

then

pushed upward steadily

nn^er

the whole

within

the passage ; with her the wire high up until husband and
was was

the lower end, she followed upon from her reach ; her it suddenly escaped

then the

called

in, who
woman, Thomas

made

fruitless

efforts to reach Dr. Thomas the

plaining com-

extract

instrument. the

The

next

morning
whom
her

requested to see foregoing history.

of acute
was

from found

he
in

obtained

Dr.

bed,
a

and

pain

in the

righthypochondriac
rise
to

region,which

greatlyaggravated on would She give no

as was a

to attempting

sitting ture. posto

definite

in")rmation
a

in

regard
that Thomas
to

the
was

length of the "wire,but

stated,in
an

general way,
At

it

perhapsas long
vea

knittingneedle.
either in

first Dr.
woman

lie be-

that
some

this

attempt of the
criminal
to

through
an

manipulation
;
or

her investigating

case,

to

get him, produce

abortion

else,that
now

attempt
the

had

already been

made

and
On

they
uterus

sought
the

throw he

responsibility upon
an

him.
sound

examination, however,

found

left of the

through

pelvic roof
by the
ana

search a ; after diligent through the opening found,

opening at the large enough to pass was a sound passed finger,

around in every direc*

swept

tion without
that it had made the wire

encountering
had and
not

been

Believing any foreign obstruction. lost in the peritonealcavity,but that

Dr. floor,

escaped
about

fallen to the
but room, attracted base of the

T. had

careful

search

the

without

success.

The
;

symptoms

complained right side,at

was pleuritis

of

now

doctor's attention

pain

in

the

the

the introduction
to

rise

to the

where local a lung posteriorly, discovered began immediately after ; this pam of the wire, and was^ augmented on attempting The coincidence was sitting posture. certainly

the

and suggestive,

Dr. Tnomas
of the
a

was

decided

in

his conviction
was

that Dr.
a

"he wire
in his

had

penetrated
view
to

to the

lung.

So

confident

T.

reading
with
were

case,

that,two

days after,he

called

sultation con-

somewhat
so

perform gastrotomy ; but, as the symptoms and the the of objection mitigated, tient's padetermined
to

friends Dr.
Thomas

strong, he
left tne of

defer

the

operation.

now

city to spend
Dr. Chas.
the
seen

the

holidays, placing the

with instructions time
rant war-

patientunder the care to perform gastrotomy

such
a

S.
the

Ward,
next

should When

symptoms

at any

procedure.
of the

day by
well
as

Dr.
a

Ward,
marked

pneumonia

rightlower

lobe

existed,as

PhilcLdeljpMa Ohstet/i'ical Society.

exteDBion

105

of
now

the

which pleuritis,
110
to

Boon

became her the

general.

Her

pulse
xrom

was

from

120,

and

temperature
introduction

ranged
of the

102"

to 104".

Sixteen

days

after

of coughing,she suddenly expectorated wire, during a paroxysm the following day she died. about on a teacnpful of pus, and derness, tenno tympanites, abdominal During all this time, there was of peritonitis other or togetherwith symptoms ; this, the and pulmonary pleural trouble, prevented Dr. very grave An made Ward from resorting to gastrotomy. autopsy was after death, discovering the situation of the wire, twelve hours follows : it was for the most to the peritoneum, as part posterior toneum having, after piercingthe pelvicroof,passed through the perithe left where lower the sacro-iliac synchrondrosis, at end found was resting; the wire then ran up, posteriorto the the spine, and the peritoentered across peritoneum, obliquely neal diately cavity on a level with the edge of the liver ; then immepassing again posterior to the peritoneum, it passed

through
inches

the

diaphragm
the base

and the

into
to

of
wire

penetrated for the right lung, where

seventeen

distance
an a

of two
was

abscess

found
in

exist.

The

measured

and

half inches

length.

TRANSACTIONS

OF

THE

PHIA PHILADEL-

OBSTETRICAL

SOCIETY.

Reported

by

JAMES

V.

INGHAM,

M.D.,

Secretary.

Stated

Meeting,

Jan.

3, 1873.

Dr, Chair.

Wm.

Goodell,

Presd^ent,

in

the

Dr.

Wm.

G. Porter
continued

exhibited

an

aborted

ovum.

tion Menstruawas pelled ex-

had

after

conception, and
second
an ovum

the

embryo

immediately
Dr. W.
F.

after the

menstruation.

expelled in the 4th month of gestation. It presented the peculiarity of apparently having no placenta, although he supposed that tne placenta was afterwards while the woman but was at stool, not was expelled looked the medical cord for attendant. The protruded closely by and membranes the termiabout inch, one through unruptured

Jenks

exhibited

106

Transactions
The of

of

the
smooth
to
a

nated
and

in

pointed extremity.
present
any evidence

membranes

were

did

not

having
of

been

attached

placenta.
Db. of the T.
last two

J. V. Ingham

presented
vnth the

specimen
momer

largefibroid
nve

tumor

rightovary,
;
were

foUovrine month.

history:
of

P., married
bom

aged

29 ; the

children.

The

Up to the birth of the last in comparatively ffood health, but child,5 years ago, she was however from that time her healtli failed. Nothing oefinite, be learned could concerning (owing to a veiy feeble intellect),
at the 7th

condition,except that pains. Two years ago but could only say that
her

she she she

was

miserable
some

and

had

abdominal

had

fresh

pelvic trouble,
This
never

suffered time the

great pain.
menses

entirely left
never

her.

At

this

disappeared

and

July she first noticed a tumor, about the movable the pubis ; it was above size of an orange, appearing but not painful. This she insists entirely disappeared, very with its disappearance her abdomen and rapidlyenlarged. On medical admitted to the the first of November, 1873, she was and 10 days of the wards Philadelphia Hospital for ascites, later she was tapped, and 14 quarts of a clear pale straw colored of a the operation the existence After fluid were evacuated. transferred to the and she was largepelvic tumor was recognized,
returned.

Last

ward

ror

the

Diseases

of Women

and above

came

under

the

care

of Dr.

Ingham.
made
a

After

obtaining the
examination and

careful
median

found
the

he very imperfect history, and a hard non-fluctuating inches entire above the

immovable
in the

tumor

reaching about
It

three

pubes
j)artof

line.

occupied

rightupper

the

The far into the left side. pelvic cavity, and extended but as uterus was appE^rentlysituated anteriorlyto the tumor, not much pain (itwas gave attempt to pass the sound every this could not administer advisable to ansesthetic), deemed an be be positively determined, nor could the cavity of the uterus and two The abdomen measured. lapidly filled up with fiuid, weeks after the first tapping she was again tapped and 10 quarts Ske the firet, It was of fluid obtained. clear,of a pale straw solid almost of 1016. and became had a alkaline, wiifl color, sp. g. tested with when albumen by heat and nitric acid, but when there hours no was for 24 precipitate. 12 allowed to stand days later tapping was again resorted to, but only as a palliative for sne was rapidlysinking from dyspnoea ana exhausmeasure, sion. the
toon

This

time

12

were quai-ts

drawn

off.

After for
a

the few

operation
hours,
but

dyspnoea was relieved and died four days relapsed,

and

she

rallied

later with

many

symptoms

of

peritonitis.

108

Transactions

of the

President, Db. Wm. Goodell, then delivered his annual the following officers the Society elected address,* after which Goodell for 1873 Vice Presidents^ : President^ Dr. Wra. ; Drs. and J. 8. Parry ; Secretary^ Dr. J. V. IngJ. L. Ludlow ham Cheston D. Dr. Dr. W. Murray Curator^ Tredsurer^ ; ; H. F. Jenks Smith, L. D. Harlow, R. P. ; Council^ Drs. A. and J. F. Wilson Harris Cormnittee^ Drs. Wm. ; Pvhlication H. Packard R. G. Curtin. J. and Goodell, W. F. Jenks,
The
Stated

Meeting, C. a.

Feb.

6,

1873.
THE

Dr. Ghaib.
a on see

Wif.

Gk"ODELL,

Pbbbidbnt,

nr

Dr. the 3rd

MoCall
and he
was

exhibited stated
that
to

month, January, 1873,

labor,
was

blightedovum, the evening

Mrs. been
some

apparently in
of

the 14th found The

her

of
in

called she

R., and

in which

condition the

had

for 16 hours.

child sized

presenting by
child it
was

feet. With

a medium difficulty

female

with

placenta and
them.

It is

ing delivered; it was asphyxiated,but, after workfor half an On hour, it breathed. removing the the accompanying with membranes specimen came a bout months three old and apparentlyanother foetus, pressure. The mother had been in excellent of health unusual of this
to

flattened

by

during having

her

and was pregnancy, occurred during that

unconscious time
to

anything
the deatn
a

which

had She be attributed. never embryo can had two term before, having miscarriages
"

carried
one

child

at 6

months, the

other Dr.

at

months. Ingham stated

of Dr. that, through the kindness nation McCall, he had had an opportunity of making a careful examiIt was of this very interestingspecimen. undoubtedly the outlines of the face and flattened as foetus, a body were also visible it both and trace to out was arms distinctly easy ; He the liberty hands the legs, far as the knees. had taken and as of the meeting, the product of announcing it in the notices as burgh, of a twin conception, Duncan, of Edinalthough l)r.J. Matthews
J. V.
asserts

that

for before
membrana

that

up time
vera or a

to the

3rd

month

can superfoetation

occur,

the
are

membrana
not

decidua

reflexa

and

the

decidua
an

of either He

ovule
been
a

in close contact, and the passage is a spermatozoon possibility. that in

(Dr. Ingham)
had

believed

this

case

the

life of

the

embryo Simpson, by
retained Dr.
a. until

destroyed, perhaps, as of deficiency the liquor amnii,

believed
that it
was

is stated and

by Sir
it had

J. T. been

term.

H.

Smpth

the

product of
thu Journal.

twin

Pub.

in No.

IV.,

VoL

V., Feb., 1873,

of

Philadelphia
conception.
of
the
one

Obstetrical
several

Society.
in which

109

He

had
had

seen

cases

the

ment develop-

foetus
on

been

going together.
Del

other

to full

generallyby hemorrhi^e, development, the two being expelled

seen a

arrested

I. L. Lm)L0w

had
been

also

similar
term

weeks

embryo had

expelledat
Dr. Smith

a five case, in which with a fullydeveloped

child. Dfi. GooDELL

his
two
cases were

asked

whether

the

twins

in

each

of

of the

same

sex?

Db.
cases

Smith
were

replied that
same sex.

he

believed
he

that the
asked

twins

in

both

of the

Dr.
because

Goodbll

remarked

that
a

had

this

question,
between those also
a

Hyrtl had
sexes.

discovered of That
sex.

vascular

communication
none

the of

placentaeof
aifferent from
those the

twins

the

same

this

sex, but anastomosis

one

between

holds

good
is

in

of triplets
sex

same

If,however,
two

of these be

of

ent differ-

its

vessels will its placental fellows, the other will

anastomose.
cases

independent,
It had
struck papyraceus,
on

while

of of

him

(Dr. G.)

that

possibly in these

of foetus he

the retention

the the

blighted
twins
were

ovum

might
same

explained
dead

the

supposition that
a

of the

the supply of blood reached but to just enough prevent decomposition,

sex, and placentaof the

not

fore, that,therefoetus

enoughto
in

mummification. work
on

He

further

remarked

that

that

prevent classical

by Caspar, the author, as it seemed hit upon the true to him, explanation of those stock cases of fullydeveloped and literature in obstetrical living children the one, three, four months after the other. bom tends or Caspar conmedicine had that these
were

forensic

not

^ases

of
were

oetation superf both childi*en

but

of

fraud.

For;
the

in

none

of these
mother.

instances the

delivered
was

by

reportingphysician;but
the
a

birth of the first child

only

alleged by
that either

It was,

therefore,reasonable

to

suppose

ashamed of her sterility, one or designing woman, had, during a feigned pregnancy, unwittingly become pregnant, months and few after been delivered a had, therefore, really the simulated On

spurious infant. motion of Db. Jenks this specimen was referred of three, consisting and of Drs. Jenks, McCall
birth and carefully

of the

to

mittee com-

Ligham, eration degen-

to examine

report
exhibited

at

the

next

meeting.
of tubercular

Db. W.

F. Jenks
mucous

than

specimens

of the

membrane'of
one

fibroid of the
He called
must

uterus, and
attention
to

the uterus, of snb-peritonial of dropsy of the Fallopiantubes. condition

a

the

in the

latter

which

prove,

whenever

it occurs,

complete bar

to

specimen sterility,

viz.,the obstruction

of

the

Fallopiantubes, and

stated that he

110

Transactions
milder

of

the

believed

in catarrh of the tubes, to form, originating of be a common cause sterility. stated that it is a well known fact that prostiDr. J. L. Ludlow tutes Is their seldom become not sterility owing to pregnant. of the tubes,resultmg from catarrh continual sexual excitement? said that pelvicperitonitis Dr. J. S. Parry was very common much it was in prostitutesbut believed not to sexual owing so
a

excitement

as

to the

diseases called

incident

to their

calling.
of

Dr.

W.

H. Jenks

attention due sound

to

to the

uselessness He

attenaptseen

ing

to treat

when sterility

this

cause.

had

Dr.
least

Duncan it had The

pass the uterine

into

the

Fallopian tubes, at
direction. from
to the

disappeared several
read
to
a

inches the

in that

L.
for

Secretarythen Hodge, in answer

the purpose

followingpaper,
addressed
on cases

circular

Hugh profession,
craniotomy.
fact that it
:

Dr.

of
Dr.

collectingstatistics
additional but
a

of the

This
was

paper written

possesses

interest, from
short time

by
:

Hodge
desire

before

his death

Gentlemen

I have
a

received
to

your

circular of the 10th

statistics did
not
as

of October,

indicating
cases am

collect

to

craniotomy

where
not
more

the

conjugate diameter

exceed

2^

inches.

able than
to
me.

to further

of

your object in this point,as, in a have to this extent fifty years, deformities

practice
not
curred oc-

is that of only case with which I have been connected well Mrs. K., the details of which known to the profession, are and more as they have been published in the journals, minutely Prof. Gibson his work in on Surgery ; by Dr. Meigs ana by works in Obstetrics. our on respective myself

The

At

present
was pelvis

I may

say

that
at

the

conjugate

diameter

of

Mrs.

inches,and that her physicians, Drs. Geo. Fox and Chas. Meigs, proposed the Caesarean section, after a consultation with but and Profs. James Dewees, and also with Dr. Physick, craniotomy was determined in acon cordance with the wishes of the patient. Delivery was effected and of the crotchet and the use by Dr. Meigs, by perforation with She again became safetyto the mother. craniotomy forceps, and delivered Dr. was again safely by Meigs pregnant, after perforation by his craniotomy forceps. When pregnant third time she consulted Drs. Beatty and Nancrede, who, insisting a
estimated
two

K.'s

upon executed

the

propriety of hysterotomy.Prof.
the
most

Gibson
The

fully skil-

it with

favorable
the and

results.

mother

recovered
In her

without fourth Dr.

and difficulty,

child,a

girl,survived.
again
sulted, con-

deliveryDi-s. Fox
Gibson

Meigs
success

were

and male child

operated. being preserved. I have

The

was

a perfect,

since

very

frequently

Philddelphia
heard
of this

Ohatet/rical

Society.

Ill

children

the is,I believe,still living, family. The mother become been have and healthy, have been married
said
to have

parents.
Mrs. life.
As

R.

was

been

the

subjectof
no

rickets in
with

early
the of
commended re-

regards yonr
It

7th
an

question
instrument

I have

experience
to

cranioclast.

is
over

similar

the osteotomist
As

Dr.

Davis,
in

and

which
Y. the

it has

several
its also
was

advantages.
as a

only

by breaking

Sir Jas. up modus

Simpson,
but
"

operation consisted
tractor.
to

not

point etc. crotchet,craniotomy forceps,

of view

its

"

cranium, operandi

In

this

similar

that

of

the

the head, more by each one less diminished in size,was or forcibly dragged through the all further compression was contracted Hence pelvic passages. effected,not by the instruments employed, but by the walls of compression thus of the pelvis ; the lamentable consequences made well known. contusions of uterus, are Wounds, lacerations, trations, followed by bloody infilvagina and bladder and other tissues, too often with a inflammation, abscesses,gangrene, etc., the real dangers of craniotomy ; hence fatal result, constitute the important principle of directlyand compressing efficiently the cranium stetric obof the great improvements of modem is one The risk of injury to the mother's tissues being science. nution inverselyto the degree of compression, the greater the dimi;

of

the

head

the

less

pressure

upon

the

walls

of

the

pehds.
neveu, of his 1832.

by

means

ought, therefore,to be gratefulto M. Baudelocque for first effectiially by means carrying out this principle in described bris^ tete," as or by him cephalotribe, In this country I had principle operated upon the same of the forceps, nium, by which, after perforatingthe cra"We
"

I reduced

its transverse

diameter

to

2^ inches,and
In
a

thus
my

effected

deliveryin pelves moderately contracted.

Mr.

1843

instrument-maker, (compressor cranii)under

even

Korer, manufactured
my
ever

cephalotribe
consequences
cases.

directions. resulted

No

bad of my

of

minor
I may,

degree
on some

in any

Perhaps
a

future
on

few

observations that form

as a

the

ciety occasion, present to your Soof cephalotripsy, great value

would render it

and
most

upon

of the

which cephalotribe
and

useful

compressor,

also

as

tractor.

EespectfuUy

yours, Hugh L.

Hodge,
.

901

Walnut

St.

Nov. To

6th, 1872.
the PhUa. Obstetrical

Society.

112

Byrne:

Clinical

Notes

on

ike

CLINICAL

NOTES

ON UTERINE

THE

ELECTRIC SURGERY.

CAUTERY

IN

Bt BCBOBOH-XX-CHZEr
TO UTJUUVX IT.

J.

BYBNB,
FOB

1I.D.,
OW

MAStS SUBOUtT

HO0PXTAL TO LONG

DISSASES MEDICAL

WOMXX; GOLUtOK,

C2LIKXCAL
KTC.

nU"IVMOB

OV

ISLAND

(OonOnuedfrompaffe

736s Vol. V.)

Ca8S Table age

is

V.

"

This for of

case

having already
little further who been

been

I.)calls

but

notice.

a widow, thirty-one,

consulted

in consequence she had cancer

same

having
a no

informed
which she

(No. 5, lady, whose Dr. J. Marion Sims, by her physician that

to

referred The

of the
little

womb,
reason

did

not

believe, at
the

the her

time had
;

giving as
or

for her
or

opinion inquiry

fact

of
in

having
region
there
was

pain
that

uncomfortable
full

feeling
she

that struation Men-

and,
no

moreover,

after

felt satisfied

to such a disease. hereditary predisposition had and she had had no always been regular, menstrual intervals she the had of but during some watery discharge of an offensive odor.

rhage, hemorlate
ticed no-

Dr.
the

Sims

recognized a large
circumference of

cauliflower

maiss

springingfrom

die cervix, and spreading out so as its advised to occupy a great part of tlie vaginal cavity. He to operate requested me by galvano-cautery, removal, and In this operation the 18th of June, 1871. the which I did on of the tumor neck embi'aced was by the wire loop and its removal
whole
thus
too

effected

; but

in

addition

to

the
was

mistake also

of another

leaving
error

much

behind,

as on

before
account

stated,there
of The
on

committed, which ought not to be

was

the

clinical

lesson

it teaches in

overlooked. used

instrument

shown
the

Fig. 2

then I the
was

new,
not

and

that
to

occasion

for

first

time, so
The

that

accustomed

this

improved
as were

means screw

of

ing contract-

loop, and
was was

miscalculated that
no

to

tlie
too

motion.

consequence though there

the loss

tissues of

rapidly severed, and

at

blood took
use

whatever

the

time,

an

alarming secondary hemorrhage after the operation,requiringtlie

No.
4

place

about

hours thirty-six in operating, This

was a

is

case

where has and

I assisted been

D.

of tampon. L. Bmwn James

and

which case, the

reported elsewhere.
termination

promising
to

its fatal of
on

had

nothing whatever

do. with

merits

the the

mainly by imprudence

operation; being caused cumstances part of the patient and other cirof her

death

beyond

the

control

medical

adviser.

Electric
The
the

Cautery
ease on

in

Uterine parts of
occasions

Surgei'y.
the

113

patient,in whose
were

right labium
(Nos.
5, 11
and
was

and

perinaeum
is

removed
a

three

12),
sorted re-

wife
to

of

physician in
instance

tliis

city.
the and

The

caiiteiT

in this
a

merely for
some measure

portions of

large suppurating
in

oi purpose offensive mass,

excising

hoping

thereby to nioaifyher
The
extent
were

to contribute

to her

comfort, or rather
and
case

suffering.* the to which

was

rectum,
as

vamna,

neighboring
an

involved such to render the utterly Earts and opeless one, consequentlynothing beyond palliativeeffects could Case be looked for from the 11th

any operative proceedings.

of last

February I was requested by Dr. J. Marion in the case Sims to operate by galvano-cautery of a ladywhose is as follows : Mrs. aged fifty* history of healthy members her father's but several oi on side, ancestiy and her mother's family have died from pulmonary affections,
"

VI.

On

one,
at

an

aunt, from
and
has

cancer

of breast.

Menstruation
to

commenced Has
gust Auin

14

had which

seven

always been regularup children,and a premature

February, 1871.

confinement

1856, from
she had

she the

recovered

speedily. From
were

February, 1871, until

in the

catamenia

absent, but
later.
a

latter month

profuse metrorrhagia
On

lastingfor several
tumor

days,and

returning
a

more

copiously three weeks

exaaunation
was

per

vaginam,

about and

the size of

hen's

egg the

found

springing from

the

cervix

projectinginto

vagina ; canal of uterus of normal depth ; body not hypei^ removed on was September trophied. This tumor by ecraseur 23, 1871, and presented under the microscope the characteristic prove The of epithelial to imcancer. patient seemed appearances in some respects until about the first of January, 1872,
when lost

hemorrhage returned throughout that whole

Sims
saw

and month. 10th

of largequantities of

blood

were

Dr.

her

on

the

February and
the

discovered
and

large

cauliflower

tumor

springing from
half ot the

cervix

pletely com-

vagina. The following Dr. S. for its removal, and day, f'ebruaiy 11th, was appointed having accidentally sprainea his ankle while steppingout of his The her and to see requested me carriage, operate for him.

filling up

the

upper

found t)atient of blood and

was 088

to

be

in

very
to
as so

exhausted remarkable
ansesthetic.

condition
a

from that

emaciated

degree

grave
or

doubts

were

entertained

to the

propriety of operating

riskingthe
*

administration

of any

Dr.

Oeo. with

M.

Beard effecU

has

also operated

previously

in this

case

by eleotroly*

but "is,

Utile

114

Bybne:
such of

Clinical

Notes

on

the
seemed the

In

state

however, things,
and ether with with in the

some

interference

urgently demanded,

having

been

administered,
manner :
"

proceeded operation was The platina loop was

embrace

following
the

considerable

made difficulty
when
or so no

to

the upper

of drcuTriference

cervix^and
; little

modr
traction con-

immersed was eratelytightened the battery etfected for a few of the loop being tissues superficial

seconds,
be
to have

that the

of
the

the

part
was

to

be

cut

might

thoroughly
entered

the supposed inch tissues a quarter of an or thereabouts, firm and steady of a vulsellum,* and ti-action was made the tumor on by means its connections tightening of by a further very slowly severed the tumor from whicii this the surface the loop. By manoeuvre and removed had been presented a deeply concave appearance, The uterine there was ured no cavity meashemorrhage whatever. No of the wound. inch from the bottom about one cal topimade. applicationwas I had no this patient resided As miles from the city, some opof of her but the one subsequent progress ; portimity observing

cauterized.

When

wire

assisted who Sentlemen he called when ays after,

at

the
to

operationf informed
see

me

some

the end very precarious. Towards visit her neighborhood, I called to about and

her, that her condition was of May, having occasion to her and found see her, going
since
ceived re-

The New
"

affairs. superintend her household following reply to a note of inquiry has been able
to

from York Dear

:
"

her

attending physician,Dr.
: a

Fiirgang, of
reauest

East have

Doctor what
the

In

accordance

given

Mrs.
or

careful very is left of them, seem

your examination,
to be

with

lier

gans, pelvic or-

in
or

condition. lead which covered

no

There

is

nothing
a

to

the

touch

perfectlyhealthy sightthat would

The

to

suspicion of
tumor
was

return

of her
a

disease.

part

from

the

taken

is

little

puckered, but
membrane,
and the any

soft and
there is

with

mucous healthy-looking on

tenderness Her

pressure

there

or

in

of

adjoining

parts.
This

gaining in
case

she sleeps well,and is'rapidly appetite is excellent, strength and flesh." calls for
"

no

further
what

comment. to
me

Case
cancer

VII. of

This

was

appeared
my

to

be

epithelial
Nott, who

the

clitoris, though

friend

Dr.

J. C.

Traction

by the canteiy
the

ayoided, and beginning to the t Dr. NichoL

instrmnent end of the

should, in aU kept steady and in the operation.

instminent

such
same

cctses^ be

carefoUj
from the

position

116

Byrios-

Clinical

Notes

on

the
health

rightof OB of ffranular appearance. but complains of shooting pains in lower

to

General abdomen.*

good,

September

30th. without

Third
trouble.

three days, has menstruation, lasting

passed over
October

12th.

Considerable
ten

pain
no

and

occasional slight

flow

during
Since

the

past
no

days

uiitil yesterday, but

and

vaginal

tion examina-

shows

ulceration above

induration
is less

perceptible.
the

the

report (October 12th)

that her
case a

well, but
could it
as a

it is evident

patient is doing than promising one

to

be

hoped for, and

side of the
cachectic
so no me

hence

I have

thought proper

present

darker has
to

picture.

She

looked
in the

much
or

street

two

however, but on the contrary when seeing her stronger and healthier, I hardly recognized three weeks ago, that
appearance,

her.
much

Nevertheless
interest IX
" "

I look
some

forward
Epithelioma

to

her

future

historywith
the

and

little

misgivings.
Involving had
seven seven

Case Cervix.

^Vegetating
,

whole

Mrs.
last been

iniscarriages ; the
has

always

aged 45, living child regular up

the

has

children
old. ago,

and

two

to

years six months less and On very

on

ation Menstruwhen the

now

flow

became

excessive, and
of the cervix

interval continual.
was

less,until
much its

(April
and

18th, 1872), it is almost

tion digitalexamina-

the whole

uteri

found

enlarged
presenting

greatlyindurated, but soft and spongy surface, tender to pressure, and bleediuff on The not enlarged and body of the organ was
intact. When

the

the

touch. slightest vaginal walls be

brought

into

view

the like cervix

os

was

observed

to

rounded sur-

the than the

by what appeared unstripped parts of the

normal. The
case was

luxuriant
were

though granulations,
in color
one

somewhat of

diagnosed as
was

paler epithelioma in
St.

sprouting stage, and she early Hospital for operation May ith.
and

admitted

into

Mary's
method

The
the

patient was
cautery, but
of

anaesthetized
the

the entire

cervix
so

removed

by

other cases already entirelysimilar to There here is for. called was detailed, no description there any secondary blood lost during the operation,nor no was carbolic and hemorrhage. Vaginal bathing with tepid water acid was the third day after operation and commenced tinued conon after for two weeks the operation a specdays ulum ; sixteen the the and surface from which examination was made,

pursued being

that

further

The

increased of the

depth of
ezcavation

the

nteras,

as

noticed

at

this
and

to

filling up
case.

by heaUhy grantdation,

examination, is due is not peculiar to

this

ElecPric
had
been

Catvtery in
excised
and the
was

Utei*ine
almost

8u/rgery.

117

disease

healthymembrane, her family,was see

not

entirelycovered with patient feelingwell and anxious to

to leave

permitted
from^
very has

the institution.

She

has

since

been No.

heara

Case of
and

X., being

similar
a

to

the

above, offers
the say

no

points
sion, occa-

specialinterest

to warrant

full

reporton
not

present

sufficient time
than that

not

yet elapsed to
less

further results,
of the any Case No. noticed resorted the XI.

they are

anything promising than

of
in

preceding

cases.

patient whose condition has been (No. 4), and this second operation,like the former, was such parts of of taking away to merely for the. purpose
is that of the
as cases were

suppurating excrescences With regard to the eleven

operative measures

could
of

be

safelyspared.
in

carcinoma resorted the

which, like
the purpose this paper length. In

the above,
of will
seven

to for

affording temporary
not

relief
the

permit of
this
to

their

merely, being referred

disease
to

limits of
to at any

of
uterus

latter class
such
a

had

attacked obliterate

both
the

vagina
and
the did

and

degree as
;

almost
no

one,

utterly degenerate the other

removal add
and destriiction of

yet in
in
a

singleinstance
tissues
as

such

diseased

could

be

safelyreached
to

fail to relieve
of these

the comfort

remarkable very afflicted sufferere.

to me,

degree,and

This actual

singlestatement, it observation, ought

seems

to

supported as it is by question the satisfy those who

such utilityof any operation surely no principleof conservative in measures,

even

hopeless
surgery

conditions.

It

is

to

ignore palliative

where life of

among
many robbed away
a

the

numerous

valuable of much

admittedly incurable ; and yet, how of this terrible destroyer, victims and that might have been safely prolonged
disease is its wretchedness has been

allowed

to

ebb

in loathsome

torment
verv

It is true, until
cancers

has of the but

been
means

want

am

in uterine recently,non-interference justinableand eminently proper, owing to a liorated, whereby such ailments could be safelyameby past experience that this fullyconvinced

want

no

longer exists.
be,
I doubt still

However
the wisdom

the relief therefore, transitory,

of those who in

may

often

the face

of

facts would

persist in thinking that their whole duty had the pathology been performed by quoting a hackneyed axiom in constitution the patient's "When which of these diseases, says : ably invariif extirpated, has really become infected,these diseases, to is affected by them the person who conduct and return
inevitable
destruction."*
*

MiiUer

on

Ganoer,

etc

London, 1840, page

28.

118

Bykne:
be

Clinical

Notes

on

the

stances, inhowever, that in very many forgotten, life of be for month but one prolongationof may the highest consequence to a family about to be deprived of a influence and watchful mother's though that mother care, even invalid. be a helpless Furthermore, in order to the to determine as proprietyof
not

It should

the

there are, or ought to operations for tne relief of such patients, of but two consideration, namely : Have be, questions worthy out withthe means be undertaken we whereby such a course may risk to life, evils ? And in any way or adding to existing for secondly.Have we hoping good grounds, i, e.^ clinical data, ameliorate ? the condition sufferer's to thereby Apropos of
these

considerations XII.
and
"

I submit
of

the

following case
and

:
"

Case

Caecinoma
"

Uterus
,

Vagina.
has time

tion Operatwo

Palliative.
month

widow, aged 30, always enjoyed perfect health until some

last. About in this
excess

Mrs.

dren, chilin the

of

January regular, appeared

was

time and

menstruation, previously
lasted
over

great
a

eight
two
on

days.
weeks,
the
whitish

This
when

latter

by copious metrorrhagia again appeared and for ten occasion continued days.
in the

followed

watery dischargefor
A

hemorrhage
watery
as

and

discharge as
in in
a

previous interval
after She
its
one a

continued

the first week

and almost

March, when, seized hotel,she was

hard

day's work
remember

to up chambermaid

with

violent

expulsive pains,
how for

fatal

hemorrhage.
then, but
for On
a

cannot

long
mission ad-

the

flooding lasted
and
was

on

ceasing she
of the

applied
York

received

into few

New

hospitals,

where

she done

remained for her.

weeks

without

at
was

the

College of
carcinoma

Friday, the 10th of Physicians and Surgeons in

of the
at Thomas, who uterus, involving

having had anything she May, applied

23d
once

street, and
discovered walls
case

examined

by Professor

extensive

the

vaginal
her these

and anteriorly
as

and posteriorly, it

accordinglypronounced
certainly
admission from
was.

utterlyhopeless,which
sue

Under St. Chas.

see

cumstances cir-

applied for
with
a

to

Mary's Hospital,
S.
me,

May
stated I

13th, 1872,
that be he able

letter the

Dr.

recommended
to

patient to
towards

in

Ward, hopes

who that

might
When

something by galvano-cautery.
admitted,
she her
to

do

relievingher temporarily
ceased

said

she had
and of

not

flowing for
countenance

eral sev-

days past, and fearful testimony

unable
to
move

wretched

bloodless

bore she
was

the

truth

this statement,

for it
was

one

step

without

support,

and

found

necessary safelyremoved

to administer to bed.

stimulants

freelybefore

she

could

be

Electric By

Cautery
I

in

Uterine
the

Surgery.

119

preciselyaB the loss of blood was as frightful, then could done the be nothing beyond tamponing vagina. This succeeded in arresting the hemorrhage its but on being ; removed of the followingday it was evident the mat something
condition

Dr.

digital examination Ward had stated,and

found

kind

would This

a^ain be
latter
was

necessary, allowed

and

fresh

tampon

was

plied. ap-

to remain

in 48

removal
I decided

not
to

being
try
what

followed
could be

return by any done by the cautery

hours, and its of hemorrhage,

at

the

liest ear-

possible moment. The operation which

be described with
was as a

took
:

place on
upper

Saturday,May 18th, may

half of the
than

follows

The

vagina being
on

'

packed
it sides,
so

mass largeencephaloid-looking

adherent

aU

a portion impossible to loop more all could be in this that taken a much removing way The soft brain-like ter characlarger proportion yet remained. of the outgrowth preventing the heated wire from as acting therefore and it blood was a was haemostatic,considemblc lost, the determined to complete operation as quickly as possible. This done was by grasping the more projecting parts of the mass forcibly tearing them by a strong polypus forceps ana crescence expiece by piece,until the greater part of the spongy away twisted the uterine the off from was cavity as well as The was vagina. cautery-knife employed to trim ofP and scoop oughly thorwhatever out remained, and the dome-shaped cauterizer It was now applied to the whole subjacent surface. ty that the hemorrhage had found ceased, but as a securientirely the uterine carefullytamponed and cavity and vagina were

found

of it,

that after

tne

patientput to bed. Iler for daily record

sufficient
was

the

succeeding
to

two

weeks
minute

contains details.
no

nothing of
The

importancie
48 hours

warrant

tampon
out

removed

after the

and operation,
was

hemorrhage
washed and No

whatever
twice

appearing,
a

the

vagina

ordered

to

be

daily with
other
many

mixture

of carbolic trouble

acid, glycerine,
followed this

water.

peritonealor
very three

inflammatory
of
she her former

operation,and
were symptoms |ind in

entirelyrelieved.
weeks
was

Her

pains and distressing turned, appetite and sleep reto sit up

strong enough

and

walk

through

the ward. of the cautery continued ing, serous-lookslight,

The
but June and

purulent dischargefollowingthe use for 15 days, after which appeared

yet
inodorous entii-ely drain.

examined carefully 15th, the parts operated upon were hard to the and somewhat found to be smooth, but uneven

120

Bybne:
far kind

VUnieal
the eye could

Notes

on

the

touch, but,
with
no some

as

as

reach, seemed
and

to be

covered

of
A

membrane,

manipulation provoked

in observed has been steady improvement her appearance from day to day, and now comparatively feeling she and her friends visit anxious was to permitted being strong

hemorrhage.

to

leave

the

hospital.
her which be

regret

to

add

that

have
be

not

been

able to trace

whereabouts the

since.

Cases,
a

of

preceding
I

one

may

considered

type, might also

related, had
remarks. of the the

not

already far
it proper

exceeded
to

the

proposed limits of my however, that in three out loid cancer operated upon,
the

I deem
ten
cases

state,

of

pelvicencepha-

included disease, though limited, far the most were unsatisfactory by of Dr. of Sims, I operated case, a patient twice, and though in the second effort he. Dr. S.,scooped out from the uterine cavity by largequantitiesof the diseased mass

uterus, and this class. In one

whole

these

means

applicationof the ed cautery, and despite a very complete charring of all the denudsurfaces within were reach, the bleeding excrescences ly rapidThis another who in resides State, lady, though reproduced. had made been not no improved by what done, was certainly
of

his currette, preparatory

to

the

worse,

and

in accordance what

with

advice

returned in arise

to her

home. cases,
use

from Altogether,
I believe but

I have

observed
can

these
from

three
the

little if any

advantage
of

of

the
when with

electric this the

cautery
has has

organ

cervix

body of the uterus, of the malady, and been the starting-point already been destroyed by the disease in its
in carcinoma the which what I shall

upward
The fibroid
Case

march.
next
or case

to

refer

is

one

of
be

interstitial

perhaps
XIII.
"

might

more

properly
of the
"

designated
uterus.
,

diffuse fibrous

of the hyperplasia

righthalf

Interstitial
on

Fibroid. of
12 she months seemed

Miss

sought
which time her

advice had

account

menorrhagia, in
to

aged 22, March, 1869,

At this in

existed

for

about

previously.
be noticed but
no

friends
that
a

stated hard
side

that

increasing
towards examination this

and size, lower

was

swelling had

been

the

and made

until

of her abdomen, right August of the same year.

found was lar^ globular and firm tumor right iliac fossa, and a digitalexamination the
same
OS

period a occupying the covered per vaginam dis"

At

uteri

dilated

to

its utmost

capacity
the

and

this

body presenting.

The

margin
of

of

traceable the

only
tumor.

to
or

the

extent

one-half
continuous

cervix was open its circumference, with the and uterine intra-

remaining

right half being Menorrhagia was

very

profuse,

each

"^Iectric

Cautery
was

in

Uterine

Surgery.
and

121

catamenial

period
character.

likened

to

severe

prolonged
an

labor, being attended

draw but down the
ttimor

with In
was

violent made
was

expulsive pains of
an

termitten into

September, 1869,
with
snch
as a

attempt
of the

view

removing
effort

it, impracticable. In December,

Bultation
a

its BCBsile

character

to

render

with
recurrent

removal. increase extended

Up
in from down

Barker the case in oonsaw 1869, Professor her Dr. attending physician, nosed Sehapps, diagfor its ana fibroid, discoaraged any attempts continued to Kovember, to 1871, the tumor

size

upward
two

as

well above

as

within

the

vagina,

and

inches the up
was

and
firm

to

the

right of
was

the
now

nmbiliciis

to

vnlva. with

The
this

pelvic cavity
and the
one

completely
mass;
use

filled

irregularly-lobulated
the

defecation of
a

seriously impeded,
called for
to

frequent
much

catheter
be

was

empty
so

bladder, which
and
as

conld

only
the

entered

by

a was

long
not

flexible

with

difficulty. Menhorrhagia
but carred
most

excessive

formerly,
to
now

violent with

expulsive pains
catamenial

already referred
was

still in loss

rea

each

period. She
from
in her

deplorablecondition
and
at

blood,

this

period

long sufferingand her historyI saw

of
the

for

Pig. 11.

first time

at

the her

patient
sound

on

could

be

Sehapps. By placing the the side and drawing bacK perineeum, a plainly passed into the uterine cavity, and
request

of

Dr.

122

Byrne:

Clinical
abdominal
the

Notes
above

on

the
the
ten

felt the

through
umbilicus,

the and

wall
and

and
at to

to

left

c"f

depth
firm

measured elastic
were

least the

inches.

The
numerous on

was vaginal mass blood-vessels large-sized

touch, and

observed

attempt now by galvano-cautery was proposed and T^he operation, which took place November
to
remove

its surface.

An

this

ramifying intra-vaginal part

consented
to.

be

described
in

as

follows

strong

semi-circular eye made be

15, 1871, may needle, seven

an

inches

length exclusive

point, and
tumor

carrying a as posteriorly

handle, with heavy thread, was

of

f of
to

inch

from

penetrate the
and the
was

high
the made

up

as

could be

reached,

until pushed forward arch, provision being A

point could

felt behind

pubic

slight additional
means

force

from to protect the urethra reach the enabled to me and the

injury.
thread

by
one

of of

tenaculum,
was

needle
down

was

end

the thread

brought

platina wire being attached to the cord, was the place of the latter. and made to take

withdrawn, while anteriorly. A strong drawn next through

At tliis stage
was some now

trifling hemorrhage
made least and
to

was

observed.

A slow

connection

the

battery,and

by

very
was

traction, occupying

at

fifteen minutes, the tumor

thus divided

of blood.

The
made but

split down longitudinally, and without loss into two nearly equal halves, left half of the mass was now moval looped, and its rewith
to

effected
was

next

An comparatively little difficulty. dispose of the remaining portion by the

effort
same

found to be was repeated trials this method and of its more impracticable,principallyon account irregular had conical Recourse the to was now shape. cautery-knife, the whole and all irregular with which removed was piecemeal, the pelvic cavity being trimmed projections within on, the

process,

after

operation, which
The

lasted- two

hours

and

quarter,
the

was

thus

pleted. com-

patient's recovery
unattended

from

the effects of

operation was

rapid, and
or was

irritative

fever.
; her

complete
no

inflammatory symptoms slightest the more distressing symptoms appetiteand strengthrapidly retumea, and
by
Relief
from
at

the

though
of

attempt
the tumor

spontaneous

enucleation
occurrence

ot

the

upper

ment seg-

took

place, an
continued

yet
of

her

general health
six months her

to
one

faintly hoped for, for and a period improve,

comparative comfort.
Dr. the

over

life

was

of

In
me,

the that

early part of June, however.

Schapps
tumor

informed
not

though
and
the

the

abdominal

part

of had

had
extent

parently ap-

increased,the severity.

pelvic growth

to some

peared, reapmuch

menstrual

expulsivepains

returned

with

124

Byrne:

Olinical

Notes

on

the
it

terruption in
the firm

its circulation

while

in consistence

presented

character

of

an

ordinary fibroid,
THE

OPERATION.

made patient being ansesthetized, powerful traction was the while below, supra-pelvic steady pressure was kept up on the it round efforts of after continued but timior was extremity ; inch beyond the pothan more one impossible to bring it down sition it had tions already attained, owing in part to its connecof its largerdimensions account on within, but principally A above. of double strong now whip-cord was ligature from passed
behind outside time

The

forward

immediately

bein^
usual

all

the

through tie centre of the tumor, the perineal commissure, steady traction ligated in the kept up, and the mass
insure As

manner,

the

object being to principal

full
the

trol con-

of

the

stump
of

during
the
a

and

after
forbade

excision.
the in
use

lar vascu-

appearance sized platina

parts

of any

ordinaryof No.
16

wire,
was

piece
fastened of

six

inches

length

(Stubb's gau^)
two

conducting
itself to whUe
;

cords

between by binding screws curved the battery, and so

the
as

to

adapt

the contour
to

of

the

tumor.

This
an

was

now

cold^ {)lied and all being igature

and
as

the

under in

surface, half slowly

carried

inch

below
next

apthe mersed, im-

readiness, the
thus

battery was
around

the heated

wire

the tumor,

in

circular
raised

amputation,
the the

completely sealingup
now

and effectinga deep fissure, The battery was vessels. superficial

and
was

wound

examined,
The
as

but
was

no

disposition to

hemorrhage
under

observable.
the
tumor
a

wire the

surface of
and
was mass

in

applied to the first instance, the battery

next
see-saw

reimmersed,
whole
this time

by
cut

slow

and

steady

movement

the

through. Though
loose

the

had ligatures
was
no

by

become the

quite

from

traction, there
to

ing bleed-

in order stump ; nevertheless, surface was secondary hemorrhage, the whole

a

from

guard

against
over

well

seared

second

every

time, and the suspiciouspoint.

stump
was

dome-shaped
returned
used

cauterizer

pressed
an

into

The

then
of

within
and
or

the

vagina,and
ordered,
necessary.

dyne anono

suppository

belladonna
was

morphine
deemed

but

dressingto the
As

wound
not

permit a detailed record of her progress space after the operation,1 will merely add that, though suffering from two extensive she bed-sores, improved rapidlyand without
the The with

will

slightest symptom
ligatures were
the

of local
to

inflammation
remain

or

irritative
or

fever.

allowed

for three
in the

four
upper

weeks,
tumor

hope

of

some effecting

reduction

Electric

Cautery
their

in

Uterine

Swgery.
a

126

by drainage
anno;aD";e,

but

presence
obvious

giving

rise to

good
were

deal

of

and

for

other

reasons,

they

taken

away,*
Case Mrs.
XIV.
"

Case

of

Sebbile has had

Intba-Uterine five children up to be

to

Fibroid,
and
two
one

"

widow, D., aged thirty,

Menstniation
her
was

misand and

carrii^.
a

alwajs regular
commenced that about she has

j-eara

half

the

when ago, flow excesaive.

at

periods
She
states

prolonged
under

been months the time

vation obserto

Believue into

irospital for
St.

three
was on some

previous
IStli of

ber iy72.

admission
Her

Marj^'s,which
had
been
was

April,

metrorrhagia
and
as

for much

continual,
blood,
it
was

she

very
to

reduced

jiast almost loss of from

and

deemed

best

prescribe rest, nourishment,

local

before aetrin^nts,
On

submitting
the
1st

her

to

the

ordeal

of

thor-

fiugh exammation.

of

May,

her

condition

having

126

Byrne:

Clinical

Notes

on

the

improved, freatly and with iagnosis

a

an

investigation was

made
:

with
the
tumor

view

to

the
was

following result
noticed
a

Above

pubis and
in size tender A

little to

the
a

left
four

firm

globular
side
an

about
to

that of

months'
the

pregnant
from of
presence
was

uterus, somewhat
to side.

the

touch, and
within silver

movable slightly os, which The dollar. and

as

digital
tumor
tent ex-

examination

revealed the

intra-uterine dilated
an

presenting
of fibrous
the its
a

soft and

to the

growth

resembled
and

ordinary

polypus,
wall size

it

uterine

far

from detached appeared to be free the fingercould reach, but as owing to

that

large
and
to

(being

about it

of

human
as

heart, which
half
tion connec-

in it

shape
seemed

consistence fill the

not

entire be

resembled), and cavity,the true

out.

in its upper character of its

not

could this time device

then made

made

I with

had the

the

good
and
no

luck

at

to be

of Prof. have
case

acquainted Thom, as by the aid of

able to estimate therefore
the

simple
i

ingenious
doubt
I

which

have

might
The

been
was

extent

of its attachment. intra-uterine It should also

fibrous
be

polypus, and most stated that manipulation

idea the of the
nature

of diagnosed as one probably pediculated.

with

the

sound

failed to

give any

clear On

of its attachment.

4th of

loop was
but
at
as

tery May, the patient being anaesthetized, the cauthe the and into uterine tumor over passed cavity was now

the

latter

found

to

be

much

less
was

movable

than with
not

first

the

supposed, this step in utmost difticulty. I soon

made it
to embrace
now

the

operation
that

attended
wire

noticed the

the

could

possiblybe
to
remove

outgrowth
the first time

far sufliciently the

up

entire, and
admitted vulsullum

for

real character

of its attachment
A

of little doubt.*

more forceps, being once carefully passed through the loop and into the cavity,was opened, and

strong
of

the

apex of

the

tumor

laid

hold

of.
uterus

Firm
was

traction then far

as

to

the

tent ex-

partiallyinverting the
while the The

tained, mainsteadily

loop by
a

was

passed
were

up

as

possibleand
the in the and of of
two

tightened.
immersed,
handle the

conductoi-s slow

next

attached of the
screw

and

when

movement
was

battery loop-

part
now

embraced

cut

through
one-half

removed.

Space being
it
was

afforded
but

for
more

the

introduction than

fingers,
tumor

fomid
been

that

little
A

the

had

taken resulted

away. in the

repetitionof the
of the

removal

scribed proceedings just deremaining half, the sur-

The

attachment

of
upper

the

tumor

is not

above
narrower

sketch,
than

the

portion
condition

being

less

quite correctly represented in the and spread out proportionately

would

the

actual

observed

warrant.

Ehctrio
face No from

Cautery
it
was

in

Uterine

Bwrgery.
at

127

which and

taken

elevated bein^ slightly

about

its circumference

seemingly
lost

blood

was

neecBsarilycome
weak solution in other

from

during the handling

The

%\ inches in diameter. operation beyond what

tlie

would
any with a

parte, nor

was

there

secondary hemorrhage.

uterus

of cai'bolic acid

and

injected daily ment vinegar, and the after-treatwas

respects consisted
an

of

beef-tea, milk

punch

and

tonics,
after the

with

occasional
there
was

the

operation
cavity
of

uterine

weeks anodyne suppository. Two was a bloody dischargewlien trifling and a explored by a polypus-forceps, A further

Sirtion freelyapplied and

en

sloiigh removed.
no

strong

solution

of

iodine

was

3Uth the

On the bleeding occurred. of May, twenty-six days after the operation,the cavity of tbree inches,and as the patient little over measured uterus a
to

seenied

be She

improving, she daily

left
on hospital

was

pronounced
Uterus,

out

of

all

danger.
Case

the

3d
of

of June.
the
"

XV.

"

Fibrous

Folypds had

Sate
,

unmarried, aged forty-five,

meuEtmated

always enjoyed good

1870. About
course

health date

and

regularly up

to

June,

this be

she

says

the intervals between

her

began

to

prolonged,

Fi6.

14.

and
was

the flow
taken

but scanty,
"

that

towards
of

the end
two

of December
weeks.

she

with

which flooding,"
she
even

lasted

out Throughof which

the she
Bome

year

1871 and
had

had
"

attacks

metrorrhagia,sometimes
for

lastingfor
stated

ten

fifteen
a

days, and

the

cure

she

taken

increase

in the

of medicine." power size of her abdomen, but it did nut

She

noticed

engage

128

Byene:

Clinical

Notes

on

the

her

attention
she
was

to

1871,

of the 30th on ; and any extent seized with severe hypogastricpain and made
its appearance

December,
"

bearing
of

down,"

large tumor Dr. J. P. Dwyer vulva. was now fibrous polypus, and recommended
a

when

outside

the

called to
her
to be

see

her, diagnosed a
to

sent

St.
and

Mary's
lobu-

Hospital for operation.

On examination the
tumor
was

found of
a

to

be

firm hand.

lated,and
which
and about
to

in size about measured

one

twice about

that four

closed
in

Its

cle, pedipeared ap-

inches
at

length,was
part,
its uterine

round,
attacn-

inch

in diameter between

its smallest
tumor

which

be

midway
to

the

and

pedicle,about an inch and a half from the tumor, was a small pediculate fibroid outgrowth. into the uterus, which On attempting to pass a sound peared apit was it found to fullydilated, beyond impossible carry
ment.

Affixed

the

one

inch
or

and anteriorly in
a

less than A

halt

that

distance

either

hind be-

lateral

direction.
a

fingerpassed
as

into the rectum be

to

came

in contact

with

firm
over

body
the

far

as

could

touched,

and very

conjoined
definite

pressure idea to as

pubes
or

failed

the

form

position of

any convey the fundus.

inveraion of the uterus was Nevertheless, partial diagnosed,and instead the pedicle near accordingly, of proceeding to sever seemed what be its uterine the to insertion^ point selected was When the half an inch above the little secondary outgrowth. the tumor heated wire had was removed^ passed through and the uterus was found to have reverted itselfand the cavity

measured
the Case First

over

three inches Large

Five

patient was
"

depth. Two discharged cured.

Af-bkr of

in

weeks

after

the

eration op-

XvI.

Fibbo-cellular Days

Polypus Parturition.
ehild
to excite

of
"

the

Cervix M

;
,

Noticed
w^'

Mrs.

aged 28,

delivered

her, third

During gestation nothing occurred her general condition in no was way

in
two

April 6th, 1870. her suspicions, and

that ed observ-

different from

previous pregnancies. In this third labor, which lasted but a few attended hours, she was by a midwife, and no occurred further than that the aft.er-birthwas slow to difficulty
come

away.
on

Yet cord. four

she
hours

was

sure

no

undue

traction

had

been

made

the
or

Three
severe

after

she delivery

was

seized three

with

very

which expulsiveafter-pains,

lasted

for

days, then

for the following two subsided, and her condition days was, on the whole, comfortable. On the fifth day, being without and a nurse, having no one for her children, she ventured and walk to get up to care had about ; but no she done so than a large substance, sooner

Electric

Cautery
was

in

Uterine

Surgery.
from

129

vhich She

ehe

tboaght

her

womb,
to

protruded
and
bo

the
until

va^oa.
Iwaa

immediate^ returned

bed,

remained

the 14th was on requested to see her, which (eight days after eonstaut a confinement). During these three days there was ansemic and hemorrhage, and she appeared very weak ;

Eaeaive she complained

ut

of

no

pain, and
the
In of

the

greater part of
after
or

the

mor tu-

had

retreated

within

the

recumbent about

position.
the size

pehic cavity soon ovoid, shape it was

a

assaming
rather
to

pyriform,
months'

uterus

at

from

three

four

gestation, and of firm consistence, escept at its lower it yielded readily from below to surface, where ward, uppressure recovered but immediately its convexity on the pressure being removed, thus giving a very distinct impression of its
being
and
was

hollow.

Several

abraded from which

spots

were

observed

on

its sides whole

inferior of
a

surface,

blood

oozed, and

the

deep

fleeb color.

In

accordance

with

my

advice, she
when
a

was

brought
examination

to

St.
"was

Mary's
made,

Hospital April 16th, 187U,

Hots.

careful

"

Owing
reada:

to
"

mistake Two
been

on

the

part
were

of

the

pdnler,
to
to
case

foot-noto
oaae

at wiUiin

pttge the
next

667,
laat

which

moDth,"

etc., has

operatioiu miiplaoed,

resorted

in

this
No.

and

relets

XL

on

the

130

Bybne:

Clinical

Notes

on

the

with

the

hope of deciding as
of the
uterus
or a

to whether

this

was

reallya
the
was

case

of inversion
within fingers
mass

the

with

tlie

vagina other hand,

the

and it

polypus. On making traction

found

two introducing
on

prolapsed
no

was

that
small

there

vical cer-

rim, but,
the tumor
which
was or were

on

contrary, the

vaginal surfaces
at
one was

and

that

of

continuous, except

spot anteriorly,
to

probe
and

depressed. Here an effort sound, but unavailing. By

above

made

introduce
per
rectum

examination
to

satisfymyself of the for the time of a uterus being desisted gresence this juncture, the case further efforts at diagnosis. At rom I requested Si's. Thomas, Noeginterest, being one of unusual
pressure

the

pubes, above, and

1 failed

gerath,and
steps
after
the in towards

James

L. Brown
a

to

see

her

with

me.

The

same

forming

diagnosiswere
Thomas from managea
to

a^ainresorted
to

to, and

repeated cavity of the uterus front,and thus all

the

efforts Dr.

get

the bottom
as

of the

probe into little concavity

a

doubts the

the
were

positionof
at
an

that

organ

and

character

of

tumor

end.

It is but

before the cavity of the uterus to state, however, that proper felt of reached all certain manual was having detected,by bipresent

examination,
could be any
to

body
the

which
uterus.

it did

ot

seem

possible
no

other

than

Nevertheless, had
uterus

attempt
evidence

reach

the

cavityof
above

the been

failed, and
than that
true nature

every other

of

its existence

found

afforded
case

by
must

the

rectal and
still have

supra-pubictouch, the
doubtful have
;

of the

remained

have

been

case

of

inversion,

it is very

subperitoneal by tlie inverted

fibroid

might

because, supposing easy to imagine how into the positionvacated swung

tlius deceive

this to
a

uterus, and
Dr.

the

very

best

diagnostician. Again, though, as

body
tissues in the uterine introduction

Thomas

observes,* the presence

a

of

of

region jnay warrant probe when, owing

more

or

less forcible

to

the

agglutinationof
have become circumstances
to

by inflammatory action, the aperture may that under such it should not be forgotten closed,
a

but

small
into

amount

of

force
or

would

be in

needed this

effect

sage pas-

cellular tissue
.

elsewhere

immediate

neigh-

b )rhood.
At all

events, this case, if

that its
no

not

unique,

instructive

apology
for

is needed

interestingand for occupying so much

so

is

space
The less

with

history.
the removal of
this

operation

polypus
addition

was

also
to

no

than profitable
*

because, interesting,
of Women, Sd

in

errors

DiseaseB

edition, p. 412.

132

Byrne:
"

Olinical

Notes

on

the
condition of

but

not

further

dilatable
wall

on

account

of the swollen down

such

tissues. flurrounding

The

vesical

was

dragged

to

cystocelewhen th^ patient stood erect. covered with sanious a on being withdrawn, was introduced, the appearance speculum being now
constitute
was

degree as to Tne finger,

mucus.

The the

of

organ
one-

such

as

might
in

half sound
as

inches

expected,the cervix fullytwo and and lobulated. diameter, purplish-red,

be

The tion direc;

passed to
to show

the extent
some

of

four

inches, and

in such

but and

with degree of anteversion evident by conjoined manipulation it was of the there

a

slightflexion
that the

great

depth
After

uterus
was

was

due
or no

to

the increased

size of its

cervix,

that

little

corporal hypertrophy.

consistingprincipallyof warm vaginal douches, iodo-glycerineto cervix, a Hodge's and she improved greatly, stopped etc., the uterus pessary, out-door the of time. the for some department hospital visiting Jan. 4, 1872, she applied again for advice, and stated that her former improvementdid not continue long. condition much Her was now general physical changed for the worse, and she had had several attacks of protractedmenorThe four was rhagia since last seen. depth of the uterus of tho inches, and gentle introduction except that the most caused sound the the cervical membrane, hemorrhage from first similiar that served. obto parts presented an appearance very
few

months'

treatment,

She
so
on

was

advised

to come

into

for operation, and hospital

did

Feb.
close

it was decided to remove the whole cervix 2, 1872, when and sequently, subto its vaginal insertion, by galvano-cautery, when would me heal, tx) take away portions of parts C. Nott's small

the

vaginal wall by Dr. J. of the Operation, By means

anterior
"

clamp-ecraseur. cautery-knife (G) a

of

circular
as

fissure
a

was

made

around

the

base

the

cervix

so

to

form and

bed

for

the
to

the
was

part

slighttraction
The

made

justed adwire-loop. The latter was next be removed securely embraced, while of vulsellum. by means (See Fig. 10.)

the being now efiPected, battery connection loop was to less than not as contracted, so slowly eight or ten occupy minutes in passing through, thereby avoiding hemorrhage.

When

the

cervix ;
nor

was

lifted
as

out
was

the
no

stump
appearance

was

found of

tol"e

deeply

concave

and other

there

ther blood, nei-

tampon

dressingwas
as

applied.
to

During
treatment

the
was

three

days subsequent
tlie had been

the

operation,no
no

special

needea,
what

patient

felt

inconvenience

whatever

from

done.

Electric
About
"

Cautery
"

in

Uterine

Swrgery.

133

the

day ^which I find is the rule in such cases of healthy pus beean to flow, and during copious discharge week the douched twice a ensuing vagina was day with
water

the

fourth

tepid

and

castile

soap,

and
water

at

later

period

with

tion solu-

of
showed which

sulphate of
on

zinc and 2d
to

made

the

the the

parts

cervix

had

tion examina( 3 i. to Oi.). An of March after operation) (four weeks be entirelyhealed, and the surface from been and covered with removed, smooth the

healthy
March thetized

membrane.

patientwas placed previous to operating on the

"

9th.

The

on

anterior

table,and wall, as
of the

anses-

above

stated, my
staff the
in

friend
of things

Dr.

i^^ott and
to

the

members

hospital

being present, when,

was

the
:

surpriseof
There
uterus
was

the all,
no

following

condition reached
an no

observed and

hulqing of
diffi(ndty
stretched
been

vesico-vagincu septum, hy the finger,as if the vaginal eanal

the

was

with
alone

had
not

upward
move

direction.
amount

The

uterus

was
means

elevated^
vutsedu/m^ operations

but

reasonable
it

of traction, by

of
furtner

could

from
she

its
was

position, lofty
soon

No

being indicated,

after discharged cured. This remarkable degree of fixation of the uterus, following by the electric cautery, is a clinical amputation of its cervix
fact worth

bearing in mind, especiallyas neither fever, pelvic indicative abdominal or pain, nor, in fact, any other symptom the of inflammatory action, followed operation. However, but that it was due there cannot, I think, be a doubt to eome
local

inflammation
the

of

subacute

form

in the

areolar

tissue

and

lymphatics of
abnormal
CASE
ON

resultingin a tighteningor ligaments, uturine of the inelasticity supports.*

broad

XVIII. Patient.
ordeal late

"

Intra-pelvio
"

Fibroid.

"

Third
case

Operation
has

Same

The

young in

lady

whose

already
from of
duced in-

been

having entirelyrecovered fully given (Case Xlll.),

severe

the
much

undergone
vesical

and having suffered August last, occasional retention

was

of

from

tenesmus,

urine, and

other

effects of distressing
to
a

pelvic impaction,

to submit

(December).
the the
tumor
cause

This

operation on first of the present month of all that part of in the removal consisted
third of the presence pelvis, now suffering complained of, and lower which
was

within of all the

at
an

the

the

ion excison

of which
account
^

earlier

period

did

not

seem

warrantable

of her

weak

condition.

not the procidentia, where amputation of the cervix is called for, would its retention for eight of a cylinder speculum after operation, and eleyation of the uterus, and a provide againat or ten permanent days, insure relapse of other parts ? In

introduction

134

Bybne:
referred
the
not
seem

Clinical
to may

Notes
therefore
was

on

the
considered
on

The

part
from

now

be

as

the
casion. oc-

stump

which

large mass
to

taken

the

former

It does

have

increased

in siz3

during

the

last three
more

months, though
and
more

has its presence come befelt late. of The painfully

upper

two-thirds
but

of the

packed, vaginal outlet

account

the
was

inferior

pelvic cavity was tightly the portion towards less crowded, principally o\\

of

the
was

The
no

latter

appearance
tissue. In

of the stump. globular form and perfectlysmooth, presented been of having ever an open
or

granulatingsurface

being

covered

wdth

tricial cica-

nay
or

the

the measures over suggested to reflecting its for accomplishing mind removal, either methods two appeared practicable, to repeat the operation first resorted to, by splitting then and into two mass looping either parts,
"

half ;
a

or

to

attempt

its removal the whole

in

one

piece by

loop
On

thrown
tumor.

around

circumference time

of the

account

of the great
not to

length of
of the

pied, occu-

however,
on a

speak

almost

mountable insur-

trouble former

and

difliculties tlie first of

; and

occasion,

experienced these plans

it seemed
means

offered but
at

little attraction

though
any

first
a

which
effort.

impossible to devise smooth globular mass

a

by
be
braced em-

might

by
The
:

wire

noose,

I decided
be

to make

the
lows fol-

method
A

practised may

described
and

as

rounded
so as

hard rubber large-sized heated at the end, was accommodate and itself
to

crochet-needle,
bent slightly
curve

to

the

of

the

sacrum

posteriorcontour
hole
was

of the

tumor.

its near transversely distal extremity,and at rightangles with the direction of its curve, and through which a stout wire was passedhalf its length. The free platina the of wire were ends now passed through two copper

small

drilled

tubes, each

-^

of

an

inch bent

in
to

diameter

and
1"Pifirsame

eight inches
form
as

long,and
rubber rod

nearly the
the

the

(Fig.16).
and

An

ansesthetic
on

having

been
two

administered,
tubes with

patient
rod

placed

her

left

side,the

the

rubber

ElecPrio

CaiUery
behind

in

Uterine

Surgery.
as as

135

between Bafe.* and

was

were

carried rubber

the tnmor

The maintained

support
half

bein^now

far up intrusted to an
and

deemed

assistant,

one steadilyin position,

of

the of

carried

around

the

circumference
from
bo

tubea copper the the tumor,

when the

wire
centre

being pushed
anteriorly
half had
been
one

up, piece by piece, had been reached, was encircled inch and
a

below, and
held Two until

the
site oppo-

in like

manner.

small

pieces

of
two

wood, each
holes
copper

running

and having flat-oval, leni;th, for the reception oi through longitudinally

half

in

the
in

conductors,

were

one

after

the

other

slippedup

so

as

nnite, yet insulate

the

latter.

Pig. 17.

This
were as

being accomplished,
passed
in

the

free

next

througha
and the All

modification
copper in the

shown
the

Fig. 2,

in

socket.
were

being
when

now

platina wire loop inairument c inductors firmly fastened readiness, the battery connections
of the
wire
cut

ends

of

the

made,

heated

through

the

136

Byrne:

Clinical
embedded

Notes

on

{he
substance

mbber tumor.*
The

support and
rubber rod
was

itself in

the

of the

withdrawn, and the loop liery slowly the time occupied in cuttingthrough the whole mass contracted, being fullythirtyminutes, exclusive of necessary interruptionsnow

There

was

no as a

hemorrhage

from

the

stump,

but

the

vagina

was

precautionary operation was, in this instance also,quite and though her pulse for several days did not get satisfactory ; and below 110, elie expressed herself as feeling very comfortable The vaginal free from abdominal pain or tenderness. dressing the third day, and the parts well bathed wil removed on were
measure.

tamponed

Keaction

after the

carbolic acid. added was tepid soap and water, to which appeared, the vagina was Copious dischargesof healthypus now several times a day, sne douched ishment enjoyea and retained her nourand and stimulants, everythingprogressed favorablyup and half the after nine the operathe of a to 10th, night tion. oays On that night the weather suddenly became intensely

cold,and

in the in persisted At
saw an

being nervously apprehensive that bladder so as to require the use

urine of
a

mulate might accushe catheter,

gettingout
hour

of bed

number

of times of the

to pass

water.

early

of the had of

morning
several

11th, Dr.
This

her, was

told she

and chills,

Schapps recognized wellcondition

means

marked

symptoms

incipient tetanus.

of
our

and though every became woree, thingsrapidly command was promptly applied and persevered

at

in, no
died

ration amelioat

of her
A. M. on

spasms
14th. An

was

enected

and thereby,

she

four

the
"

Autopsy.
to the

incision

was

made

from

the ensiform

cartilage

symphysis pubis, and the integuments dissected from me This being effected, latter preparatory to its removal. a ful carethe abdominal and in of situ contents was pelvic inspection
thus
or

afforded. evidence
ovaries
were

There

any

The

tubes, with
The the

their

adhesions, peritoneal inflanmaation. small and but healthy,and the shrivelled, and in free other w ere attaclunents, peritoneal
was a

almost
or

total absence

of

of recent

remote

respects normal.
utero-ovarian

plexus of
one

veins

on

right side
the

was

in

cose vari-

condition, and
outer to
a

as largeas full^

jugularissued

from

circumference The

passed directly ward upthe gall-bladder, it entered the wnere point opposite
cava.

of this varix, and

uteri

ascending
^

fundus
was

was

cup-shaped,as
the
the encircle
mass was

if partially

inverted
On aocount
were

; the bladder

healthy ; and
required
a

surperitoneal

of the length of wire

and

to

tumor,

two

teries bat-

connected
was

used

until

part of the

cut

through,

after

which

one

found

sufficient.

ElecVinc
faces The

Cautery

in

Uterine
free
the

Surgery.
from

137

all

over

anterior

remarkably pale and Vaginal wall, of which

next

lymph deposits.
seemed and
to
a

uterus
an

to

be

continuation, was
the
more

slit

up

to

within

inch

half

of

fundus,
the

when

the and

partialinversion
was

referred

became

still

manifest,
lateral

exactly
of the
to

central, each

tubal

opening
nected con-

bein^
The

boundary
now

tumor to

was

found

depressed part. he not hut interstitial,

the uterus
in
a

ide proper,

opening,
covering
down This

hy two separate attachments : one^ thepedr springing from the right wall hdow the Fallopian diamMer about and short ; the other two i/nohes, great portion of the opposite side, and extending
to its junction
was

the cervix
latter

wimthe

vagina.*

evidently secondary, and the result of inflammatory action at some remote period. The vaginal the which from of surface been a part had tumor, excised,was covered the healing process with healty granulations, and markably refar advanced

connection

considering the
The

short

time
tumor

that
was

had
not
moved re-

elapsed since weighed, but

by
As and close my
as

the

operation.

post-mortem

to be not appears the last operation.

quite twice
exceeded my

the size
its

of that

this paper

for otner for the

remarks seemed

already equally cogent

I have
a

has

far

proposed limits,
cases

reasons,

history of
endeavored

must

present.
to
a

purposely
of such

to

confine

plain statement

facts and

occurrences

in uterine instruments It is

bearing on the value of the electric cautery surgery, includinga description of the apparatus and required,and rules for their practicalapplication.
to have
manner

of
and

cases

possiblethat the discursive and operations are given

but I would
a

in which be

my
too

reports
inexact

may

considered
students

disjointed ;

state

in

explanation,that
than of
members of the details

this for

is written paper the information

;
so

less with it may

view

to instruct

that

the

dry

convey daily record

to

to active

sion profes-

and the
one

minute

however
attractive

useful
nor

necessary to the profitable of this

and

would class,

cases, be neither

other.
am so

Independently
that any
my
means so

feature, however, I clinical report, as a whole, is neither

complete,
diseased
in which
as

fully aware
full, nor by
scribed, dethe tion in addi-

could
conditions

be

wished
and

because,
one-fourth of

to

certain and

operations therein
but

whole

number

realityconstitute observed, there are many

of

others

great practi-

This

adhesion the

of
first

the

tamor

to the

left side enucleation

of

the
in

ntems

undoubtedly
1869.

le-

Bolted

from

attempt

made

at

September,

138

Bybne:
interest

Clinical

Notes

on

the
and

cal

that

might

also be
latter

related

did
be

time

other
chronic

cumstances cir-

permit.
Prominent
among the

might

mentioned

tarrhal, ca-

inflammatory,
mucous

and
a

ulcerated
the class, but

states

of the

intra-cervical

opprobrium acknowledged in most ana readily yielding gynaecological surgery, deed ininstances to one application of the electric cautery.* Nor
membrane
"

as

of

does ailments

recourse

to

such
use

radical

measures

for
; for

these

obstinate
follows

demand

the

of any
no more

ansesthetic

patientshave
or

repeatedly
such

declared than made.

that

sufferingattends
when any

treatment

is observed

other

active and

topical

applicationis
states to suffering

So

also in

regard
as

to inflamed
a source

of the the

membrane, patiept,and, so far

alleviated the

urethral

always
my
own

lar granuof intense

but

treatment

rarely even by ordinarilyemployed.

these with

most

experience goes, of judicious method

not

Yet

painfulaffections also,when
vesical

seriouslycomplicated
met lately proceeding.f
mere

have, lesions,
less

in

several

instances

with, disappeared no I regret that, on these

to

rapidlyby

the

same

the

facts

can

be be

points, nothing beyond this ventured at the present time

taken
to

erence refan

; but

early opportunity
of what
With

may

submit

some

trations clinical illuscases.

regard epitheliomatous outgrowths from

clinical material has been all reasonable

in such be reasonably hoped may the value of to galvano-cautery as a means the

for

of

cising ex-

uterus, I think

ficient suf-

yond presented to demonstrate, beover doubt, its great superiority every other

mode

at

our

command.

My
freedom

reports also indicate

with which
we

pretty conclusivelythe boldness and by this agent, safely encounter may,

the
to
curity seme

however disease, it affords

vital parts, connected with intimately against hemorrhage, and, what appears

of

even seem

more

would

the very remarkable immunity it consequence, almost to cellulitis, guarantee against peritonitis, other

pyaemia,

and

fatal

erwise sequelaeof intra-pelvic operations oth-

effected.

In

order

to

make out

such

first well

dried should should

by
is

means

applications properly, the of compressed sponge

introduced
to be
as

ceryical
or

cavity shoold
The

be

cotton.

cervical

cauterizer eM.
The

then

be next

far

as

batteiy
be well

immersed,
around and

may and

rolled

half

be judged proper, and whUe strument during cauterization the inbe back, so that the parts may

equaUy

its influence, brought under of the cervical canal for cauterization f A similar proceeding to that advised The be completely emptied, and bladder must be adopted. should the urethra An dried ansesthetio is indispensabl by cotton, before introducing the instrument
and

in these

urethral

cases.

140

Bykne:

Clinical
and

Notes
better

on

the
than be

immediate claimed for such

or

remote,

promises
of

results

can

for any
ailments. be

other method

treatment surgical

yet devised

aiid perhaps profitable, to notice some interesting, features characteristic important points touching the distinctive morbid each or case or having neither space nor ; but group desire to indulge in pathological the discussion or hair-splitting the under of questions irrelevant to what consideration, subject
It would has been

already said

must

suffice for of
my

the

present, and

mav

be

accepted as a brief Before disposing of

r^sum^

opinions and
my paper,
venture

convictions. and in

this section and

of

however,
to

conformity with
for the
to

its aim

I would spirit, of this class

destructive of

guidance
all
cases

of
of

others, the induration,

uteri
a

submit, following aphorisms pertinent

oi cases :
"

the

operative management
of the cervix

1. In

and ulceration,

growths out-

to be

therefore so, and such operations should never other or means, between sound apparent line of demarcation
but
more

malignant nature, or believed warranting excision by galvano-cautery

be and
at

limited
and least, that

to

the

healthytissue,
even

must

include be.

the whole

vaginal

cervix

if need 2. When

(See Case I.) the shape of a part to be excised

to embrace

is such

loop

cannot

be

made wire

it,a
made

circular

furrow

for the

tion recepbe

of the
3. The

may

first be

by

the

cautery knife.
should
never

wire-loop,knife, or
to
a

other

instrument

brought
or

white

heat

when

tissues passing through superficial Cases XVI. and should into be excised well

cellular
on

growths. (See
the

4. Traction avoided
structures.

part

to

XVII.) be carefully
the submucous

until

the

wire

has

passed

loop should in all slow to insure so as gradual, yet interrupted^ of each cauterization stratum as passed through.
5. The and 6. Towards wire becomes the close

contraction of the

cases a

be

verv

thorough
circle

of

such

operations,and
of

as

the

of

small, let the

the if

amount

be electricity
to be

tionately propor-

lessened. 7.

Apply
and,

knife

to the

spot intended

cut
a

mg

be possible,

always provided

with

Jieatbefore duplicate of

this little instrument.

persulphate of iron as and, should any dressing,when possible, styptic solutions of alum, or acetic needed, substitute
8. Shun the
use

of

utero-vaginal
such

agent

be
or

acid, dilute
tumor

strong, as
The been

circumstances
a verv sucn

history of
described

may remarkable

warrant.
case

of

fibroid

has
un-

at

length, and

the

three

operations

EUctric
dertaken little need

Cautery
removal
in in

in

Uterine
fully

Sv/rgery.

141

for be

its

part

bo

detailed,that but
in the
ports. re-

said

addition

to what

is contained

the time, proof has been wanting to convince and all who, on skeptical, purely theoretical grounds, denounce certain forms of galvanic apparatus, because, as they say, their action is not sufficiently constant, these three operations furnish have it. tofore, Others, too, who amply imagined, heremay that the galvanic cautery in surgical practice must or necessarilybe limited to small epitheliomatous pedunculated birth-marks, will find for the tumors, fistulous openings, and
to

If, up

this

first time extended. That and

a

how

much

wider

its range

of

applicability may
in

be

highly vascular
within removed the and

mass,

fifteen inches
been loss of

circumference,

situated

pelviccavity,has
circumstance it is

through

without

blood

or

successfullycut flammator subsequent inthe

is a complications, as galvano-cautery suggestive as

in

historyof
fatal issue
to

The
in this however

unfortunate
case

occurrence

that

worthy brought

of record.
about
a

with

the

accidental and

operation,namely, exposure deeply to be regretted,has nothing whatever of the operation, because merits up to the time misfortune the patient was in a much better

after

the

third

cold,
to

do

of this tion, condi-

after either

period previous operations. of an The intra-utereport of an operation for the removal sessile I another rine and fibroid (Case XIV.), exemplifies that the than of enucleation, by which believe safer means
a more

promised
of the

rapid

recovery

than

at

like

two

removal

of these
or

tumors

may
a

sometimes

be effectea.

Avulsion
a

enucleation best

of intra-uterine
most

hazardous, and at though encouraging

of
from and I
am some

results in
are

have
this best
most

admittedly difficult undertaking,because, attended the efforts occasionally

fibroids is

surgeons
those who

which

the operation is one direction, gers to qualified appreciate its danhas

an

difficulties
not
aware

will be any in

that
sever

apt to shrink. successxul attempt

of
sucn means

been

fore heretoelectric

made

to

the
the in

connection my
case,

intra-uterine
of

growth
cautery
found when
sense,

as

that

described

by

the

; and

though

proceedings therein
some

impracticable
it is deemed be

instances,a would, I think, in possible,

advisable. attaches
to

adopted may be persevering effort,

a

conservative

proper

and
that the

The

interest

the
to the

case

of

fibrous
more

polypus
to

springing from

fundus

uteri

(Case XV.)
means

is due

the
re-

lesson dxagnostic

it conveys

than

by

which

its

142

Byenb:
effected

Clinical

Notes

on

the

moval
its real

was

because from

an

error

in

regarding diagnosis,
in all

point of departure
been
a

the

uterus, would
When
Obstetrical

bility probawas hibited ex-

have
at

fatal to the of the

error

patient.
New
in

this tumor

meeting
as

York
cases

Society,two
were

examples
"

of

this fatal

preciselysimilar
clinic other both
or

lated, re-

one

having
last

occurred
years,

in the and the In

Professor

Scan-

zoni
a

within

the

two

in the

practice of

fundus York the cases prominent New surgeon. the the of mistaken for base was extirpated, being uteri, pedicle, and the patients died in consequence. When Dr. Graily Hewitt,* referringto this subject, says : be the polypus has a large basis of attachment, the fundus may
"

pedicleof the not specimen was long polypus is reallythe uteras and referred exhibited Dr. at the Patliological to Society, S;o arion Sims, Dr. John Ogle, and myself for examination, in
BO

drawn

downwards

that

what

appears itself. A

to

us

the

which

such

tumor

had

been

excised,and
been removed introduce features last

circular with

piece,
of less

comprising
I have

the

fundus

uteri,had

it."

thought proper, also,to the clinical polypus (Case XV I.),

peculiar and
as case

another of which
to.

example
are no

instructive

than

that

referred
was

However,
in this

certain have

inferences
been

deducible

from

what and
on

noticed

suggested elsewhere,
galvano-cautery, based
in the
on

important principles,
facts
then

applicable to
have
seem

observed,
remarks

been called

defined
for

aphorisms subject.
some

and

4,

no

further

Case

XVII.

presents
have
well
as

few
think

of which

a points for reflection, interesting already been glanced at in the report. I

this,as
as

other

similar in the

cases

met

a establishing

fact

clinical

far goes historyof such

with,

wards to-

ments, ail-

well

as

certain

principlesapplicable
Dr.

to their

ment, manage-

of

great practical value.

however successful his

Thus,
who and down

James

accept

pathology and

ers Henry Bennet, and othof inflammatory therapeutics have

cum

congestive
"

uterine

voluminous

diseases,may cervices by potassa

most

been calce

in and

'^

melting
rosive cor-

other

substances,the
destruction

by no means the electric by cautery, parts be relied cannot copious purulent discharges,
of such
nutritive in justified of the

thorough, and

cial, superfiand
on

sequent subas a

remedy
that witli

for

1 feel

hypertrophy concludiug,from
cervix

of

the

cervix my
own

uteri.

over, More-

observation,

amputation
local

and caustics, depletion,

by galvano-cautery,as compared offers the quickescharotics,

from seoond London

Diseases

of

Women,

first Amerioan

edition,

page

520.

Electric

Caviery
painless,and

in

Uterine'

Surgery.
successful Whether

143

est, safest,most
for
this

by far
class

the

most

ment treat-

very

numerous

of
to

cases.

the

planation ex-

already given

in

regard

the

elevated
case

position
correct

and one,

immobility of the or likely to aid us guidance, will, of

opinion
This of others.

uterus

noticed

in this
some on

is the

in

establishing

course,

depend

principle for our further experience

future
and tlie

add the much, however, I may circumstance, though : noticed novel othere before, appeared probably to so me by well avoid that I could the and not recording it, explanation and inferences for what offered be deemed are they may worth. In in

concluding this galvano-cautery, I

their
to

brief
would of

summary

of my
remark

clinical that those in

experience
who
fine congery sur-

simply
this

appreciation
attractive

invaluable

agent
to

uterine

its

blood-saving

properties, omit important

take

into

tion considera-

consist, in the peculiar manner in which this hsemostatic effect all, the vessels, and which I surmise is produced is in no on way analogous to that effected by ligature, torsion,^crasement, or styptics. Secondly, as there are no disorganized blood-clots or other effete material become the absorbed into to circulation,
fii-stof

its most

and

attributes.

These

blood-poisoning, as
as a

I have
of

before

observed,

need

not

be

hended appre-

In

other

hence

sequel cautery operations. that not vessels words, it would only are the bloodappear the but securely sealed lymphatics as well, and up, the and from liseraatoxic plications. immunity inflammatory com-

"

Note.
instrument

"

In

the

first part

of this

paper

was

induced

to

promise,

on

behalf

of

defects in the that certain construction of my manufacturers, I justly complained, henceforward be would of which remedied, instrument would
no

culum, spe-

and

in defiance to be made of every longer continue I regret to orig^inaldescription of it. principle as explained in my say now, I have that these been fulfilled. not promises and expectations have however, it is worthless possible to imagine as specimen as a quite recently seen posed exand I am that for sale in one informed and believe others establishment, constantly being disposed of elsewhere. are equally useless I cannot let this opportunity Under these without circumstances, ing warnpass of the these H7i"n the purchase imperfect instruments. profession against and the anterior exceeds incfi iiu outgide measurement blade, transverselp, one of that the
a

quarter^

ihe speculum
to their
as

cannot be

be

used As

without
to those

considerMe
who have

and these
as are

therefore ought
instruments, perfect, both

rejected. is to insist on only remedy to principle and workmanship.

being

pain to the patient, already purchased such supplied with

144

Quarterly Heport

on,

Obstetrics.

QUARTERLY
AND CHILDREN

REPORT DISEASES

ON OF

OBSTETRICS WOMEN
AND

Contributions
Heart
and

to

the

Clinical
in the

History

of

Affections

of

the

Vessels

Puerperal

State.

Hermann

Lebert.

{Archw.

1871

; Schmidfa

Jahrhucher^ No.

fur 4, 1872

sor By ProfesGynakologie^ iii. 1, Science^ ; Ab, Med.

Jan., 1873).
In the the complicationof work on appendix to Spiegelberg's fessor afifections of the heart, Propuerperal state with chronic
an

Lebert defects
not

remarks

that chronic
in them

endocarditis
in girls than in the

with second

valvular
half the
same

iinfrequently occurs
and
more

of

childhood,

often

in

boys of
acute

of life. These which affections, generally consist in Seriod isease of the mitral articular valves, developed after
are

rheumatism
sometimes

and

chorea, or often
much

come

on

insiduously,and

then
not

causing acts unfrequently favorablyon these the circulatory disturbances

eases,

without

disturbance.

Puberty

however,

terminate defect

dition as affections, by this conbe restrained; some may after pufatallv just before or soon berty.

Congenital
rare cause

of

the has

right side
seen

of

the

heart

is

event.

Professor
death
was

Lebert

but

of

congenitalstenosis
Lebert
of advises
are

one case ; in this the the of the aorta near

ductus
cases

botalli. where lesions

Professor conditions Not

but second
a

against marriage
present,
and because

in

compensation-lesions
the do the

upon
act

these very
on

pregnancy

lying-in may

unf avorablv.
more

readily,more
pregnancy,
in the

compensation-lesions come only with and rapidly, greater intensity

the valvular half of which endocarditis, pregnancy,
shares of with may

during

be the
are

developed
formation

peral puer-

endocarditis
of

tendency to breaking up deposit and The thJee following cases secondary emboli.
of this
:
"

reported by Professor Lebert as examples Case I. The a pregnant woman patient,

age ; acute
articular

twenty-one
month

years

of

rheumatism
endocarditis

in the

fourth

of pregnancy

; signs of

mitral

symptoms right lower

osdema.

of

embolism
;

in

ering; ; repeated attacks of shivin the the left and

upper
from

extremities

abortion

death

pulmonary

Autopsy,

Endocarditis

with

ulcerative

down breaking

and

Diseases

of

Women

an4
the

OhilJren.

145

of miti-al
termination
common

valve,embolic

of plugging
the

subclavian

artery, the
both

of the aoi-ta, ana iliacs.

commencing

portionsof

thirty-six years of age, just fourth dead ; in the evening strong time ; child delivered dant shivering,severe puerperal fever,intense dyspnoea with abunrhonchi and bellows-sound the tricuspid valve ; a over death. of the tricuspid Autoj)8y. Suppurative inflammation
The

Case

II.

patient, a

woman

for

"

valve,

large embolus
Patient before pregnancy

in

the

right branch
of the

of
same.

the

pulmonary
abortion
at

artery, with Case III.

months month of left

suppurative
; ;

inflammation

twenty-fonr years
afterwards
two
on peritonitis

of age
the

an

teen fifsixth later of

abortions

the
a

left

side,at

period
more

side, and

then

and rightside pleurisy,

symptoms

left

and profound inflammation ; swelling of the right knee bolism in twenty-four days. Autap^xj, Emelbow-joints ; death of pulmonary of the pleurisy, artery, double gangrene
"

lower ri^ht

pmgging

or

Seriuterme of the rightknee-joint, chronic ammation

In mode

in the inferior veua-cava, pulmonary lobe,thrombus the left renal the left side, on vein, periovaritis endometritis, suppurative phlebitis, suppurative inulcer
ot

duodenum.

puerperal pysemia
of extension of
too

and

septicaemiathe

mechanico-embolic

bert, been
venous

thought
"

process much

Lehas, according to Professor of the of, whilst the inflammation

"

walls little

purulent phlebitis has, on

the

other

hand,
in

been the

too

of the inflammations I'egarded.Multiplicity puerperal state exists not nnfrequently without any

evident

dependence
through
embolic

on

continuity;
detritus which

the
as

actual well
as

molecular

be produced may thrombolic and through

lesion

to infarction,

Professor
that

Lebert
and
no

plugging through thrombosis infecting

results.
on

opposes and embolism

non-

their

Proiessor

Lebert

thinks

this obscure and

subject
before

before
one a

renounced,
name

has

every ceased of

exclusive

light will be thrown theory has been

under the which either in

to confound

of

puerperal fever
be

number

pysemic

should

understand the with On

must separated. One quite generallyek)"Ty

by

processes puerperal fever

febrile

process occurring

only endocarditis puerperal condition, or quite specially and septicaemia. methrophlebitifi

the

Secondary of

Signs

of

Pregnancy.

By
1832

Pkofessob

C.

Hennig, No. 6, Jahrinlcher^

The
less certain consequence,
10

Leipsic.{Memorabilien^xvii.
1872.

Ah.

Med,

1, ; Schmidfa Sciences^ Jan., 1873.

pregnancy
are

and

secondary signs of
reason

of of

ial spec-

for the

that

in the

early mjonths

preg-

146

Quarterly Report
wlien the

on

Obstetrics
the be

nancy,

only
divided sential
"

obtainable into^those
; to

rank ai-e absent, they are signs of the fii-st These secondary signs may phenomena. that
are

'

essential

and

those of the

that

are

nou-es-

the

fonner
which

belongs distension
is
never

foetal
of

coverings
the

baloiniement,
of

absent, but

which, during
increase of

early weeks

pregnancy abnormal coverings of the size until of the the end

In cases is indistinct. pregnancy simultaneous be observed a may and foetus,

a

ine extra-uter-

the in

sympathetic
flexion
or

increase the former

uterus, which
of the third

progresses
month.

equally with
balonnement

With

version, and
occui-s

also with and To

or
"

hypertrophy of
evident. second be division

uterus, the
of those

earlier,
absent,

is

more

the

signs which
there is of
no

may

be

may relaxation (1)

which

present, when of the vaginal

of the
cases

absent

in one-tenth in these

portion registeredby Professor

woman

belong pregnancy, the womb this was ;

C. Henhad

nig, and
from of tlie form
murmur

exceptional instances the in previous confinements parametritis

OS

suffered
transition rounded

uteri

from

transvei*se

slit to

an

; (2) the orifice of

; this

frequently fails,especially in multipara3 ; (3) the

pregnancy,
murmur

of
; this

which is not

is fii^st heard

after

the

third
to

month the

always necessarily transferred

or

iliac and

but arteries, epigastric bluish red tlie womb and

itself ;

(4)the

in many brownish red of the

cases

to the uterus

coloration
the

of

the the

vaginal portion of
vagina

upper
to

portion of
os

coloration ; tliis

is sometimes

limited

it may womb be hypertrophy of the pregnant has Professor observed not unfrequently llennig

uteri ; in quite absent ; this condition

during a According
the with the uterine

catamenial
to

period
and

in

non-pregnant
after

woman.

which
lateral

labors or one Luschka, Naegele more cavityloses its triangular form and becomes oval, the border, according to Kaegele, and change upper riably. invaborders, according to Luschka, remain convex

Numerous

post-mortem
that of the in the womb
as

examinations seventh week

have

convinced

Professor

Hennig
the

after
the the of has

delivery the
form of that

cavity of
of
the with
or

body
The

again presents
well the
as

virgin.
when
or

coi'onal

that

sagittalsegment
pregnant
of
tracted cona

cavity is oval
the
os

whether

woman

been

not,

uterus,

especially in

closed

contains iiteri,

consequence viscid fluid or

incloses

morbid On

growth.
Elimination
of the

the

Puerperal and

Poison.

By

M. 23.

Her-

viEUx.

Med.

{Medical ScieficeSy January, 1873.)

Times

Gazette^ November

Ah.

148

Quarterly Heport
these and

on

Obstetrics
often also accidents
then

both

profuse sweats
of

are

too

of the
under would

the disease, and, occurring stage cannot desperate circumstances, we expert that they
ulthnate

operate
open
to
cases an

cure.

The

surface

of

blistere

may

in

issue in

for the

puerperalpoison

; and

M.

cases, also, Hervieux refers

some

account

for

which, without anything existingin their condition to exhaled blisters a horrible it, fetidity. In these,apparently
the influence sensible improveexlialations, ment its normal condition, etc. pulse approaching had
use a

under
took We but may have

of such

place,the
thus
cases,

far
to

to term

deal of

witn

the

natural
"

channels

in other be

M.

Kicord's,an
This

affraction"
from the

advantageously
or

established.

results

spontaneous
that the

artificial these
are

when especially

and opening of purulent collections^ knows peripheric. Every accoucheur

an

development uterine peritonitis,

of the limbs

of

abscess

of the diffuse
same

breast

may

often

rest ar-

or phebitis,

possess
menace

the from like

at
a

scesses phlegmon ; that abof diverting a power

; and

serious arthritic action inal

inflammatory
manifestations organs

the

viscera

that

even

in
are

manner

determine

upon

which

distance

fi-om the

morbigenous pclvi-abdom-

be long followed sphere. Tne practiceof maternity cannot discovered that these without different affections its being are that the but result of not they are expression or merely local, the the efforts made to repel the evil from by the economy the periphery, rendering the elimination of the towards centre inoffensive toxical principle at those remote more points. The subordinated such is the efforts of to success intensity of the it otherwise, how comes epidermic movement ; for if it were the mq^t painful chaps, or the deepest fissures that in certain years never give rise to abscess of the breast,while at certain the seat of purulent formations in the epochs this organ becomes of number whether puerperal women, they have chaps greater has of the nipple or not ? Experience taught us that we should with satisfaction first, regard these peripheric manifestations tary because they are an indication of the amelioration of the sanicondition of the establishment they ; and next, because individual the in chance additional for the cases an provide of septicmatter. elimination
"

On
AND

the

Influence Involution

of of

Neighboring
the

Organs Uterus.

on

the

Position

Puerperal
"

HELM

Pfannkuch,

of

iii. 1.

1872;

Schmidt's

Marburg. {Archiv fur No. 7, 1872.) Jahrhuclvtr,

By Dr. WilChynakologie^
peral puerto

The

and also before the during the lying-in period,presents generallya oending of the fundus

uterus,

the

and

Diseases
rotation

of

Women

and

Children.

149

right side,with
is,indeed, to
viscera. 2. This be

of the
the

posteriorborder
in the

is already consummated disposition referred

to

forwards; this foetal condition,and fii'stdevelopment of tlie pelvic

life, dispositionis favored duringextra-uterine by the of the viscera, especially oi and the rectum, by the pressure effects of gravity vrith rightside decubitus. This latter cause and the lying-in. acts especiallyduring pregnancy the bladder 3. When it presses is filled, oi a lying-in woman
the
uterus

upwards and
enect

to

one

side.

small quantity produced by a relatively (about centimetres). also from the fundus the symphysis and 5. The of separation the angle or lateral deviation generally'increase in direct proportion
4.

This

of urine

be may cubic 70

to

the

distension of urine

of the elevate

bladder. the
uterus

On

an one

cubic 6. less

centimetres

by
uterus

100 average centimetre.

a

Large degree

quantitiesof urine
than small

elevate

the

to

relatively
ing increas-

lateral

deviation

in consequence quantities, and the less rapid increase of the

as is, or

of the
in volume

of the

bladder.
7. The lateral direction the
uterus
more a

rule, to
on

side,

because the
to

from
bladder

first it lies
towards has

less

forcing
veree

over

the

left side.

according
8.

decubitus,
of

and great influence, above the

right right side, Here gravity,, readily remay

the the

the

this relation

phenomena.
sphincter elevates
the

Distension

of the rectum

favors therewith uterus, and The chief cause, however, is

bending
always

towards the

right side. dispositionacquired

next to this there

through
the 9. when 10. without The

development influence of gravity.

there In is
no

the

of the

uteAs, a^d

is

post-partum enlargement of

the uterus

is apparent,

and,

hemorrhage, is caused
involution, the
uterus

of the bladder. by filling diminishes

normal any

continuously
Certain
then ances disturb-

in

position. of and this affect involution, may process as complications. positionmay occur of urine 11. Ketention by itself gives rise
to

important deviations

in

deviations afterwhen

neither

to

bleeding nor
both these
course cause are

faulty involution present togetherthe

pregnancy and
uterus.

during
common

the
cause

lying-in;
at

generallylies
the
most
an

in the

of the with

birth.

It is

occasional 12. of the Even

relaxed

after the
as

completion of
of disposition in
"

involution the
a

the of
manner

uterus

to

degree

dependence repletion of
and
to
a

neighboring organs may, though out. degree, be still made sligiit

modified

150

Quarterly Meport
Puerperal

on

ObsMrics
A. D'Espine.

On

SEPnc^anA.
de

Bv

M.

{Archives

GeneraltB
1.

Medecuie^ Octobre, 1872.) by

dose
a

Puerperal
more or

less

Bepticjemia is constituted severe according to the

on

series

of

of toms sympsepticmaterial the

are

absorbed
2.

by

wounds

These

symptoms

canah utero-vaginal present nothing that is special to the walls of the those which in animals.
or

to puerperal condition,and may be assimilated caused subjects and by septicaemia in wounded 3. The point is always in the uterus starting

vagina
wound its

; all

the

causes

which

prevent
of

cicatrization

of the

uterine
on

and

which
are

favor

the
causes

development of septic materials

puerperal septicaemia.
habitual the road of the
not
a.

surface,

efficient 4. Tlie

the

lymphatics are the poison ; lymphangitis is

of its passage. is Peritonitis
an

absorption of
cation indi-

usual, but
due

necessary,

5.

associated lesion
which

to the

transmission
; it may

by the uterine septic material compared to local inflammations

of
infected 6. wounds.

lymphatic
are

vessels

be

developed

around

The

effecjtof

se])tic absorption on
inflannnations

the

and congestions

in all

lungs, kianeys, and intestines ; subserous inflammations localized apoplexies,internal ("r external is membranes by preference in serous ; during life this action manifested pulmonary' congestion,epistaxis, by fever, diarrhoea, often and cutaneous eruptions. by tempotary be con7. Purulent absorption and septic absorption may founded by the bedside.
^

mine oi'ganism is to deterthe especially organs, stitial ecchymoses or inter-

8.

There

is

no

such

afl^ection
a

as

milk-fever

; the

fever
to
an

of the

first week tion of the

is almost lochia

always by small
the

due septicflemia slight wounds

uterus
on

absoi'pvaginal utero-

the
not

walls
contract
some

of

the and

canal. remain
cases or

When this foetid,

one

does

the

chia loIn

fever

of this kind

may

may almost

for pei-sist

weeks. in the

always find

ulcers

neck

vagina.
9. These

are often, but not always, accomslight infections angioleucitisand signs of mild perimetritis. by uterine patiied When the infection lead to consumption is prolonged it may death and (septicphthisis). and 10. Puerperal pycemia is a complication of septicsemia, coincides with almost in the veins of the always suppuration

uterus.

This

complication, which to septic emboli.

is

relatively rare,

is due

in all

ability prob-

and

l)i8"as"8 of Wom^n
metastatic of the

and

Children.
wliilst this, articulations

151

Visceral
due

abscesse^lare tributaiT
cellular
twsue

to

all
are

inflararaations
to

and
not

of tne

an"f are lymphatic infection,

Researches
on

embolic

in their nature.

Some M.

IlifFANT D of

D., Pisa,
an an

Editor
Florence.

j"estion. the ^'Medical

By Pbospero Newspaper,
of last
the

Sonsino,
the
"

7m-

of parzicde^'^ In I article
account

{London

Practitioner^ Jan., 1873.)

published
of
some

in th^ Practitioner

September,
with of
a

gave

researches, which, physiological

to

other

arguments,
of
infant

me* bi'ought

establish
to

existence in the

or physiological

normal life.

dyspepsia
Since I have

starchy food

first

portion
order
to

published that
series

I article, ence exist-

thought
of limit
was were

convenient

to institute

another

of
if

researches, in
of the

not merely more bring forward that dyspepsia, but t"t establish

evidence

also,
motions

possible,the
of researches

of age directed fed

in which
to the

it

ceases.
^

This of with It the

new

series

examination aliments starch.

can

of infants

that

with contain the

starchy
motions,
well

the is that

object of
clear that
not

if

they
for

imaltered
we

recognizing by finding
find tions condi-

starch

in

infer

it did

being

starch

were

starch, and

digested. The tests used for discovering iodine, w^hich gives a characteristic blue color with the microscope, by which the granules discover we
same

peculiar to
The
at the

the

matter.

researches

of which

were speak

East

London

for IIospitS.1

Sick

made, at Children,

my

suggestion,
I have

which

frequented during
their execution officer in that

for indebted stay in England ; and I am my Br. to the courtesy of McGrath, resident medical hospital. Though few in number, I wish to publish illustrate

more

them, to invite our confreres to repeat them, and the subject which, in my opinion,is of paramount
in the I will

ance import-

hygiene of

infancy.

tried at Basel, begin by giving the result of one case last where days during September ; and then I passed some will give an of the othere in the order in which the exaccount periments Dr. McGrath. made were by Case I. into the Kinder Infant, aged three months ; came Spitalof Basel in very bad condition with atrophy for want of It was fed food. then with Nestle's convenient powder, a Dr. Riescher, of the milky compound, which, analyzed by found contain Basel Univei:sity,* to was only a little quantity of starchy matter, being principally composed of nitrogenous I
"

The

analysis

of

this

food

is

giyen

in

Correspondem

Blatt

fur

Schwevser

Aerzte

of September,

1872,

p. 366.

15i

Quarterly Heport
and is
sugar.

on

Ohstetrtcs

matter

This used
now

Nestle's
in

Powder, being conveniently

for

boiled

much of

Switzerland

mfant
Mr.

feeding.
Oeri,
blue the of the

The
house and

motions

the

littW

infant, tested
the
was

by
also

surgeon, the presence

with

iodine, gave
starch
case

characteristic

color,
scope. micro-

of

confirmed
had the

by

This
in ioasel. Ga8e II.

is the

only

opportunity

trying

with

patient inas months, received for Children, being affected London in East Hospital advanced and atrophy, enlargement of glands or the neck,
"

Sarah

Grey, aged

sixteen

with diarrhoea.

She

took

for

some

da^-s in

her

food

some

of

" Gosden, prepared by Messrs. Darby compound called tdctosCj Street,containing a certain amount Chemists, 140 Leadenhall of this child, notwithstanding The motions of starchy matter. that she
was

affected

with

diarrhoea, did
thus
we

not

manifest that

of starch

with of

iodine, and
^Arthur

must

conclude

presenc^j she was

capable
Cask
as

digestingstarch.
"

III.

received Read, aged five months, healthy, from

"

only for club-foot. It suckles in-patientin the hospital, Idctose^in the days some the mother, but after giving it for two of starch the presence find manifested we subsequent motions iodine. with by a strong blue color obtained with
Case milk and IV.
"

Martha

Jessop, aged
was

fifteen

months,
presence

fed

to beef-tea,

which

added

some

lactose.

The

amination ex-

of the after
was

motions

does

not

give sign of
then
we

of starch

the

use

of the

and lactose,

inferred

starchymatter
from
test
so

digested.
Case V.
"

E. Collonson,
; used

aged

five

pneumonia
of iodine
as

starchy food.
of starch of evidence

convalescent years, show to the motions His

the blue color
was

presence
to
"

; but

not

intense Case empyema motions Case milk with

give
John

large amount
milk of the

of starch.

VI.

three Ci-utchfield,
; fed

and

rickets

with

from years old, suffering Its and starchy articles. of starch.

offered VII.
and
"

strong

evidence

Emily
Therefore
"

Murdoch,
The
we

presence aged twelve do

not

months;
any blue

takes color
takes milk.

corn-flour.
VIII.

motions infer

give
was

iodine.

that starch

digested.
months;
animal of

Case
mother's The wliich

Elizabeth
and twice

milk,
we

Brown, aged bread a day some

evidence
with that of the

three with

motions

give strong
recognized
it must be
too

the
aid

presence the of

starch,

Therefore
so. partially

inferred

it is not

microscope. or only digested,

half
was

Case food

IX.

"

W. of

being

Dorrill,aged four coni-flour, groats, and milk

G.

and

months,
not

its

; child

reared

and

Diseases

of

Women

and

Children.

153

from

the and

breast. the in

The presence

motions of starch

with
was

iodine also

give

the

known with

blue
the

color,

recognized

microsc""pe
Case and
X.
"

large
with

quantities.

Eliza of of eggs
arrowroot

Emary,
milk,
twice

aged
to
a

ten

months,
has been

fed

with

beef-tea
one

yolk

which

added

tea-

spoonful
motions

day.
evidence

The

examination of the presence with

of

the of

does but
can a

not

^ve
bluish that
a

distinct

starch,
and The above
we

few infer

spots
very

appeared
little the starch

in

test-tube
was

iodine,

present.
of
the

following
referred
to
:

table

shows

results

experiments

I
it

do

not to

draw
me

any that

new

conclusion
are

from but

these

researches,
will afford

as

seems

they

too

few,

they

sul"

ject

matter

for

future

investigation.
Infancy.

Digestion

of

Stakch

in

{Gaz.

Med.

Ital.^ November,

1872.)
It
not

has the

been power

known of has

that

the

saliva

of

newly
into

bom

animals A

has
recent

transforming
taken that the the the

starch
from

sugar. and these

experimenter
and when into has

pancreas

kittens

puppies,
animals starch
or

ascertained

pancreate

juice
of
the

in

young
sugar.

is, like
The
to

saliva,
of
this

incapable
fact
is
on

converting practice

bearing
very

giving

starchy

food

young

infants

obvious.

154

Reviews

and

Notices

of

Boohs.

REVIEWS

AND

NOTICES

OF

BOOKS.

Treatise
Wm. II.

on

the

Theory

and

Practice Professor
in

of

Obstetrics.

By
aad York: Medical

Byfori), A.M., M.D.,

of "c. " Women 2d and

of
the

Obstetrics

Diseases

Children

Chicago
New

School,
Wm.
As

Wood stated

edition,thoroughly Co., 1873. pp. 469.

"

revised.

this book is intended by the author in the preface, information the to guide to contain practical only necessary in the acquirement and and 'busy practitioner' the student exof our far the and' ercfse of this important branch as so complishment acart,"

of this purpose

alone A
a

goes,

we

will allow

that
than

the

attempt

has

been

quite successful.
and
can,
we

compendium
great
deal

of Obstetrics
more

should, however,

contain
cannot

Dr.
a

Byford's
little
more

book

does, and
had

but

express

the

wish

that

mention

been

made

of the

nistory, pathologyand

etiologyof the various subjects; that this would be of interest and still more and to to the even so utility, busy practitioner," that it can without the student, lies beyond doubt, and be done from or detracting overstepping the limits of a concise treatise, demonstrated its practical value, has been by Prof. Karl
"

Schroeder,
der

of

Erlangen, the
"

third last

edition

of

whose the

"

Lehrbuch

Geburtshiilfe of which
is fill the void

appeared
in

now

press.

and year, That Prof.

lation English trans-

Byford's book

did

not

in the modern

obstetrical

literature

of America

and in
to

England, and did not quite come up to the latest advances and scientihc midwifery, is an opinion expressed physiological
us a

nearly Britain, and

Schroeder's
We would

year

ago,

by

well-known

Professor

of

Great

demonstrated sufficiently

by

the

translation

of

work.
not

ing mideretood, however, as condemnthis book, but simply wish to state our impression that the while in theoretical portion of it has been somewhat neglected, find deal of the a practical and therapeutical part we gfeat useful information, and, as a rule,opinions and statements sistent conwish
to

be

with

and

based

upon
an

the

most

recent to
our

and

generallyapproved
cism critithe

principles. As
on

exception
we

unfavorable

the

theoretical

part,
of

should

mention
"

the the

"

Female

Organs

of

Genei^ation,"and
these

chapter on Generation," in which

the
ana

anatomical

relations

organs,

and

physiological
generation,
and six dia-

changes taking place

are

in them

during
described.

ovulation Six

and clearly

admirably

pages

156

Reviews
sometimes

aiid

Notices
to the

of

Boohs.

CUB,

extending down
heal

delivery they gradually of cicatrices, which, if they were and remain not distention, signs of a previous abdominal lasting them in of utero-gestation however, for we have seen necessarily and in moderate even a degree in large ovarian tumors, ascites, the distention where of the skin had been not simple obesity, with the rapidly accumulating adipose tissue. able to keep pace this is Of course most as frequentlyin pregnancy, they occur
the
most

and

thighs; after become whitish glistening disappear, extent, never any

groinsand

frequent cause
cases are

of abdominal fresh
ones,

distention prove
an

; the

red

marks

in these

existingor but dences eviai-e just finished pregnancy glisteningmarks ; the In a multipara, of of previous utero-gestation. course, found both oiteu are together. Reviewer.) the principle so decisively enunciated We in to see are glad which the followin^sentence, is so much infringedupon in this
white
"

the

and

country:
man,
are

"The

ovum, the
same

the

only
...

embryo, living being

an ovum an

the

foetus,infant, child,
stages
of
istence. ex-

in different

It
arrest
as

is,therefore, as
in the

much hour

murder,
after

morally, to

the

vital be

action
to

fructification

it would The

newly-born infant." author, as we deprecates the justly, "c., advocated by by caustics, injections,
strangle
tliink for chronic and

active Bennett and such

ment treat-

and cervix
as

Whitehead

inflammations advises
milder

of

the

uterus

during

pregnancy,

remedies,

sitz-

the uterine dynes, baths,injections, region, anowater-compresses over local applications. etc.,without strong and of the Carl Braun some others,the removal Contrary to placenta in abortion, if the os be open or easilydilated by the the opinin accordance, I think, with ions linger,is recommended, of most neither be authorities;force, of course, should the of removal in the placenta. The used in dilating nor paratively comsmall
ease

size it the
can

of

the

uterus

in

abortion-cases, and
towards into the the

the vulva of

with

which
on

generallybe pressed
or

by the
tne

hand

sacrum,

abdomen, ought hardly ever

of the
:

retroverted
to

hollow

for the extraction three

stages

The
to

first is let the

ment require the use of an instru" Labor is divided into placenta. the when uteri is suflios completed

ciently dilated ruptured ; the

foetus pass, and

at this

the and in

membranes in the

are

second

begins

time,

ends the

entire

expulsionof
membranes also

the and

foetus ; the

third
This

consists

expulsion of
of labor is

placenta."

division

of the act

given by Scnroeder, adopted by bcanzoni, where the second the dilating, and

loc.

and cit., the the

is much

superior to that
preparatory,
of

first stage is the

third

me

expelling stage

Itevi"V)S
child and
seciindinae. which

and

Notices
mechanism German

of
of

BooTcs.

157

The various

labor,that
have of

most

cult diffi-

problem,

authora of
to

late been

attempting to simplify with the result comprehensible, is described according theory so far has not been gele,whose
answer
"

making
the and

it still less of Naeto

doctrines

refuted

appears

all

reasonable

expectations.
of the head

Scanzoni's

axiom,
itself

that

longest diameter

in the always places its pehis," during through that passage anism canal, is perhaps the most simple way of expressing the mechof parturition. The now generallyrecognized theory of of the foetal head the spiral Trwvement through the pelvis is also adopted by Prof. Byf ord. Scanzoni head makes says : The of the

the

longest diameter

five distinct

movements

pelvic canal : 1. The the pelvis ; 2. A rotation on posterior fontanelle descends

A rotation
on

its passage through and descent through the various in its transverse towards the floor of the

out

of

the of

cavities

axis, whereby
the

the

its

perpendicularaxis
the
axis

whereby

pelvis; 3. posteriorfonrotation descends

tajielle
on

approaches
floor of the

its transverse the

symphysis pubis ; 4. A second whereby the anterior fontanelle

a

to
an

pelvis on
5. A

level

axis

extension; and caused by the

towards

second the

is turned

of passage the thigh of

pregnancy

in reality posterior, rotation its perpendicular on shoulders,whereby the face

with

the

the mother.

cultation palpation and ausby inspection, is discussed it snould with some be ; but the as detail, diagnosis of the various positions of the foetus by the same is but and means certainly not stress brieflytouched upon, foetal posithe laid to each enough tion. peculiar appearances upon This is a species of obstetrical manipulation which, judging and heard, appears from what we have seen to be as much neglected and as little generallypractised in this country as it is universally The agnosis diesteemed, used and taught in Germany. of of doubtful is multiple pregnancy presentationsor tation. often possible only by the aid of external palpationand auscul-

The

of diagnosis

The believes
younger far as

author, in
that
"

accordance

with

most
more

modern tedious

obstetricians,
labors than

old

primipara have
This
lact

women."
as we are

aware, but

it is

attempt to explain; the greater firmness owing, partly

not to

he

does

and

diminished
years, and the

suppleness principally to
that statistics, diameters the

of

the

tissues shown
a

the

fact older
the This

peculiar to by numerous head,

of and the

creasing in-

measurements

the of

primiparais
place, in

the the ameters di-

greater
more

are

relative course,

chilcrs

of difficult,
of the

delivery.
is also found

increase

foetal skull

to take

most

158

lieviews

and

JVotices

0/ Boohs.
hence
we sionally occa-

as iniiltipanc,

rule,with
with easy,

find
were

women

new every contracted

delivery; pelves whose

from
a woi*se

fii'stdeliveries
to
worse

comparatively
child
to

going
itself her

on

until,
and hard

the finally,
as

presents
the
woman

with life.

head Dr.

so

large
ord

perhaps

cost

Byf

recommends

the

when the presentthe hand ing 6uj)port of the perinaium with " is The nc^t to on it,and says : object part presses down of the presenting part, but to mould, or passage of the assist the perineum in guiding it along the curve axis." lie considei-s the actual the

retard rather

perineal
as

benefit

of
the

this

cedure pro-

regardsthe

would bi^it of

prevention of a rupture as Btill advise its being done, to avoid

her friends attendant.
as

rather

ful, doubt-

reproach

the

patient and
of the

well

as

for the

faction personalsatis-

medical

If the

too

long, or diseased,or if the head is too rapidly,the rupture will occur, no matter is supported ; if the parts are all normal nanim no rupture will take place, even if the support be neglected. This, we know, is also the opinion of Scanzoni still but cannot help think-, we ; rememl)er believe eral sevcan ing that there are cases we we (and such) where by judiciously moulding and retracting the the head and perinjeum over softlypushing the latter towards the symphysis an be prevented entirely imminent rupture may its extent much diminished if it does happen. or
The

perinseum is too rigid, too large or descends much the perihow

quotation
would
seem

from
to

the Richmond that the

and

Louisville

Jounuil^

p.

220,

diarrhcea,which are life,

as

jaundice,colicky pains and suggest fantile so during the first week of inconnnonly occur of the umbilical much inasthe oord, owing to ligation
babies whose cords
were were

those

not

tied, while

not

from sufterin^

hemorrhage,
be
an

not

affected
cessation

by
of

these

ders. disor-

,It would
to

interestingsubject
the sudden

for further the the

tion, investigaumbilical liver witli icterus

; all

discover and in
some

whether the

circulation blood
are,

consequent
the

engorgement
this

of

explanations
The author

of cause way, hitherto given still leave very

this infantile

sensibly recommends infant as lightlyas possible,in order the free not to cramp of favor the the does but movements to not mean limbs, surely injurious habit of keeping the baby in bed with its mother. This is a practice good neither for the child,which becomes
chilled and
more

point doubtful. dressing the new-bom

liable

to

cold

and

other

external

influences she would be

risk

thereby, nor to the mother, who loses her rest unless child suffocatingher child during sleep. The the fii-stto occupy its own taught from cradle,when being nursed or carried about.

should

it is not

Heviews
A

and

Notices

of

^ooJcs.
of the

159

full account in pp. 252-76 very of the breasts during pregnancy, pathologicalconditions. The very
to

is given

and lactation,

ment managein various

indiscriminate

administration

of ergot in tedious
attention called
to

labor is
the
doubted un-

wisely

cautioned

against,and

toxical

rupture
Chloroform
at

of the

incessant

dnig on the child and the liability lent uterus, vagina orperinseum, owing to the vioit. contractions produced by
and

effects of the

the

same

ergot time, and

are

recommended
action thus

to

be

tered adminis-

their

combined

favorablyspoken of.
before
of the
or

(The
after

i^roper time to administer of the child's the passage and aid the

is very mediately ergot is im-

possiblehemorrhage post partum placenta. tteviewer) of the pelves,their various classes, The deformities degrees, and importance, are not treated of in the thorough and scientific should and manner we oughtto expect in a book like Dr. Byford's. Various forms of pelves are entirelyomitted, such as the spondylolisthetic, kyphotic, funnel-shaped,oblique anchylotic and transverse and none of them are anchylotic, thought worthy of more than a very imperfect general description. Schroeder devotes of deformed 108 pelves and the pages to the discussion and conditions indications therapeutical dependent pathological 5 on them; Byford barely pages! A frequent and speedy use of the forceps is recommended of the and tedious all the conditions when labor is becoming introduction and for the exist necessary adjustment easy organs of the forceps ; it is by this is very sensible advice,endorsed as children thus (by the administration the statement that many are which of ergot) sacrificed, might safely be delivered by the of the forceps who is skilled in the use forceps." A practitioner harm whatever will do no bv its frequent application; an skilled unskilful the oftener he the ment instrubecomes uses physician the therefore allow mother should to suffer and we ; why ? To perfoito become a needlesslyprostrated dangerous operation but extraction an unnecessarily is certainly wrong, easy from and with the forcepsto save a woman prostration suffering We is neither nor are dangerous. glad to see the unnecessary ceps, author advocating the position on the back in applying the forand in no instead of the inconvenient tion preferable posiway
"

head, to prevent speedy expulsion

'*

"

"

on

the left side. author is the

The the head

toward
turn

oblique application of the forceps when has turned in the pelvic cavity and before the vertex symphysis, and changing the blades, if they do not
advises

to spontaneously,

the sides

of

the

pelvis when

the

peri-

158

lieviews

and

Kotices

oj Boohs.
hence
we sionally occa-

as inultipaiie,

rule,with
with easy,

find
were

women

new every contracted

delivery; pelves whose

from
a worse

first deliveries
to
worse

comparatively
child
to

going
itseli her

on

until,
and hard

the finally,
as

presents
the
woman

with life.

head

so

large
the

perhaps
support
the

cost

Dr.
hand

Byfoi'drecommends
when

the

of

the

perineum
on

with

the says:

ing presentis nut

to
or

part presses
retard rather

down of

it,and
in

"The

passage assist the perineum axis." lie the

the

presenting part, guiding it along the

the actual

but

object to mould,
curve

of this

the
cedure pro-

perineal
as

considers

benefit

of

regards

of

bijtwould the patient and

of the

prevention of a rupture as still advise its being done, to avoid

her friends attendant.
as

rather the

ful, doubt-

reproach

well

as

for the

faction personalsatis-

medical

If the

too

long, or diseased,or if the head is too rapidly,the rupture will occur, no matter is supported ; if the parts are all normal no rupture will take place, even if the support be neglected. This, we know, is also the opinion of Scanzoni still but cannot we help tliink-, ; believe remember eral sevcan ing that there are cases we we (and such) where by judiciously moulding and retracting the the head and softlypushing the latter towards perineum over the symphysis an imminent be prevented entirely rupture may its extent much diminished if it does happen. or The Louisville and Journal^ p. quotation from the Richmond to suggest that the jaundice, seem 220, would colicky pains and which fantile diarrhcjea, so during the first week of incc^mmonly occur the umbilical much inasthe of oord, are life, ligation owing to
as

perinseum is too rigid, too large or descends much the perihow neum

those

babies

whose

cords
were

were

not

tied, while

not

from suffering

hemorrhage,
be
an

not

affected

by
of
of

these

ders. disor-

.It would
to

interesting
the

subject

for further the the

tion, investigaumbilical
liver icterus with
; all

discover and in
some

whether
the

sudden

cessation

circulation blood
are,

consequent

engorgement
this

explanations
The author

of the cause way, hitherto given still leave very

this infantile

sensibly recommends infant as lightlyas possible,in order the fi'ee to cramp not favor of the the but does movements to not mean limbs, surely injurious habit of keeping. the baby in bed with its mother. This is a practice good neither becomes for the child,which
chilled and
more

point doubtful. dressing the new-born

liable

to

cold who

and loses

other her

external
rest

influences she would be

thereby, nor
risk

to the

mother,
child

unless child

her suffocating the

or

during sleep.
its
own

The

should

taught from behig nursed

first to carried

occupy about.

cradle,when

it is not

Iteviews
A full account breasts

and

Notices
252-76

of
is

Books.

159

very

in

pp.

of the

during

pregnancy,

given of the management and in various lactation,

of ergot in tedious
attention called
to

pathologicalconditions.
The
very
to

indiscriminate

administration

labor is
the
doubted un-

wisely

cautioned

against,and

toxical

effects of the

rupture

of the

drug on the child and the liability lent uterus, vagina or perinseum, owing to the vioproduced by
are

incessant

contractions and
same

it.
to

Chloroform
at

the

ergot time, and

recommended action thus

be

tered adminis-

their

combined

favorablyspoken

time to administer proper the of the child's heau, to prebefore or after passage vent possiblehemorrhage post partum and aid the speedy expulsion

of.

(The

is very mediately ergot is im-

placenta. lieviewer.) The of the pelves,their various deformities classes,degrees, and importance, are not treated of in the thorough and scientific like Dr. Byshould and ought to expect in a book nianner we ford's. Various of pelvesare forms omitted, such as the entirely kyphotic, funnel-shaped,oblique anchylotic spondylolisthetic, and and transverse of them none are anchyiotic, thought woiiiy of more than a S(;hroeder imperfect general description. very devotes the 108 discussion of deformed to pelves and the pages conditions and i ndications theraj^eutical dependent pathological 5 on them; Byford barely pages! A frequent and speedy use of the forceps is recommended of the when tedious and all the conditions labor is becoming exist the introduction and for adjustment organs easy necessary of the forceps; this is veiy sensible advice,endorsed it is by as thus (by the administration that many children the statement are of ergot) sacrificed, which might safely be delivered by the of the forceps who is skilled in the use forceps." A practitioner whatever will do no harm by its frequent application; an unskilled he skilful oftener the the ment instrubecomes uses physician therefore allow mother the should to suffer and we ; why become ? To perfonn a dangerous operaneedlessly prostrated tion but extraction an unnecessarily is certainly wrong, easy from and with the forcepsto save a woman prostration suffering
of the
"

**

"

"

is neither author

imnecessary advocating the of the the left side. author advises

nor

dangerous.
the and in

We

are

glad

to

see

the

position on

back
no

in way

instead
on

inconxenient

ceps, applying the fortion preferable posi-

of the forceps when oblique application has turned the head is in the pelviccavity and before the vertex the symphysis, and toward changing the blades, if theydo not the periturn spontaneously, to the sides of the pelvis when The

160

Reviews
becomes distended.

and

Notices
This is

of

Boohs,
; if the

nseum

entirelynnnecessary
diameter

of the forceps are regularly applied in the transverse will turn the head pelvis, spontaneously within the blades as it be applied in the 18 pulled down ; if desired,the forcepsmay dom and rotation be made, but this is sela oblique diameter single double required. As for the double application and the
"

rotation
to

of

the

forceps recommended

"when

the

vertex
to

is left

right sacro-iliac junction and the forehead groin," we should not advise any one to try it. It dangerous to the mother, and quite unnecessary.
the who first described in and has advocated these rotations

the

is very with the

to
us

cult, diffi-

Scanzonj,
ceps for-

Germany,
he has
not

since, by

verbal

communication of

though (allast

change After Obstetrics, 1867),entirelydiscarded them. tried of times, we once performing the single rotation a number there the double after some and succeeded rotation difficulty; in the vagina, which rents however, two nearly cost the were,
edition of his
woman

mentioned

this

in the opinion

her

life. the under

In such

case

it is much diameter

better and

to

introduce with

the the

forceps in
forehead

regular

transvei-se

extract

3ie pubes. We have never tried tlie short that admit forceps as recommended by Dr. Byford, but must looks his plan but cannot feasible, although we object to the

dangerous
The when the mother

rotation

curved the in

proposes. forcepsare much

he

better child

introduced
over

and the

lated manipuof it is

body
breech the

of
or

the

is held

abdomen

than f(X)tling presentations,

the

when and
of

depressed
We

between

thighs.
particularmention
"

cannot

help regarding
of the
"

commendation re-

Obstetric
a

Extractor
of

of Dr.
on was

John

Evans,
the for with

of

Chicago,
are

author.
nets

merely The days when surely past.

as or

piece
the

courtesy
utero

the

part

foetus'in

fished

The

vectis

lever

is not

called

have

ever

Scanzoni, Schroeder, which read, call it Ilehel^'^

"

by the German spoon all the other authors and

a means

stetricia obwe

literally

"

lever."

The
No

blades

of

the
at

forceps are
all is made

called

spoons,

however. Loffel^

mention

head, nor of the advantages and faults.

is not
tiiat

the foetal

trephine as a perforator of of cephalotribes, their different forms

of the

The

diagram

given

of

the

cranioclast of
one

of

Simpson's
The of
tlie

originiS instrument, but

improvement

proved im-

in Vienna.
in

latest

(describedat length

this number the

to

Carl

to Le known Journal) does not appear its author, notwithstanding frequent successful employment in Vienna and the account of it published two years ago by Uokitansky,jr.

162

Heviews
and colpeui-ynter),

and

Notices

of JSoohs.
termination insufficient. the
woman

or

advises powers is

an

artificial pi'ove

of If has

the
we

labor
can

only
arrest

when the

the

of nature

lieraorrhagein
there

time, before
reason

come be-

exhausted, why we cannot generally no of quietly await the spontaneous delivery,unless the condition the foetus or unforeseen fortunately, occurrences compel us to interfere ; unthe after profuse case only see very frequentlywe then taken and has are compelled to hasten place, hemorrhage An delivery for the sake of the mother. easy version, besides, is not likely to injure the mother. As a temporary expedient against uterine hemorrhage. Dr. B. recommends compression of the aorta, to prevent the blood this profrom Scanzoni into the uterus. being thrown position opposes the the that abdominal caimot on w^e ground compress certain almost of stopping the circulation aorta alone, but are which lies to the left of and unascendens in the vena der cava also,
the
uterus

aorta, and
and
an

thus

cause

retention

of

venous

blood
reverse

in the

increase

of

the

the flooding,

very

of what

is intended. and for the most diagrams are numerous, part excellent, those in the chapters on the Organs of Generation particularly and The

Generation
where

an

exception is that of
looks
as one

the

on cephalotribe, a

page
stead in-

344,

the instrument
correct

if it had

lateral curvature axis the

of the
canal. and The

corresponding

to the

of book

the is
p.

The

tj^e

and

general appearance

of

pelvic good,
m.

worthy

of commendation.

r.

Treatment Diseases Pathology, of Diagnosis, and of of Pregnancy, by Grailly Women, including the Diagnosis F.R.C.P., Professor of Midwifery and Hewitt, M.D., iSnd., Diseases
to

of the

Women, University College,and Second American etc. Ilospital,

Kevised and 8vo.
as

Obstetric fi'om

sician Phy-

the third

London "

edition.

Blakiston, 1872.
this book

say Lindenlarged. Pliiladelphia: Pp. 751. the latest expose of

Considering

Gyn"BCology,we
review of

while shall, endeavoring to give an those it, lay particularstress on points in its most

English impartial
which it

differs from
Prof. T. G. of which Prof.

distinguishedAmerican
Diseases
his book of

contemporary,
extended review

Thomas's

Women,
number
a

an

appeared
Hewitt of

in the November with

of this lournal.
on

Pathology
the the

opens the Female

chapter
Uterine this work

the he

General mentions since

Sexual
his

Organs,
on

in which

complete change
ap]3earance
after of the

of

ideas

Pathology
nine
cases

first edition

of

years

ago,
seen

and,

giving a

list of all the

gynsecological

(1,205)

Hevietos

and

Notices

of

Books.

163

by

1865 from to 1869, University College Ilospital, origin his adherence confesses mechanical to the theory of the placements of the majorityof uterine that class of disand places affections,
at the

him

known and

as

"flexions the
uterus

"

in the first causal

are

order
a

; flexions

inflammation
upon tne

of the

therefore, as
and Utenis and
woman

rule, to
the

be
^

looked

in

lightof
History
"

cause

efiFect. In

second is very up of

chapter
ably
three
;

Natural
1. The of

of

the

Ovaries is made

and

lucidlydiscussed.

Life in the

periods : 2. The period

cessation
in
most

ty period preceding that of sexual activisexual activity;3. The period following

the

of

sexual the

activity."
....

"There

are

two

great
and

functions which textural

are

which

uterus

is

prominently concerned,

There

is

congress, of

powerful disturbing influences in regard to its menstruation and gestation. are condition; these the sexual third in which it is also concerned, viz., a gree, which is also capable, though probably in a less de-

affectingits
in the
uterus

textural

condition.''

The

physiological
and

changes
of the

and

ovaries of

during
these this

menstruation

tation, geson

the ovulation

anatomical

relations

organs,
process

the

phenomena
system

(Kouget's theory
of
an

of

dependent
vascular

forming
seems

presence the
to

extensive

muscular

and

erectile structure of the

of the internal

generative organs,
average

be

accepted by Prof. Hewitt),the

catamenia, their
of the menstrual
to
a

the cessation and quality,

to to
some

berty, puage of the quanperiodicity, tity,

duration

flow, are

all treated

of

length ; contrary
the fimbriated in close embrace inclines of

which ovary the

long accepted theory, according extremity is the active agent, and grasps
at
to

the

the

period
opinion

of

the

escape

of

the

ovule, the author

that contraction

the

advanced

by Eouget,
the the
to

the

muscular

apparatus
the ovary

spreadover
by

uterus, ovaries,and
of the of the tlie ovary

broad and its and

assisted ligaments,

bulb, brings
effects the

ment engorgethe mouth

Fallopian tube
a

adjustment necessary
states

for
his

ovipont.

Startingwithout
views
on

uterine
"

the author preconceived theory, led him have which to pathologj^ "The
conclusion and has

the
on

ing followme

deduction: the

forced
the

itself

that cially espe-

changes
in the

in the

shape

position of
are

uterus, but

invariably responsible, for in one the of the patientswho sufferings way or another, the subjects of them. And are further,tne conclusion, no less that the restoration of the proper inevitable, shape of the uterus
orc^an,

shape of the

almost

is the

means

of

removing
the
basis

these

necessarilyform
enunciated."

of the

sufferings.These views uterine pathology now

....

to

be

164

Meviewa
clinical

and

Notices

of

Boohs.
follows

The

changes
of the

in the

uterus

are

enumerated

as

1. Undue

fulness

referable
in the
;

to flexions principally

blood-vessels, congestion of uterus, sliows the (adiagram compression

the

of the blood-vessels
anterior
2.

and

rarefication

of the tissue at the internal

bulk

ob

wall

occasionallyto during anteflexion),

increase in the

other

causes

Actual softness

of

the

organ,
or

slight
times with of

hypertrophy, sometimes
with undue of

associated the uterine

with

induration

at

tissues ; 3.

Together

these may be frequentlyfound a decided change in the the uterus, amounting to a deformity of the organ ; 4.
in the membrane living
; 5.

shape

Changes
in

of

the

uterus

and

the

Changes pelvis; 6. Acute

and

in the

positionof the
of
; 9.

tritis cervix, endomeuterus, as a whole,

uterus ; 7.

the

inflammation
8. Carcinoma

the

Fibroid

tumors
a

polypi ;

Tubercle.

After
the

giving
first six

short definition
of the

of the

and aetiology devotes

pathology of
eight
and

of these
discussion

changes,the

author

treatment

of

acute

to a general pages inflammation cm-onic

of the
on

uterus, and gives a very which of the the treatment

mineral

of the principles survey and latter by constitutional

good

topical remedies,
The
with the

waters,

"c., is injections,
and
on

to

be

ducted. con-

chapter
sound conditions

on

Digital Examination,
speculum,
and
a

and

describes
to

the be

normal

Exploration and logical pathoseen

We

are

glad
the

to

see

appearances view correct

felt and

thereby.
ing shortencaused

taken

of the

supposed
which has which

of

cervix

uteri

during
within

pregnancy, and

considerable
to be
out

discussion
to the

owing gradual alter the vagina of the in the least shortened, and also that mention is made of which sounding of the Fallopian tubes, as to the possibility still doubts entertained felt authors. A tumor are by some examination be through the walls of the vagina on digital may der caused by : 1. Distention of Sie bladder in the blad; 2. Calculus of the rectum of the by faeces ; 4. Cancer ; 3. Distention and the of retroflexion rectum unimpreg; 5. Retroversion
of the
"

years, drawing up of the vaginal portion the cervix ing befourth month, without

late

is shown

nated
uterus

uterus ;

; 6.

Ketroversion
and from
uterus

and

retroflexion
of in the

of

the
uterus

gravid
;

7. Anteversion
tumors

anteflexion
and itself ; 9. cause;

the

8.

Fibroid
cervix of the

growing
from from
due the

uteri,or
uterus,
and

whatever

Fallopian tube,

to distention

by

serous

posterior part of the General enlargement of 10. Enlargement or or purulent fluid,

pregnancy
;

b^
12.

blood
Blood

Fallopianpregnancy;
of the
also

11.

Abdominal

tumors

Ovarian

tumors,

hsematocele) pelvis (peri-uterine ; 13. enlargement and congestion of the ovary ;

Heviews
14.

and

Notices

of

Boohs.
14.

1B5

Cystsof

the

broad

ligaments (Wolffiancyste) ;

Hydatid
or

cysts ; 15. Pelvic cellulitis and abscesses ; 16. Osseous solid tumors Anteflexion growing from pelvicwalls."

other of the

gravid
common

uterus

experience, a rather is, according to Dr. Hewitt's condition,and frequently occasions miscarriage; the
becomes

dislocation and the

reduced, if
may the and
we

at

all,during

the

fourth often
we

month

patient is relieved.
abortion of does
are occur

That

during
aware

and

in

sequence con-

anteflexion Does

well

of, but
result
mean

have

always
and
not

considered vice
versa.

miscarriage as
not

the

of

the

flexion,

Dr.

Hewitt

Impregnation

quently uterus a common anteflected condition,and freThomas ends Scanzoni in miscarriage ? Neither nor and abortion and in the order speak of anteflexion, gravidity, mentioned connection by Hewitt, and the idea is certainly a He novel to us. to say that the norone mal surely does not mean is rather
uterus

of the

of All
these and

frequently becomes impregnation?

anteflexed

after

or

in

quence conse-

pelvic tumore, which become abdominal, as

or some

may well
not

or

not may others as

extend which

wards upare

and really abdominal may treated of to also,are

manner

in

this and

the

next

and become vic pelappear and in a very practical length Examination the and chapter on may and the difficult

Diagnosisof

points of them between forth. Dififerential Diagnosis set are distinctly will find a careful perusal of this Both and student practitioner chapter (the arrangement of which is,to my knowledge, a new and on an Gynaecology) most appropriate feature in a work and the latter will be materially aided mation by tne inforinteresting,
Abdominal

Tumors,

and uterine The of Women

or

hints abdominal

it contains disease.

in

detennining a
pages

doubtful

case

of

propriety
to the

of"
"

devoting
mention

46

of of

a
"

treatise

on

Diseases

Diagnosisof Pregnancy
made

notwithstanding
manual of the

the

be questioned, may In it in tne title. a

-

Obstetrics, the
of the
to

chapter
bv

in

question,describingas
to the

it

does
the and of

relations

gravid uterus
the the

surrounding
the

parts,
sounds

information

be

obtained

auscultation, inspection,

palpation
the foetal

of the

abdomen,

of peculiarities

sound
color
a

and the funic the souffle, heart, the uterine the produced by the foetal movements, changes in the

of the

vagina,and

the in

condition

of works

the
on

breasts, would
the

fill in

often found vacancy this book, however, it

it contains

English
that the

subject ;

seems

certainlyis,might have
nearer questions

space, useful as the matter cussions been employed for the dis-

of

its character.

The

differential

diag-

166

Reviews
between could the have

mid

Notices

of

Boohs.
and than

nosis

gravid uterus and ovarian stated been more concisely

and 70 pages,

abdominal
it is. In

mors tu-

ters chap-

YIII., IX., X., XL, we a survejr disease ths the uterus essence flexions, (" a of (f which is those acquired deformities which rise to change (fshape^'*) give female and the disturbances in so so important many economy, in regarding them the principaldisease to which to justify us as the generative in the woman liable. are o^an flexions Tlie disposing causes or are predisposing and exciting. Preof : An unhealthy state of the body generally,want and nation tonicity, Exciting: Exaggeration and combipregnancy. of the predisposing causes, sudden shocks a or jai-s, of the the of sewing-machines constrained use body, position the in of active production anteflexion). The (principally delicate adjustmentof the uterus in the pelvis,and particularly its want oi regular anterior support by any other agent than the ever-varying as a circumstance urinary bladder, ]s mentioned of the flexion. occurrence predisposing to The effects of dress, imprudence largement during menstruation, enof the body of the uterus, tumors, accumulation of
of fluid in

find

careful

utero, endometritis, abdominal

false of

tumors,
of is

ascites, faecal
round

accumulation,
are our causes

membranes,
which
no

shortness
mention

the

ments, ligato

made, somewhat
the

considering the surprise,

tlie minuteness inferred
"

importance
in their

and to flexions, be It is
or some

by descriptionnaturally to
the fundus
occurs moves

attached

author

therefrom.
a

matter

of

accident "Version

wliether ver}-

ward forwithout without

backward."
of

rarely

nor flexion, usuallyoccur degree of version." some degree The the gestion conauthor, contrary to those writers who believe of the the body accompanying deformity to be the of the pain and the flexion itself of primary evil,and the cause A tlie holds gestion consecondary consequence, loUowing views :
"
"

does

flexion

of the
to

upper

part

of

the

uterus, which

we

may

consider

primarily, may, in the first instance,produce flexion. the congestion and on that,the flexion will react Having Qone it ; and, unless will increase of cured, it will prevent the cure
exist that

congestion."
effects of

long-continued flexion are : hypertrophy of the uterus (often increased by defective involution) ; descent of the uterus, ^adually produced by the strainingduring defecation which and itseli is caused micturition, by the irritation
Further of the
the

pelvic organs
canal,

accompanying
disturbance of

the flexion
the

; contraction

of

cervical

menstnial

functions

Reviews

and

Notices

of

Boohs.

167

(menorrhagia and
in
occurs more

amenorrhoea)
than in the

sterility ; abortion
"Anteflexion the of

more

monly com-

ante-

because retroflexion, latter.

impregnation
the
uterus

rarely in

leads
uterus

to

miscarriage

generally in
in the
to is,
an

following manner:
during possibly
has with the

the

remains

confined
ovum

pelvis,and

all this time and

growth of the miscaiTiage results.

the falls

extent, interfered

Shortly
before

afterwards
uterus

patient

pregnant
And

again

the

shape.
five,or
is the the

this may be observed to go on six times in succession. The proof that

cause

regained its proper in some cases four,

this condition restoration of carriages, misthe

of uteri

the

miscarriage is,
circumstances

that

fundus

to its proper

positionwill prevent further

of
the
case

and, being done, the succeeding

How does the which
uterus
are

if the

allow

of this

pregnancy confined remain

will

in the
to

proceed naturally." unless by pelvis,

be
rare

adhesions,
anteflected

generally supposed
to
our

in

flexion? ante-

There
uterus

is

notning,

from

increasingin size and

;

pelvis

uteri,and the generally corpus and often do prevent the retention existing chronic endometritis, may of the gradually and the are primary enlarging ovum,
caiises

advances pregnancy condition of the f uiidus and

as

the

knowledge, to prevent an risingout of the table irrithat the congested and

of
we

its premature
"

might,
abortion.

expulsion, is a well-known think, sufliciently explain the occurrence

A restoration
"

fact, anli
of the

of

the

fundus

will,"of course, prevent further the congestion and of irritability be removed treatment. by special
with abortion is the
to the

position miscarriages, particularlyif

uterine
"

to its proper

the

mucous

membrane connected after canal.

Another
ovum

result in the

retention

of

the

uterus

death," owing
A

acutely flexed

direction
us,

of the uterine

knowledge
the

Among
ions, the
in the and the

ening straightby artificially the relieve the ovum and patient. uterus, to evacuate the various and discomforts pains produced by fiexof intense mentions author constant two cases pain
on on a

of

this fact

will enable

abdomen other for in

level

with

the

umbilicus,
cause

one

on

the had

right
been

the

left

side,the

of which

was vaginal displacement rectified, made, an More in ninety and the pain permanently relieved. generally, of cases, the rule holds good that the pain is located per cent, and in the inguinal regions in cases of retroflexion, in the back

sought

vain,

until

finallya
found

examination

acute

retroflexion

the
"

in

cases

of

anteflexion."
retroflexions of the and anteflexion in the is
uterus
as

The
"

frequency of
actual appeal's
to

112

to 184. flexion] retro-

The

acuteness

bend

[in

influence

the residt in

regard

to

suffering."

168

Reviews

a/nd

Notices

of

JBoohs.
the is

"An

state oBcillating

of

thingsin
now

which

uterus to be to

so

placed
which

that

it is

now

more,

flexed,appears less,,
trouble in

that

of all
such

others

gives
One

most

regard
likely
to

comotive the lolooked over-

power."
as

form
rather of

of

anteflexion
one

be

is the

uncommon

of
; the
os

acute

flexion ante-

with

retroversion These
cases

the whole
are

organ

uteri looks
to

quite upward.
with.
"

extreme^

troublesome

deal

Miscarriages
fact is not
as

are

latter

yet
to
or

common very admitted

(in anteflexion). The by the profession,but I am

Out
had

quite
women

certain with

its

correctness."

of
had

235

married
24

ante-

51 retroflexions,

abortions,
with
one

retroflexion
;

with

32

abortions, 27
number in any of
one

anteflexions
in any
not

54
case

tions aborof
"

the

greatest
was

abortions
case

retroflexion
appears occasion

3 ;

of

9. anteflexion,
so

It

that,on

the

whole, anteflexion
i*etroflexion."

does

certainly

miscarri^eas
of

Treatment
is to

Flexions

of

the Uterus.

The

flrst indication

as regards its shape place the uterus in a natural condition and indication as regards its position. This mechanical may should and where be fulfilled, is acute and the flexion even attended with congestion. The longer a flexion has existed the longer it will take to cure it. the face in retro-, on Position on of the Body^ horizontally the back in anteflexion, for a longer or shorter period. For a

recent

case

of the

retroflexion
uterus

Dr.
the and

Hewitt sound the

recommends every
2
or

the
3

cation rectifi-

of
at

with

intervals of
cases

of

week,

pessary chronic week for be up

covered wire copper the sound be should

or

days, perhaps fiexible ringa wearing with For gutta-percha.

of
introduced in the
at intervals

of

for half
an

two

three
or an

months, leaving it
hour and the time

rectified uterus

hour

examining finger. mentioned is very mended just strongly recomring-pessary in its favor ; by Dr. Hewitt, who cannot say too much inches in from in it measures and is made 2i to 4^ diameter, various sizes, the numbers 2, 3, and 3^ being the most rally gene"The for is form instrument the typical applicable. than the the other, and ovoid, one end being a little wider
uteri

very the fundus

curved slightly with

should at a ; the sound its introduction aided by

always

pushing

The

whole The

curved slightly instrument

to

adapt
the be

it to

the

curve

of end the

the

vagina.
a

is introduced

with

the smaller
of
os

first and
The

little

obliquely as
or

regards
end
must

aperture
behind
the

vagina.
It acts
os

smaller

upper
tne

uteri."

by
in

supporting

dd-de-sdc

of

the vagina

behind

the

uteri

170

jReviews exertion, should

is be

and

Notices

of

BooTcs.
of

sual

recommended.

The
allow

wearing

dle-pessary cra-

to preto frequently necessary pregnancy, vent of and the obviate the anteflexion return to miscarriage, after delivery; in the latter case it might even be worn soon as twelve ten as or days postpartum, and thus the patientsaved the tedious from necessityof lying on her back for four or five

weeks.

pessariesor modes of treatment, such as Iloge'slever,Thomas's, Ilurd's,Cutter's, and others, of Sims's division of the posteriorlip in anteflexion The onesided. "c., is rather surprising and looks somewhat complete
omission

The

almost

of all other

reports of
cure

other

of note, gynsecologists
to

on

their

success

in
to

the the formity de-

us flexions, might cause in the improvement permanency was

of

be in
or

little

skepticalas
where

those
more.

cases

the

of
much

year's duration
Ilewitt space
treatment
"

The
be
our

importance
excuse us

attached

by Dr.
so

to

flexions

must

for that

devoting
the
In the
the
"

to their

discussion.
to

Let
the

hope

cradle"-pessaryreallyis able
the

supply
"

want

hitherto
called

felt in the radical

of ante-flexions.

chapter

on are

Prolapsus Uteri
in many

attention is
to

to
as

fact that flexions

instances

be

considered

of the starting-puint
manner

prolapsus; the the bulky and drawing

the
recto

displacement ; the in which the descent

uterus

various is

stages

of

the
or

displaced after it,and vagina and its attachments cystocelebeing the primary change and
absence cervix both

sometimes

brought about, and descending fii-st

sometimes the
uterus

entire gradually the of elongation ypertrophic

following; the

of connection

between

gmal,
and

and

prolapsus (descentof
confusion
;

some

has

been

supra-and infravawhich the fundus ject subon uteri), made by Huguier, Carl Braun,
between the various

others of

the

differential
and

diagnosis

points are treated this heading, and ings. of under illustrated by comprehensible drawThe principally hypertrophicelongation is stated to occur and other to stand laundresses, women cooks, compelled among a portion apparently dragging on the rest great deal, the vaginal of the uterus and relaxed condition a elongating it. (Possibly of contractility and of the uterine tissue may be the priwant mary for this pathological reason condition, thus allowing the cer\dx to become lengthened by the mere weight of the portio prolapsus
as vaginalis

forms

all these hypertrophy,

if it

were

made
a

of putty
case

"

an

illustration Dr.

1 take

from

the

descriptionof Seviexoer,) The excision

verbal

in

point by
the

T. A.

Emmet.
to to

of

the

elongated cervix, according

stump

Huguier,
Lewis
is

with

or

without
and

covering
the

according

recommended,

wire-rope^craseur

preferredto

jRevieios
the

and

Notices
for the

of

Boohs.

1 71

knife

or

other

instrument

amputation of the hyper-

trophied part.
in its the uterus be maintained principlesby which may place in the pelvisand simple prolapsus be cured, viz. : roper Ey of pessaries, rendering the vaginal canal rigid by means by the canal itself operations on the perinseum, or by constricting for some the aperture views little distance from adopted by Dr. Hewitt since the publication of the last edition, and now forward for these the fii-st time principles are by no put been acted means new or originalwith the author, and have of prolapsusby numerous in the treatment on operators almost
" "

The

since medical Of

the

time science.

when

gynecology

became

distinct

branch

of

all internal Dr.

the oval-ring pessaries pessary

mode, of
best, and
them

according to others only are

Under
naenm

idea, is considered unfavorably mentioned,

and
a one

H.'s

the

course, few a

radical both Dr.

operations,the
old

among operation for of rupture denudation

Zwanck's.

restoring the periis described in the

in fresh II. makes

cases

latter.
the wall unite

semi-lunar
or

of
the be

perinaeium,with.
with silver

two

on triangles

edge of posteriorvaginal
the and the

if constriction wire

of and

the

vagina
beads

is to in

combined,
"

ebonite

preference to

amenquill-suture. The dyspepsia occumng during chronic orrhoea well out, withand is discussed, (which subject extensively is best treated however, advancing any new points), by adin very small quantities^for some TnmisXerms^ frequently ana character the food or milk-and-water, days together, simplest beef -tea, yolk of uncooked with weak beaten milk," the iip egg by Dr. lirown-Sequard in the first plan described very same of his new number journal. The credit of priority would therefore seem to belong to Dr. Hewitt.
"
"

"

Flexions

of

the
or

uterus

constitute
causes

one

of

the

first and

most

common

direct

indirect

fibroid
malarious
a

tumors

of

the

cervix

ovarian influences, other

causes

menorrhagia." uteri, defective involution, and over-excitation, irritation, are

Attention is called of
to tlie

of

tial Intersti-

few

of the

mentioned. of the

occasional menstruation

coincidence with of the

formation
are

profuse abrupt appearance of peri-utrine hsematocele.

numerous

The

causes

metrorrhagia

and

well known

; the

pulsion explacenta, spontaneous subjects of abortion, moles, retained exfoliations and fibroids, membranous of fibrous ix)lypi the pendently indemembrane uterus irom occurs (the aysmenorrhoeal of conception according to Dr. 11.)and vagina, etc., are successivelydiscussed in this connection.

Dr. H. holds

it as

"

unquestionablethat dysmenorrhoea is to

be

172

Hevieiva

and

Notices

of

Boohs. instance,an
"

as regarded

symptom
escape pages

in indicating,

almost

every

pediment im-

to the

of the
the

menstrual

fluid from
"

the uterus."

are Dysmenorrhoea chapter on internal the ital gendevoted to the diagnosis of pains referable to useful and novel including dysmenorrhoea, "a organs, felt and mode OT explaining and discussingthe various pains have and pelvic regions." We complained of in the abdominal the hypogastric region, the pain in the back, in the groins, ter, inflammatory characless constant, pains of an or pains more in sudden pains, hysterical pains, bearing-down pain, pain is principally cal surgithe lower extremities," "c. The treatment

Seventeen

of

"

and

procedures mechanical, and the various others for and bv Sims, Greenhalgh, advocated
incision
never or

and

ments instru-

tion the dilata-

and
"

the cervix used

os

uteri any

should

be the

after

Sponge-tents cutting operation has been

are

described.

performed
weeks
"

in

uteri,except after
"

an

interval

of

some

of fresh-cut (probably for fear of the supposed liability iteviewer) surfaces to absorb septicmatter.
The into
two
"

nervous

disoi^ders
:

referable
of

to

the

uterus

are

divided

classes
"

Increase

direct
to

(the
one

irritable

uterus

is asserted

flexed
of

organ)
the
not

and

increase remarkable
to

of

reflex diseases

of the uterus sensibility a be nothing else than or hysteria, sensibility,

most

peculiar to
and witli

the

numan

race,

confined
the

the

female The

sex,

consequently
or woman

not

associated always, though exceedinglyoften,

to

referable
to

disease

oi

uterus.

greater

of liability

emotional

and of

reflex

disturbances

greater explains the infinitely

frequency

most in the female sex, whose irritability both in an important part the uterus, plays such sensitive organ, of the disease is The essence and her spiritual organic life. the (Dr. Keynolds) an exaggeration of involuntary motility, and reflex movements being in excess." The disease sensational

reflex

"

may

originatein
emotional The

two

ways

in the
; 2.

female

sex

1.

From

nal exter-

disturbances
treatment

From

organic internal

ances. disturbof the

abnormal and

naturally consists in the removal Sickness sea (nauand the exciting cause. susceptibility result of reflex irritation proc^eedis another vomitiiig)
the of and

ing
in
a

from
state

uterus, which

organ

will

very

frequentlybe
or

found

flexion,a

condition
not

(either permanent
be the

only
the also of

temporary

evanescent),

with together unfrequently,

cause increasingdistention of the womb, found to the flexion of The rectification the sickness during pregnancy. by rest already mentioned, and during pregnancy by the means is the the air-ball pessary, or the back, the cradle"-ring on treatment usuallyfollowed by him vnth, success.
"

Reviews
A

and

Notices

of

Books.
"

173

formations, MalUterine practical feature of the chapter on the to plain exare plates which materially serve and somewhat otherwise the mind the plicated comimpress upon varieties of tliis species of deformity. In the chapter on Leucorrhoea," etc.,the various Kon-sanguineous Discharges, kinds of discnarge, the watery, mucous purulent, and'pnriform, each sanious,offensive, are gonorrhoeal,and syphilitic separately
very
"

treated

There
form

of,and their causes, nature, and are, according to Dr. McClintock,

Hfiematocele."
less
severe

treatment

discussed. of
;
"

three

forms form

uterine Peri2. A

1. The

sudden

and

acute

and

overwhelming
; 3.

in its

evidently
beiiiff be
:

threatened

sort

of chronic

life not being so effects, form, the symptoms The

causes or

developed gradually or of one Jiupture of some

plexus, apoplexy
and menstruation from the

in the

succession. vessels

may
rian ova-

in the the

uterint

rupture

of

ovary, and

liemorrhage
tlie

during
into the

Graafian

follicle into
the foetus

neal perito-

the cavity,hemorrhage from peritoneal cavity, rupture and pregnancy, other sources,
a

uterus

tube Fallopian

of

ill extra-uterine
tonsBiim
etc.

hemorrhage
cachectic
or

from

vessels of the

containing cyst peri-

other
to

Dr.

Hewitt.is, as
a severe case

rule,opposed
without the the

althongh, carefullydone
would
"

causes, of the tumor, puncture of air, it introduction of the

constitutional

in

shorten Abscess

Pelvic

Cellulitis and

pelvic cellulitis (Duncan^,

cellulitis the

and

(Tnomas)

"

peculiar hardness

is very well of the tumor

malady. tis parametriperiuterine pelvic peritonitis, discussed; attention is called to

duration
"
"

and perimetritis

great frequency of pain in the the psoas muscle, an 18 extended, owing to the distension around almost ficial and to the benepathognomonic sign of pelvic cellulitis,
effects

after its effusion,to the the thigh inguinalregion when

soon

of
a

is

placed
The

on

side rest, particularly if the leg of the affected double-inclined plane with the heel elevated,
"

etc.

chapter on exceedinglygood
fibroid and

Fibroid
of

Tumors
the
nature

of the
of

Uterus
the

"

contains

an

review

various

forms

of

polypoid uterine growths, of their diagnosis,and mation The cysted transforparticularlyof their operative treatment. does not appear fibroid affect tumors. to (We parietal remember where uterine in tumor a large Vienna, seeing a case ness, of unusual fibroid was as a vascularityand softdiagnosticated orrhage The perhaps a sarcoma. woman dying suddenly of hemand
at coUapsus,

the

autopsy
was

the

tumor

was

found

to

be

mukilocular walls
;
a

cyst

contained

entirelywithin
of the
was

the
a

right by
the

rine ute-

the

contained

cyst, which serous, viscid

size of

child's head,
pa-

fluid,and

considered

174

Reviexos

and

Notices

of

Boohs.

thologists present to of a parietal uterine

The
"

Recurrent

originatedin the gradual liquefaction fibroid. Reviewer,) Fibroid Tumor described by Hewitt as a
have
"

"

and growth proceeding from the inner wall of the uterus jecting prodownward through the os like an ordinary fibroid polypus, after to liability again soon grow shovm removal, has been by Gusserow, Ilegar, and Winkel (Ajchiv fiir Gynakologie, Vols. 1. 11. and III.)to be identical of the with, and really a medullary sarcoma coi^pus uteri,or a calls it; judging by the polyposum," as Winkel "myo-sarcoma but number of
cases now

from differing

it in

its

known

it is not

so

rare

an

affection
and
as

as

was

formerly supposed.
The uteri
"

rdtionale
to arrest

of the

deep

incisions

through
is no

the

os

cervix
:

Tlie

hemorrhage hemorrhage is arrested

in the uterus
so

from The

fibroids
blood

stated

follows

because

further
oozes

accumulation away

of blood
and
"

occure.'' noticed

gradually
ovaries the

is not The

much

(?).
entire
a

removal appeal's
tumor

of

the
to be

uterus

with

the

by
moval re-

gastrotomy
of the
"

less

fatal

operation

than

alone."
excrescence

case

of
the

cauliflower
cancer

(epithelial cancer) is
the

one

in which uteri

attacks of
cancer

; but a case the disease which

a

of the

simply the medullary

of the
of and The

surface
cervix

of
form
more

the
is

cervix
one

in

attacks noticeable

tissues

deeply,
affected the jacent ad-

producing
m

very

the

first

instance, which
the

hypertrophy spreads into

free surface.

the

parts

invades
two

parts, including
exist form
or

diseases is

quently freside very

together,etc."
found
more or

Medullary
os

tumor

another
one

of

cancer

other, and
Cases

the growing from less pedunculated.

uteri, on
form

This

is not

common.

flatus is physometra are rare, and instances where tlie vagina stated as being expelledfrom can probably generally admission well-known be explainedby the now tact of alternated the and tion expulsion of air from vagina by a spasmodic contrac-

of

and

relaxation

of the recti-abuominous
so

muscles. in
so cases

The

minal abdo-

tumefaction with
or

frequently

found

without

ovarian

and irritation,

much bv

anteflexion, complained of
Dr. the llewitt
as

of

by being owing to adjacent to the

The Diseases

is but patients, the

imperfectly explained
mechanical

stretchingor
and and

peritonaeum

ovary. of the

Ovaries
macron are

(illustrated by pathology diagnosis,and

and minuteness.
treatment

Ligaments, their miscroscopical diagrams),

suflBcient clearness
"

Broad

treated

of with

In the

of description

ovariotomy,"the

author

Reviews
mentionB makes of
a

and

Notices

of

Boohs.

175

his

abdominal it

by

means

all should three with of

improvements in the buckle-damp, which and fastened No. 4 ring-pessary, bent double to the pedicle is secured wall with adhesive plaster, the operation, no food of its ligatures. After be given by the mouth, but only per rectum,
or more

he the
to at

for

days

to

prevent

the

distention

of the

the

intestines suction is to be

of the inner edge of stretching puruleTit products,pysemia, and death. gas, the with

wound,

Pysemia
of wound
to

treated

brandy per rectum, opium, very careful drying of the of decomposing products thereof,dry warmth
doses

frequent doses

al food, occasionand the removal

of

abdomen,
of

no

moisture. The last three

are chaptei-s

devoted Vulva

to

the

discussion of the

Diseases
,

of the
account

Perinajum

and

; Diseases

Yagina,

being given of the operation for vesico-vaginal fistula as practised by Drs. Sims and tmmet) ; and Diseases of the Urethra Bladder and tary, involun(difficult, frequent, painful, and impossible micturition, caused by or complicatedwith uterine disease, etc.) the A contains various supplementary chapter on sterility of infecundity, causes mechanical, uterine deformity or tumors, illinflammation, vaginismus, leiicorrhoea,ovarian disease,*
(a
short

timed
cure

or

too

frequent
upon the

sexual

intercourse,anaemia,
of the
a cause.

etc.

The

depends
Our review

removal

has, indeed, acquired

; but
to

much

greater length
interest of

than

was

intended originally and

book,
an

partly

a%-oid

the

partlythrough real possiblereproach

of Dr. usual
to

in the

to partiality

American
our

author article to find

(seeReview
overstep
an

Thomas's

work), we
trust

lowed althe

the

limits,and

that

reader
may

may book a careful

in it

inclucement

give

Dr.

Hewitt's

lent excel-

he perusal ; or, if his time do not permit this, from benefit the items in a small way draw some tioned menin the review. Judging from a brief review of the first in the has American

edition

Journal
the

Dr. Hewitt
like Dr. of each

improved
has

Obstetrics, Aug., 1868, arrangement of his chaptere,and

of

Thomas,

affection

and ment treatdiagnosis, giv^n the patliology, the devoted in speciallyto it. chapter

The

arrangement

of the

book
"

arbitraryand
uterine

peculiar, and

little a occasionally may appear the deduction of the majority of

"

affections from

Flexions

little overdrawn and

can

and
so

sided one-

not

of good in the book ; still there is so much contained in other works of its kind, that we

much
ommend rec-

but

it
draw work
an

to

the

professionand
comparison
difficult and

the

advanced it and

student. Dr.

To

accurate

between almost

Thomas'

would

be

very

necessitate
one

doing
to

so

chapter by

chapter; taking both

however, together,

sup-

176

jRevietos

and

Notices

of

BooTca.
need
p.

plement the other,we

desire
on

have

all the information

we

and
f.

can m.

the

present
on

condition Diseases

of

gynsecology.
to

Clinical'

Lectures

Peculiar

Women,

by

Lombe in wifery, Mid-

Athill, M.D., Univ.

King
woodcut 1873. This

and

Examiner and Dub., Fellow Queen's Collegeof Physicians,etc.

Second

edition,revised

and

illustrations.

plates and enlarged, with six lithogr. Blakiston. : Lindsay " Philadelphia
its title

Pp.

241.
as is,

little work

proclaims,a

series of

clinical

lectures delivered
All and

to the

class at the Adelaide

Dublin. Hospital,

speculation is omitted, tended Gynaecology discussed. Inonly the reallypractical part in the it is for students and practitioners not yet versed as of gynaecological intricacies it will be found to contain practice, perienced numerous practicalhints and directions,whereby the inextheory, hypothesis, and
scientific
of

physician will
find or diagnosis,
In connection and and with
a

be

often the

enabled

to

form

correct

employ

condensed

appropriate treatment. nosis diagdescriptionof aetiology,

disease, various

forms ot uterine common complications of the most of manipulation, small pointsaftid technicalities which has the specialist acquired by dint of long practiceor after considerable experiment, are explained in concise terms,
and their

knowledge
the

will

often of

save

much

trouble

and

of the

"

Thus, specular would well it be not to (by-the-by, specula"instead say of the sound, of speculums on page 4 'i\ the introduction kinds various or pessariescommonly in use, the operation
minutiae and digital
"

ance. annoyexamination

"

of incision the
and

of the cervix of the

with

the different

of species

metrotomes,
surface

plugging
Athill

vagina,the
of caustics

applicationof
to

sea-tangle bougies
uterine

sponge-tents,
the

the in

internal obstinate

(Dr. the painting of

nitric
to

strongly recommends liningmembrane

an

menorrhagia
with condition

of the

uterus

strong
due

acid, when

it is in

unhealthy granular

been

inflammation, the cervix and os internum having efliconsiders and this method more previously dilated, the cacious, safe, and reliable than inti-a-uterine injections or
sub-acute

curette) and
as

to the

cervix, etc.,are

all described

in their

chapters
this branch of

and

adapted
many useful and the of

to

it does

special indications. the latest practical innovations

by
its condensed the

their

respective taining Conin

medicine,

it will
to

arrangement

occasionallyprove
advanced
a

student and be

experienced specialist ; to the it will be found general practitioner

work
; and
to

valuable
to

convenient

these

men,

for whom it.

F. M.

it

claims

written,we

take

pleasure in recommending
p.

178

"

Parry:

The

Hiatcyriea

of

Three

Cases
In upon
dition con-

symptoms
one

of
the

rupture of

the

uterus

may

be
are

absent.

of

patients

whose

histories

put
of the

record

all to-night,
were

of the

typicalphenomena
in another is aware, instance

absent, while
as

unusual,

and,

so

far

the writer

unique

and

previously

undescribed,symptoms
Case I.
"

presented themselves. Mwpture of

Uterus

Rachitic

Dwarf.

from

Neglect.
Mrs.
about

E., aged 23,

full term, March
but

an

American, 19th, under

fell the
care

into of
was

labor
an

at

ligent intel-

inexperiencedobstetrician.
48

She

dwarf,
chitic ra-

being only
in

inches

high, and
Her

had

probably
in

been

infancy. They
child

labor-painsset
continued

during
the

the
20th the

night
and head
P.M.,

of March

19th, and
were

during

21st.

during this period,and slight

be

of the
on

could

felt

presenting. "frequent
and her

About

2^

the

21st, they became

recalled

and

hard." her

Her about He
was

physicianwas
15 minutes

immediately
head of

reached

afterward, when
the
"

pains had
child,and
woman

ceased.
the
os

could
"

just reach

the The

tolerablywell
and
were

dilated. she
was

said Her skin and

that
was

she

felt very
she

badly, and
was

uneasy. the

moist
nseum

very and

pale,while
relaxed. At of

vagina

peri-

moist

4^^ p.m.
the

mity, pelvic defor-

and

decided

conti*action She

anteroposterior
no

diameter, were
head
than
was
was

diagnosed.
the

still had and

pain.
more

The
blood

felt above
was

promontory,
the

usual
seen

from issuing Dr.

vagina.
not

At

p.m.

she

by

J.,who
The

could

feel the head

more

above

the

promontory.

bleedingwas

profuse.

An

of Mwptv/re of
hour The later the loss of blood head
could
was

the Uterus.

.179
and

decided the

increasing.
The and
posterior antero-

just be
of the
2

felt within

os.

diameter
not
to

pelviswas
The
could
os

measured,
and

ed decidwere

exceed

J inches.

cervix uteri

and flabby,

clots of blood Uterine

be
were

felt before

reaching
; the

the head.

contractions
of

still absent of

patientcomplained
lower her
A

feelingbadly, and
Her face
was

pains in pinched
made.

the and

part of the abdomen.

weak.

pulse rapid and diagnosis of

and

internal
were

hemorrhage

was

got Erwas

stimulants

directed, while

the

vagina
there

tamponed.
At been

9i
but

P.M.

she

was

much

worse,

though
the be
not

had

little external

bleeding after
the
not

introduction

of the

tampon.
to

The

forceps could

applied,and
it
was

owing
decided

the that

extremity of
she

woman's survive

condition the hour

could died

operation
and
a

of

craniotomy.
later.

She

collapsed an
the

quarter

Autopsy,
the The
anterior

"

^Upon opening
wall

cavity of
clots
was

the

abdomen,
in it.

child,placenta,and

several

were

found
above juvst

of the uterus

torn

the
the
was

bladder.

The
were

walls

of the organ

in the

vicinityof
the fundus The
os

ruptui'e

exceedingly thin,
and

while

thick, hard,

contained
above it

some

clots.

and

pointsimmediately
blood.
The

were

filled with

coagulated pelvis:
"

following were
inches.

the diameters

of the

Antero-posterior,2\ inches; transverse, oblique, 4^ only

four The

J inches;
was

height

of

the

woman

feet.

180

Paeey

Tlie Histories

of

Three

Cases

The matic

child
and

was

of

average

size.

The

cervico-breghead
ured meas-

of the bi-parietaljdiameters
the

dried

nearly 8^ inches, while

4J and
the

was occipito-frontal

occipito-mental 4J
"

inches,

Hemmrhs.

^This the

histoiy
was

is
not

exceedingly

instructive.

Rupture
seems,

of

uterus

hardly suspected until gentlemen

symptoms
that in attendance

and, it diagnosticated, had the woman perished.

The
grave

fully appreciated the

themselves, and they
of the

which another

manifested

concluded
room,

serious accident had of

set in.

lying-in
likewise

concealed

hemorrhage,
off their
was

They
the

fully recognized the gravity

but
severe were

the

pelvic deformity,
absence

thrown

guard by
noticed The
"

of

which labor-pains,

during
the

the whole
but

of the

parturientprocess.
about
even

patient made
until ceased before

little of

complaint

her

"

pains
he

afternoon
her

Tuesday, and
reached

then

they
was was

cian physiwithin

her, though
after he

.at her bedside called.

It

twenty

minutes

is

probable
that
uterus

that the laceration

but
was
one

occurred

at this time.

It

seems

characteristic
this
case

symptom
; this
was

of

rupture of the
the value

present in
from

recession of the child^s of this

head

the brim

of the
to

pelvis. Upon

it is not

necessary

since insist,

it is well

recognized.
Deli/oer

Case

Failwre DifficultLabor. Forceps or Version. Craniotomy.

"

1L

to

hy
the

Rv/ptnire of

Uterus. Mrs.

Recovery.
27
"

G., aged
with

primapara
Mustin
at
on

"

seen on

in

tation consul-

the late Dr. Labor had

7 p.m., the

Tuesday

evening.

conmienced

previous Sun-

of Mwpimre of day morning.

all
were

the Uterus.

181

The
and

pains
the

had

continued

strong during
The
waters

that

day

succeeding night.
a.m. on

discharged
and

at

Monday.
suffered

During
but

the

day
in
no

succeeding night she

Dr.

much, when

called
moned sum-

physician until Tuesday morning,

Mustin,
who

she

found
and

the moist

pains strong, the

The the

os

dilated, the vagina cool

was a

head, which

large one,
extended

was

presenting at
that the

superior strait
It
was

in

the

position. right occipito-posterior

so

tially par-

diameter occipito-frontal of the

was

in the advance

oblique diameter during

at

pelvis.

There
was

was

no

the

day,

and

the

following
were

her

condition

my

visit.

Her

pains

very

strong,

pulse good, tongue clean, morale

hot
There and
was

the excellent,
and

vagina
of the

dry, the dischargesbrown

a

rather
; the

offensive.

large caput-succedaneum
left the uterus, and
was

head down

child the

had

not

forced

into

superior strait.
to
secure

Attempts
and

flexion faileA

Ether

was

istered, admin-

Simpson's forceps were

traction
was

applied with
until
11

great

difficulty.Strong
but

made

o'clock,
a

without
a

producing
over
an

the least effect. inch

At

this time

fissure

little

long

was

discovered
not

in the

lip of posterior
the
not

the uterus.
organ, and

It did

extend

through
did

tissue of

the

reached

down

to, but

involve, the vagiua.

The
was

forceps
to
so

were

removed,
was

and

cautious

attempt
The
rus ute-

made
was

turn, but

soon

abandoned. that there

was

firmly
be

contracted without

no

hope

that it could
A

done

rupturing
with

the organ.
was now

large

dose

of

morphia

stimulants

182

Parey

TTie Histories

of

Three

Cases

administered,and
3
A.M.
on

attempts

at

delivery suspended
when Dr.

until

Wednesday applied
hours

morning,
and

Wallace's
ceeding suc-

forceps were
four

traction made
any result.

during the
It
was

without
to

now

determined after
the

to resort

craniotomy, and
membranes the

hours fifty-two

rupture of the

operation was
hours

commenced, after the

most

Delivei^
violent

was

effected
The

three

later,
but
ure meas-

efforts.

pelvis was
a

contracted,the difficulty slightly being in

due
to

great
and

the

large size of Immediately

uterus

the child's

head

its firm

ossification.
a

after the labor

was

was

ed, completnearly five

rupture of the

discovered.
and
uterus
an

It involved

the

posteriorsurface long.
that

of

the

organ, the

was

inches

The

cavity of long. The

of the

communicated
at least two

with inches

of the
a

peritonaeum by

aperture

and

half

were fingers

thmst

through
the

this into
were

the

cavity

peritonaeum,and

tines intes-

felt rollingand contracting beneath distinctly

The

them. and
to

margins
The

of

the

rupture
the

were

quite regular,
of
a

certain

conveyed degi^ee hemorrhage.

exhausted. her
friends The

idea

clean

cised in-

wound.
was

placenta separated readily.

woman
was

There

but

little
very

replaced
of
we

in
were
no

bed

much

Large

doses

opium
had

and prescribed,

informed

that

hope
The

of her

recovery.
saw

writer
could

her be

but found.

once,

afterward, when
was

Dr.

Mustin
from

not

She

which was general peritonitis, she fully recovered, and it is but, notwithstanding this, said upon good authority that she has since given birth
to
a

suffering extremely severe ;

then

livingchild

without

difficulty.

of Rv^tv/re of
Remarks.
was
"

the Uterus.

183

^The

rupture
the usual

of

the

uterus

in this

case

unattended

by
reason

pain
ether.
first

and

profound shock,
while the
was

for the
was

simple
the when

that

it occurred
of

patient
tered adminis-

under

influence

This

the

forceps were
detection of the
actual

applied,shortly after
in the

P.M.

After

the

of

the fissure
were
was

cervix,
measure

the contractions

uterus

in
not

great

suspended, but
time. The
as

rupture
was

suspected at

the

morphia
much be
as

traction given to prevent uterine conments possible until craniotomy instru-

could has

procured.
us
as

The

laceration
somewhat of the

in thi"

case

always
that

struck it

being

peculiar,in
characters from of
the

the fact
an

presented so
There
was

many
no

incised

wound.

hemorrhage
the

vagina, nor
The
blades

did the head

not

recede.

injury was
of
the the the

caused

by

forceps,since
into with

the the that

instruments, though
uterus, did
organ
no

introduced in contact

cavity of
The

not
was

come

portion of
Mustin. any before

which

torn.
was seen

patient took
The

ergot after she

denied that

by

Dr. her

midwife

she

had

given

his arrival.

Case

III.

"

Disproportion
ChilcPs Head.

between

the Size

of

the Pelvis

and

Left occipitoposterior position.

the Uterus.

Ituptv/re of Forceps.
M.

Delivery by

the

Death.
22

S., a primapara, aged

years,

fell into

labor
She
was

in

the

PhiladelphiaHospital,March
the
to
care

29th, 1873. Stone, resident

for the

under

of
I

Dr.
am

Edward indebted

cheur, accou-

whom

following

his-

184

Paeey

TTie HiHories

of

Tli/ree Cases

toiy.
learned
the

Dr.

Stone she

was

summoned
suffered

at

9.30

p.m., when

he

that

had

from

labor-painsduring
waters

entire

day,

and

that

the

bag
was

of

had

already
abdomen

ruptured,though
could
was

the

who girl,

rather

feeble-minded,
The

not

tell when

this had

occuri'ed.
on

imusually prominent, and

the
outline and uterine

palpation
the The

Dr.

Stone

distinctlydetected
the abdominal with
The median line
OS

of

foetus
head

through
was

walls. the

senting pre-

the

occiput to
heart
was

left sacro-iliac heard

to not

drosis. synchonthe

foetal of
was

the

left of

the

mother,
one

and

was

very half

distinct.
in eter, diam-

The

uteri

about

inch

and

and strait. mother's

dilatable ; the head

No

above entirely

the

superior
:

contraction
was

of the

brim
her

was

detected

the

condition and

good, and
of

pains were

tolerably

strong
At

frequent.
P.M.

11

the

dilation

the

os

was

nearly
set

plete, com-

and

strong expulsive pains had

uterine
The
tumor
was no
more

in, during
than
nor

which is usual
was

the

prominent
to bear

patient had
to
on

desire

down,

she At
5

urged
A.M.,

do the

so.

20th, the

head

had

entered cranial

the bones

pelvis.
the

It

was
one

somewhat

compressed, the
and there
was a

overlapped
over

another,
The

large caput
was

vertex.

mother's
of

condition tired.

good,
ejected
of

although
At
matters

she

complained
she
was

being

A.M.

vomiting profusely.
had the face

The

were

dark-colored, and
Her
and
was

appearance

coffee-grounds.
160
not

pale, hands
She
was
was

cool,pulse
did

per

minute of

feeble.

drowsy, but

complain

pain, and

satisfied with

relief

186

Paeby

The the

Histories

of

Three

Cases

of

the

child

for

f/rsttime.

The

placenta
more

was

pressed ex-

by
The

Crede's

method,
ceased
became

without

than

the ordinary

loss of blood.

vomiting
the abdomen

after
very

but delivery,

in

short

time

tympanitic,but
the

the tenderness

disappeared. During hemorrhage,

sufficient to stain and exceedingly restless,
21st

night
or

she

five

six
at 5

slight came napkins, bea.m.

on

had

died

the

Autopsy.
A dark the thin

"

Five

hours

after death. of trunk

are

and Face, lips,

posterior portion
resembles
was

livid.

fluid which She

coffee-groundsflows layers of
a

from

mouth.
"

59|- inches high.

visceral of the

Abdomen.
are

^Parietal and

naeum perito-

deeply injected and

a

brilliant red color. the membrane.

There The thick

was

little recent
was

lymph

upon

bladder and
dense.

empty, strongly contracted, walls

The
mucous

membrane

was

injected,
Near effused
a

over especially

the

surface posterior

of the organ.
had been
over

the middle
into and

of the

posteriorwall,blood
the
mucous

beneath
inch
was

membrane The and

mucous

space
at

nearly an
the fundus

in diameter.

membrane

thickened

oedematous. of the womb

Uterus.
was

"

Before

the removal

fluctuation
From

detected

in the utero-vesical

peritonseal pouch.
and
a

thence
It
was

it extended

upward
the

for three whole

half

inches.

perceptibleover
extended

of the left side of the the

uterus, but
The
was

little

beyond
space
was

median

line.

peritonaeumcovering this
detached could from
be
seen

deeply injected,
fluid

the

surface it.

of At

the uterus, and the

upper

blood

beneath

margin

of Mupl/ure of
of
and the

the Uterus.
"

187

large fluctuatingsurface by
one

was

smaller .The two could

one,

two

inches three-quarter
a

in diameter,

cavities

communicated

canal,and
the

the blood

easilybe ment, ligathe

pressed Upon
was

from

to

other.

the left side of the

a

uterus, in the left broad

which

tumor large fluctuating

nearly filled
was

that

side of

the

pelvis.
of
the

Its upper

boundary
The

superior margin
reached
the the
a

broad
os

ligament, and
uteri.

below, it
contents

point opposite the

removed, with

of

pelviswere
The

considerable
to

portion of Upon
the

peritonsBum,by cutting close

uterine

the

pelvic walls.
of the

cavity was
organ,

nine inches
the

long.
five

left side of the cervix

and

just above
a

attachment inches into

a

vagina,was
the
was

rupture
be

long. large
of
not

Through cavity
blood. and fluid, It

this

hand

could

passed

which
was

partially
of the

filled with

coagulated
a

capable
formed
had

holding nearly

quart
was

was

by
been
as

peritonsDum,which
up
over

torn, but

which

dissected

the anterior
over

siuHface of the
a

uterus,

previously described,and
of the
organ.

portion of
The the

the

posterioraspect
blood

tissue of the broad left the effused

ligament was
was

largely destroyed.
in contact

On the

almost
not

with the

pelvic wall.
sheath
rent

Below, it

did

extend
a

beyond

point mentioned, though

the of the psoas
was

it involved

small

portion of

muscle.

The

longitudinal.
of
a

The

edges
The stained

were

what some-

were irregular,

deep-red color,and
bruised. dark
was

had

the
face sur-

appearance

of

having
was

been very

external

of the uterus
The

and
near

with

blood.
on

attachment placental

the fundus

the

188

Paeey

Tlie Histories

of
The

Three

Cases

right
the

and
no

posteriorsurface.
evidences of disease. Dr.

uterine
was

tissue

sented pre-

It

examined
that

with it
was

microscope by

Bertolet, who

states

healthy.
The
and
stance.

right ovary

was

normal. blood
was

The

left

was

ged, enlar-

nearly black
of the

effused

into

its sub*

The

brim

pelvis measured
five and
a

four

inches

in the

and antero-posterior, diameter. The

There with
tumor

half

in the

transverse,

other
is
one

organs

of the

body

were

healthy.
connection
that the has

point in extremely interesting

This
over

this

casa

is, the

fact before

fluctuating
of
been

existed So

the
as we

pubis

death

the
ticed no-

patient
The
tonaeum

far

know, this

never

in connection
occurrence

with
of
a

rupture of the
a

uterus. rent

rupture without
fact

in the A

peri-

is likewise
case

worthy by

of note.
Dr.

somewhat
of Manchester,

similar

has

been

recorded
on

Radford,
of

in his

able paper

lacerations vol. viii., p.

the

the uterus.
In this of the

(^Trans.Ohstet. Soc, London,

instance the

187.)
side foetus

rupture

was

upon and

right

uterus, and

the buttocks

body
when

of the

escaped
reached
two

through it,tearing up
without
so rupturing it,

and
that

separating the peritonaeum

Dr.

Radford

this

whom patient, in the

he

found

dead, he discovered
"

tumors

abdominal

cavity
the says

one

the

large uterus, by
the of

the

other

the
Dr.

body
Radford
no

of

child
"

covered

naeum. peritomedical
"

The

records

science the
one

furnish which

case

bearing
described.

the least The

analogy

to

he

has

only

difference

of Ituptv/reof
between related the

the Uterus.

189

historyrecorded
in the The
seems

by

him

and did the due

the
not

one

just
escape

that is,

latter

the child of

through

the rent.

separation
to tore

peritonaeum
to

in this instance

have
up

been the

the hemorrhage,
until it

which

slowly

membrane has
a

produced
and and

the
was

large cavity which

characterized

been

described,
tumor

which

by

supra-pubic

fluctuation.
are

There

several

points which
cases

are

presentedfor
been

sideration con-

by
the
to

the

which
error,

have the

related.
was

In

first,through

an

patient
made

allowed
to

perish without

any

attempt
the

being

effect been
or

delivery. Undoubtedly prevented by

Csesarean
a

accident
to

might
hope
to

have

timely
no

resort
one

craniotomy
of

the
a

for section,

could

deliver But

living child
this not combined indicated with the back

through
been the grave upon

conjugate

2\

inches.
of

having

done, the

recedence

the

head,

profound collapse and hemorrhage,

character

of from

the
our

accident, and,
"

looking

the is

case

present
This

point, standwas, to

the indication

dear. sufficiently the

perform gastrotomy, and, removing

dines, and
have that clots of blood

foetus,secuncavity,to only
the chance

from

the

abdominal the
Dr.

afforded
there
was

the

unhappy
to

patient
recover.

for her

Trask, in his
of
uterus

admirable

monograph
Jour,

upon

rupture
and

{Amer.
and

of

Med.

Sciences^Jan. think, shown

proper

April, 1848,
of
one

July, 1856), has, we

have been

that conclusively
treatment

this would under

the

the

method

cii'cumstances.

Certainly no
of Hunter

would

vocate ad-

at this

day

the doctrine

and

Denman,

190

Paery

Tlie Histories

of

Three

Cases

that

these

cases

should

be

abandoned
be

to

nature

; but

larger
attempt

number

might probably
rent

found

who

would it

to relieve

by introducing the hand, passing

in the

through
in

the

uterus,

seizingthe feet,and
successful this may
be

attempting to pelveswhich
in

extract.
are

However

ample
to

in size, the

procedure
of the
there
case

would when

certainly add
undertaken of

much
a

the

dangers
which

pelvisthrough
unmutilated
are
so

is

no

hope
the
a

extractingan
of

foetus,and great
as

in which

dangers

craniotomy

to

make

it

ribly ter-

grave

operation in uncomplicated
the patients between
cause

cases.
was

In all of these
same,
"

of the rupture
the size found

the

disproportion
and the

of

the

child's

head
to

pelvic brim.

Trask

this condition
cases

be has All

present in nearly one-fourth

of all the

which

he

analyzed.
the

histories

here

related

illustrate in

marked

degree the influence

Sir James Y, called

of

or delay in delivery,

rather

what

Simpson

{Obstef.Works

8vo, Phila.)
dent. acciwas

protractionof the labor in producing this In the first patient,operative interference

should
was

clearlyindicated, and
soon as

have dilated

been
or

commenced

as

the

os

uteri

dilatable.
efforts

The
to

patient
relieve The and had

lost

nearly

three

days

in

fruitless

herself.

history of
she
so

the second

patient is nearly analogous,

the life temble accident have been
been her

had

timely assistance
her

which

nearly destroyed
attendants
of

might
have the

prevented,and
the

might
The

spared

dreadful

alternative of her

plunging

perforator

into the head

child. living

third

history is

of Rupture
and equallyinstructive, of whole
over as

of

the Utenis.

191

delay

in

forciblyillustrates assisting delivery. It is true

of labor
was

the that but

ger dan-

the
little

duration

not

great, being

twenty-four hours
from
o'clock

; but

the

bag

of waters
until

ruptured
five

early,and
and
to
seven

eleven

in the

night

between

the next
very

morning
this
no

the uterus

continued

act, though
the

not

without violently,
At

materially
overworked
gave
to

advancing
organ could better

labor. the

time

the

bear

strain
of

and longer,

way.

No

illustration could
be the

the

dangers
; and

due

tion protrac-

of labor
to

detailed fact

it has

called forciblyre-

the writer

he that, a short time since, that if the

more

publicly stated
labor

in this hall

second

stage of
two

should
any

continue advance

for actively of the be

than

hours
of

without

head,

the

propriety
to

aid,

ing
**

the

patient should
is
more

considered. seriously
the writer Year in admit

No

one

willingthan
maxim uttered
vast

that
we

meddlesome heard
are

midwifery
this

is bad."

after year and

have

lecture

debate.

We rior

told

that in the head

majority of occipito-postedescend, rotate, and

the be

positionsthe
with
the

will

livered de-

occiputunder they

pubic
in the

arch.

Patience of

is the these their the

watchword

of accoucheurs
are

management
sit

and positions,

told

to

supinely by
until bora.
no

watching patients, suffering

has
occur

the throes of labor

been

child's head this will of any

are

descended, rotated, and

in
a

That
man

large majority
have
the
a

of instances

can experience

shadow

of doubt
a

; but

there

cases

in which

delivery of
mother
or

livingchild offspringis

without

injury to

either the

her

and practicable, perfectly

in which, if left to nature, the

192

Parry

Rupture

of

(lie

Uterus.

result

may
does

be
not

fatal

to

one

or

both.

Judicious the the

ence interferskilful

jeopardize
better
than
not
err

either
"

nay,

more:

operator
version

had

in

resorting

to

forceps

or

early
We do

in

postponing
to

either that

operation
we

too
to

long.
rule

hesitate

repeat,
to

adhere consider

adopted
of

several

years

since,
when the

gravely
second

the labor
Thus
not
"

propriety
has

interfering
two

stage
advance.

of

continued fearful

hours of medical his

without uterine

any

the

accident
and the

ruptui-e

is

prevented
the

treated
"

attendant
hand
to

avoids

ble disagreeainto

task the

of

passing

through
seize
the of

the
child

laceration and

abdominal
the

cavity contracting
it

drag
the

it

through
and

wound,
the

or

opening
Thus

belly
he
comes be-

extracting
not

through

incision.
but the the

the

substitute As

for,
such

handmaid

and

assistant
to

of,
the

natui*e.

intelligent
patient,
of
in

physician
the
the and
sore

goes
hour

bedside

of with

his

suffering
a

of

hef
resources.

travail,

full

knowledge
of his
and 1
"

extent

of in
"

his their

Conscious
he

powers

strong

possession,

anticipates
is bad

prevents

danger.

Meddlesome

midwifery
are

Delay

and

timidity

in

operating

bad

194

Lee:

Remarha

upon

the

In

women

it
more

sometimes

follows

ovariotomy

wlien

oozingor
from the the

takes place rapid secondary hsemorrliage

pedicle;

in other

cases

it is diie to

rupture of

Fallopian pelvic tumor

tubes

during

extra-uterine
is
so

though alfoetation, that

this lamentable the

accident has time

rapidly fatal display its

veins

seldom

to

teristic charac-

symptoms.

Rupture
broad

of

the

ovaries, of
aneurism

varicose

in

the

ligaments,of
walls

of the

ovai'ian artery, of
all been shown

the vascular

of ovarian

have cysts, the

by autopsic
hsBmatocele. These
be But ranked
cases

examination

to be

occasional

cause

of

are

so

rare

that

they

may

perhaps by
or

among

the curiosities of medical

and

observation.

what

is

commonly

property

understood

gynaecologistsas "pelvic"
blood into the

"peri-uterine," "retro-uterine,"
or

hsematocele

hsematoma

"

an

effusion arrested

of

pelvicperitoneum, due
of menstrual the

to

struation, men-

reflux

blood, or
in
a

to

direct transudation
or

from rotic state

than in

pelvic vessels
more

purpuric
am

chlolieve, be-

of
is

health, is

frequent,I
In my

led to

generallysupposed.
the
seen

own

practice
cases

this

city dm*ing diagnosis

an

last six years

seven

have
in

occun'ed, all of them

all the without effects
as

by

other

and physicians,
out
as

accuratelymade
;
as

is

possible
the
tainty cer-

autopsy

only one
reach.

of them

died

(from
of

of
was

that secondary septicsBmia),

element

beyond
I

our

This
the

experience may
errors

sibly pos-

be into

exceptional ; but, from

was

of of

diagnosis
cases,

which

at first led in several

these

I incline to think

they

may

often

pass

without

recogni-

Diagnosis of
tioiL in I

Pelvic

Hcematocele.

'

195

must,
a

however, acknowledge
paper in the

my

amazement,

reading

St. Thomas'
to

Hospital
no

ports Re-

(of London)
53
cases

for in

1870,
the

leam

that

less than author in in tion quescon-

occurred years. Robert

practice
that

of

its author

the last ten

is Dr.

It is true

the

Barnes, who

enjoys an
in of four the

immense
or

suitingpractice in obstetrics,and
gynaecologicaldisease;
in extra-uterine
cases

recent
cases

acute

that

he

tails de-

originatedin rupture
pregnancy,
cause
as was

of the while

uterus, and
in
to

five others additional could ducting de"

three

the
be

same

supposed
total
to

exist,but
:

not

proven,

the

patientsrecovered
a

yet, even
years

these,
ratio On

we

have

of
me

41

in ten

which,

at

seemed first,

exceedingly large.
however, subject,
for of haematocele I

looking more

carefullyinto

this

find that in the Berlin

Archivfur Oynakologie*
Halle, reports 34
while
in
cases

1870,

Prof. Olshausen, of
in 1145 had
met

gynaecological cases,
with
66
cases a

Seyffert,of Prague, Perhaps

"it is
cases

total of 1272. he

Dr.

Barnes
necessary order In this

is right, when therefore,

to

insists that

only
in

look

with

for intelligence

these

to

find them."

May, 1872, Dr. subject before

he
of Dr. that

Alfred the

Meadows

read

paper

upon

London

Obstetrical
accuracy

Society,in diagnosisin
and
asserts

which
a

sharply questionsthe
Barnes's the
But

of

number

published cases,
of
the

his
much

conviction

frequency
in the

affection
of this paper

is

exaggerated.
shown that

discussion
had

it

was

Dr.

Graily

Hewitt
; Dr.
Heftl.

seen

12 25

or

15 ;

cases

within

the last five years

"Baiidi,

Greenhalgh

cases

196

Lee:

RemdrTca

ujpon Dr.

the
Hicks and the

Dr. Tilt 12 Mr.

cases

in 20

years.

Braxton

Spencer
common

Wells

thought
occurrence,
rare.

the
but

lighter forms
the
cases

of

disease of effusion
The all

of extensive

comparatively
recent

German haematocele
whom

authorities, excepting Scanzoni,

to
we

consider

be
are

frequent,
indebted
its for

while

the

French

writers,to
of its

dation the eluci-

pathology
it
a rare

and

nearly all
Bemutz each

ture, early literaand

thought
and

accident.

Goupil,
few
; Nonat

Huguier, N61aton, Voisin, Vigu^s,

cases,

specify a

describe

them

with
which

much
one

minuteness

tabulates Trousseau

fifteen,of

only
on

was

fatal, and

gives

an

elaborate
"

lecture

the

subject in ancy discrepupon the

the fifth volume

of his

Clinical Medicine."

This

of

observation
many

is

explained by

Dr.

Tilt

suppositionthat
have
some

of the

allegedcases
in the

of haematocele he instances
to

been

and simply pelvic peritonitis, Barnes's

cases

of Dr.

paper

referred
most

in

illustration.
and

In this country
of

by

far the

thorough
in Dr.

systematicaccount
Treatise
come
on

the

subject is given
of
Women. of

Thomas's
cases

the
his

Diseases

Ten
one

have

under

observation,
the

which

died

of

general peritonitisand
One in the of

rest

made

good only lished pub-

recoveries. last month

these

was

treated successfully

Woman's

Hospital, and
York the
in

is to be

in the next As
are

No. of the New

Medical

Journal.

the
so

essential

points in

diagnosis of
Dr. Thomas'

haematocele
account

painted graphically
"

of

its onset, I shall quote his

:

entire. description
occurrence

He

says

The

absolute

of which
are

haemorrhage

is

preceded by symptoms generally

premonitory.

Didgnom
as

of

Pelvic

Hcemaiocele.

197

fixed

dull

pain
The in

over

the

ovaries, derangement
the

of

struation, men-

metrorraghia or prolongationof discharge.

will

menstrual of blood

symptoms

of the actual
upon

escape and

depend

great degree
which
has

the nature
rise to it. violent be
to

gravity
and that of

of the

accident

given
any It will due

Sometimes

the affection almost without

occurs

without

symptoms

warning.
so

appreciated gradual
reflux

this would
blood
on

be
account

if it

were

of constricted

cei-vix, or
sudden

transudation,
manifestation
as

the result of

of purpura.
occurs,

Generally a
and the

symptoms

accident

is announced

rapidly as
"

is cerebral

apoplexy.
the

Most

prominent
Severe Faintness Nausea

among
in the

symptoms
of the

are

"

pain
and

pelvis,
extremities,

and

coldness

vomiting,

Metrorrhagia,
Uterine
tenesmus
"

^Tympanites,
bladder
and

Interference Febrile
"The in the

with

rectum.

reaction.
as

patientfeels
and pelvis,

if

large and

heavy body
to

exists the

strives instinctively

expel it by
acute;

vagina.
"At others abate

times it is
in
a

the
dull

pain complained
and
a

of

is very

at

heavy aching.
few

These

symptoms

severityin

days, and
and

are

replaced by

Great Extreme

exhaustion

feebleness.

paleness.
to
"

Tendency
Great

chilliness.

of urine. Constipation ^suppression

tympanites ^Apyrexia."
"

198

Lee

Hema/rha

wpon touch

the reveals
almost

He

further

states

that

vaginal

tumor

generally posterior to
that the

the

vagina
that
a

and

closing
of

canal; that
bowel

rectal

touch
and

merely
hard

shows

closure

by

pressure,

abdominal
mass

palpation extending to graphic, but previously

if the three

will disclose the the

presence
or

of
the

superiorstrait

to

naveL
terse
as

This admirable
observed

descriptionis
attacks

not

only

and

in all its details

for such

have

of

haematocele.

To

others,however,

the very

fulness

of detail is

confusing; and pelvicpain,

striking symptoms
Severe

of
or

abdominal

Vomiting,
Faintness
were
an

and

collapse,
would
cover

alone observer
of

specified, they
is

all the

pomts
severe

likelyto
at

notice when
the

called

to

case

hdBmatocele
cases,

inception of
seen
an

the attack.

In

milder
less

and

in those
to

at

later

period,it

is of for the

importance
time
and
cases

make

immediate
upon
to be

diagnosis ;
nature

ample
disease
as

is left to
upon the

decide

the

of But

treatment

pursued.
effusion

if,

in the

to be

cited,an

extensive

of blood

be mistaken
not

for bilious

for hysteria, for septicaemia, colic, be

only
It

may

precious time
which
not

lost,but lines

of

ment treat-

adopted
lives.
occurred in
seems

will

cause

the sacrifice of valuable these

or cases

improbable that,as
others
; and

have
occur

under

my

observation,they have
it is
"

will

the
were

practice of
cases

because precisely and

so

they
which

of mistaken
to

diagnosis
the local is

mistaken
upon
to
rest

because

they
the

failed

present

symptom

decision

of

haematocele

supposed

Didgnosia of
"

Pelvic

HcBmatocele. of

199

^tbat I

think

them

worthy

being placed

upon

record.

Case

I.
"

^A.

K.,

8et.

strumous 31, single,

and

ingly exceed-

delicate.
this
at
a

During

the last week

sat
on

of

August, 1871,
the

patient,while Long
Island On

menstruating,
felt

damp
hours

grass in the

country place for

several

afternoon.

risingshe
flow seemed the

and slightly chilled, On

the

followingnight her
to
see

ceased.
an

Sept. 6
but
an

was

called of colic
most
:

her

for what

agonizing attack
abdomen,
was

the

pain pervaded
on

whole of the

tense in-

the

left side and

pelvis;
and

unaccountable
this

amount

of shock
was

prostration accompanied
and The

pain,

the

pulse

feeble

thready
matter

there

was

trollable uncon-

vomiting.
was a

from ejected
came

the stomach
in such tities quan-

thin bilious
as

which fluid,
to

away
one

to lead

me

think

the and

case

of bilious

colic,

the

patient being
believed
was

sallow

obstinatelyconstipated.
to

The
was

thready pulse was

to

attributed
On

the

shock

which
the

be
more

nervous.

the

following day
attacks
was
so

exhaustion

alarming
lest she

; several

of fainting

occurred, and
as

the

condition patient's should

prostrate
'

to

cause

anxiety

die

of

syncope.

Under
Dr.

these

circumstances

her former
was

family physician.
in

McClellan, of Brooklyn,
aided
me

called From

consultation,

and
case,

with
was

his advice. from

the

history of
failed

the

haematocele
the
most

the first suspectedas

possible,
as

but
to

careful

vaginal examinations
A very

yet
of
"

detect of

any the

enlargement.
anterior

slightamount
was

cedema

vaginal wall passed

perceptible
any

nothing

more.

week

without

notable

200

Lee

Bema/rhs

upon

the
and and

change;
the

the

pelvic pain,
rectal

nausea

vomiting, and
several
made

excessive
and

prostration continued,
examinations
were

fi'esh

vaginal
attack, a
wall
was

without
of

12 days after the beginning avail,until finally,

the

very

bulging slight
at

of

the

posteriorvaginal
the

detected the
of
rectum

the this

extremity of
was more

cul-de-sac.
gave

Through
evidences hsBmatocele which
become the

and distinct, of
a

and fluctuation, seemed evident.

the existence Two

diffused

days later, during

added the

effused

liquid had
confirmed this

partially coagulated and

was

more

Dr. Metcalfe distinct, and the

to

consultation

diagnosis. The
somewhat
uterus
wjis

quent subse-

historyof
As and the

patientwas
attack of

remarkable. anteverted
in

haematocele
a

solidified the

fixed;

sharp

perimetritisensued,
as

which
a

the uterus diffused

itself

participated ; and,
filled up and and

sided, this sub-

indurated
and ovary

deposit involving the

the left side of
rectum

left the

broad

ligament

both pelvis, deflecting After

severe
a

uterus

to

the

right
of

tedious

convalescence the

frequent attacks
married
at
once

dysmenorrhcea,
from

patient

in

seven

months

the date

of her

and illness,

became she

pregnant. In

the third month

of her pregnancy
a

again

sought
which

advice
was

for the

relief of
as

dragging pelvicpain,
the left side.
to slightly

most

severe,
a

before, upon

Examination
the and right,

revealed
a

gravid uterus
movable
connected
mass

flexed

diffused
or

in the left iliac

fossa,either

ovarian
a

with
tumor

the

left broad

ligament;
as a

while

third

bulging

nearly as large
Dr.

foetal head
saw

filled the

right iliac
at
a

space.

Emmet,

who

the

case

with

me

period when

the uterus

202

Lee:

Hemarhs

upon had

the ceased

and illness,

her last menstruation

full week pation, constia

earlier.

A had

sharp

attack the

of

pain, with
on

obstinate
the

followed
was

exposure

ferry-boat ;
case one

physician
colic, had

called

in,and
several abdominal very

believing the pain, and exhausting

for
was

of

ordered the

strong purgatives,which

greatly increased
a

brought
and

on

diarrhoea

that

proved

in1ii*act-

able. The little

or case

remained

under

my

care

week,

with

no

change
led

before of the
more

hsBmatocele
left iliac

suspected. A
then served, obtions examinawas

tumefaction slight
and of the
to

region was
careful

frequent and
a

pelvis:
of the

vaginal
could
"

examination

tained, ob-

but

nothing more
uteras

be detected

except slight
not

anteversion Another
stomach

^itsmobility was

affected.
the

week

passed
tender

without

important change,
abdomen the

retainingalmost
and

nothing,the
upon pressure,

slightly pain

tympanitic kept
A second
an

intense

in check

of morphia. only by hypodermic injections

was now

careful examination indistinct

:

made

per

vaginam,
the up

and

bulging
when
the
more
was

was

perceptible through
carried
no

posterior wall
the rectum
be traced of the
case

finger was
but distinct,

high

this
in

was

outlines The it
was a

could

it,nor

there
me,

fluctuation. that

history
haemaas

convinced
not

however,

tocele,and
first

cellulitis of the utero-rectal

In
a

space,

I at

imagined.
Dr.

few

days

more

it had

partially
town
a

and solidified,
at the

Metcalfe, who

chanced

to be in

time, was

called in

consultation,and, after
the

very the

careful

exploration,confirmed
The

diagnosis as

in

previouscase.

from prostration tendency to collapse,

"

Diagnosia of
blood, and
the

Pelvic

Hcematocele.

203

loss of

other

symptoms
for

usually attending
in

hsBmatocele after the

slowly
first week

made
; and

their appearance three

weeks

this

case

longer the
causes

patient
from

remained

exceedinglyill from

these

and

pelvicperitonitis. Recovery slowly ensued, suppuration

or

out with-

discharge of

the

contents

of the

tumo;*.

Case
care

III. the

"

L. late

D., married, 8Bt. 33,

Dr.

was

placed
of

in my
1870.

by

Elliot, in the
suffered from
to

summer

This from

patient had
a

long

and perimetritis

uterine
of

tumor,
which
and
at

supposed
had much

be

velopmen fibroma, the deattacks of

caused

intense

uterine
She had

tenesmus

constitutional
a

disturbance.

married
a

20, and,
in had

year

subsequently,given
Two
at

birth to

child while she

Europe.
From been
at
was

years
sea,

later,in
and had she

returning home, nearly died

came

miscarried
this

of
my

haemorrhage.
care

period until
third

under had

she had

pregnant eight times

the
or

and

invariablymiscarried
The

fourth

month.

supposed
which

cause

fatty degeneration of
of

the
in
were

for placenta,

chlorate

potash, absolute
usual results

rest

the

recumbent

and position,

all the

remedies
of these
ine uter-

employed

without
were

success.

The

frequent

abortions

marked

anaemia, chronic
and
a

hyperaemia and, subsequently, metritis

followed
fibroma from ihe

metritis perismall

by

'the

development
While still very
afternoon

of

fundus

uteri.

recovering from
anaemic of and

the

attack

of
was

and perimetritis,

feeble,she
with violent

seized,on

the

July 6th,

emesis,abdominal

pain,and

f aintness ; the

204

Lee: intense
and

Remarka
almost
over

upon
to

the
loss of

pain
which

was

so

as

produce
whole

sciousness, con-

extended
to

the and

abdomen,
I
saw

was

tender
an

the

touch

flatulent her

her within

hour

of the

attack,when

pulse was
her ance appearwas

her scarcelyperceptible, that this time first had

and lips colorless,

of

approaching
occasional

dissolution. effort at
soon

There

at at

only an
been

vomiting, which

violent ; this
on

returned, how^ever, and

with

very

little effort

the

patient's part

quantity
half fill for
to

of thin
a

greenish fluid
hand-basin.

was

sufficient ejected, continued

time
at

to

large

This

intervals

several

hours, during which

the

persistentefforts
without
and
rectum
success.

resuscitate The
once

patient given
a

were

made

stimulants

her

by

mouth

were

at

and rejected,
a

powerful

hot-air

bath
No

maintained immediate
or

only

feeble

warmth

in the extremities.
was

vaginal
symptoms
most

examination
were

made,
on

as

no

uterine

pelvic
the
to

presented exploration
surface
was

the the

first

day;

but

careful
any

of

abdomen

failed

show whole

swelling or specialpoint of
was

tenderness.
on

The

abdominal

resonant

percussion; sleepless
no

and, although there

was

much

diffused

tenderness, it
a

not

increased

by deep
her of
of

pressure.

After
to be

night the patient seemed

and Dr.

next

morning
consultation.

better,

Peaslee
as

saw

in

He

thought spearmint being

ad-,

the case,

did, one
the
to
use

severe

and colic, indigestive of hot

were

recommended
tea

large enemata
stimulants
enema

in addition

the
first

that

ministered. and
without

The

came

away

unchanged
away less

but effect,

second

brought
became

large
tense

and of flatus, quantities

the abdomen

Didgrioaiaof
and
whole tender. The

Pelvic

HcBmaiocele.

205

pain,previously
surface,was
and in the
now

diffused
felt

over

the
in

abdominal

mainly
the

the

rightiliac region
made
bowels another

perinseum,and
attempts
of
to

patient
the and
but

frequent
:

ineffectual

evacuate

she

also

complained
rectal

uterine

tenesmus,
was

vaginal and nothing.

free

examination
had
no

made,

detected this

The little

nausea

continued

during
the

day, although Up

or

vomiting occuiTed, and morphia kept

occuiTed,
were

only the
in

hypodermic
to

use

of

pain
of

abeyance.
or

this

period repeated
also

attacks
to

faintness

partial syncope
and
to

relieve
and

which, iced brandy

Vichy

water

given

spice-bagsapplied
still very and

the about

epigastrium;
130, and
As and the these
to
nervous

the

pulse was

feeble

and

face patient's
were

lipsremained
due
no

blanched.

symptoms
the

thought
excited

to

the

nausea

shock, they
On
so

inquiry in
the

other

directions.

next

day, July 8,
of the rectal

patient again complained

and the
sense

urgently
in the

tenesmus
a

of
was
an

weight
obscure

perinaeum,that
and
now,
mass
as

vaginal
first

examination

again made,
ating fluctu-

for

the

time, detected
This
was

behind
was

the uterua swollen

a

very

indistinct,
and
so

the

vagina
as

and

cedematous,
examination

tender

to make uterus

prolonged
a

very but

ful. pain-

The

seemed

little
was

higher
still too

perfectly
to

movable,

and

the
or

abdomen
any
was

sensitive

permit

pressure No

attempt
drawn
next

at

tion. conjoined manipulathe

inference
and

from three

vaginal
no

amination, ex-

for. the
a

days

change

occurred, except

gradual amelioration
retain food.

in the

patient's

strength and

to ability

206.
On bowel the
was

Lee:

Remarhs

upon distress first

the
in

July

14

the

pain
of
;

and

emptying

the

increased,and attack, the

made it
cause

for the
the

time, eight days

and

after

f aintness

prostration
the

evident
was

for, on
an

passing the finger into

inch above

rectum,

arrested

the

sphincter
cluded oc-

by
and

smooth, globular swelling, which

the bowel gave
an :

completely
firm and

this

was

moderately
of fluctuation iliac

tender,
counter-

obscure made

sense

when
In the

pressure it

was

in the
a

regions.
mass,

vagina
the ing feel-

simply presented
forward
the and

bulging
a

which

pressed

cervix
to

gave

thickened

oedematous

posterior vaginalwalL
now

No
an

doubt

remained which
had
no

in my

mind

that

this

was
so

haematocele,
as

remained

for several
to

days

diffused

to

cause

perceptibledistention
had

either

vagina
sac so

or

rectum,
from

and

reached

the posteriorcul-deto
tain re-

slowly

the

patient being compelled

As

the

supine position.
was

far

as

could

be

ascertained,
and the

the

mass

not

larger than
a

goose-egg;
and

production by
No
so

of
a

such loss of

degree
blood

of shock

prostration
the

small

was

only explicableby
condition
of the the

exceedingly feeble
actual above used

and

anaemic

patient.
mained re-

occurred, although peritonitis

100

pulse
were

for

week and

; hot

enemata

sistently per-

in the

vagina
one

rectum, with
of

the

hope
the

of
no

causing

discharge by
in the
to the

those
In
a

outlets, but
month

softeningoccurred
was

tumor.

tient pa-

removed

and sea-shore, of air and

under
scene,

the stimulating the

mass

effects of the

change

slowly
a

diminished

in size and in the

slightincrease

disappeared, leavingonly deposit left by the former at-

Didgnosis of
ta";k of

Pelvic

HcGmatocele.

207

perimetritis. At good health,and

which

present the patient is

but

in moderately

slightlyincommoded
sole
remnant

by
of her

the

fibroid

tumor,

is the

pelvicdisease.
No

satisfactory explanation for

could be found

the

occurrence
as

of the

haematocele been
no

in this

case,

there
no

had

previous menstrual
be

and irregularity

evidence is the

of unusual

: pelvic congestion

the

predisposing cause
state

probably patient.
Case

to

found

in the

chlorotic

of

IV.
to

"

For

the

case following interesting

am

indebted

the

kindness

of my
occurred
one

friend, Dr.
:
"

John

G.

Perry, in
Mrs.
two

whose
set.

practiceit
25, had
had

C,

child
18

at

full term,
the of

and
last

miscarriages occurringwithin
October, 1872,
Four
or

months,
week
a

in

at

about

the after

sixth this

nancy. preg-

five

weeks the

flow

appeared
from its
hausting, ex-

similar

in
was

quantity to supposed
was

catamenia, which,
;

date, it

to be

but, proving
to

rather the

it

thought Perry
time
On the then

best

check
no

it at

fifth

day

with

gallic acid.
Dr.

This

produced

effect

for 24 for two

to
a

hours, and

tamponed day

the

vagina
reduced

days, by
"

which

the

discharge was
advised
benefit

mere

show."

third

after this the

to
a

patient,
for
of

who
her

was

becoming dyspeptic,was
she did

sit up

meals, which
On

with

for

couple
her

days.
seated

the

following afternoon, Dec. 3d,

dinner
; and

band hus-

assisted her to rise before herself when she

she had
very

just

suddenly

became

faint ;
con-

and,

in

spiteof

the administration

of

brandy,

lost

208

Lbb:

Rema/rk%

v^on

the
was respiration

scionsness:

when
and

she

recovered, her

oppressed
left reached anxious tenderness The

painful,the pain being

In three
the

confined
Dr.

to

the

hypochondriac region.
the
in

hours

Perry
and

house, bed, with

and

found

patient pale
and

tympanitic abdomen,
in the

great

in the left iliac and

was

hypochondriac regions.
minute;
the

pulse
and

feeble, 120

tongue
from

dry
had

clean, with
; the

occasional
were

eructation

of gas

the stomach
acted

bowels

but constipated, slightly

imperfectly on
tender
os,

the

previous day
and

from

the

effect of citrate of
The
uterus
was

magnesia.
on

pressure, and

little

larged, en-

with towards
the

patulous
left

painful
otherwise.

when
From

pressed
these
cumulations ac-

side,but

not

symptoms
which without Vec.

Dr.

Perry
about

inferred
the of

the presence

of fsecal
to
was

sigmoid flexure,
warm

dislodge

large enema
effect.
4.
"

water

and

oil

given
acid,

Condition

unchanged:
stiU

stomach

still

lipsand

gums

skin cool,urine scanty, but pallid,

; abdomen

wise othermuch
an

normal

tympanitic
At
extreme

without
12

distention,no
other visit
was

increase

of tenderness.

(noon) pallor

made,
the

when

the
once

and

prostration of
the

patient at
and
too

attracted
to

attention;

pulse

was

feeble

rapid
the

be

counted, the
drawn

eyelidsdrooping,the angles of
the While

mouth and

down,

patient apparently
Dr.

unconscious
rouse

moribund.

Perry

was

trying to
he seized

came her, the pulse bewater

: imperceptible

glass of
to
was

which raised
but

chanced her head

to be ; for

at
an

hand, pressed it
instant there

her
no

and lips,

response,

210

Lee:

Rema/rJcs

upon

the

toneal
above
as

cavity,producing collapse with

and detailed, advised

the

symptoms
; but

washing

out

the uterus
was

the

patient was
next

extremely feeble,this

deferred

until

the

day,
uterine
dered ren-

Dec.

7, when, the patient being stronger,the

was

cavity
small

thoroughly injected. by
the which showed

The

water

was

turbid
clot
8.
"

discharge, and
no

brought

away

signs

of

decomposition.
still
stipated, con-

Dec.

^Urine secreted

more

bowels freely,
but
was

pulse 140, pain

; in the

diminished the uterus

to

creased inflatulency

afternoon

again
excessive.

washed

out, but

the

patientbegan
became

vomit

and, towards again,

and

evening
but

the emesis
"

violent

Dec. 9. the

labored, vomiting still continued, ^Respiration

iced-milk
made without another

patientretains

difficulty ; the
careful

Dr. Perry pulse being firmer.

nal vagi-

examination, but could elicit nothing whatever

what had been

beyond

previously detected.
rectal
tenesmus

Feeling confident
that

from

the continued existed

in the

faecal

lation accumu-

colon,he againadministered
hot
water.

ous copi-

of injection

oil and
was

It
two

was

returned
and
a

without

efEect,but
retained.

repeated in
two

hours,
was

portion
a

In

hours

more

it seemed

repeated
clouded

second

time, and when

ejectedit

by

minute

particles of
the
two

fsBces.
enema

again repeated
away

Encouraged by this, he in six hours, and brought

masses.

small

scybalous
and

From

this

time

until

the
each

16th, seven

days, injections were

evacuation

repeatedly
lowed, folfaecal of

given

day,
more

after

evacuation

until
matter
were

than

seventy evacuations
As

procured.

the

bowels

were

relieved,

Diagnosis of
the
the

Pelvic

HcBmatocele.

211

vomiting

and

acidityof
from
130

stomach
to 160.

diminished,but
On

pulse remained pulse

and mounted

the 17th, although

the accumulation the

The above had skin

seemed

thoroughly removed,
and
was

160,

very

feeble. became
A

tongue, which

been

quite clean, now

and

furred
now

dry, the
became

moist

relaxed.

ing swell\

perceptiblein
until it

the
rose

left iliac
to the level

region,
of

which
anterior

slowly

increased

the

superior spinous process

to within
one

of the
linea

erally, ilium,and, lat;

inch

of the the the

alba

it

was

soft

and

distinct painless,

from

uterus, which
induration remained

retained
ticed no-

its former
in On
was

while position,
the

formerly

anterior
December

cul-de-sac
it had

imchanged.
fluctuation
upon

the

19th

and softened,

clearlyproduced by gentlepercussion made

with
enemata

its summit
Hot
to

the

finger
were now

in

the

vaginal
into
at

cul-de-sac.
rectum

water

thrown

the the

induce

the

mass

to

open

there,which,
On the and 23d

end

of

three
a

days,was
enema

successful
had attack been of
or

December,

after

hot
a

given
of

ejected,the patient
with
a

had

sudden
a

expulsivepain,when,
more

lent vio-

burst,

quart
was

composed semi-fluid, partiallydeand

blood,
as

discharged
had been

fortunately secured,
under her

the

bed-pan
was

placed

when

the

warning
to ten
same

given.
in the

Up
this
pass
two

o'clock

morning

of December

25th,
to

mixed fluid,

with

fsecal masses,

continued
more

from

the bowel, and

A

amounted

in all to

than
its

quarts.

microscopicalexamination large as

confirmed

character.

Dec.

26.

"

^A clot

as

goose-egg

was

passed

212

Lee:

Hemarhs

upon

ilie

fiom
serum.

the

rectum, with
This
recent
was

quantity of
and,
the

faeces

and

bloody
feeble
ondary sec-

and fresh, highly-colored, effusion

;
as

indicative of
was

more

pulse
the

and

the

patientcomplained hemon*hage
was

of unusual

exhaustion,
internal
use

feared, and
for the

of

acid gallic Jan.

was

was

substituted

injections.
as

1.

"

^The

were injections no

resumed,
of
the

the

patient

stronger and
Jan.
15.
"

evidences

haemorrhage remained.
iliac
the

The
and

swelling in
the
mass

region

is

now

minishin di-

behind
to

uterus

contracting pulse 118.

moved

and

drawing
1.
"

that organ

the left side ;

Feb.

Pulse

110; patientsitting up ; bowels

naturally.
Feh.
9.
"

Menstruation

appeared pain
of

and

ran

its

course

and naturally, Feh. the

14.
"

with
Catamenia

no

specialnote.
100

ceased; pulse below

for

first

time, and

the

patient practicallywell.
from
cases

What
as

if inference, ?

any, is to be dravm

such
haps per-

these

Clearly,that
when shock

haematocele

sometimes,

and

often, occurs
to
to

without
the

if it be recognition ; for,

liable
as

be
cause

overlooked

effusion

has been

so

great

profound
detection.
occurrence

and

exhaustion
are

to the
more

patient,
apt
to

the

lighter forms

of the

malady

much

escape Its

as

should possibility with

cases

be

borne

in

mind and

whenever sudden be

we

meet

of

obscure

shock
to

prostration in
added
severe

women;
or

and,

if

this

f feature

abdominal

pelvic pain, and

other

retching or
cause,

persistent vomiting,mthout
will
rectal be
or

evident It is
not

its existence that the

highly probable.

necessary

vaginaltumor

should

exist

Diagnosis of
at

Pelvic

Hcematocele.

213

the

beginning
and the

of

the

disease, when

the

patieut
the

is

supine cavity.

blood
is
not

diffused

throughout
to
occur

pelvic

This

likely
renders
an

immediately,
with which it and

although
is most

its absence In milder be I

absolute

possible diagnosisim-

cases

the

conditions
are

likelyto

confused
say

pelvic cellulitis
of uterine is and sound

pelvic peritonitia
as

nothing
or

ments, displacethe

very

little skill between these

knowledge
conditions uterine

to requisite

discriminate
caused necessary. is
as

tumor

by hsematocele;
As sudden

the

alone the

is

regards cellulitis, although

as

mation inflam-

the
never

onset

of

hsematocele, the
moreover,
or

swelling swelling
broad

it
is

produces

is

sudden;
at

the the it

generally lateral
on

in first, in

about

ligament
to

either

side,while
in the

hsematocele

is believed

be

always
states

posterior cul-de-sac,
had

although Courty*
of
to
a case

that

Chassaignac
was

charge

where

the

effusion
In

entirely confined
the
faction tume-

the

anterior
is hard

culde-sac.
and

cellulitis

resistent

from

the

while first,

in

hsematocele hardens
as

it is at first soft and the

contents

and fluctuating,
"

only
trary con-

gradually coagulate
of

the

being here, also, true

in abscess.
In the pelvicperitonitis
more as difficult,

where cellulitis,

the

swelling gradually softens, especially when

differential

nates it termi-

is diagnosis
not

haps per-

the

pain

is here

only

sudden is
tainly cer-

but

sometimes
less acute

quite
than

severe;

but

ordinarily it
never

in

hsematocele,and

produces
-^"^

"

Mai

de

rutems,

p.

913.

214

Lee:

Diagnosis

of

Pelvic

Hcematocele.

collapse
internal
occurs

or

lainting, which
Like
or

is

so

strongly

indicative

of

haBmorrhage.
after while

cellulitis, it

commonly
upon the
an

parturition
hsematocele

follows is
most

operations
common

uterus,
arrested

after
occur

menstruation,
The

although
that

it may
follows

at

any

period.
less

pelvic swelling
in

peritonitis is
haematocele;
without it

notable very

size
and

than

in

ordinary
and

forms

slowly
the

is hard of

"boggy,"
When
as

elasticityor

feeling during

fluctuation.

pelvic

peritonitis occurs happens,

the

menstruation,
is

occasionally
or

discharge

suddenly

arrested
at

pressed; supa

whereas

hsematocele

occurring
arrest

such Both

period

does and

not

necessarily

the

flow.
to

lulitis cel-

pelvic peritonitis are

with while functional
traumatic

believed of

be

always

associated organs;
occur

activity
hsematocele

the may

generative evidently
tion menstrua-

at
or

any

time, without

regard

to

either

parturition.
it

Although
either
be and

has

not
or

been
treatment

my of

intention

to

discuss it may

the

prognosis
in

haematocele,

stated

general
treatment

terms
a

that

the

prognosis

is
one

good,
"

the

best

judiciously expectant
and be the local in the

by
of in

rest, opium,

gallic

acid

application
first

cold,
the
or

if the

haemorrhage
and

severe,

stage

second, by tonics bowel,

to

hot

injections into
of the

the

vagina
of
the

limiting
such
cases

evacuation

contents to
cause

tumor

only

as

threaten

caemia. septi-

Meadows

Ovarian

Physiology

and

Pathology.

215

REMARKS

ON

OVARIAN

PHYSIOLOGY

AND

PATHOLOGY.*

BY Lectnzer
on

ALFRED of

MEADOWS,
Women for and

M.D.,
Ohildrm
London. at

Midwifery

and

the

Diseases
to

St

Mary^s

Hospital, Fliyai-

dan

the

Hospital

Women,

PROPOSE

in this paper with the

to

consider
and

some

points
of

in

connection ovaries
; and

physiology
chosen
;

pathology

the of

I have

this

because first, subject,

its extreme
it to be
one

importance
of

because and, secondly, which of

remove.

I believe
a

around great difficulty,

good
I

deal

of

obscurity
be

still

clings,and
I

much

which,
That

fear, I
the

shall

unable
an

to satisfactorily
one

subject
as

is
we

important
know,
the

need

hardly

say,

because, depends
and
not

whole

generative function
of ovarian energy
mean :

upon I the

the

due

performance
"

when

speak
of

of

the of

generativefunction,"I
but utero-gestation,
;

only

function

the

entire
it for
struation. men-

physiology granted
the
now

menstruation that without

the

for

may there the

take
is
no

ovulation

Therefore
very
are,

physiology of
in the of the up be

ovaries

is

central
if I may
commencement

point
so

generative system,
the

and

they
of
and

say, masters

from situation,
to

the very the

a

of

puberty
It would

decline

procreative period. if, with

chance
of

well, indeed,
whole
race

subject for congratulation to

the further decline
trouble

the
of

of

womankind,

the

generative
the ovaries

period,all
*

with

Lecture

deliyered

in

London,

and

communicated

especially to this Journal

by the author.

216

Meadows:

Hema/rhs

on

ceased.

But, unfortunatelyfor
this

women, most

we

know

tliat of all It is of

just at
the

period
diseases

some

of

the

formidable
occurrence.

ovarian

are

of

frequent

to impossible,therefore, exaggerate

the

importance
existence

this

subject;
is human

for its

and value, physiologically

gically, patholoof

commensurate
race.

with

the

very

the

But, unhappily for

ment

us, upon

whose

skill

and

judgthe

depends,
and of

in

very of

many

not instances, women,

only
the

health

comfort

individual whose

but

ence exist-

numberless
to what

others
term

very

being

is subservient

I may

pily healthy ovulation," unhapI have with

the chosen doubts obscure for and eases dis-

for us, I

say, the

subject which
is surrounded with

present consideration
difficulties of the
is not
to
an

compared
brain is

which

even

light itself.
one,

That

this statement
for

exaggerated
At all

I need every
can

only appeal
one

proof
with
for

the

common

experienceof
the

conversant

the

subject.
that

events, I

confidently say
the
seem
more

myself,
know the
more

longer I
to learn. to
me

live and

see

and
and

of ovarian I have

pathology,the
But the

less I then

to know

the

consciousness
augury

of my

ignorance is knowledge
to

most

hopeful
so

of
to

future

; for there

is

nothing
so

damaging
with

scientific
the way

reputation, nothing
progress,
as

which

bars effectually

self-satisfaction with

fect imperwrite
among

knowledge,
There
are

contentment

blissful
talk

ignorance.
and

many,

unfortunately, who diseases, as

if

glibly
the best

about

ovarian
most

they
Their

were

known,
treated

and easily diagnosed,

most

cessfully suc-

of all human

ills.

contentment

218

Meadows:

Remarha

on

be

reached

by

digital vaginalexamination morbidly

or

when

either
are

the

vagina

is

relaxed,

or

when

they

themselves, with
to
come

without

the uterus,
are

depressed so
upon
or

as

within
of

reach.

They

situate

in the

folds The and the

the

the

broad

ligament,on
to

its

posterior aspect.
free
sources:

supply
each

of blood
is

the ovaries
from which

is very three
comes

indeed, first,
fi'om

ovary

supplied
vessel

spermatic artery, a
aorta, high up

direct the

in the renal
the ovary the

region,in

situation descends

originally occupied by
with
entered the
ureter

; this branch

behind

peritonaeum, and
between

having
the the
of

the

pelvis,it

passes this

the

folds of

broad

ligament, where
Here

joins the pelvic wall, at

so

sacro-iliac the
som'ces

and synchondrosis,

reaches

the

hilum
two

ovary. of

it anastomoses
the

with ovarian branch

ovary

the

other of

supply ; namely,
the

branch of
as

the

uterine vessel.

artery and

Fallopian
the blood

the
a

same

Having
of

permeated

minute
in

plexus
venous

the capillaries,

is

again
from

collected
that

which radicles,
its

finally emerge they

are

organ in
one

at

hilum, where

grouped together
what
more

very

complex network, forming

of
mass

is called
than
venous a

*'the
fused con-

bulb

the

ovary," which
of veins

is

nothing
kind it

a constituting seems as

of

plexus
These

in which

the

ovary

were

imbedded.
venous

veins end side

of

unite

freelywith
the

the

uterine

plexus,and
of the the

finallyin going
the renal

spermatic veins, that

vena

right
of

into the
vein

cava,

just

below

junction
that

with
in the

that

great trunk, while

vein.

the left side ends Such

left renal

the is,briefly,

arrangement

provided

for

the

Ovarian

Physiology
of blood
; to

and

Pathology,
and

219

proper

supply

the ovaries

for

its due of these be be is

as

reiumfrom
noted.

them

and, taking a general survey

because that I think

the following points require, I think, to provisions, I refer to them hereafter

to
now,

I shall

able
of

show
in
a

you

their consideration

some

importance help
I
us

pathologicalpoint of view,
more

it may
the

to

understand

perfectlysome
ovarian

of

symptoms
am

which
not
aware

accompany

diseases.
to

Moreover,
shall

that

the

points
the

which

I
of

allude

have

hitherto

attracted
are

attention

gynaecologists; certainly they

work
on

not

mentioned

in any I
am quainted. ac-

the diseases Yet

it
seems

of

women

with

which
on

evident, even
the arrangement arteries and

the

most

sory cur-

examination,
of the
must

that
"

and
"

distribution of any
its organ

blood-vessels

veins

have

most

important bearing
which
are

upon

diseases,

especiallythose changes
in

characterized
this
seems

chiefly by
more

of
the

vascularity ;
case

and

the
we

tant importhat
cases

of of

the

ovary,

when

remember in all

the
to

performance
the most

its

functions

leads its

strikingincrease

of

blood-supply,and
of

to

periodical, though temporary, turgescence

Now,
the

all its

blood-vessels.

point to

which which

I would

first call
on

attention the which

and the

is the free anastomosis

is carried

between
"

principal

ovarian with
the

artery, the
uterine

spermatic
of

that
"

supplies it
two

largestamount Why
for

blood

branches
the

of the

artery, namely, the ovarian

is this ? it.
we

and

Fallopian branches.
there
not

may
as

be
we un-

quite sure
call

is

some

reason

Nature,
of this

is it,

in arrangements prolific

kind,

230

Meadows:

Iteniark%

on

less there is inasmuch

uterus
comes as

some

definite

purpose

and and

object in
that uterine

it ; and

the the

Fallopian tube
ovarian branch

part of the

whence
are

of the

artery
as

unquestionably of secondary importance

with
the the ovary, it can

compared
that

hardly, I think, be
to

posed sup-

elaborate

arrangement
the

which

I have

referred

is

primarily for
may is for doubt

advantage
better
an

of either of those

parts.
this

We

then, I think, reasonably assume

the such

that
ovarian this may,

provision
No certain

discharge
as

of

functions.
under

arrangement
use

circumstances,be of
; but

to the

inferior and
of

subordinate
I think
"

parts

it is not be

in the

nature
to

things,
in be

it

would, indeed,
nature
"

contrary
careful

the

ordinary

workings
the way

of
of

^that
or

such

provision
should

vascular for

nutritive

supply
the

made

primarily

structures

of lower

physiological
arrangement
and

importance.
in

Secondarily^ no
prove very

doubt,
convenient

question may
parts.
It

useful

to

those

might perhaps
in the

be

thought by
the
to

some

that

though

dinarily, or-

non-pregnant state, the

about ovary the and

arrangement
their

of

the blood-vessels

free anastomosis
none

is of little service

uterus, and

to

the

Fallopian tubes, yet, when

of
an

pregnancy than

the value exists,

that

extra

blood-supply,other
as

of the uterine with the

artery and such

is afforded be

by
very

the anastomosis

spermatic artery,would
be in of any
use

great.
of

to But, sui^ely,

this extra
a

source

supply
the

must

increase made
in be

somethinglike
and it, that

fair

proportionto
involve
:
an

demand

upon the

would

enormous

increase
it would

size of the

spermatic trunk

otherwise

Ovarian

Physiology
But
if this

arid

Pathology.

221

useless. practically
took For

great enlargement really

it would

place,see
one

what

consequences would its

involve.
derably consi-

thing,the
active, and
almost could

ovary

become certainly

hypertrophied ;
more

functions
under

would

be

vastly

pregnancy

such

cij'cumstances because disease,

would there
uterus

inevitablylead
not

to ovarian

be the

increased

supply

of

blood

to

the

through
is not, such the
to

spermatic artery
the tittle of
reason

without the

also adding ovary. in support

considerablyto
There
of any that of
not

blood-supply of
one

however, view, and

smallest
the ovary

evidence whatever

no

for supposing
the ply sup-

change

takes

place in
"

blood
way

during
is

pregnancy

certainly
I say, the

in the

of increase. in

Therefore, again
not

arrangement

question
of the

primarily
the other

for the

vantage ad-

of any

inferior parts of
or

generative
times.
this

system, either during pregnancy

at

If,then, reason
free

and

analogy

oppose it does

the idea that

anastomosis, providing as
to

copious blood-supply primary

am,

the

parts in question,is for the

or

benefit I

of either the uterus

the the

Fallopian tubes,I advantage

I

think,
or

entitled fairly
may client
accrue,

to

claim

which
on

accrues,

from
ovary,

this whose

arrangement,
cause
am

behalf

of my
in the

the

espousing

present instance.
In the first

place,then, I
venture

think

that such
so,
an

an

ment arrangethat

is,if
could
to

I may

to say
case

by

far the best which

be

adopted

in the

of

organ

is subject
; for

such

remarkable that and

the
more

periodicalaffluxes
necessary

of blood is way

it is obvious
much better

supply
in

provided
than it

equably

this

222

Meadows:

Hemarhs

on

could
ovary,

be

from

any

single trunk.
its the in
a

If

we

compare

the ment excite-

for
and

instance, with

regular periods of
or

quietude,with
their functions

kidney
uniform

the
manner,

which liver,
we seem

perform
at
once

to

different
seems

the propriety and fitness of their recognize The of this tion circulations. feasibility explana-

again, by observing the strengthened,

in the
"

liarity pecuof

circulation
the
uterus
"

provided
which Here

in is

the

case

another these

organ

also
most

subject to
elaborate between its

periods of
made

excitement.

the

provision is
several
that the for be

for the freest anastomosis of of

sources

blood-supply ;

and

do

not

doubt
cated, indi-

purpose
we can

all this is that

which

I have there
were

imagine what
period
the after

confusion if the

would
plied supfor

during
with

the menstrual blood

uterus

fashion

of the

kidney,
in
we

instance.

Again,
the

the

importance
of
our

of
is

the

ovaries
that

regard to
can

continuance
very

race

such,

gine imaformance per-

specialarrangements being made

of their
man

for old
more

the

function.

There careful
in the
to

is

an

saying
than

about
one

cautious
his

being
; and

have

string to
of of least
to

bow

case

of the
welL

ovarian
to

channels the

nutrition

it is
one

clearlyquite as
were

say

it,that

if

cut

off

it should have

have
some

others
relation it out the

fall back
to

upon. in

This

possibly may
I

the

point

question,though
for have I
am

only

throw that with

as

suggestion; explanation I
is most the

inclined
best

to think

other

offered

accords

the facts and

consonant

with
us

physiology.
a

Leaving

now

let arteries,

glance

moment

at

OvaHom

Physiology
the
venous

and

Pathology.
And

223

the

in peculiarities first

circulation.
attracts

here,

again,the
ovarian

thing which
plexuses.
arrangement

attention several
be
no

is the free
uterine and

communication
venous

existingbetween
There
has the this

the
can

doubt,
the these
plete com-

think,

that

reference

to

unity
organs
; for

which

pervades
be another

functions
in inind
to

of

two
nous ve-

it should

borne

that these

plexuses have
that blood
no

function
for
were

perform
return

besides of the
be

of

merely acting as
for the very know that

channels

the

from

these parts. If this

all,there would
which

need
we

complex arrangement
the
the

exists ;
most

but

veins
due
or

here

fulfil another

important office, upon depends,

ovaries
An in in the

performance
no

of which

it the

part, whether
married
this their
state

the
or

product
of veins

of

shall

shall not

be wasted.

injection of
at
once

complex

system

demoii

strates

office ; for both

are

pian the uterus. Falloerect

so soon as

tubes, and
the
in

ovaries
full ; and

immediately
as

veins
the

are

inasmuch
which

excessive
necessary

activity
quence conse-

arterial

system,

is the

of of
the

healthy ovulation, involves

system,
erection
the

equal turgescence
as a

venous

follows

natural

result,and

by
The

this
of

means

apposition of
tube
to

the

ated fimbriovary is

extremity
secured.

the

Fallopian
between

the and

distance
over,
as

the

ovary
route
are

uterus

is for
to

thus
the

bridged escaped ova

under be

it were,

and

provided
afterwards

to the

spot where
of veins

they

develop point to
this

the

influence in these

noted
has

impregnation. Another is the absence of valves

the
same

; of

I believe

reference

to

function

EREOnOIf.

224

Meadows:

Remarks

on

Such, then, being the physiology of the

it is in of
one

venous

tem, sys-

scarcely possible to exaggerate

and
in
we

its

tance impor-

generation;
its allotted

the may

incomplete performance recognize,I think,

of

duty
is

of

the

many

possible causes
as

sterility ; and
from the

one,

too, which
of

unhappily

far removed
it is

region
the
cular vas-

certaintyin diagnosisas
of

hopelesslybeyond
the

reach

therapeutic art
We
come now

So

much, then, for

consideration

supply.
nervous

to the

of

the

arrangements, and here the followingpointsseem

of notice. the In the first is derived but

especially worthy
nervous

place,the
from the

entire

supply
of the

to

ovaries

single
a

source

spermatic plexus ;
is,first, a
branch

this

plexus has
from
from

somewhat
sources :

complex origin,for
there

it is formed
or

three the

branches
the

renal

plexus ; secondly, branches

; and

from
the

aortic

uses plex-

branches thirdly, receives

from

plexus, hypogastric
from these
are

which

latter

communications
nerves.

the three

second,
sources,

third,and
the branches

fourth from
it is

sacral the

Of

renal

plexuses
notice

by

far

the

largest ; and
allude
me

important to
to
some

because this,

I shall
seem

hereafter flow

consequences Now

which both

to

to

from

this connection.

the

aortic
a

and

the renal

plexuses are
the renal

situate in the
The
; the

abdomen,
is
near

tle litthe

below

the above

epigastric region.
arteries the

latter former

kidneys,
the

between
ries arte-

originof
;
so

superior and
nerves

inferior

mesenteric
a

that in the

the ovarian

spring from through

the into

veiy

high
pathetic symtion rela-

source

abdomen,

and
are

various

plexuses they
with
the

brought

intimate

several

abdominal

with viscera, especially

226

Meadows:

Rema/rTcs

on

brought
Such
to

into

close of

and
course

intimate

relationshipwith
the brain.

the

spinal cord, and

then
uterus

also with

being the
on

nervous
one

connections

of the ovaries

the

the

hand,
to

as

their of in

companion
the

in

work, physiological

and
we can

the

rest

organism,
at

organicand
how
so

animal,
to

understand,

part
are

least,

it

comes

pass

that these

little bodies

enabled

powerfully to
of
we this,

influence

the whole

system in the performance

their

normal
some

functions; and, reflecting

of

upon

gain

sort

insightinto
the it would

the

manner

and

degree

of their action
I do

upon
not

organism

in certain

morbid
to

conditions.
the be

think

be

possible
How is well function
its
non-

exaggerate
it is may

importance
withdrawal
once

of this influence.
the

great
known,
after

imagined by

fact,which
ovarian
even

that
it has

the
been
at

of the

established, and
most

development
is sufficient to

puberty, but
the

of

all the whole

former,

change
in

character moral

of the
natures.

being,
is
no

both sexual
the

in

her

physical
which We

and
this

There

difference

respect. See, for

exercises

instance,
upon

influence

castration
the

the it

individual.

all know

wonderful

effect which

produces upon the voice,though it is very difficult to is produced. that effect Nor explain in what way in its applicationto the human is this limited species,
for it has much

often

been

remarked
notes
season

that
the

singing-birds duce proof

sweeter

at

time
at

pairing
time
of

and

during
the from
to

the

breeding
In the
to

than

any

other

of

year.

human

the change subject,

seems

voice

childhood

manhood
; and

to

be

closelyrelated

development genital

I have

frequentlyobserved

Ova/rian

Physiology
of full voice,
"

amd

Pathology.
the

227

that in persons
to

even

changes
to

tal inciden-

menstruation

or, I

ought

rather in

tion say, to ovula-

"

^giverise
It the fact

to

marked be

changes
in

the
some,

quality
is
of
are

of

voice.

might perhaps
of the that

objected by
in the that

mitting that, ad-

changes
stand

question,it
relation the
two

by

no

means

proved
effect
;

they

cause
temporaneous, con-

and

for while

it is allowed
other

yet, as
the I
am

changes quite

also

take

place

in

organism

at the

same

time, the phenomena

be due
as

of which
to

speaking
as

may

much To the

these

latter I would

to

the ovarian the

modifications.

this

objection

reply,that

fact

that with
other

ment non-developin

of the

or ovaries,

all testicles,

developmental
tion questhat

changes taking place as usual, the phenomena

do of the
not
occur

and, again, the fact

without testicles, lead
to

extirpation
in the
sults, re-

ovaries,or
will
not

any much least I

am

change
the the
same

organism,

often

very

is,if

absolute in favor
case,

proof, at
of the

strongest,

possibleevidence
If

view

advocating^
necessarily,I
be
ex-*

such
that
to

be

the

then,
in

it follows these

think,

mOrbid

action

parts may

pected
extent

produce

changes
of the

commensurate

with

the

and
as

importance
on

physiological processes.
remarked, pathology
to, I had
so

For,

I have I may
so

many

occasions

is, if

say, first-cousin

almost
indeed

said
are

twin-brother

with, physiology;
it is almost

closely
ends and

they related,that
cases,

impossible to
for
or

say, in

some

where

physiologicalaction
In
cases,
excess

cal pathologiare

change begins.
characterized
or

instance, which
diminution draw of the

merely by

tion secre-

excretion, it

is not

possible to

line

228

Meadows:

Memarlcs

on

shai-plybetween study
of the

the

two

states.

Hence
so

it is that

the

physiology
to

becomes
or

of

much
; for

portance impractical

physician

surgeon any
or

indeed

it is

well-nighimpossible to
either in the
a

understand
at

morbid
any of

process,

system
clear

large

in
at

particular general
or

organ,

until

idea

is arrived the
our

special physiology.
of ovulation
that
we

It is upon
must

physiologicalbasis
system
this
to

found

of ovarian
in
two

pathology, and
my
own

it is the
which in has this

strength of
induced
paper; does
me

conviction link these

I fear
me

mind

subjects together
present
that
ness

although
not

the
use

state

of

our

knowledge

permit

to

of language precision

which

springs from

definiteAn est honthan basis know the

tentment con-

of

thought

and

accuracy

of information.

expression of
a

doub't

is,however, always
which what has
we no

better better

positive, dogmatic conjecture;

better

statement to know

than

and

do

not

gives far
One

hope
first

of ultimate

knowledge
claims

than

which of the

springs from

ignorance.
attention in

subjects which
in

consideringthe physiology
which
about take
to

of the ovaries

the changes is, I

was

place
"

them

during ovulation;
the
or

say,

^in other

words,

changes
at

which

occur

during
menstrual

the time

of

menstruation,
the
woman.

least

during
it

the lieve, beup

life of

But that

though

is,I

commonly
to

supposed
first final

during childhood,
of of

the

time after

of the
the
not
case

occurrence

menstruation, menstruation,
are,

and the

again
ovaries
in the

cessation any

do
one

perform

function, but
in my

in
case

fact,

and developing,
am

the
own

other

clining de-

yet

from satisfied,

observation.

Ovarian

Physiology
no means

and

Pathology.
inactive
at state

229

that

they

are

by
in
no

in

an

; and

though
not

it is true

that the

their

action

those

periods

does

eventuate
can

phenomena
of their
most

of

menstruation, yet
we

there be

be

doubt

and activity,

should

in

danger
in

of if

overlooking
we

important pathological
to

processes times
both

shut The

our

eyes

what

occurs

at the

question.
and of

fact that pregnancy

menstrual

has occurred of ovarian

if it were sive, pas-

before

after

life is

proof

and activity
true

healthy

ovidation.

Moreover,
were

that then

at

these

periods the
seem

ovaries

simply

it would

to

be, if

not

impossible, at
become
case,

least most of
we

improbable, that they

So that far
at

shoidd the

the seat

disease. know the

from

this in

being

however,

the

times

question,and
organs
are

especially
to

at

later

period,when
died away,
as

these

supposed
are

have the said

simply
naost

it were,

they
is

subject to
can

serious of all
the

organic diseases.
in

Nor

it be of

that

disease

question
of

one

indicative

functional

declension, or
On

and simple inactivity

to

eration. degenstration demon-

the
this

contrary, statistics prove

disease

that ovaries
to
are

is most

common

where

the

most

active

; and

therefore
of the

it

I think, fair is, of the

assume,

that the

simple fact
before
or

occurrence

disease

in

question

after

menstrual of the

life is in

itself evidence of
and the

of ovarian

and activity,

possibility

ovaries

influencing the
"

system

physiologically
throws

pathologically ;
to

it is

an

instance,in short,where,

contrary
some

the

more

general rule, pathology

the mode in which the

lightupon
Now,
in

physiology.
to

regard

ovaries

act

physiologically upon

the

uterus,

whereby

ovulation

230

Meadows:

IteniaThs
is of the
; but
or

on

leads
that

to

menstruation, it
blood-vessels
are

course

evident

at

once

the

structures

volved inprincipally
tain equally cer-

in the

phenomena

it is at least

that, though
take

nutritional

functional
of the

changes

may

place quite independently

as

nervous

system,

inasmuch

in many

organisms no
and

nervous
a

system exists,

yet where system

are are

complicated organs
distinct

complicated nervous
the blood-vessels

where present, and especially

a

supplied with
to consist cannot

set of

nerves

whose

function
blood-

appears

in be
nervous

and regulatingthe controlling

supply, it

doubted,

think, that
an

in

such

cumstanc cir-

the
a

arrangements of
in

organ

play
and tem sysis the

most
we

important part
consider how

its

physiologicalr61e;
is the
nervous

when

very

complex
the
"

of the female relation which

in

generativeorgans,
between

how

intimate

exists

ovaries and

the uterus
we

regard

to their

nervous

supply,
the direct

when,

moreover,

consider

the marvellous

activitydisplayed by
connection the
we

the and

ries ova-

and during ovulation,

free of
prised sur-

anastomosis the ovaries

at

which
and the and

exists

between

blood-vessels
cannot

those

of the

uterus,
which
ova;
on

be

consequences

result

from

the

maturation
the

dischargeof
conditions

the contrary, given know

and exist,
we

anatomical
almost

which

we

might
such
limited

certainlyhave
would
to
ensue.

predicted
Nor
are

beforehand

that

results

these

considerations
On

merely
if

physiologicalactions.
any

the

trary, con-

they they

have
must

bearing

upon

phenomena, physiological
processes classes
;

also be

related

to morbid

"

^itis,in

fact,impossible to separate
in many
cases

the

two

of

for activity,

we

cannot

draw

the

line be-

Ovarian

Physiology
and and

and

Pathology.
we

231

tween

healthy

morbid

action

cannot
we

tell where
are

physiology ends
as

pathology begins,and
the
one as

often
other.
ous nerv-

powerless

to

control

to

regulate the

But, admitting to
system
still not upon

the full the influence of the local

the

physiology
the
us

of these

parts, we
to how
moment

have

quite answered
is exerted. Let
occur

question as glance for

of
to
a

that
at

fluence inthe ing duras

phenomena
the

which

in tlie ovaries escape I have

an

themselves
ovum

preparation and
to

; and
on

prefer by
relate
years

illustrate
to

what I
came

say

this I

point
will
ten

reference
a case

what

have

myself observed,
my notice
some

which

under very which

ago,

because

it shows

clearlythe
take

extent

and

character

of

the

changes

place

under

these

circumstances.
The of age,

patient was
and
a

singlewoman,
in the

twenty-three years
From
birth she

gave

the

following history. taught

; it

had she
but but

had
had she

swelling

right inguinal region,which

to

always
had
never

been
worn

regard
for

as

rupture,
it gave did

anything
never

it,and

little inconvenience in At

disappeared,nor

it increase from
it.

size,but
fifteen
so

she

occasionallysuffered
to

pain
tinued con-

she

began

menstruate,

and

doing
or

at

regular intervals, always

had
no

with

more

less

pain, but
About

this

effect
ago in and she

upon

the

inguinal
that
other an-

swelling.
this

three

years

first noticed rather

to

swelling had
one

increased below it
was

or size,

that the

had and

come

internal
and

origi
she
; she

nal says

one,

that

very

tender how

painful;
not

it

came

quite suddenly, but stooping just before

she knows

had

been

she

perceived it.

At

the

232

Meadows:

Remaarha

on

menstrual

period followingthis
to any

she

suffered

most

lent vio;

pain, different
it the and

she

had
at

experienced
the lower

before

preceded through

the

discharge,began
and swelling, inside the

part of
the

last-named

extended

along
at

groin
time

the

to

back;

the

same

the tumor
the
more

much

increased suffered that in

was

in size.
a

From way,
or

that

time

to

present she

similar
a

sometimes
at

acutely,so
would

she

week

more

every the be

monthly period obliged to keep

tumor

her bed. size

Sometimes
two

swell

up

to

the

of

and fists,

tender exquisitely the from

to the

touch. she

In the interval between

menstrual
it.
as a

periods
has been

suffered
to

little

or

nothing
her

She

compelled
has become months

give up
I

tion situa-

sei'vant,and
About into
one

very

hystericaland
saw

delicate. had been that she

was

three of
the there

before

her

she

London,
formed

and hospitals, of her

case

I learned
was,

the
a

opinion

that

had

congenitalinguinalhernia, and
adherent
to

that
never

the bowel could and

more

probably
; it

the

sac,

as

it

be

returned

was

thought
The

also that due

the
to

lower

recently-formedswelling was right

after
a

the

presence
care

of the she was,

to

ovary.

surgeon

under
his
to

whose

consultation

with

declined colleagues,
run

terfere, in-

thinking it unwise
unless

the

risk

of

an

tion operabowel in

symptoms
on

of

strangulation of
it

the

should
order

come

and life.

render

absolutely necessary
and the It

to

save

her her had that

I first

saw

July 27th, 1861,

no

after
nature

one

or

two

examinations
tumor
"

doubt

about

of the

er low-

it

was

ovarian.
the

was

then

situate in the
upper

the

upper

part of

right

labium.

Of

234

Meadows:

Remarlcs

on

The

tumor,
and ovary;
one

whicli
in it

measured

about
on

two

inches
to be

in the

length right

diameter, proved

section

had, however, undergone

Instead

remarkable usual

structural

change.

of it

presentingthe
contained

dense, compact
numerous

appearance,

throughout
size from all
as

irregularly-shaped spaces, varying in

to
a

pin's head
filled from

quarter
the
same

or

even

half
of

an

inch, and
fluid
to

were

with the

kind These

serous

flowed

pedicle.
with

cells the

appeared
organ

municate com-

with

one

another, and

whole

to

be

infiltrated, as
were no

it were,

the fluid in

question.
seen.

There
end sented precells

proper ovaiy many

Graafian
near

vesicles to be stalk
w^as

The

of the

the

cup-shaped,and
with

openings communicating
; from

the

already
fluid

mentioned
The

these, with

gentle
well

pressure,

escaped.

whole

weighed
did

about

3^ drachms.
; but

The
a

patient subsequently
after the

very

about
in

week

operation
formed

some

inflammation

arose

the A

wound,
small

accompanied by
where

good
the

deal of

tenderness.

abscess

pediclewas
It

secured,

probably extending to the pedicle itself.

after
for
a a

ever, burst, how-

few

days' poulticing,discharged freely

healed
up, and in less than
a

day
the the
was

or

two, then

month At

patient was

quite welL period

after the

first menstrual
some

operation swelling
nience inconveted submit-

there

pain in,and
was,

increase
but

of, the
little

yet remaining; it
and in the
two

however, of

importance,
or

subsequent periods no
Since careful

pain
and

has occurred. the ovary that

to
a

the

operationI

have

examination,
of the

it appears
was

probable

that

portion

pedicle which

Ovarian

Physiology thought
in
to

and

Pathology.
of
the

235

left,and

then
was

be

portion
of
a

broad
had

ligament,
formed
and
to

reality part
of the ovary
in

cyst
to

which
the

at the

end

nearest

abdomen

the

uterus

when the

situ.

This

supposition is
observable
seen

strengthened by
at

cup-shaped
ovary, where smaller

appearance
were

the

end
as

of the
if into

also

some

openings peculiar
Now upon the and
was,

and cells, ovary

further

by
as

the I

appearance
numerous

of

the

itself, which,
different

said,contained
the

of interspaces
I wish
more

sizes. sist inof

;
"

point which
the is,
or

to particularly

here

very

great increase

in the

size

ovary

during,
no

rather

preceding, menstruation
"

although
in

doubt
due least,

the size described

to

as

two

fists

part

at

something
did very

not

ovarian, yet
crease in-

it is certain

that

the

ovary

considerably
It

in size at each be

catamenial
the
were

period.
I have

might

haps peras

thought
this

that
case

changes
somewhat

described

occurring in
and that of

exaggerated
taken

and

abnormal, owing
therefore what

to the

unnatural
cannot
more

of position be
as a

the ovary, fair criterion

they
To

occurs

under
some

natural
extent
no

and

able favorthis is

circumstances.
true ; but

doubt

the

following

case

goes

pose far, I think, to disin the

of this

objection. It
in

occurred

practiceof
bears
out

my

colleague,Mr.
statement

Christopher Heath, regard to

in the I of had take

and

the

just made
Graafian
case

the

magnitude during

of the

changes which
of
a

place

ovaries

the rupture of

vesicle.

the

satisfaction

seeing this phenomena

E.

also, and

observing the following

for disease
of

B., aet. 19, single, was

operated upon

236

Meadows:

ItemmH this had

on

the left ovaiy.

was

After the it
was

been the

removed, search

made

for

ovary found

of and

opposite side, the

it
was

right.
size ; it and

When
at least
was a

examined,
three

covered dis-

twice, probably

times, its normal

ted peculiarshape,being considerablyelongatowards of the

conical
on

point,where
In

it seemed

dently eviwas

the

eve

rupturing.

this situation it that and of

a

of

deep
it

blood-red

color, resembling
was

dark-

colored
and

cheriy;
was

its surface that

shining
a

glistening,
in quantity of
a

evident
blood
as

only

very

thin

cealed covering con-

the about

beneath, which
as

seemed the

to be

much
currant.

would
All

occupy round this

space
was

goodzone

sized black
of
a

there

and deeply injectedblood-vessels,

beyond
in condition

this
a

again
of

fainter

zone,

the

entire Such

organ
was

being
the

state

active

hypersemia.
the

of been
were

this
moved re-

ovary;

other,

as

I stated Let

just now,
us now see

having
what

in the consequences.

operation.
The 4th

the
at

operation
October;

was

performed patientwas
was

10

o'clock
on

on

the

of November
of

; the

ted admitthat

the

31st

and
a

it

noted

the

last catamenial

period occurred
of the 6th

fortnightpreviously.
November,

On hours
next
on

the

morning
the
it was

of

just
;
on

48

after

operation,menstruation
very free and

began

the

day
the
no

of dark
three

and color,

it ceased
can

9th, having lasted

just
the

days.

There

be

doubt, therefore, that

described indicated

the

phenomena

which
of

I
a

have

approaching rupture
to

Graafian
amounts

follicle ; and
almost
to
a

it is fair

assume,

indeed
menstrual

it

demonstration,
so soon

that

the the

discharge

which

occurred

after

operation

Ovarian

Physiology
of that

and

Pathology.
and

237

was

the

result

rupture

though
out

it is true

that
course

this catamenial and it

seem was so

period occurred
far

of
no

its

regular
sense

abnormal, yet
so

in

other

does

to

have
and

been

on

the

dom contrary, in its freeof

from

pain

in the
as a

amount

discharge

it may

fairlybe
We
learn
:

considered therefore
that the

perfectlynormal
the
case

menstruation.
now

this fact from ovary, in its

referred
ation, menstru-

to, viz,

preparation for
its natural distinct

may

become

quite double
seat

be size,

tensely inand may

vascular,the
even

of

hemorrhage,
all this

undergo

species of rapture

; and

take

place without
normal

givingrise
and
most

to

any

indeed, suffering,
and rently appa-

without
as

occasioningany symptoms
a

whatever,
of

natural

state

things. This,it
much

seems

to

me,

is

important physiologicallesson,
to

one

which

is calculated

teach it is

us

more

than

appears

at first

sight;
like

for the

evident, I think, that

ovarian the

if

this
then
must

be the

anything
condition

usual

phenomena,
term

designated by widely
the
cause

ovaritis be

differ from
to

it very

; otherwise

it would

impossible
in the

explain
one

of

the

painful

toms symp-

case,

with

the

entire

absence

of any

such
If
more

in the
we

other. the condition

the process

examine

of
in

the

ovary

little

minutely during
think, find
some

question,we

shall,

other
which

in tissue-changes
may

its normal
at

physiologicalaction
least to
stractural for

help
some

to

explain,or
of

throw

some

light upon,
which
occur

the

graver

diseases

in
:

these this
:

parts.
is

Take,
of

instance, a
I may

Graafian say

follicle
two

composed

three,or

of

coats

the first,

external.

238

Meadows:

Ilema/rJcs

on

fibrous,or
blood
coat

vascular
to

coat; it is through this

the contained the
true
ovum

coat

that this

is
is
a

supplied
second

within

membrane,
fibres of

follicle, composed
tissue, some
round of oilis
closed en-

of

embryonic
and

connective
a

cells

granules,and
this what

considerable is the

quantity
which

globules; within
in

again
less

ovum,

is termed
more or

the

memhrana
a

granulosa^ sero-sanguinovaries
or a

surrounded
lent

by

of fluid of

character. in

It

is to this is due
on

which fluid,

good

deal

extent, that
follicle

the

greater
of

less

nence promipre*

of the
vious that If
now a

the In

surface
some cases

the

ovary
so

to

its dehiscence.

it is
to

great
ovary.
or

sense

of fluctuation section
were

is

imparted
the

the

made

through
the
a

ovary, the

that

portion of
in

it which

contains

at follicle,

period
or

we question,

should

observe I have in its

cavity of greater
said,a variable

less extent,
of

as containing,

tity quan-

fluid, varying
to

also

composition,from
it is evident

simwo

pie serum
have here
some

pure

blood.

Now of

that

the

elements in the

possible mischief,wanting
of the order

only

change
I may
so

direction

developmental
to occasion

force,if
serious normal contained its way,

express

it,in
In the

very

organic disease.
state

ordinary

natural

and
its

of

things,the
in the from the
course

Graafian

with follicle,

ovtun,
as

of its development
more

works

it were,

the

central

to

the

pheral peri-

portions of thinning of
and

ovary the

and

this it does

in order

that, by approaching
the the
be

surface,and

by

the

gradual
rupture
tube

investing membrane,
of the
ovum

its final

escape

into
we can

the

Fallopian

may

accomplished.

But

readily understand

Ovaricm

Physiology
of

and

Pathology.
this

239

that

this of the

process

development,
the

gradual migration
at any

follicle to the

periphery,may
rupture which
of
be

time

be

interfered

with, and

so

ought

to take

place is prevented;
contents
cannot

in consequence

which, either

the

of

the
other

follicle must

absorbed,
which
The of

or, if that

be,
to

changes
the

may

ensue

will

give

rise

very

serious

organic disease.
in

consideration

of this

question shows
the it proves also

importance
the
of the

accurately appreciati
of ovular

successive
that the

steps
minute

process

tion ; the take forms

study
of the

physiology, and
of

investigationof place in
the best the and

which tissue-changes function

a a

performance
most

part,
tem sys-

rational

basis for

sound

of
Let
uterus

pathology.
us now see

what

is the effect of ovulationoccurrence

produced
Stated

upon

the

by
that

the

process

broadly, we
;
one

know and hand

the result is the here

to

of menstruation whHe
on

it is the
a

important
ovary is that may
on

note, that
of

the

capable
the

affecting the
of

uterus

in in

such

manner

performance
other

its function and

menstruation

be
the

seriouslycompromised, hand,
be it is affected
cannot

ease disclear

result, so,
that and the ovary

equally by

may

in its turn
ensue.

the uterus
at

serious mischief intimate

to

We

wonder

this,
the
tems. sysder won-

seeing the
two

connection both their

which vascular
be

exists between
and
a

in

regard
On the

nervous

contrary, it
that

would

subject for
reference
at

if it were

otherwise

; for it is
we
can

only by
account

to the

fact of this in

timacy

all for We organs

the

phenomena
know
how

witnessed

during

menstruation. of the

all of

completely the

blood-vessels

240

Meadows:

Remarks

on

organiclife

are

under
of

the control
nerves

of the

sympatheticor
?

ganglionic system
of menstruation the
state
an one

and, viewing the phenomena

what do
we
see

as

whole,
at

On

hand

we

have,

certain

regular periods, a
and very
nervous,

of intense which

both activity, is admitted

vascular the

in

organ

to be

central

point
be

in the
no

generative system,
function

without
and

which

there

would

such I

whatever,
its

which

by

its

cal, physiologiing-point start-

might
of

also say the

is the anatomical, position,

"

generative act
in

^the

highest of
to
no

all the

generativeorgans
all the rest
are

and dignity, physiological If this be

"

which
one,

subservient.
to

so

"

and

think, will
a

venture to

dispute it
of

it is

clearlyaltogether
its

misnomer

speak

the uterus

and

appendages,
;

by which
in

is meant

the ovaries

and

Fallopian tubes
both

for,

the vagina is the only appendage, in reality, of the

the proper

sense

word,

to the
are

uterus, and
all the

vagina,uterus,
to the

and

Fallopian
before,
intimate

tubes

appendages
others there
at

ovaries.
I have

Between

these, then, and

a

is, as
same

said
most

most

complex, but,
"

the

time,
it is
responding cor-

connection
conceive

so

intimate, in fact,that
the
one

impossibleto
blood-vessels with
uterus

of

in activity

without

in activity of the

the other.

Accordingly, when
organ

the
charged sur-

dominating
those of

(theovary)

are

blood,

the

subsidiary ones

(the
;

and

Fallopian tubes) become place,be

is very

similarlyaffected
asserted,but
the

and

this takes

it

or observed, not indirectly by

reflex
most
a

action,as
direct certain
some

commonly Possibly
upon the

by

relations.

the

ovaries

may
at

cise exer-

reflex action

organism
organs,

large;

but

upon

of

the

abdominal

and

notably

242

Meadows:

RemarJcs
is

on

believe

it to

be, that the

uterus

only
the

an

appendage tc^
the

the ovary,

is all in favor of the

of

the view

that

ting dominais of
a

influence

superiorover
that
we

inferior

direct character.
I assume, of course, of what
an

by

reflex

action
energy

is meant
from

the
one

transmission

call
nerve

nervous

point along
nervous

incident

to

some

part of the

tral cen-

system, and
from
more

its

subsequent

re-transmission
nerve

back
some

again
other

that
or

centre

along
reflex

an

efferent

to

less distant of this

part. It is unnecessary

to

give

illustrations

action,for they
are

are

of

tolerablyfrequent occurrence
Now
to

and the

generally well just given

shall
to

understood.

if

we

apply
case

definition

of reflex action
see, I

the the

under

consideration, we
in

think, that
of

term

is

misapplied
the

regard
for

the the

influence
nervous

the

ovaries between

upon them

uterus,
the
most

that

action

is of
to

direct
to

kind.
character be
no

This

being
I

so,

we

have
How

next

inquire as

the
can

of that

action.

is it exercised

? There action

doubt,

the think, that here,as elsewhere, is direct upon

of

these It

sympatheticnerves
been and

the blood-vessels.

has

proved by
others, that
upon

Czermak,
temporaiy

Bernard,
excitation

Brownin
an

S^quard,
organ will

consequent
attract
a

increased of

functional
to

activity
part than
that
or

larger

amount

blood

the and
more

is usual

under

ordinary circumstances;
of blood will

this

temporary

afflux

give

rise to

less

and paralysis in immediate

or an

dilatation relation

of blood-vessels

in other
a

organs blood

with

it, so
of
water

that may

flow
be

of the

increased
There

secretion
are,

direct
exer-

result.

in

fact,two

kinds

of influence

Ovarian

Physiology
"

and

Pathology.
and

243

cised

by
and and
;

nerves

upon

blood-vessels In the
one

tion afEectingnutritract, con-

secretion. there is
a
"

the

blood-vessels
or

diminution
the

of nutrition

of

tion secre-

in the of
a

other

blood-vessels

dilate, in

quence conse-

greater
tissues." the

attraction It is the

for

ai'terial blood kind in of

oped devel-

in the that The blood I

latter

influence

believe

ovaries
their

exercise

menstruation.
attracts

perfoiTaance of
to

function
the

in ovulation

them the

; and

through

influence

of the

pathetic, sym-

blood-vessels

and

about capillaries

the
set

fundus
nerves,

uteri, v^^^hich is supplied by

and those the

the
in

same

of

vessels of ovaries
is

which

are

direct

relation
are

with

of the

by

free

anastomoses,

lated; di-

secretion

consequently increased, and

the particularly fundus and

actual

lasemorrhagemay
I mention
more

result. upper
to

part of the body of the uterus, because

noted that
uterus

it deserves between the

be

the

nervous

connection
more

ovary

and

is distributed

especiallyover
from other

those

parts, though it is true

that branches
so

plexuses
into
not

commingle
one nervous

with

these,and

bring the
seems

entire organ

communion.

It

to me,

however,
nerves

unlikely that
relation I believe

this arrangement
to

of

the

has

cial speso

another

fact; namely,
menstrual

the

fact,fpr
comes

it to

be, that the

fundus and

secretion of the

entirelyfrom
that the the way

the

body
in In

uterus, and
least
not

cervix

is not

concerned

it,at
of

in

of supplying blood
from and Dr. Arthur

proof

this,I would
on
"

quote
Uterus

Farre's He

monograph
says
:
"

The

its
has

Appendages."
died

In the uterus

of

one

who

whilst

menstruating, a

remarkable

244

Meadows:

Remarks

on

difference
mucous

is

usually perceptiblein

the

condition

of of

the

uterus

lining the cavity and respectively: that of the body

membrane

body
is

the
jected, in-

highly
exhibits

of

deep-red color,the
That
of of

vessels the

and distinct, cervix

the
a

numerous. capillaries

condition and
such free
a

the from

opposite
be

this ; it is

pale,uninjected,
vessels.
are

all appearances

of distended
same

If served ob-

uterus

the injected,
marked

conditions all the

are

in the
mucous

more

degree ;
of the

on capillaries paratively com-

membrane

body
the

but filled,

few

of the

cervix, an
at

abrupt
of

line of demarcation
os

occurring
And he

sometimes

internal this

uteri." that

adds,

in further

confirmation

view,

if the uterus of blood of the

be

gently pressedunder
seen

water, little
the pores

lets streamor

are

welling up glands
in

from the
none

fices ori-

utricular

lining membrane
from
the- cervical

of the

cavity of
all this

the uterus, but

cavity.
Now

is. in direct
some

contradiction
observers. if the

of

the

ions opin-

expressed by
with cervix
found Dr. is the

other that

Dr. be

Henry
ined exam-

Bennet, for instance,affirms

uterus

speculum
into

dui'ing menstruation,
view,
and
us

and

the is But

brought
does
same

"its
a

mucous

surface

greatly congested
Bennet the
not

of

deep-red hue."
he took
care

tell

whether

to

amine ex-

cervix

in the

non-menstrual

condition,

so

that

possibly the
been made been
at
a

great congestion here

state

spoken

of

may that

have it
was

morbid
worse

unconnected

^vith, except
function. this I
was

by,

the menstrual
examine

I have for

some

pains to
instances

question
enabled

myself, and

in two

where

Ovarian

Phys'iology
cervix

and

Pathology. speculum during

245

to

examine

the

with

the in

the

catamenial
cases

period, and

again
from color
no

the

intervals, both disorder, there

the Dr.

being perfectlyfree hardly

any

uterine

was

change

of

perceptibleduring

menstrual

epoch.
observations dwelt
at

I have
are

doubt, therefore,that

Farre's
I have with
some

correct. strictly

some

length
of

upon

this

question and
seem

minuteness

detail,though
to

it may I

at

fii'st sight liardlyto hand

; but

belong
very

the

subject
it serves,

have

in

it appears

directlyrelated
moreover

to the

ology physito

of the ovaries,and
illustrate the modus
some

I may

think,

operandi by
of the of the ovaries
or

which

we

in time but

hope
the

to

elucidate
effects

at

present
upon

obscure

undeniable

other
it

parts of

system, in health
the

disease. secretion

I think

extremely
occurs

likelythat
in similar

excessive

of urine which in
a manner

hysterical subjectsis produced

to the
"

precisely
the
one case

secretion

from

the

uterus

in the

of ducing pro-

menstruation
a

in physiological activity secretion from the

case

normal

organ

functionally
case

related
to

to
an

it ;

in pathologicalactivity

the other

ing lead-

abnormal

secretion

in

an

organ

anatomically,
it. In both

but
cases

not

connected physiologically, is starting-point the is of result

as

with

the in

the

same,

viz.,the
action

ovaries,
upon

and

both

regards the

the

blood-vessels the such influence

a

identical, liamely, dilatation,through

the
vaso-motor
nerves.

We
cause,

know
we

that know

result may in
as a

follow

from

such

and is

also that

glandular structures
consequence

secretion of

always

creased in-

of dilatation

blood-vessels,

whUe

it is diminished

by

the

opposite condition.

246

Meadows:

MemarTca

on,

etc.

This, which

I take

to

be

fact clearly-established
an

in fluence inbe

physiology, must
upon that many of the
our

eventually exercise study

of

important
it may
to

pathology

; and

present difficulties

in

regard

rian ova-

those which diseases, especially called

erroneous

arise from

what

are

functional

in

oppositionto organicderangements,
the

though
of life

I believe
to

expressionto be, will

;

be

explained by
o\yr

reference

this law

and,

what

is more,

system
new

therapeutics may,
from
once

it is to *be
source,

hoped, placed
exact.

receive upon To chief both

a

the
more

same

and
more

be

footing at
up, then the

scientific and

sum

I have

considered
of the

in this paper

the

points in
in

anatomy
and

ovaries

themselves,

their

general
to
near

microscopic characters,and
and
more

in their have
seen

relations how
in

distant
their way
to

organs. functions

We
are

and

in what

manner

performed
that

health,and
organs with I how

in what

it

seems

probable cally, physiologiIt has

they
or

influence connected

related
them
a

them

anatomically.
manner

been truth

demonstrated,
and
reasou,

think, in
that

consistent
are

with
the
;

the

blood-vessels

chief
that
same

agents in

the the

performance
most

of the ovarian

functions

they
the

are

affected the
"

by

them

but,

at

the

time, it is through
"

nerves

of

those

sels blood-ves-

vaso-motor
are

nerves

that the

principalchanges
we

in the

latter

effected. ^f or I fear
our

Therefore

may is not that

expect

to

find hereafter advanced ogy

"

knowledge
present
"

ly sufficientthe in

to make

it clear at

pathol.
tion propor-

of the
as we

ovaries
are

will be
to

best

understood

able

recognizeand

appreciate changes
system, in
its

affectingthe great sympathetic

nervous

Thomas:

Septicceniia.
At these the
same

247

general or hope
best that clue

local
a

aspecta
of

time, will

we

maythe of

mastery
a more

details and

afford

to

rational

scientific system

therapeutics.
(7b
be

continited.)

CONTINTJATION
BEFORE THE

OP

THE

DISCUSSION YORK OBSTETRICAL

UPON

SEPTICEMIA*
SOCIETY.

NEW

BY

T.

QAILLARD

THOMAS,

M.D.

At had from

the last the Dr.

meeting
of

of this

Mr. President, we Society,

an

pleasure
Peaslee

to listening

interestingpaper
standing underexact

upon the

the

subject of septicsemia. The

were,

chief

objectsof
the

essay

according to
stricter and
to

my
more

of it,to confine
limits the

within

diagnosisof regards
to
as

this
a

and condition,

check
to

what
as

author

growing tendency
of At that

view

belonging
should
not

this
thus

class

affections,disorders

which
I
tured ven-

be
a

classified.

meeting
and Dr.

to make

few

desultorycriticisms repliedto by
was

upon

the author's

views, which
To these

were

himself from

Jacobi.

I replies

prevented
the chair
I
now

responding,by
of

the announcement had

from

that the hour

ment adjourntunity opporto

arrived, and
to
me

avail

myself
so.

of the I

accorded

of

doing

As

propose

quote

somewhat
commit

from my

authorities
remarks
not
to

upon paper but

this
; and

matter,
as

prefer to
to must
an

reply
I I
in

essay

which

I have
to

read,

only heard,
should
263-278

beg

its author
of the

bear
York

this fact in mind

Obstetrical

See

"Transactions

New

Society," pages

this number.

248

Thomas
of

SepticcBmia.
and

misinterpret any
incorrect

his

views,

attribute

to it any

quotation of
to

his statements. the

Every attempt
must

improve

certaintyof diagnosis
as an

by

every

physician be regarded progressive

advance, and
as

effort at true I
to too
am

such

I hail the
am

essay

which

about

to

review. I feel

Nevertheless, I
that evil may

constrained from
which the the

confess

that and

result

rigorous
has
me

somewhat
"

arbitrarylines
my and
own

author
renders
out

drawn

^lines which

observation
I think
are

unwilling to accept,
with
most
a

which

of

keeping
dicta

the

opinions
in number

of

those

authorities
with in which the
an

whose

carry

weight
be

connection

subject. Against
erroneous

certain

of

cases

diagnosiswill
believe
in which
course

prevented by
will
be

these
a

rules,I

fear number fatal

and

that

there

balanced and

larger
run

will septicsBmia

develop
of
the

its

unrecognized and
circumscribed
cases

untreated.
limits

My impression
author

is that exclude
in

the many

will

in which it

this affection has

developed
which

parvo^
in

while
magna.

correctly represents
He appears
run

those

appear
cases

to

me

to
courses

ignore slight
and remarks end
too

of

septicaemiawhich
to

their

favorably,and
much
to

confine

his attention
cases.

and

exceedingly grave
to
cases

In
as

saying this
admitting
I

I do that

not, however, wish

even

be

understood

in

very

grave

his rules for

their

hold true, diagnosis

for

I shall the

presentlydeny Society that

and, validity,

think,

convince
to

I have

good grounds
sustain the

ing for refus-

accept them.

Before
cases

going farther,let
as septicaemia,

me

positionthat
those

of

true

and

unquestionable as

250

Thomas

Septiccemia.
not

and basis

ovaries.
can

For

this I do

think

that

any

scientific that
an

be

found.

Pathologists are
fluid is the

agreed
the

absorption of putrescent
and that its

constitutes
same

disease,
the

pathology
and

throughout D'Espine
to, that
he

field of
the

medicine the

surgeiy.

M.

sounds clares, de-

key-note to
in the bear
no

prevailing impression when already alluded

to the

essay

these

dents acci-

specialrelation
with those
and last animals.

state, and puerpei*al

should

be classed persons

which

in produce septicaemia

Abounded
The

other, and

general objectionwhich
to

I would

present, has

reference any

the

belief

that

looseness

of

diagnosisappliesin
Now,
of

specialdegree to deplore the

this affection. many

cases

Sir, I

admit

and

fact that

of leucocyof pleuritis, typhoid fever, of pericarditis, and

a

themia,
in
our

host

of

other

diseases,are
an

daily detailed sion, impresregard

There made. with
to

journalsand
an eiTor

societies under

erroneous

in make

diagnosishaving
the I would
same

been

I would

admission admit
no more.

but septicaemia, far

as

is,as
tainty uncer-

my

observation

goes,

no

greater laxity or
than make

in the

diagnosisof
whole.
to

this affection

of others. upon

So

much
as

for the
a

criticisms I my
now

which

I would
to

this essay

proceed
recollection

certain
Dr.

special
be

points. According
essay, it assumed

of

Peaslee's
should that

that the

following conditions
of and septicaemia, crucial
tests

regarded as pathognomonic
of them
:

most

should

be

required as
and

of

its existence

1st, a very

high

rapidly-varyingtemperatui'e,
a

the

thermometer
;

recording
very

blood-heat

of marked

104*^

or

thereabout

2d, a

rapid pulse ; 3d, a

degree

Thomas

Septicomda.
a

251

of

mental

hebetude,

or

certain

degree
marked odor of

of

mental
to ;

excitement

ending
cadaveric that I

in this ;

4th, a

tendency
the breath At

sweating ; 5th, a peculiarsweetish

and
same

6th, a
time

hue admit

of

the that

complexion.
in very with
one severe

the
cases

of
are

all septicaemia

these
I
am

symptoms,
not

exception,
admit

apt

to

develop,
in in very

willing to
nor

their

necessary presence

existence
even

slighter cases,
grave
ones.

their universal
other

In

words,

deny

the

propriety of refusingto
because septicaemia
some or

believe
even

in
most

the existence
of these

of
are

absent.

Guided
views
1st.

by

my

own

experience,I
upon the
at which

would

contest
"

the

of the As
to

author the

following points: septicaemiamay

time

nate. origi-

2d.
to

As

to the

high

rate

of

temperature

as

an

essential

correct

diagnosis.
to the

3d. upon remark

an

As the

propriety of laying any degree of

breath
as a

stress

saccharine the

symptom.

(I would
make

that

author

does

not

by

any

means

it

essential To maintain
two

one.)
my first

I, at objection,
to make

our

last

meeting
second

related
must

cases,

which,

this paper memory,

complete,I
the

here
notes

repeat; the

first from

from
The age, for It
a

by
case

Dr. Ward.
was

first

that the

of

woman

about

30

years

of

who

entered

Stranger'sHospital
in the
was

for treatment the

uteinis.

large fibrous
found

polypus
removal

cavity of

being
was

that

a practicable,

sponge house-

tent

introduced

into the cervical canal

by

the

252

Thomas

Septicceniia.
hours it
was

sui'geon, another twelve the the

and

in

twenty-four
When

removed in

and

inserted.

this

had
the

been

position
:

hours, it was
a

removed, for
violent

followingreasons
up
to

patienthad
temperature
which
this time the and

the pulse ran chill, she in

was

150,
the

to
we

106^, and

put under

treatment

adopt
the
:

developing peritonitis.
the

From
were

until

death, patient's temperature

103
was

following

symptoms

the
to

very

lar irregu104 to to

jumping,

101

in

the

morning,
from
and in and
120

106

in the

evening;
was

the

pulse varied
and

150;

the

complexion
dull and lean

sallow

dusky,
lived

the

gence intellias

wandering.
about recollect,

She
a

this way,

nearly as
we were

week,

thqn, just as

becoming quieted in
A

our

anxiety about
examination in any

her,she
revealed

suddenly died.
no

post-mortem
no

and peritonitis,

abscesses

viscera, only
I remember. of interest this

engorgement
In that

of

and lungs,liver,
case,

spleen,as
as a

relatingthis
when the member had

stated
annexse

matter

uterus

and

were

presented to
of

a Society,

suggested that probably

from this

this sudden

toxaemia
Dr.

resulted

absorption
case as

the
the
as

sponge.

Peaslee

regarded
in which the veins
nor

out

of
it

category
had

which
to

his essay
cases

considered, looking upon poisonous

of animals. do I
now,

equivalent
been

those

elements

into injected
I that did
not

then,

accept
from
a

the

theory caemia. septiof

absorption of septic material

and I carbolized gave
as a no

thoroughly
mentioned

washed

sponge
to

created

this fatal but

weight
resulted

the

view,

it
the

merely
blood

curious

reminiscence. from
a

Intoxication

probably

lymphangitis from

Thomas

Septiccmtiia.
contents
one

253

absorption
This
case

of

the

putrescent
maintain
as

of

the

uterus.

I would
not

illustrating tion posimy

consultation
will

and

outside
case

of the

category.
in

The

second
the

I attended this

with
now

Dri read

Ward,

Secretary of
of it
:
"

Society,and
I

his notes
"

On

the
to

4th take the

of

March, 1873,

was

requested by

Dr.

Thomas
then
"

charge

of

case

of Abbot.

placenta praevia,
of full term, and
that

under The had

care

of Dr. within

Mary
two

patient was
three Thomas between

weeks

had
"

haemorrhages previous to
saw

morning.
a theter ca-

Dr.

her
uterus 4

at

a.m.

and

introduced with
a

the

and

membranes,

view

to

induce
at 5

labor.
p.m.

At

p.m.

regular labor-painsbegan,
the Barnes' largest-sized
a

and

I introduced
to

tor dilasure pres-

in order

check

haemorrhage by making
and
to

against the bleeding surface

"

hasten

tion. dilata-

At

8 P.M., dilatation
were

being nearly accomplished, the

Dr.

membranes pressure dilator.

ruptured by
foetal head

Thomas,

and

thus

by
No

the

substituted

for that

of the
p.m.

further

haemorrhage resulted,and
of
a

at 11

the
"

patientwas
Thus

delivered

vigorous boy.
and

far, as regards the

duration

termination
as

of
dinary or-

labor,the

patient was

in

as

good

condition from

after

labor,being neither exhausted

nor

haemorrhage
unfavorable

protracted labor.
"l^iJ

day,
"

On

the

followingday
she
was

no

symptoms
"

were

apparent, though

quitenervous.
hours after her

^d

day.
"

During
a

the

following night,27
in the

labor,she

had

and chill,,

morning

pulse was

254

Thomas

S^ticoBmia. Evening temperature

had
99^

112

and

temperature

102^.

pulse 86.
"

3^

day.
"

During
102^.

the

night followingshe morning dry

was

another

chill,and

her

pulse in
No

the

found

to be 1

20,
;

temperature
lochia normal.

Tongue
abdominal the

and

heavily pelvic roof

believed of

coated
on joined con-

tenderness, even
whole
It

manipulation, and
bear

would the

rough manipulation.
train of

being
the

that

whole

symptoms

was

result

sorption septic ablocated

favored
recourse placenta,

by
was

the

"ite a"
to

the

abnormally
done

had
was

intra-uterine

of iajections

carbolic
about

acid,which

thoroughly
the for
no

by

me

once

in

eight hours
of the

during

followingfour days.
and injection the

The
sary neces-

introduction

catheter her

manipulations gave
"

pain

whatever.
hibited freelyex-

By pain

direction and

of Dr.

Thomas,
to

quinine was
nervous

opium enough
existed.

quiet the

system

no
"

whatever

Evening temperature day.

"

104".

"4"A

MorningtemperaturelOl^; profase slightmental

"

sweats,

sallow
was

complexion, and
first taken and with

aberration,which
^the lower upon

at

for cinchonism
a

lip
it ;
160.

much

swollen

herpiticeruption
106",
his

tongue
Dr.
to

dry.
Thomas
see

Evening

temperature

pulse
Dr.

at being ill,

request I asked

Sands

the

who, patient,

after

examining her, believed

did
not

that be

was peritonitis

settingin
so

; he

think

it could

at septicaemia

early a
of
140.

date.

'"5^^

day.
"

Morning

temperature
;

101", pulse 140,

generalappearance 105",. pulse

patient better

evening temperature

Thomas

SepticcBmia.
this the

255

"

5th

to 9th

day.
"

After

pulse was
aberration

never

low be-

185, while
101^ to 106^
more
"

the

temperature

would

fluctuate
was

from

and

107"^ ; the

mental

gressivel pro-

marked,
On the

but

of

mild

character. ninth

9th

day,
"

morning
to
to

of the

day
she

she
gave

was

drowsy
her

and

little inclined
in relation In which and the

talk, though
herself and
she
was

tional ra-

answers

the
a

members

of
dition, con-

family.
from
at 2

evening
she 7

in

soporose

lapsed
at
p.m.

into

entire

ness unconscious-

A.M.,

died

of the

tenth the

day. following

*'A

summary
"

of

this

case

exhibits

points :
"

1st.

Marked second Extreme

elevation

of the

pulse and

temperature

on
"

the 2d.

day.
variation the of

temperature
course

and

rapidity

of

pulse throughout
"3d.
"

entire

of the

disease.

Mental

hebetude. absence

4th.
or

Entire
other

of

symptoms
trouble."
Peaslee

of

metritis, tonitis peri-

inflammatory
this
case

The
to

diagnosisof
while
so

Dr.

was

unwilling

admit,
case

Dr.

Jacobi
not

expressed a deep regret that

one

any
out
as

palpably
this

of
I

septicaemiashould
when been
case

go

one

from

Society.

admitted,

relating
I could I

the

case,

that, no
be it to

autopsy having
that positive be ; but of
as

made,
was

not, of course,

the
to

what
of it its

agnosti di-

the

fact

being

plainly
and that I

not

case

I deny septicaemia,

positively
confess
as

without

reservation. Dr. the

me

Furthermore,
criticisms

I must it

regarded
he

Jacobi's facts with

upon

being
night to-

unsupported by

presented.
his
reasons

I trust for

that

will favor

questioning

256

Thomas

Septicceniia.
that

the

correctness

of

my

diagnosisand merely
case was

of

Dr.

Ward.

This
but
am

I do

not

desire if this in the

in the
not to

of disputation, spirit
one

because
so

of

I septicaemia,

much I

dark

as

diagnosisin

similar

ones,

that

reallydesire enlightenment.
shortest limit for the

Dr. Peaslee's

development
may
not

of septicaemia have
stress

is 48 hours. made upon

This

requirement he
him
non

absolute, but
and it,
to esteem

I understood it
a

to

lay great
for certain

8i7ie qica

nosis. diag-

The other

two

cases

just related
Let
us

eventuated,
see

one

in

36, the
the
perience ex-

in

27

hours.

what

has

been

of other M.

observers. is based Not of

a

D'Espine's essay
of 1 1 7
cases.

upon

the careful
the

vation obser-

to
:
"

weary

I give Society,

the

headings only
Observation of

few

XIII.
access

"

Sub-acute of the

septicaemia;application
disease

forceps;
; death

during
the

the

first and

24

hours

in the

night

between

second

third

days.
XV.
; death

Observation the first

Acute the
"

septicaemia ;
sixth

access

by

fever

day
of

day. sporadic septicaemiafrom

of the fever the fii'st

Observation retention

XVI. the the

Acute

placenta ; eighth day.

cases,

access

day
He my be

; death

presents other
The

but

these

are

sufiicient for
must

purpose.

evidence

of this observer

either
that

entirely discredited, or
24

it

must

be

admitted itself.

within

hours

septicaemia may
traumatic

declare

Billroth,viewing
one

fever
latter

and

as septicaemia an ex-

and

the

same

thing,the

being only

258

Thomas

Septiccemia. Temperature
of the these that last
not

followed
No

by

moderate
over

fever.
any

taken.
no

tenderness and

part

abdomen;

tympanites;
were never

I may

remark

symptoms

present dui'ingher illness.

21st, symptoms Insomnia
gave
were
me

On but

Friday, the
little fever.
one

not
some

alarming;
uneasiness,
effect.

for which
On
a

gr.

opium

was

given
of fever

with

good

Saturday, 22d, in morning,

exacerbation of
next

very

comfortable, with

considerable
sallowness

; in

evening,a

liar pecuyou

skin

manifested

which itself,

remarked For this also

the four
or

day (Sunday). days subsequently,I

became
more

five

may

remark,
; the urine

jaundicedhue
became

pronounced
bile.

deeply tinged with

before
death the urine the

Two almost As from I

days
did

jaundice disappeared
normal
case,
as

and entirely,
not

became of the

in color.

keep
the

notes

can

only

say
a

memory from

that

temperature, 22d,
never

taken

twice
than
was

day,

Saturday, the
increase in the

went

higher day
entire there

103^, until the day of death, 106^.

a

Each The

marked

evening.

sickness

was

characterized

but by sleeplessness, three

with

little

pain,
the
couraging en-

except for about

in days succeeding the rigor, very she

right hip.
on

The

temperature, pulse,etc., were

that

day,

until

10

p.m., when

plained com-

of
"

bewildering headache,

and

said

she should

go

crazy." deepened during

death
on

Friday, 28th, semi-comatose, which

the

day

to

complete
secretion

coma,

in terminating
was

the

29th.
coma

The

of urine

abundant

until the

appeared.

Thomas I regret that

and make

Septiccemia.
time
to review

259

I have

not

the

above,

the account

at least

intelligible.
J. L. Campbell.

Very truly yours,

P. S.

"

now

recollect

that

on

the in
a

4th, typhomania
less

manifested

which itself,

continued

degree
the

sequently. sub-

Sweating
of death,
269 W. 43d

occurred

May

20, 1873

early on

day

herpes labialis
street.

existed.

The

authority
as

of

Billroth

will, I
this

presume,

be

mitted ad-

being

reliable upon
and

and fortunately point, it. On upon where elevation their

course

he of

is

clear perfectly American says

positive upon
of

page

337

the

edition
:
"

his
also

work
occur

Surgical
the
onset

Pathology, he
of the fever is
; and

Cases

scarcelymarked
some lastly, cases

by
run

an

of tem.

perature

out with-

fever, or
This
moment

with

abnormally
to
me

low
to

temperature."
be
one

point
that

appears I must

of

so

great

urge

its careful could

consideration
not

by
so

the

Society.

Surely
unreserved himself
my

Billroth
a

make

positive and fully satisfied

not

statement

without
I

having
cause, be-

of

its truth-

accept it fully,

only
as

from

respect for the

last

but authority,

I stated

at the

meeting
the

of the

Society,my
breath been it
a

own

observation

endorses the
as

it.

Lastly,as
look upon

to

value
almost

of

saccharine Such
to

this
upon
at

nil.
and

has

my

ex

perience

the
the

point;
last

illustrate
to

by
case

an

example, I,

meeting, alluded

of

260

Thomas

SepticcBrnia. recentlyseen
existed.
to

septo-pysemiawhich
merer,

I had

with

Dr.

Kamand

where

several

joints were regard

of
two

filled with

pus,

yet

no

saccharine Peaslee

breath

Dr.

preferred
and have

this

case

as

one

of know may

metastatic
that such

abscess abscesses

not

septicaemia. We
sources :

first, they

arise from from

emboli
the disease

which

have in the

been veins may

displacedby
near

ment detachof the

thrombi
;

the
as

seat

primary

second, they

occur

secondary
Billroth

consequences that the

of
"there

septic blood-poisoning.
are

clares deof

metastatic

diffuse

abscesses

eye, cerebral

membranes,

subcutaneous

tissue, joints,

periosteum,liver,spleen,kidneys, pleura,pericardium,
etc., which
The
occun-ence are

independent
of
these

of

abscesses
cannot

or

emboli. be

metastases

easily

explained." D'Espine's 10th

is
as

conclusion,based

upon is
a

his 117

cases,

follows

"

Puei-peralpyaemia
is almost the

complication of
a

and septicaemia,

always accompanied by
veins of

lent puru-

condition
It is
a

('purulence ') of

the uterus.
to

comparatively rare
visceral all the
to

due probably complication,

septicemboli.
"

Metastatic almost due

abscesses

are

consequences of cellular
are

of

it,

while

inflammations

tissue and
not

are joints

and lymphatic infection,

embolic

in their

nature." upon this

case as one

Looking
the it for
some

of this

character,and
who had watched

cepting ac-

of diagnosis

Dr. I

Kammerer,
saw

time
a case

before
of

it,I regarded it,and

now

as regard it,

septicaemia, complicated by
an

tatic metas-

abscesses,and

presenting

instance

of entire ab'

Thomas

SepticcBniia.

261

sence

of
disease.

sweetish

breath,

even

in

an

advanced

stage

of

the

The

appreciation
of when
I

of

this

symptom
nowhere

by
in

D'Espine
his essay

may do I

be find

judged
one

say

that

solitary
which is
altered

allusion

to

it.
and

His

r68um6 includes

of

toms, symp-

thorough
f

minute,

chill,
elevated
state

rapid

pulse,

acies,

dyspnoea,

diarrhoea,
suburral

temperature,

mental

derangement,
no

of

digestive
unless Billroth it

tract,
has

but

mention

of

this

occurs

anywhere,

escaped
is

my

notice,

equally

silent

about

it,

so

far

as

my

ing read-

of

his

articles
I

informs

me.

This

is,
;

admit,
it

negative,
so

and

therefore

not

conclusive

proof
me

but

is

strong
a

as

to

satisfy
from

me,

and

to

induce

to

give

the

Society

reprieve

the

production

of

other

evidence.

262

Dawson:

Circuiiicimon

for Oongenital

CIRCUMCISION

FOR

CONGENITAL
CAUTERY.

PHIMOSIS

WITH

THE

GALVANIC

BY

B.

F. DAWSON,

lt.D., ETC.

Simple
are

and

safe

as

the
to

operations for
is

circumcision

generallyconceded
some

be, yet the fact that

they

may

in

instances
and
even

(rarely it

true)

be

followed

by
of

severe

dangerous hemorrhage,
any
new means

is sufficient to
or

justifythe operating danger

Aside
called

recognitionof
which this
the
to
or

method

wholly
other

removes

all

possibilityof frequently
in
as

from from
upon

causes.

Jewish

rite, surgeons
this
the
as

are

perform
of

operation
prepuce,

cases
an

of
mediate imthe

congenital contraction
remedial
functions

both
as

measure,

well life.

to

insure

of the

penis in
to

adult

As

in

general experience (as is

months
of the knife

parents
also often and ago and of the that

consent
case

it with

great
the

reluctance

the
loss

in

at adults),

thought
to
me

of blood, it occurred circumcision

be of
a

some

by cautery
would

the

above
to

objections
say

dangers
the

greatly overcome,
trial, as
there

nothing
at

advantage give
the it

greater facility. I resolved

seemed
no

least to

idea

ble possi-

objectionsto
A hands of age,
case

suitable
last

for

the

operation
The

came

under three

my years

in March and
was

(1873).
to
me

boy

was

brought

by

his mother

for relief

Phimosis
from

with

the Galvanic

Cautery.

263

the troubles On my
to

due

to

an

exceedingly contracted
mother consented students

puce. preto

requesting it,the

allow

me

operate before the

at my

Clinic for

children this
was

in the Medical

Department
in which I in my

of the

University of
to

city.
to
noose

The

manner

proposed
of
fine

operate

the the

prepuce
same

loop

platinum
remove

wire, connect
it

to

battery,and
two
or

then three

by
the

after constriction,
mucous

which with

snips
would

of

membrane
retract
on

the the

scissors

enable

me

to

and

liberate
March

glans.
15th, 1873,
the

Accordingly being
of

Saturday,
in the my friend

boy

anaesthetized

lecture-room,with
and

bichloride
P. ter, B. Porclose and
was

methylene, by
the prepuce the

assistant

Dr.

was

engaged
the

in the the
mucous

platinum loop
latter

to

glans, connection
removed;
at

with

closed,

the then the

prepuce

membrane

snipped

four

points,the
minutes
home

prepuce

retracted,and

glans readily exposed. boy

in
a

The

few

recovered
his

from

the

and anaesthetic, but

went

with

mother, suffering
been

a slightly, simple

cold-water

dressing having
lasted

applied. Unfortunately expected

not
or

the

operation
have

longer
to

than

it should power

done, owing
to

my the

battery loop
red

developing

sufficient the
a

render

hot.* into
*

Consequently
the

heat

had

more

time
firmer
last

to radiate

tissues, giving
used
zinc
was

deeper
bj
me

and

eschar

than
being of

The
carbon

batterf
and
so

purchased
different

in London and

sammer, The

the the

pattern,
the

requiring sulphuric points of Neglect

nitric adds.
as

use

of

latter

affects
to

connection to

to
was

call for their the

cause

stant con-

cleansing, non-dCTelopment

obtain

full power. necessaxy power.

do this

of the

of the

264

Dawson

Circumcision

for Phimosis^
occurred and had

etc.

was

desired

or

would

have

full power been

tary. momen-

of

the

battery
This

been

obtained

removal

unexpected
less
to retraction,

firm

eschar

rendered

the

tracted re-

prepuce

and elastic,

constricted slightly
all

the it

penis;
For oedema

after

avoid

danger, I snipped
there
of the
a

on slightly

each first the

side. three
or

the of

four
at

days
end

was

some

parts, but

the

week

row, nar-

soft, granidating
eschar. class and The
at

line

marked
was

site of before

the the

In the

two

weeks

the

boy
the

shown

college,vnth resultingfrom
the

parts perfectly healed

all

previouslyexisting symptoms
the

wholly signs of

relieved.
ingly exceedso

cicatrix

operation was
no

soft,and
recent
an

penis

showed

very

operation.
of this
case

The the
can

result

demonstrated satisfactorily of

success

of this mode
was

operating,which
of the

so

far

as

ascertain
commends The

the

first instance

kind, and
cases.

tainly cer-

itself for trial in other which

I

advantages
the

claim

for

this method

of

operating are
Entire

following.
of immediate
or

avoidance

secondary
other

rhage. hemor-

Quickness
when should the wire be but

of

the

operation over

methods, for
of the prepuce

is fullyheated

the removal

momentary.
of the the patient necessityof restraining

Avoidance
as

to

etc. exercise,

In

the next
to

case

coming
with

under

my

hand

it is my

tention in-

operate

the cautery knife

instead

of the

loop

as

in the above

instance.

266

Bailey

Case

of

Meningocele.

few
could

days
not

after

birth

but

the

nature

of

the

deformity

correctly
of

be this

ascertained. malformation

The

subject
and

was

one

of
in each

twins,
case

male,

weighed
but in the

eight
case

pounds.
of

Labor

was

normal,

twins

was

quite
than the

tedious.
child's

The

meningocele

Sne-third
was

larger

head,

emerging
externally

fi'om

the

posterior
like the

fontanelle,

and

ered cov-

with

hair

scalp.
at

It

was

soft

to

the harder

touch,
and

except
of
a

its

base,
color. in

where It the

it

was

somewhat
with

darker

was

filled

subarachnoid
the

fluid,

enclosed

branes mem-

of
The other

brain. twin

was

male,
and

and

weighed
from

precisely
malformation.

the

same

"

was

healthy
survived
until

child until

free
the

The

child

fourteenth
hours

day,
its

and

nursed
A

well similar

within is

few

of

death. in
the tographic Pho-

case

reported
of

and

illustrated for 1870-71,

Keview

Philadelphia

transactions

of

the

new

york

obstetrical'society.

Eepobted

by

Charles

S.

Ward,

M.D.,

Secretary.

Stated

Mebtino

of

Mat

6,

1873.
THE

Dr. Chair.

B.

F.

Dawbon,

President,

in

There

were

present:
L.

Dre.

Jacobi,

Peaslee,

Blake,

lain, ChamberDe-

Jenkins,
wees, Ch. F.

A.

Rodenstein, Janvrin,
the

Thomas,
Ward.

Byrne,

Dawson,
read

Eodenstein,
of

The

minutes

preceding
of

meeting
committee of which

were

and

cepted. ac-

jDr.

Thomas,
the

on

behalf
to

the

appointed
James

at

the
sented pre-

meeting

subsequent

the

death

Dr.

L.

Brown,
:
"

following
it has

resolutions,
a

were

accepted
from
it thus
our

Wherefis,

pleased
Dr.
we

Divine L.
mooxn

Proridence
;
our

to

take be

midst

our

loved be-

President, Hesolved,
an

James

Brown

therefore,
loss wise in

That devoted
the

deeply

being

suddenly judidous
friend with

deprived
labors
were

of

able

and

President,
value
the
to

whose

counsels

and

always

of

highest
That

this
of

Society.
Dr.
Brown
we

Besdved,
whose
the very have

by

death
and

have

lost
have

and
us

ate associsince
ezer-

warmest

interest of
our

hearty
and

co-operation
whose

been

foundation

Society,
to its in

unceasing
and

and,
success. career

zealous

tions

largely

contributed
in

present
the

position
of
an

Unsolved,
qualified
severe

l^t
adorn

the

removal

midst

active this

of

one

so a

to

its ranks,

the

medical

profession

of

city

has

sustained

loss. That
we

Besolved,
Dr. Brown.

tender

our

heartfelt

sympathy

to

the

bereaved

family

of

Revived, Brown,
and

That that

copy be

of

these

resolutions
in

be

sent

to

the of

family
this

of

Dr.

they

published

the

medical

journals
T. E. G. B.

city.
M-D. M. D.

(Signed),

Thomas, Peaslee,

The

President,
and

on

motion
a

of

Dr.

Jacobi,
to

appointed
suitable

Drs.

Sims,

Emmet,
on

Thomas,
of
Dr. J.

committee

draft

resolutions

the The

death
next

C.

Nott.

business
a

in

order
on

being

the

reading

of

paper,

Db.

Peaslee

read

paper

268

Transactions

of
TO

the

SEPTICAEMIA

IN

ITS

KELATI0N8

GYNAECOLOGY,

its symptoms,

to

and treatment. diagnosis, he wished Disclaiming any attempt at originality, bring before the Society the various points which

especially distinguish
frequently tendency at
in whicn its

septicaemia from
mistaken the time

several
thus

other
to

conditions the
too

which
common

are

for it,and

check

to present recognized symptoms

invoke do
not

septicsemia
exist.

in

cases

being the condition,or rather the of 'a of conditions, which are produced by the admission group it from septic poison into the blood, and thus distinguishing

Defining septicaemia as

uraemia,

cholaemia,

all
or

the

fevers

and

metastatic

abscesses

produced
H. Bedillot,
to

by
a

emboli and

artificial

injectionsas
jDr.
blood be

practised by
ticaemia sepne or a

Lee,

others, and might

attributing the effects in septine by

enter

principlecalled

Richardson,
in
a

showed

that

this substance

the

fiuid

form hence septicaemiamay ; and gaseous be developed in the patient's body.

contagiousor
as

may

Dr.

Peaslee

objected
was

to

the

term

pyaemia
the pus
;

not

expressing
this term
and the still
dition con-

the fact of

in the blood 8e})tine and

unless

had

first been

composed, de-

therefore

no

longerpus
had
:

under still,

two

entirely
moi-e

distinct

conditions

hitherto

been,

very

generallyai-e, included, viz.

true

septicaemiaand
the

especiallycharacterized frequently in abscesses, most

which the but condition he termed the metastatic admission abscesses
an

by
tne

formation
and The

of multiple

Uver abscess.

lungs,
cause

and of

being, not
emboli
or

of

septine into

the

obstruction

of the circulation other substances.

in the part affected

blood, by the

abscess He but

by

also alluded without of the

of the bacteria in septicaemia, presence natural ment eleascribing to it a causative ; no agency blood can being preproduce septicaemia without viously
to the

decomposed, fatal condition,unless

diminished
to
a

lie
the small

stated
cause

that is

septicaemia

is

rapidly
or

very

amount,
its and

promptly removed death occurring

while many sometimes is usually

kept
from

in

eight
from
from of its

to

nine

days

after

invasion,

recoveries
a

metastatic

abscesses weeks.

occur,

after
had

uance continin

for several
two

Septicaemia
an

developed
two

to nine

days after

operation.
aiter

Dr.

r,

cases

development twelve days ovariotomy. then proceeded to specifythe most characteristic toms sympof septicaemia,dwelling especially of its manner upon invasion,the very high temperature of the patient (always over and rapid pulse,great prostration,the 104^), the very weak
He

New
sudden mawkish of

York
of

Ohatetrical

Society.

269

alternations

the temperature, the

cerebral

jaundiced skin, the

the delusive dence subsiand

breath,
some

the

dulness,and
for

of

these

symptoms

several

hours, now
and

then, to

return

again.
a

Occurringafter
septicemia
in connection

great variety of accidents

interests the

most

surgical rations, opewhen ring occurgynsecologist

either parturition, premature or at the enaof with and term, operations for the removal ovariotomy of uterine He and in cases of imperforate hymen. fibroids, cussion leave the particulars, in the dismust however, to be considered his remarks to which might, perhaps, give rise. He then spoke of the diagnosis from of septicemia as distinguished the conditions most frequently mistaken by the gynaecologist for septicaemia, viz. : peritonitis, metastatic abscess, typhus and enteric fever, and cerebral disease. of the source Dr. P. regarded the removal of the Finallj^, the and indispensable point in the septiue as all-important of septicaemia,and spokealso of perfectventilation, treatment sary nourishing diet,stimulants, and sulphate of quinine, as necesof the for tne sustention the septine is patient while

with

being
Db.

eliminated Thomas paper

own

from

the

blood.
that

remarked,
are

the
all

general
are

features

of

Dr.

Peaslee's
with my

those

which We

I think

will,in the

main,

observations. the
term

willing

to

agree accept liis

definition

septicaemia. With regard to one or two points,I do not feel so certain as does Dr. Peaslee. and is with The first, more gard reparticularly, which before to the length of time elapses septicaemia and develops itself. Until within or more a so, year ticularly parof tlie opinion that within the past few months, I was three four days at least must would or elapse before septicaemia show the introduction the into element itself after of poisonous
the
me

of

system.
to

But
the

I have

seen

number

of

cases

which

have

led

two

very the

opinion. I will mention only one or which make feel this doubt, and that to believe cases me take place. At rapid decomposition and absorption may I exlast meeting of this Society,as may be recollected, hibited
doubt truth

of this

uterus

with

conditions recollection entered the the of

its annexae, in connection

in

illustration uterine is

of

some

with that
case was

fibroids.
:

pathological My
have

the

history of
removed dilate

this

tlie

woman

Strangers' Hospital,and
fibroid
to

very of

anxious of the

to

uterine
was was

from the

the

cavity
the

uterus.

It

decided
then

if it

found the

primary steps of

cervix, and, cavity The the to tumor. remove practicable, follows : a sponge-tent as operation were

270
introduced
its

Transactions
into

of

the
in that and

was

the cer\dx

took At

twenty-fonrhours, and place. This remained

the end Her of that time
ran

by myself,and left then it was removed,

tion posi-

another
violent

the

place twelve patienthad a sudden

in
to

houra.

and

chill.
above

temperature

that
so

point. Pulse
seen

160,
the

up and

106^,

the

subsequently was that peculiar patient wore

with these
cases. me

and

facies
was no

commonly
sweet

in connection

There remark

odor found

to

breath, and
an

this leads

to

that
one.

I have

this

symptom
; but
case

exceedingly unsatisfactory
is present,
an

think, indeed
symptom.
and it
was

admit, that
I have
was

it sometimes

and

very

markedly present

found

it

This
the

regarded as
some

reliable exceedingly unof septia case caemia,

supposed
uterus,
from

that and

septic element
was

had

been the

absorbed

from

it

also

suggested that
This
time that below I

septic material
so

came
"

the

sponge
at

itself. the
same
"

patient got

much

better
course

the

temperature
has Her been

taking that
regarded
her her and

erratic
as

which

referred had

to

out

of

danger.
was

pulse

fallen

100,

nearly normal. Suddenly her temperature and and the patient died within a few pulse began to rise, days. Several of the gentlemen who her were of the opinion that saw the patient died of peritonitis, thei*e was of but not trace a In found this be when made. to peritonitis post-mortem was
temperature
case

not

more

than of

36

hours

elapsed
to
case

from

the of

time the

of

the

firet appearance
of which the the

the

symptoms,
Another

the time I
saw

opment full devel-

disease.

with

Dr.

Ward,

in

the disless than ease 48 hours before lapse of time was all rational That the was fullydeveloped. patientpresented and physical signs of placenta pi^sevia. It was svmptoms aecided labor to bring on at once. Accordingly a gum-elastic

catheter
woman

was was

introduced

into with her

the

uterus, labor
At the

induced,
She
of end

and did

the very time

delivered
hours after
a

but

little

hemorrhage.

well

for
was or

27

delivery.

that
ran were

she
105"

seized

with her

violent

106*^,
of

pulse
the

chill ; her became verj' marked firm be

temperature

up

to
no

rapid;

there

symptoms
was

no peritonitis,

fetid

discharge; the
made
at

cervix in that

lifted up
no woman

with

fingerand
could died

region, but
That
appearance In that caee, obtained

tenderness

pressure discovered

sank of

rapidly,and
symptoms.

in nine

days

point. any from the firet

was

these

No
that
no

post-mortem

made.
was

that

be said

favor

of the

not ably reasonpresent, and this may the but evidence have we now was decidedly.in ; existence of septicaemia. Tlie fluctuations in temperature,

then, it may be was peritonitis

said

positive evidence

which

Dr.

Peaslee

has

mentioned,

were

markedly

New
In the
it would 107^.

York

Ohstetrical
the temperature
the and
same

Society.
would be The

271
found

present.
102*^

; in the

morning evening of
be The

at

day

106^.

morning
106^
a

98^,

toward

evening
of

of that the

following same day

a

and of

sudden
a

appearance

from disease, and

look

with perfectsafety, and

so

temperature
thatl
deemed but in the within be

at 101^

pulse

under continue
same

135,

comfortable

day
and

my she

consultations
was

; longer

soporose,

and

before died

inexpedient to the evening of the morning comatose,

the next 24 hours,

it

temperature "ulse his,it is true, would

conviction In it character,
our was

high, and
not

strong
seems

in

prove mind my that

it to

septicaemia,but the of septithat it was a case caemia.

several
more

the

lightof
to
me

these cases, and

we

of similar

shall

yet

regard and decomposition absorption. I think we shall find undergo that decomposition and absoi"ption take place within a may very
short With is the time.

views

with

to the

time

in which

materially change will septic material

regard to symptomatology
most

the

thermometric

evidence
viceable. ser-

valuable
The

we

have. in

In every

variations

respect it temperature which

in this look

is the most
are

presented
cases are

to

us

by thermometrical
A and
a

observations

class of

wonderful. certainly

patient may
a

well perfectly of 107"

to
us or

in the

morning,
which is

in the

evening have
itself sufficient

temperature
to

108",
she is

fact of
some

indicate

that

sufferingfrom
certain
seen

thennometrical
in connection
not

There great disease. are, however, very which variations exacerbations and are with many them

diseased
out

alone
which many have

would
case

make

to

be

classical

of

Dr.
cases

Peaslee
in

septicaemia presents made has ali'eaay

we are m cases

conditions,but these septicaemia. But a to just the symptoms

reference. doubt
come

Still I

see

which

great

with
on

in diagnosis,particularly very

those

which

commonly
six
a

found
was

the sweetish

odor

to the

regard to slowly. I breath, to

which
About She
to
was

specialreference
weeks

made,
I
saw a

absent.

ago

patient with
four feature
of the
or

Dr.

Kammerer.

German had A

my

visit she

ladv, and about and soon a chill,

very of noticeable

five

days previous
symptoms
was case

developed
filled with

all the

of the

septicaemia.
that
a

in that pus.

the filled
a

fact

number

jointswere
in
one

Pus

was elbow-joint,

present

and digital joints, of

one

collection

of

pus

produced
all the

exophthalmos
of
severe a

eye.

The sufthat the

patient presented

lering
patient
breath.

from
there I do

appearances septicaemia of a very

was

person

who
odor

was

character.
the
sweet

In of

entire

freedom

from
to throw

not

wish, however,

discredit upon

it as"a

272
but

Tranaactions

of
my

the

Bymptom,

simply

wish

to state

own

experience with
I think prognosis,

re-

fam ^easlee

to

its existence. has

Witli

regard to
If

Dr.

the spoken properly. poison can be has said that one destroyed,prognosis is .good. Virchow ing poisonis not very likely and if the focus can to destroy the patient, be removed, the patient has a good chance I feel for recover3\ that my when experience fullyaccords with that opinion. Still, I have done the have remove focus,1 by no means evei-ything^to
cured

focus

of

Ward
that the

all my Tor cases. also saw ; Dr. Sims it was

a case

example,
the

in

the

case was

saw

with the

Dr.

of

patient, but In that case peritonitis.

with But
of
a

of

opinion

Dr. Ward
carbolic

injected
acid every
fully care-

cavity of the
twelve and

uterus

solution the

of

ei^htor
whatever done
to

hours, and
the

washed
this

entire

cavity most
no

thoroughly.
upon
remove

treatment
ran on

exerted in

influence
was

which disease, of

spiteof all that

the

the focus
was a case

acting upon poisoning,

tion supposi-

that In results very

it

connection

with

of efforts at The

different.
removal of that effects,

septicaemia. of ovariotomy my of observations cases removingthe focus of poisoning have been the peritoneal plan ot injecting cavity for
material has been
so

the
its

decomposing
I it

beneficial in

have
was

found
almost the the

position where
so

myself many impossible to

temperature

times believe

placed in
the

marked the

have condition that and

been of

fall in

and

results, improvement
the
stantly, con-

in

opinion

the

in pulse. I believe very much poisonous influence is kept up pretty that is cut

whenever

off,an

amelioration

of

toms symphas

takes
With been Dr.

place vei-y rapidly. regard to treatment, I have

the paper

nothing
Peaslee.

to add

to what

in siiggested

of Dr.

Dr. inquired whether, in the second case which Thomas the related, symptom of somnolency was present. Dr. Ward answered that there were some quite well-marked
manifestations

Peaslee

of that kind.
:

Dr.

Peaslee

When
of

was

of speaking
order of

four

fore bedays elapsing

to
cases

the it
no

development
a

I referred septicaemia,
natural

in which
can

presented doubt, if
enter

itself in the

things. There
in

be

sponge-tent
circulation
hour. A

has
within

poison
an

it, that
and also

the

poison
svmp-

might
toms

the
an

hour will very

produce
hold the

within then

sponge-tent
cases

tfuids,
I
was

and
not

they undergo decomposition

of that class of when which

rapidly. But

speaking
time

of

septicaemia. sejf is this : When

The

elapsed ordinarily difference between only

I do
not
see

before

to the length referring the development of

Dr.

Thomas

and

mv-

symptoms

that

undoubtedly

274

Transaotioiis

of
the

(lie
have look

diseased
proper

blood, in
cause.

order

to attribute
we

symptoms
when
are or we

we

to

a a

One

pathologicallesion
tor

make; produced by disease,we

mistake

for
to look

very
some

apt

it in the

spleen, in the
ever

gastricorgans,
are

in

other

portant im-

viscera. We which and

hardly
is that
so

look, or

less of
are

frequentlythe
blood. in which which
use

seat

likelyto look, to that organ the most dangerous diseases,

cases,

is the

There

for

instance, of

leu-

cocythaemia

there
the of

glands,in
time, except by
of which Within the

the

phatic swelling of the spleen or lymfor made be cannot a long diagnosis the microscope in making ination examan
is
no

blood.

There
be
so

ai'e,

however,

cannot diagnosis

the

last

careful Peaslee
from

about
means

referred to. as easilymade little more few years a physicians have been diagnosticating septicaemia. Evidently Dr. throw
out

many in that

diseases

in

to

land, Engsepticaemia. For a within the in but more more especially recently, Germany, studied has been last two larly particuyears, in France, the blood for the presence of vegetable parasites. It is said that of found blood in the abundantly vegetable parasites are blood that of the presence bacteria in the septicfiBuiic cases, and of the taken of the symptoms be must as particular cause septicaemia. If this is true concerning this disease, it would point to the necessity of making a microscopical examination of the blood in every of suspected septica3mia. case There all know, chemical poisons which affect are, also, as we
the blood.
to
we

of case e\ery of years, number

metastatic

abscess

in esj"ecially

It may be that we yet shall learn of tlie different chemical poisons as

the symptoms distinguish between now distinguish

of tlie symptoms in the future, we

uraemia,
bacteriae and
come

and
are

septicaemia. I fully believe that, to diagnosticateamraonaemia, if the other and aemias, perhaps bacteraemia the only real symptoms of septicaemia by chemical
ursemia shall and be able
" "

of the blood microscopical examination how in the blood, how they destroy tissue,
how blood-vessels,

; how

bacteriae into the

they get

the

they

swim

or

are

carried

along

in

they may even give rise to embolism, how in this abscess be manner pyaemia or septicaemia and metastatic may All this has been shown, at least complicated, and may combine. of in a number I feel sure and in my own instances, mind, that far in the future shall make able but be not to one we nosis diagcurrent, how
in We
must

tliQsecases.
not

wish

to

make

single

remark

more.

viscera

of

of alterations for any large number patient who has died of septicaemia. The

look

in

the

spleen

New
be

York

Obstetrical

Society.
a

275

may may
as a a case

slightly degenerated,perhaps
here and there infarctions

little

enlarged.

We

find

in the

different organs,

but,

in rule,we are not apt to iind much change in the viscera of septicemia. I believe, therefore,as I have already it
to

said,that
to
are

requires a
arrive
to at

very
a a

sound

and pathologist

diagnostician
If of
we

be

able

correct

not

able of
at

make

diagnosis by diagnosis by an examination

must

exclusion.

the

viscera arrive
cases

the
our

body, we
diaOTOsis

fall
same

back
manner

upon
as w^e

the
now

blood, and
do in
our

in the
a

of

leucocythsemia, by
Mat

microscopical examination.
Dr. Chair. B. F.

Stated

Meeting,

20, 1873.

Dawson,

President,

in

the

There

were

present, Di-s. Skene, Chamberlain, Sims, Thomas,

Janvrin, Barker, Perry, Nocggerath, Dawson, Byrne, Ch. F. Rodenstein, Muude, L. A. Rodenstein, Otis,Peaslee, Reynolds,
and Ward. The minutes

of

the

preceding meeting
behalf of the

were

read

and

cepted. ac-

Db.

T. Ga

Thomas,
form
:
"

on

Committee

appointed
the

to

draft which

suitable
were

of

resolutions, presented
God of
His infinite

following,
to
remove

adopted
It has
our

WJiereas^
from
our

pleased Almighty
late

wisdom

midst be it That late

rare

fellow
bow

and

former

President, Dr. Josiah

to

C.

Kott,
in the

therefore death
of

Hesolved,
our

while beloved

we

in submission
we

His

wiU,
a

we

feel

that

associate

have

sustained

loss rendered

rable irrepa-

cinating scholastic acquirements, his genial and fasprofessional and nature. qualities,and his simple, honest contributions he to the profession which Heaoloed, That by his valuable himself had Dr. Nott rendered member of whom and loved a we honored, of medicine weU whose loss the science all feel proud, and deplore. may may towards his with conduct his relations and in Thtit lissoloed, professional he has left us an example by a long and active brethren, illustrated career, of imitation. worthy felt tender to his bereaved family our most sincere and heartBeaolDed, That we in their great sorrow. sympathy be be to his family, and resolutions sent of these Besoloed^ That a copy journals of this country. published in the medical

by

his

social

J. Marion
T. Gaillard Addis

Sims, M.D.
Thomas,
M.D. M.D.

Thos.

Emmet,

CASE

OF

METBO-PEBITONITIS.

Dr.
ten

Janvbin
after well
a

presented
confinement.
until

the

uterus

of
labor

primipara
was

who and she Dr.

died the
was

days
with

The

normal,

patient did
taken

five

days

severe

cliill.

delivery,when Iler physician requested

after

J.

to

276
.

Transactions

of

the

see

her, who
carbolic

found
acid

slie had and

water

Intra peritonitis.
were was

-uterine

injections

of

Pulse

at this time
was some

hibited. used, and opium freely ex116, and the evening temperature

the to tj-mpanitis. In addition three Her hours. given every quinine were opium, 4 grains the same about condition during the two following days ; the much the temshe grew next day, however (Thui-sday), woree, Intellection 32. pei-aturebeing 104", pulse 126, and respiration occurred before remained death, which good until ten minutes made Dr. Janvrin tion ten particularmendays alter confinement. tenderness there of the fact that on was scarcely any

103^";

there

of

pressure.
An
as

autopsy revealed
well Dr.
as

much the
was,

lymph
uterine whether

interested
in this
case case.

pus Janvrin

in

and pus over sinuses. The there that

was was

all the viscera,

Dr.

Peaslee

retnarked

he

any considered

point which septicaemia

this the usual
a

of

metro-peritonitis, tliough there

less than

tenderness.
OVARIAN TUMOR an WITHOUT PEDICLE.

Dr.

Peaslee The

exhibited
the

ovarian

cyst which
the is
now

he

had in

recently
the old.

removed.
iliac
tumor

patient first discovered

age

tumor

right
The

region, at
remained

of

20

; she

45

years

stationary,as regards size, during a period Since the discovery of the she has tumor years. five children. At last the tumor took on borne a rapid growth. On from the abdominal found it was removing the tumor cavity,
of
eleven that there
was no

pedicle;
cyst.
matter

but

the tumor

was

attached
to
a

to

the and

omentum,
radiated

from
over

which the

several

arteries

passed
Dr. the

the

tumor

The
the

cyst
and absence

contained

small

dermoid gave the

cyst, with

sebaceous

bone. of

Peaslee

explanation of following

"

pedicle. The cyst appeared to have developed slowlyduring a period of two years, when it is probable that the tumor rotated to nearly cut so as in the arteries of the pedicle,so that,poorly off the circulation nourished, the cyst remained stationaryfor a long time, until the vascular became established hesion supply, which through an adthe became to so omentum, great as to allow of rapid Mr. Wells mentions five cases he in which Spencer growth. found Brown records no pedicle,and Mr. Baker one case. The regular order of business being suspended, Dr. Thomas * in read a paper of Dr. Peaslee, of the to the paper reply previous meeting, in wiiich,after statinghis undei-standing of Dr.
P.'s paper
to

be
**

an

attempt
original department

"to
in

confine
thie

within
p,

stricter

and

See

number^

347.

Neiv
exact
to

YorJc
the

OhstetHcal

Society,

277

more

limits what

diagnosisof
author this class

tliat condition

and

check
as

the

to view

belonging to
thus
be

regards as a of affections, disorders

"

(septicemia), gix"wing tendenc^y

which

should

prove classed," he said : Every attempt to imof certainty diagnosismust, by every progressive physician,be regarded as an effort at true advance, and as such he hailed the essay which he was he about to review;" but that the circumscribed limits would of the author thought clude exwhich in the has affection cases developed inparvo, many while it correctlyrepresents those in muffno. which appear Thomas Dr. of septicaemia thought Dr. Peaslee ignored slight cases
not

the

"

which his attention

run

their

courses

and much be

end
to

f avorablv,

and

to

confine
cases.

and did grave also

remarks
not

too to

exceedinglygrave
as

Dr.
even

Thomas
in very Thomas the
or

wish

understood

aamitting that,
true.

cases,

Dr.

P.'s rules
the

for

held diagnosis of Dr.

P.'s in the

Dr.

(" to
room,

consideration
after that
no

objected to of septicasmiaas it operations upon the uterus

scientific basis could
also be

limitation
occurs

essay

and

lying-in the on ovaries"),

for such
a

ground
Dr.

found
"

tation. limi-

to the belief objected to Dr. P.'s reference that looseness of diagnosis applies in any specialdegree to this that in his affection," no experience he had seen adding greater affection of this in the of than or laxity uncertainty diagnosis

Thomas

others. J^r. Thomas Finally, followingpoints:

"

contested

the

views

of Dr.

P.

on

the

1st. As 2d. As

to

the

time

at which rate

septiccemiamay
as an

originate.
essential
to
rect cor-

to the

high

of temperature

diagnosis.
3d.
the make Dr. As
to the

propriety of laying any

as one. a

saccharine
it
an

breath
then

symptom,

degree of stress upon though the author does not

cases

essential

Thomas

presented details of three

from largely

in his from

own

practiceand
as

quoted sustaining his objections to Dr. Peaslee's

conclusion
was

D'Espine's essay, and

roth, Bill-

positionon

septiccemia.
At the of the

reading of
some

Dr.

Thomas's

Noeggerath
Dr.

invited
to

to make

remarks

Dr. paper, the tions relaupon

septicaemia. replied,that the subject of bacteria in this connection was so complicated and extensive that he would not do justice to it in the short feel that he could space allotted and much there are many rial matetoo disputed points interesting he thererore to at to pass over; an give a promised earlyday the form of in of the a renume complete subject paper.
Noeggerath
"

of bacteria

218

Transactions
of the

of
and

the

Upon the.paper
evening by
did
not

evening

the

paper

of the

previous
as

Dr.
the

Peaslee, Dr.

Xoeggerath remarked,

that

he

hear

acquainted with taken in his paper. positions by Dr. Thomas and the lie could only imagine that the facts, the consequences, in which Dr. Peaslee has brought forward points in diagnosis his paper, relate not to spontaneous but to an demic ensepticaemia, in it our large hospioccurs occasionally tals, septica^niaas
the lie could do

of Dr. Peaslee,he did not feel thoroughly paper in taken. But he fully concurred the position

septicaemia

very take

well

imaginethat
all the

certain

epidemics of
in the
are

place mider
symptoms,
which
seasons we

favorable

circumstances

where liospitals,

all the have been

of peculiarities occurred. There fever

disease,as they
seasons,

described, have
have in whicn times
we

instance,in and there are peritonitis,

with and pleuritis,
to all

for

puerperal
we see

with

have
cases

puerperal
purely of
and
not can-

fever

at

other

septicaemia. The
relate

description of Dr. Peaslee

cases or

does

not

septicaemia.
that the
the
amount
amount

It has

been

proved by
in sej)-

experiments upon ticaemia corresponds

into
a

animals
to

of symptoms

of
a

septic matter
for

injected
instance

the

blood

of the

animal.

If

heavy animal,

dog, weighing 20 or 30 pounds, has injectedinto his system a quantity of septicmaterial, the symptoms developed may be almost and the and the raised, nothing temperature hardly animal is taken, soon recovers. If,however, a smaller animal of and the same amount septicmaterial injectedinto his system, then more striking symptoms are developed and true septicaemia There results. is no reason results may not occur why the same in the human have two we If,therefore, individuals, subject. with delivered the is taken but at time, not same one septicemia after the and other imtil not innnediately deliveiy. eightor nine that the former should days have elapsed,it stands to reason have fever and a higher temperature than the latter, for more that the surfaces from the septicmaterial the reason which is absorbed are abundant, giving greater facility larger and more for the introduction of septicmatter ing strikmore and, as a result,
small
and definite

symptoms.
the

Dr.

Noeggerath
ana

has

seen

cases

of

septicaemia beginning during

labor

followed
forms

them of

developing into
Dr. Carl Braun

most
same

intense

gradually septicaemia.
up, he tiates substan-

describes that that he

the has

by saying
labor
a

occurrence, examined the

cases

which

secretions

and

found

in those

there

was

during already existing

uterup.

of bacteria from the in the secretions large amount Now labor that septicaemia beginning during becomes in intensity, increased of the that three end at so days an advanced stage of the disease is attained.

ually grador

four

Nexo

York

Obstetrical

Society.

279

Dr. Noeggerath's observations regard to temperature, the positiontaKen Dr. Thomas, for there are many by the temperature under in which is scarcelyraised. A case cases observation will illustrate this point. The at present patient
confirm
was
one

With

delivered week

about

three Dr.

weeks N.
was

ago

of

four

months'

loetus

afterwards
result
at the

rhage, the
removed

of retention
as

of

account called, on the placenta. This

was

of hsemorcould From
not

be

time,

the cervix

contracted.

the ap:

patient,septic absorption already begun Eearance removed. semorrhage again occurred, and the placenta
had
was

of the

Septica3mianow
and the

exists, though
96"
; but

the

temperature
with these

is but is

37".5 cent,
an

pulse

associated

there

sive offen-

vagina and sweating, while the whole oithe is unmistakably that of septicaemia. disease character With of septica3mia in general, Dr. regard to the symptoms
the

dischargefrom

N-

does

not

think

that

there
The

is any
most

one

symptom
one

which

acteristic is char-

of the disease. sudden

reliable
of

is the occasional of
perature, tem-

perspiration. The
the

amount

fever, the height

mental

depression of
in connection the
same

the

system, the
with in connection

disturbance,
of the

may abdominal Our

all be

seen

inflammatory disease
with such
cases we are

organs,
means

as a

septicaemia.
is,if the
can clude ex-

only

of
of the the

making
and

diagnosis in
abdominal

patient has high

lesions
to

fever

occasional
or

sweating, and
viscera,we

pelvic

forced With in

believe

that

patient

is

from suffering

septicasmia.

regard
most

to the

sweetish

that

this symptom cases it miglit be due to a lack Peaslee

a

of his

breath,Dr. Noeggerath remarked was wanting, though he

of education

that admitted

of the nasal
Dr. Dr.

passages.
paper nis his

Db.

commenced decided incorrect

his remarks

upon
and

Thomas'

by expressing
paper,
not to

objection,should
statements

certain

publisn of interpretations
contained. He

T.

(Dr. P.'s)own
so

which paper, far stultified himself

Dr.
as

Thomas's
that

had
not

to state

septicaemia does

exist the

except after the operation of ovariotomy, the operation for

removal of uterine

and in case of imperforate fibroids, men hystated and after parturition. He expressly that it occurs after a great variety of surgical operations,but that he should confine himself to its development in the conditions just stated, be the most since he supposed. this view of the subject would of this Society. He therefore need to the members interesting of Billroth,quoted by Dr. Thomas, not replyto the remarks since

they do
TnoMAS any

not

come

within that he

the did

Db.

said such
a

of his scope understand not that nowhere

own

Dr.

paper. Peaslee his

as

making
would

and restrictions, be

in

such

statement

found.

He

merely

stated

paper that no

280

Transactions

of

the

ing and puerperal cases, or those resultseparation between surgical could of be sustained the the from ffvnaecologist, operations since scientific tne patliologyof septicssmiawas grounds, upon the
same

in all the

fields.
criticism
on so

De.

Peaslee:
to

it better

I accept that confine paper my

at

its value.
a

judged
the
lations re-

extensive

topic to
this

Society septicaemia to gynaecology alone, of and and of not mainly obstetricians, gynaecologists the subject and the scope But of a paper must, I surgeons. always be decided by the writer. suppose, Peaslee that he Dr. remarked cism thought the style of critiDr. Thomas would fritter to nothing any adopted by away and intended elucidate the to diagnosis of any symptoms paper he referred to By way of illustration, pathologicalcondition. made the attempt of this Society a few years since by a member and differential diagnosis of pelvic cellulitis, to give the symptoms from distinguished pelvic peritonitis. To tliis end that as the of a well-marked stated all writer case distincuy symptoms of the former in the form of a condition, and arranged them out. synopsis, tliat the diagnosismight thus be surely made that Dr. Thomas Some (for I of high authorities still maintain
consists
course

of

since

refer he

to

him)
a

did

not

succeed

in his

attempt
to
a

; for

myself,
oi the

I think science.

made But

very

creditable knows alone

contribution

gynaecological
either

everybody
given
or can

that

not

single one

symptoms

he has

pelvic cellulitis

the existence of prove if we one pelvicperitonitis ; and reject

come

after
have
can

another for this reason, we at all of any no symptoms if it do exist, be detected or Peaslee of had also

to the conclusion

that both that neither

not.

value,
to

and

therefore
not

be shown

to exist if it do

Dr.

give the symptoms and diagnosis it from certain other conditions as septicaemia, distinguishing
attempted
very

with had

which
rather

it had

often
the

been

confomided,
lie
has
case,

and also and

;

Dr.

Thomas
as

approvedof
ot

attempt.
well-marked marked

assumed,
not
one

his standard such the there

same

septicaemia, a
has
no one no

(if

be), wnich
time tliat the

symptoms
is

symptom

remarking at pathognomonic of this

sudden still rise and

jaundiced condition,though of the debility pulse, the very high

temperature,
the

skin, the
but and

great

greatly var3dng
heaviness
this
dition. con-

mawkish

breath
and that

the
blows in

cerebral

being
Thomas
of his

the

most

marked,
Peaslee

together demonstrating
the

Dr.

added did

directed
touch fact,

by

Dr.

againsthis paper
paper, the views he disclaimed of

not,
he all

however,
had said
at

himself

(Dr. P.) personally ; since,as

at the

commencement

attempt
he

and originality,
as

posed pro-

septicaemiawhich

holos

now

demon-

282

Transactions
in the

of

the

some

point
is

made

Practice Wunderlich Dr. this

of

by Medicine,
and

than progress of the case Aitkin work in his Dr. his

104".
on

This

ment state-

the

Science

and Prof.

principal authorities
met

being
thus

Pi'of.

Ringer, of the
with

lege. UniversityHospital Colno

P. had

himself
the

exception
small effect

far
which

to

proposition.
reference
to

With

Dr.
wei-e

Xoeggemth
in

makes

experiments mention, to

on

animals, of
that the

the

effects

proportion to the amount Dr. Peaslee replied that the same

in the conditions and then he limit had the
measure

of would

septine introduced, etc.,

doubtless
we

be

the

case

considered dose
not

could

experimentally
But in the
cases

of the

poison.
exhausted till the

source
as we

of
see

supply,
them,
Dr.

if left to the

did itself,

get
he

but

septine accumulates
the symptoms
remarked had he that

manifests
make

itself

by

poison specified.
the

at

length
to

Nokgoerath
a

thought

attempt

differential

diagnosisbetween
have that
to

and

septicaemiawill
up the idea
remote

be

puci^peral metastatic Virchow given up.

scess abhas from

already given
the

the

ijterus to any
that of the
or

portion of
one

organ, great advances years, the

organ, will be the which

of an embolus passage and its lodgmentin the

cause

central

of been

inflammation.
made the within the

It is last
is is

has

three

four

discoverythat, in
which
which

puerperal state,
the with thrombosis it. This

the

inflammatory
by
the

caused

process septic element

goes

with

is mixed

noticeable in the

with in connection metastatic abscesses particularly The for the thrombus principal cause puerperal state. down the and is of the breaking becoming separated presence which with the is mixed effete matter thrombus, and being the circulation mixed with the thrombus, is carried into with irom the thrombus, which the emboli and enter circulation, these elements the which the elements are produce abscesses, that these and abscesses manifestations are again of the only be separated clinirjally or logically pathosepticaemia. They can never if of must we we therefore, speak septicemia, always ;

include
not

as

part

of

it,metastatic
metastatic

abscess, which
abscesses of

may the

or are

be

present.
of it.

The

pyaemia

may also

only
result

another

manifestation

of
he

septicaemia and
could
to

immediate
ory, that the-

Dr.

Peaslee

repliedthat
it seemed

understand
from

how

to

improbable as secondary abscess

could
not
see

him, might

he

in the

formation

cmy of

produced by emboli of septicaemia taking poasiiility secondary abscesses,in case they

the

possMy apply a thrombus, but

any
are

part
pix)sub-

duced

by

the

into injection

blood

of

metallic

or

other

Philadelphia
stances

Obstetrical

Society.
by H. Lee
and

283

incapable
to

of

In

reference

the

septic changes, as change of Virchow

P. remarked
that years Virchow
next to

others. Dr. the

in his he

views,
would

which wait his

Noeggerath stated, Dr.

confident views

that will
conne.

expectation
the three

change
If

present
is tlieory between

within

his

correct, then
P. holds Dr.
as

his

own (Dr. P's.)

ideas
are

of the distinction

septicaemia and
that the

metastatic

abscess of this

of

no

importance.

Dr.
tirely en-

theory

is pathologist distinguished that these

unsupported by Nokggeratii explained by saying

and do not other materials which
ai*e a

facts.

metals, such
the while
are

mercury

injected into
of gangrene,
that the
are

culation, cir-

produce abscesses, but

abscess of it has

sort

in the

true

metastatic

been that

proved
even

they

only
these Dr. be

accumulations
are

bacteria, and
cases

which
same

in circulating asked
case

of

pyaemia
what

cles pus corpuswith crowded

septic elements.
Dr.
which
was a case

TnoiLvs
third

Noeggerath
he

his

diagnosiswould
answered

ill the

without The made

doubt,
hour the for

it

reported, and was of septicaemia.

that,

adjournment having an*ived, on special business of the next meeting

on

motion,
to

it ,wa8 the continue

discussion

septicaemia.

TRANSACTIONS

OF

THE

PHIA PHILADELSOCIETY.

OBSTETRICAL

Stated

Meeting,

Mabch

6,

1873.

Dr. Chair.

Wm.

Goodell,

President,

in

the

Dr.

W.

F. Jenks

exhibited

an

UMBILICAL

CORD

TIED

IN

SQUARE
were

KNOT.

The

foetal heait-soundswere
upon about the left side. the

feeble,and
The cord middle child
was was

heard born twice

at

with

culty diffiwas

term,
ai'ound
a

small,
knot. The

3J lbs.,and
also tied

wound of its

its

neck, being

in the

length in

square

interesting question
Wm.

arose,

how

far

tlie feebleness in the cord.

of

the

foetal heart-sounds Dr. Goodell

depended
had
seen

upon
two

the knot
knots

in the

same

cord

and

284

Transactimis

of

the

thought
of the from Dr.

they were child, by loops

the

that

Bometimes of the neck. cord

produced slippingdown

in

the
over

the

delivery body

around

child's

Beecheb

exhibited

LIVING

CHILD

"\TrH EXTREMITIES

CONGENITAL
BELOW

DEFICIENCY THE KNEES.

OF

THE

LOWER

The
committee

details
Albert of
a

of this
H.

case

will

be it.
seen

given
cases

in

the

report of

the

appointed

to examine

Dr.
of Dr. which
a

SMrrn

had

of

spontaneous

one

limb, but this case imperfect development. J. V. Ingham referred

been noticed

at first

sight appeared
of the

amputation be to

to

condition Y. of
was

right leg,
ed presentof the about

had small

by

Sir Jas. the size

Simpson.
the
a

This

tubercle
on

about

hist

phalanx
tubercle

little the

finger ;
the
no were

the left hist

leg

there

similar On in
some

size of

phalanx
had J. Y.

of

the the

thumb.
case

these,however,
of the children

there

as nails,

been

referred
Dr. W.

to

by Dr.
p. Taylor

Simpson.
to
a

refen*ed

young

lady, aged 17,

whose
was was

right arm
a

was

congenitallydeficient
useful

below

perfectand
Dr. J. V.

finger on

the

stump

the elbow ; there left arm ; the

perfect.
Ingham

presented for Dr. Ludlow

THE eighth WEEK OF

an

OVL^

IN

GESTA'nON.

specimen patulous OS uteri

not
a

The

was

of

great interest,as
The
on one vera

it

clearlyexhibited
decidua reflexa there vice
was was

and

Fallopian tubes.
but
to

attached
free passage

to the

decidua
the views

side,and
Dr.

from the

vagina
third

the

ovaries, and

versa.

This the

supported
effect Wm.
that

advanced month

by
a

J. M.

Duncan,

to

up

to the

second

impregnation
from Dr.

is

possible.
Dr. committee F. Jenks then
at

read last

appointed
specimen
of

the

followingreport meeting to examine

the

the C. A.

McCall's

blighted

ovum.

Your Ovum

committee in
a case

would
of

report
a

that the

specimen of

"

ed Blightfor
months

of twin

submitted conception,"

to them

examination, consists old,the body of which

apparently about is flattened by compression

foetus

three

in the antero-

Philadelphia
diameter Ijosterior
while tilt! head k

Obstetrical

Society.
in the back

285

(the presentingBurface
the twisted
on

drawing representing, therefore,

the
over

of

accompanying the child),

neck,8o
the left

that the cliin looks

view shonlder, a profile

of the face

being thus
arm

otitained. close

The

left

i-estfl in

contact

with

the
on

flexed right,
across

face,while the is tlirown itself,

the

chest.

Anteriorly,

the
a

cord, thin and flattened like piece of tape, can l"e traced
some

with

diflicnltv from

the
der, shonl-

nmbilicus, over
to
a

the" left

the neck, closely encircling

point wlieie
and

it becomes of
brane memare

lost in the

fragments

attached

to the

coaguja specimen.

wliich

Tlie

lower
are

extremities

deficient lower
is

and converge tlie kneebelow of

a

joint; tlie
at the

appearance

foot

portion

of tlie

right
due the of the the adherent
structure

limb
to

fallacions,being

the flattened
A

condyle

of

femur. careful
and the

examination micrositopical
of tissue still be be sliowed ibat

brane mem-

shreds could

minnte
no

of
the

decidua

easilyrecognized, but
the appearance

trace

of

villi {"Iacental tissue

eonld

discovered,
hardened

of
were

placental
ically mechan-

being due attached

but has

to the
to

coagida which
fcetus of
"

pc"ed,

Bi"ecimen. The undergone the process

the the so-called with tissue

is not

at all decom-

mummification, being

converted

therebyinto
of each

foitus

papyraceus."
sliowed
some

The

examination individual

the

microscope
were

that their instances

at
once

characteristics histolt^ical preserved. The muscular extpiisitely

in

tissue

showed

the the

disassociation
sarcous

of

the

and librillffi, here fi'om

the there

transverse

striie of

elements,wliile
derived probably

and
the

pigmentary granules, the of muscle, coloring matter

bi-own
were

and

cliolesterin The
otlier

crystalswere
far
as

found.

tissues,so
well

they
by

examined,
and

the

changes, so
*

described

Oornil

presented Ilanvicr,*in
p. 89.

all
re-

Monael

d'Histologie pathologiqnfl, Coinil

and

BaoTiei,

286

IVandoctioTis
"

of
of

the
'*

counting the pathology of

without

this process which of this

mortification

or

death

putrefaction." the Among questions examination an by

to

were

them

possess consideration :
"

to

sufficient

mittee suggested to your comthe ed specimen, followingseeminterest tailed deto justify a more

1.

Can

this be
causes

regarded as
the death

case

of the

? superfoetation foetus in
utero

2. What

of

at

this

early age?
3.

What ?

are

the

conditions

which

lead

to

its

expulsion
?

or

retention 4.

What
the

is the nature health of

5. Is affected In

of this process the mother or

of raummitication
of the

remaining

child

foetus ? by the retention of the mummified of superfoetation, considering the possibility your
would call

mittee comcases

attention,in

the

of analysis

the

mass

of

this term, to the stricter a grouped togetherunder classification of than and would is principle usually adopted, recommend the division suggested by Kussniaul, viz., superfecundation, to designate a subsequent impregnation during the

necessityof

first menstrual
where of and

or

ovular the

already conceived,
for those
The
cases

while

who has period, in a woman is reserved term superfoetation

occurs a

impregnation
two

after

this terminus. with the

two

fructification
at
one

ova,
same

or

of

single

ovum

nuclei,
twin
two

the

coitus, results

in

so-called

while, in order to constitute pregnancy, several approaches at difl:'erent times are

superfecundation,
The necessary. is uterus scarcely

of possibility

superfecundation
while

in the normal

the cases bifid uteri, in of its occurrence questioned, though numerically rarer, are quite beyond criticism. mental Experithis point can on fully investigations be, and have been, so carelower made the have on animals, and tlie results obtained this the confirmed that text-books so universally view, general
on

obstetrics

contain

full

and

exhaustive

intormation

on

this

restricted point. Adopting this moi'e phraseology, we find no in extending this theory to tlie human in race difficulty ; and the of thrown off the same menstrual at ova impregnation different and of before the successiv^e coitus acts period, by of the next menstrual occurrence period, we find a satisfactory where and authentic instances explanation of the well-known white have women given birth to white and mulatto tihildren

after

corresponding sexual
question
cannot

relations

with

white

man

and

negro.
The
which of
so

be

the other superfoetation, on hand, i^eadily disposed of ; and while your

is

one

com-

Philadelphia
mittee find that
the and
some

Obstetrical

Society.
which have be been

287

of
of

the arguments
this

urged
We

against
other
can,

adoption
more no

hypothesis must
have been the
statement

abandoned,
tlie cervix
as soon

forcible
with

objections
an

suggested.
that of
mucus

indeed,

longer accept
has

uteri
as

is obstructed

impassable plug
admit

so an can we conception occurred, nor the exists and uterine between the adaptation developing ovum second at least until the third month to render a as parietes would we impregnation an impossibility. In this connection call the of attention abortion at the to specimen accompanjang for examination to us eighth week, submitted by Dr. Ludlow, mutual the where, in view of this question of superfoetation,
"

that

close

"

relationship of
especial
date
are

the of

maternal your
oetween

and

foetal

decidua

claimed

the
to this

attention

committee. these
two

There

exists,up
so

at

least,a space
in close

structures,

that

they

nowhere the

and
mucous

Fallopian
membrane
to

uteri the orifices of the os contact, while tubes are although the patulous; and
and

is swollen the

engorged, no
of
an ovum or

obstacle

could

have The alluded the

existed real
to

passage in the difficulty

either

spermatazoon.

function and

theory is scarcely authors, viz.,the fact that during gestation by most of ovulation is in abeyance, for the periodic ripening

adoption

of

this

dischargeof
In of Scanzoni who had

ova

from
to

the

Graafian
we

follicles

does

not

take

place.
women

opposition
that died of the

this view many

have,

statement

in

post-mortem
aiter

it is true, the examinations had found

of

shortly
recent

delivery,he
of Graafian that

indisputable proof
In

rupture
view

follicles.

addition,
fact
that

to

substantiate normal and

his

ovulation

during

gestation
the

is the

pregnant women menstrual nisus, the "molimina

oftentimes take

condition, he urges physiological the regularly recursuffer from ring

while catamenialia,^' would have been ^a tions aborstrual men-

place

at

what

epoch.
unanimous evidence found.
never saw

testimony
whatever of in of
a

Opposed totliis statement, however, is the almost of other experienced observers, that no
recent

Kiwisch,
a case

hundreds this kind

;

ovisac is to be rupture of an of post-mortem examinations,

paid especial of an point during the existence unusually fatal epidemic of puerperal fever, bears similar testimony: from have Kussmaul, wnom we largely quoted in the conattention
to

Virchow,

who

this

siderafion

of

this

subject,has

never

foimd

more

than

the

the individual luteum testimony of your single corpus ; and committee fullyaccords^with the authorities last quoted. In this case, however, as in most all possibility of exclude can of the
cases

of

blighted
the

ova,

we

from superfoetation,

fact

that

288

Transactions

of

the

the
as

two

products of conception
as can

far

be

learned, were
:

and, only a singleplacenta, of enclosed in a singleset branes. memof these enclosed where
cases

had

IIolil writes twins had

"We

find in most
were cases

that the

the
one

only
and in

one

chorion,"

placenta and nearly all of the

was cause

in any

detailed

historyis
In

given regai'dto
would
cases cases

this condition the of

to

found. death fact the of that the in

mittee comfoetus, your a large majority

the the

call attention this takes

of

the

place

from

tliird to the

lifth niontli.

In 22

quoted by Ilohl, we
In

find that
at

13, death

occurred

the

4th

month.

Druman
most

relates

case

in which

"

lady
no

was

delivered
answered of her born from

of

delightful girl, though her which might have expectation

kH)ks and of the

size been

by

means

the

rormed there the

the

patient ; 13
a

days

afterwards had

was

the bead

parts
at

of

child which
fouith took month."

the

just appearance V elpeau reports six

in

of

carriage mis-

of

which

death

place early
Is the

gestation
"

and

cases, in all in fact, this,

at

is the time and hav6

usual
to
more

statement.

death

of the

fcetus,then,

this

exerted it be ascribed to the pressure upon of Crede healthy product conception, as

can

by

the

other others

and

asserted,or
of the

we,

abandoning
the foetus which In this the of imder it

this fratricidal

theory,find

in diseases

either affecting placenta fix)m

of its death? of the

the cord, or that poritself, tion draws its nourishment, the

we

true

cause

connection,
death
in tne

would abnormal

draw
ditions con-

the

attenti"jn of

society to
as a case cause

of frequency
consideration

tlie cord In

early
the the

months
of

of

pregnancy?
foetus ; and
at at
or near

the

it is flattened neck cord the

out, ribbon-like, and

however the end of

wound around tightly this condition of trifling

is

gestation,there
nutrition
we

can

be

no

doubt

be may but that, Ilohl that short

this
:
"

early
In
was

date, the
cases

of the

child

must

suffer.

says

all the

have and

collected thin

it is mentioned and
or twisted, was

the cord and

In
so

membranous in
one case

thin,or
in his
own

lean, while
the four
cases

the

umbilical

artery
it at
once

wanting."
cofd
was

occurring twisted,that when tightly

twisted condition with the

practice,the
than the
one

unwound

resumed
case

its this

Ereviously been associated

as

in more ; and stricture of true umbilicus. In

cord

at

a was

point
the

f iH^m

to

i inch

from

six

cases

this

290

Transdctions

of

the

tion,or disease of the cord, whereby its nutrition is only gradually which t hat the of it affected, supplies with placenta portion nourishment its function,and the uterus to periorm slowly ceases of the foreign the becomes to insensiblyaccustomed presence body, just as certain large intrauterine polypi of slow growth while a small amount do not produce contractions of the organ, the most of blood rapidlypoured out is enough to cause violent
uterine

cohc.

As

the

foetus

is thus

gradually arrested

in

its

development, and deprived of its independent existence, it is by the advancing growth and againstthe uterine parietes evelopment of the jointoccupant of the uterine cavdty,which latter no longer enlarges in proportion to its double contents. relation the blightedovum have originally Now, whatever may held with regard to its fellow,it is graduallypushed towards for there there of the fundus exists thq greatest amount uteri, the flattened-out ovum corresponds admirably to the space, and

Sressed

"

lesser is that when

of degree of curvature" the imperfect product pregnancy

some

this of

part of

the is

organ.

Ilence

it

conception
to

has

advanced
or

term, after the

between

always expelled, livingchild,

the

oftentimes
the
two.

hours

days elapsing
intact the

birth of

If

the

membranes

are

foetus

does in the

not

decompositionafter its
may be retained for

death, but, preserved

in
at the
:
"

undergo liquoramnii,
fate took
amoimt

months its

the time

uterus, its ultimate

when death

being

determined

by
Scanzoni

age

place.
of

On^is point
salts which the

writes amnii

The

considerable
solution In is

element

in the

contains in liquor preventing decomposition. first few weeks of

an

tant imporring occur-

aboi-tions
trace

during
embryo,
ova or

no gestation,

of

the

and it
more

can only fragmentary portions,, the membranes when unruptured, are of the liquor amnii cloudy appearance

be

found
the

in aborted

while

thickened makes
has been

in these

cases

more or

than less

probable

that

the

of product

conception

it.

In the been

completely dissolved in the fluid which surrounded fourth, or fifth montli,the foetus looks as though third,

it had

preserved
IS

for

long

time the

in skin

feeble

saline

tion, solu-

viz., it
are

thicker
we

which

is in folds,the muscles shrunken, condition entire foetus that in the is harder, In the of "^mummification." derignateby the name somewhat and the alterations
are are more

last months is and in

marked

; the

entire

ver cada-

swollen, all the organs

raised ; the
are

is oftentimes

in

softened,the skin is discolored blebs,and may easilybe removed

cellular tissue and
a

large placques
of the

subcutaneous

all the

cavities

body

filled with
are

discolored, bloody, serous

fluid ; the hemes

of the head

connected

only loosely together,

Philadelphia
and cord
are

Obstetrical

Society.
other
; the

291

readilypushed
These of and

the
serum,

one

over

the
a

umbilical

is infiltrated with

softened.
amount

bluish-red tint,and livid, the diffei*ent changes are explained by ing varysaline constituents in the liquor amnii. contained

is of

Scherer

Voigt
the

have

shown of

that the

the

salts diminish

in direct

relationshipto
the
to
ana

duration the

end

of the

process

solution

but that even at pregnancy, is always sufficiently strong membranes with

are

prevent decomposition,unless
the

the

ruptured,
deprived
the fact

atmosphere

admitted

in contact

the parts
to

of

In

vitality." 'your committee closing,

the health
to

would mother

call
nor

attention that of the

thatneitlier
child ovum, other
seem
so

of

the

remaining

be

at all affected

by

the

retention

of the

blighted
is this

long as
we

the

membranes

remain

unruptured.
ovum

Nor

than
of

the

remember we expect, when with the which afiFected placenta the

would

that

the stands

portion in

direct is

as relationship,

necessityfor
other

undergoes, is the seat or degeneration,

removed,
converts
las

like

of
a

activity body, fatty organs which infarctus, haemorrhagic

of
the
mass.

its functional

it into hardened, discolored ffi*adiially for place in the present apparently taken

This

that four
one

one

of

inches inch and

edges along the circumference,

its

the

of

"

the

placenta, for
and altered of the

it is stated case, distance of about a

a

for in

depth of
"

about

into

substance,
In
are

was

character
as

white,
one

dense,
under

indurated."

most
no

cases,

in the

consideration, there

unusual

phenomena
of
some

the occurrence gestation,though in a few cases after powerful mental emotion, or produced bv would with labor-pains, commencing cause, that taken in these but the
cases more or

difting hsemorrhage,
cal mechanius

lead

to

pect sus-

less

place ;

in the

majorityof
to

placental apoplexyhad there is nothmg in instances

the

historyof blighted ovum.

the

pregnancy
then

warrant

supposition of

JDr. J. L. Ludlow

gave

the

followinghistoryof
THE LUNGS

CASE

OF

ACUTE

CONGESTION

OF

AFTEB

LABOB.

The
was

following
so

case

occurred
and

recently in
to

full of
to

interest the

instruction

me, who

my and

practice,which I hope will be always enjoyed

her

equally
an

members 22

of
years

tliis

Society.
had with

about My patient, exuberance

was as

of

health,was
much
as

age, taken in labor

and

of

first child.
lochia The
was were

Its progress

natural perfectly

free,

but

not

could

The easy. have desired.

womb

contracted

immediately

and

firmly.

The

urine

passed

292

Ti^ansactions
after
of the

of

the
the

freely
occurred

soon

confinement.

During

day nothing

She slept well durinff ordinary course. and the night, and expressed herself as having had a delightful o'clock the in I her 9 ing, mornsaw sleep. refreshing a^ainabout which I found when her somewhat agitatedby something her I left her a soothing draught, had happened with nurse. I found her oreathing and saw ner again in about three hours. with the countenance purple, her greatest difficulty her and features extremities cold,her pulse feeble and oppressed. she 1 at once that relief must, be prompt and as saw efficknt^ acute was congestion or apoplexy of evidently laboring under for a bandage, intending to bleed 1 called the lungs, her, of and I was the when met some surprise by present at outcry doctors did told that the idea of bleeding one so weaky2LvA was I resolutely held more." to my not bleed determination, any
out
"

"

and the

opened
orifice The
a

vein

in

her

rightarm
of fat which

; it

was

small, and
the
more were

justat
opening. like

small

few
than

pouch drops of blood

almost

entirelyclosed

escaped
I called

molasses

blood.
blood

bathed
vein.

the

left arm,

Immediately water, and and after using gentle frictions opened a

for hot
at first

drop by drop, and like that from the orifice on rightarm. By continued bathing with I iinally succeeded in securing a freer hot water, and frictions,
The
the

flowed

fiow, until it
the about

came

in it had of

moderate
a

stream

; and

I and

did

not

check
taken

fiow
a was

until

assumed

bright color

I had

quart

blood.
to

The
around.

cliangein
The

visible

all

relieved

; the returned, and almost relief I had

was

pulse rose ; the face lost with a good a sweet inspiration, death-stricken patient, and a whisper of
afforded

dition patient'sconhad been oppression its dusky hue ; warmth

my

smile
thanks

from for

my the

her,
Iler

gave

me was

assurance

that the covered

were soon

present
cloths

dinger
saturated

past.

diest

then

with

with

of turpentine, which spirits

replaced
who

by

the At

fiaxseed-meal
this with time
me

jacket.
called
in

Dr.
under

I.

Forsyth Meigs,
treatment,
was

fully

agreed
me

in the my

propriety of my

and

lated congratucause

upon and

resolution
once

such

circumstances. trying the

course

The

question at
1 had
no

this sudden

What suggested itself. condition? frightful During examined had the been

of

the

of her nitric
or

pregnancy
and acid,

urine, botli
found I

by heat

and

albumen her

days before
present.
urine but

confinement the arrival of

; in fact,only four had done none so, and

five
was

Before
heat

Dr.

by
upon

alone

(not having acid

Meigs I had at hand), and

it both

examined found
and
none

the
;

his arrival I

again

tested

with

heat

acid,

Philadelphia
and found
an

Obstetrical

Society.

29S

Our precipitateof albumen. patient for congestion of now was placed upon ordinary treatment the kidneys, and after a few the urine no days deposit. gave She progressed favorably until about week a afterwards, when and her milk began to fail, pain and swelling in the left leg which followed was developed itself, by acute phlebitis. This, there was however, soon yielded to treatment, and afterwards her to nothing impede rapidrecovery. A few thoughts naturally suggest themselves. the Ist. What carry
one,

abundant

would and

I have

done

without
to do ; but

I advise for

all of

you

lancet my the same. I

was

always
not

I had

used
2d.

mine

before the

five years

prepared for the

the
upon
no

emergency.
Was

congestion dependent
should
case

To
few

answer

this,observations
labor.
the In this

be

upon made
was

albuminuria?
urine taken

just before
3d. Does

there

albumen

only

days before
of the

labor. effort of
as

labor
well

have
as

an

effect in
organs

kidneys,
far in
on

of other

gestion producing conof the body ? we

4th.
not

If

albuminuria
too

gone

have fi'equent during pregnancy, neglecting the use of the lancet and
other
means

is

in

too relying

much

to

restrain

the

plethoric condition impression

be albumen of the
count
on

of tlie system,
Dr. Ellwood

especiallyin fii-st pregnancies ?

remarked
was

Wilson
case

that

his

firet would

hearing
found in
was

the
the
a seen

detailed lie of
in the

that

there
that of

urine. result
a case

thought

this

condition in

the

lungs
He

had

presence which it was

albumen

urine. the

pulse, from
He

its

frequency. The
relieved
case,

impossible to bled, and patient was

stimulated,
the
woman

after the
recovered.

congestion was
recalled
found

she

was

and
was

another
a

in which

delivery, in
and

her

lie was good apparently dying, but

condition.

called she

to

her

after left, hastily,

under
a

recovered

similar
In
cases, recur,

treatment.
cases

all these after and the

albumen
has

was

found
removed

in the

urine.
treatment

In

albumen

been

by

many it will

watching. is to test, weekly, the urine Dr. Wilson's of those custom especially primiparse,who manifest ill-health during patients,
these

patientsneed

careful

pregnancy.
Db. Parry
to
use

gave
those

the

details of
alone.
was

case

of

pulmonary apoplexy
which the recovered albumen of in

analogous
under the
venous

given by
cases

Dr.

Wilson,
He

the urine

of stimulants
all

of

these

thought probably the

result

the

congestion.

294

Transactions

of
to

the
confirmation of albuminuria
"

Dr. fact

Wilson

said

he

was

glad
of

have
cases

of

the

that about 85 per in first pregnancies.

Dk.

cent,

the

occur

Goodell

then

detailed

CASE

OF

EXCESSIVE

MASTURBATION, the

in order

to

obtain

the of

sense

of

Societyas
and

to the

advisability
him

of the
A
to

operation
her

clitoridectomy.
came

woman, She and has she

aged 30,
began
continued

to

him

earnestly begged
she

amputate

to clitoris,

which

organ

referred
at

her
age
a

whole
of 14

trouble. years, of years

was a

to

practise seB-abuse
the habit
ever seven

the

since.

For
times
at

number

masturbated
in had

seamstress

five,six,or and occupation, by

instance
was

worked
sensible

daily. She the sewingtreadle-

machine,
movement

but

no

she

that the

awakened
now

the

erotic

orgasm.
somewhat

effort

she

could but

control

tlie desire the

By strong during the

day-time,
Even when but

at

night
the
severe

imsolicitea
now

night,

with and

sometimes

awoke

found

irresistible. temptation was erotic on impulse came day and of pain. At night she spasms herself the rubbing parts. The
had the led
a sex

patient,according to her own statement, far with in intercourse life so as pure

cei'ned. while
.a a

perfectly
is
con-

other
Two

Her
resident

menstrual of

flow

was

regular.

years

ago,

surgeon,

that Baltimore, her health suffered so much finding the clitoris enlarged in size,amputated a It
was

benefit. portion,but this without pain, and for the excessive nervous relief by an operation. Dr.
Goodell alluded
to

for

these

that prostration,

of spasms she sought of

the

fact

that

some

of

the

cases

Brown were amputation of the clitoris reported by J. Baker the whether and asked he should permanently cured, Society

operate
Dr.
in the

or

not.

J. II. Packard

asked

whether

the root

of the

trouble

was

clitoris. Page
of

Dr.
number
a

suggested the
experiments
the with animal

use

of

lupulin.
He

He
had
cases sense

had
believed
never

made it had

this

substance, and
In these

great effect upon

111

passions.

it
was

combination, but alwaysalone. though the uncontrollable, even

Sometimes

the

given passion
the but

moral the

forbade

habit.

notliingwill
removal mind of of

control

masturbator

securingthe hands.
He did
not

think

the

clitoris would

prevent

turbation mas-

unless

the

the

person

had

been

directed

to

Philadelphia
that
the organ
use as

Obstetrical

Society.
recommended

295

the

of
J.

lupulin
L. LuBlow
the
to

the He desire. causing in doses of 10 or 20 grains.

one

Dr.

advised

the

combination

of

bromide

of

potassium
also be
Dr. had

with

lupulin.
the Smith base of wished in
so

He the
to

thought that
brain. know

treatment

should

directed
Albert been

H.

how

much

of the It
any

ris clitowas

removed
an

likely that, in
Dr. because Goodell

organ

to. operation referred be scarce small, there would

the

left

replied
woman was

that in

he

could
too

not

answer a

this condition

question,
to

the

excitable
of
a

be

examined

without

the
to

presence
nave

third
to

therefore, arranged
when
had this another also

her

come

person. his oflSce

be

He
at
a

had,
time He

physician, besides
this that interview in order
^

himself,
until be

could

present.

postponed

after

the

meeting

of

Society,
members. Smtth be of

he

might
the
course as

governed

by the opinion by
the Dr.

of the
Dr. would He

thought
as

that

suggested
excision of

Page

much in had

service

the

clitoris.

recommended,
Dr. Ludlow of soda

addition, the application of strong styptics. used of sulphite hypopermanganate potassa and
x. case

however,
been

grs. the

to

the
an

seat

of
woman

irritation. whose

He

bered, remem-

of

old kinds

clitoris

had
no

perfectly
was

tanned

by
to

all

of

applications, but
masturbation the chorea in and

benefit Dr.
schools
nervous

derived.

Page
as

alluded
the

the
cause occur.

practice of
of
much

large
other

probable
Packard
He

of

complaints that
J.
H.

Dr.

asked

as

to

the

extent

of

J.

Baker clitoris of the of

a

Brown's
would

operation.
not

thought

have the male.

any hood

more

amputation of the the effect than amputation

the
the and

penis

in

He
but

suggested
the
crura

removal
erector

not

only
of

portion
clitoris.

of

the

muscles

the

Dr.
his

Goodell

replied that
but
states

J. Baker
that
"

Brown

does

not

describe

operation,
Dr. Harris

merely

the

clitoris

is

freely excised."

said
the

that

reference
of

had

been

made

hj
This

French

physicians to
to

evil

effects

sewing-machines.
were

applied
a

the

French

machines

only, which
alternate American

worked of

by
the

double
On

and ti-eadle, the

a

necessarilywith
hand,
the
which

action
were

feet

other

machines feet
were

worked

with

single treadle, on

both

placed.

296

Qua/rterlyHeport

on

Obstetrics

QUARTERLY
AND CHILDREN.

REPORT DISEASES

ON

OBSTETRICS
WOMEN AND

OF

On
IN

new

Method

for

Effecting

Reduction Robert Britain

of

the

Uterus Lend.

Chronic

Inversion.

By
Great

Barnes,
and

M.D.,

{ObstetricalJov/mal
1873.)
After
a

of

Ireland^Aprils
of
two

few

preliminaryremarks

on

the

the author gives the by forcible taxis, exerted reduced by elastic pressure ; in the first, bags, assisted by incisions of the os uteri at two of ite

dangers historyof
by
or

tion reduccases

caoutchouc three

points

circumference,

so

as

to

relax

or

weaken
was

the

constriction

formed

by the
and the

circular

fibres.

Reduction

plished, easily accom-

patientrecovered
correct

completely.
by
"

In

this

case

the

being passed into I turned the point of the bladder and a fingerinto the rectum. the sound backwards, and readily felt it, by the finger in the the root of the tumor. I subsequently felt rectum, just above still the which in the of the point was sound, bladder, by a

diagnosiswas

rendered

sound

fingercarried
the ing^that The

up behind
was was case

the root
absent reduced
was

uterus

of the tumor, from its normal

in like manner, to time
"

second

determinclearly place." occupying four

days, during which

conclusions, arrived
pressure,
overcome

taxis
at

from

time

practised. The

aided, if necessary, resistance the more

sustained elastic by Dr. Barnes are that will not by slightincisions, only

surely, but

also

with

greater

safety."
Varicose Uterus

Hemorrhage
complicating

from

the

Cervical

Zone
C.

of

the

Labor.

By

Gustavus

P.

ray, Murand

M.D., Ireland^ Ajprily1873.)

etc.

Journal {Obstetrical

of

Great

Britain

The mention

author

considers
made attention

these

cases

if any, extremely rare, little,

most

being
His

of the
was

subject in
drawn labors.
"

of

the works

on

stetrics. ob-

to the

subjectby hsemorrhage
the
first labor the

occurring
of blood
to

in two

successive

In

loss

was
us

unaccountable. the
cause

The

second

confinement

strated demon-

of the

hsemorrhage

at the first labor,and

298

Qua/rterlyHeport
to

on

Obstetrics

Contributions

Physiological

Obsttetrios,
in Rostock.

Professor now SciiATZ,Leipzig, Part 1, pp. 3i~lll.)

These

By Dr. Fried. {Ilnd.yVol. IV.,

contributions

are

one

of

series of

appeared first in Vol. concluded, which in Vol. IV., Parts 2 and Archiv," and are continued 3, to be and of othere the the author. leisure followed at option by They treat of the hitherto but little explored mysteries of the The tigations invesphysiologyof partoritiouin its most scientific sense. The of the such determination are on subjects as: in parturition; of the expulsive and resistinff forces amount
"

not articles, yet III., Part 1, of the

The

the utems pressure of the fluid-contents of forces. of the parturient {Der intrauterine RuJie

daring

the

pose re-

Wasserdruck

der Geburtskrdfte) The in form-restoring ; power the pains {Die JFormrestituttonskraft intervals between the The abdominal in the painless in der Wehen/pav^e) ; pressure with abdominal intraintervals and muscles; The reposing abdominal when the m body non-pregnant women, pressure
oei
carries
no

weight ("J^'
muscles
exert

nimt
no

oelastetem

Kdrper^\
pressure ;

and

the

abdominal

voluntary
etc.

The

theory

of intra-abdominal
is very of the

pressure,

The

the the evident, as and and it is intricate the questions proposed ; of the experiments and reasoning called for nature complicated to prefer deferring causes us by these difficult problems which solution
our

also

importance of these difficulty attending

vestigati in-

report of them
shall endeavor
to

until
do

the

whole

series

has

appeared, when

we

them Amount
and

justice.
of

Investigations

on

the

Blood

in

Breeding

Dogs.
Breslau.

Spiegelberg By Otto Vol. IV., Part (Ibid.,

Eichard

Gschetdlkn,

1, pp. 11^120.)
Andral

Former diminution
months

researches
the

by

and

Eodier, Reignauld,
of of

Kiwisch

and

Gavarret, Becquerel and Scanzoni, had ascertained a

of
the

solid

constituents

blood

in

the

latter

and given rise to the term chlor(HinoBmia gestation of Weighty reasons, however, were brought forward pregnancy. and \y the majority of French obstetricians, particularly by this the Kiwisch promise Gennans, against theory,and a comamong
was

made

between

the
the

two

opinions, according

to

which
was

combination

of
to

plethora and
be normal

hydraemia,serous
condition

ora, plethgravid
defined un-

supposed
To

of

women.

determine of
blood

experimentally this still somewhat

authors instituted
a

condition, the
on

series of

investigations
and without

the amount

in female

dogs, both

with

and

Diseases
former
and

of

Women

and

Child/ren.

299

young.
in the In

Six of the

and

ten

of the latter

were

employed
at
:
"

experiments,

the

followingreeultfi
cent.

arrived

non-pregnant sluts the average of the weight of the body, or 7.87 per
the

quantity of
; in
or

blood

is

-A^.^
sluts

pregnant
9 per

average
Of the

is

^.^
nve

first

weight with breeding sluts,

grammes, ; of uterine
GQnt.

of the

of the
an

body,

cent.

average

weight
a

of the later
mes, gram-

uterine
was

contents

of 657
P"^

the average the last

contents
was

quantity of blood
1193

^V-sj ^^
of the Thus

^'^

five, belonging to

period

the gestation,

weighing
-^.^,
is
or

an

quantity average ahaolute increase

but

of blood

of hlood

per discernible

10.5

cent.

during

pregnancy,

'fileaverage
was

dogs
a

found

only during the last half of that period. quantity oi hxmnoglobine in the non-pregnant ing to be 0.733,in pregnant dogs, 0.766 ; thus showwater

The

slightincrease. quantity of average

was

in the blood

dogs
Thus

ascertained
; also
see a

as

802, of pregnant
whole the
amount

of non-pregnant dogs as 810, out of blood

is increased

1,000 parts
we

slight increase.
me

that

of

during
fluid of the

pregnancy, constituents but

but

relative

augmented,

undergoes but a generallydependent

quantity of solid and slight change, being a little

on

the

degree

of nutrition

animal.

Kemarks

on

Twen-Pkegnancy.

By

Dr.

P.

Reuss, Wilrzburg.

Vol. {Ibid., This Lehre

paper den von

IV., Part
is
a

1, pp. 120-144)
on

criticism

Kleinwdchter'a

book

^^

Die

ZwiUingen^ Prag.y 1871," and ably refutes the advocated maxims extreme on by therapeuticalinterference from his that author, who, speaking experience in the lying-in the of the version and extraction of advises wards Prague, without child second immediately after the birth of the first,
waiting
are

to
to

see

whether it
or

the

spontaneous

efforts

of

the in

uterus

able

expel
the

not, and

brings
numerous

various

reasons

of his position.
and hospitals, mother and who

Heuss of

quotes

statistics from

proof authors,
of

Wiirzburg Institution, compares

Klemwachter's the
and from
at treatment

the results for and those

child

operators
arrives

followed

expectant
''

at the

correct doubtlessly

method, and generally adopted

finally
sion, conclu-

expressed in the motto Corbei, Frankofurti, 1620,"

when attitude there
are

Gynseceium
of
same

Hermann!
paper, that

the
uterus

head the

the

twins be

in

the
as

therapeutical
all
necessary un-

is to

observed

in

single birth, and

avoided.

and

hasty interference

is to be

300

Quarterly Report
to the

on

Ohntetrics
formed De-

Contributions
Pelves. Vol.

By
2, pp.

Dr.

Version Question of Podalio S. Borinski, Sohrau, Silesia.

in

{Ibid.,

IV.,
author

Part

226-237.

1872.)

of podalic of 93 cases account a detailed publishes the in clinic or Prof. version performed in deformed pelves, from the in of 1865 to February, autumn Spiegelberg, Breslau, the therefrom Since 1872, and draws following conclusions: The
53.3

after all the other (94r:322) offers the best chance, it would the preceding head seem in any kind of deformity. The varieties of deformed pelves even diameters with from flat 9.5 to : were (platt), conjugate varying below 8 centimetres (3^" to less than 3"), generallyand equally and flat, and asymmetrinarrow narrow generally cal. ; funnel-shaped, of child alone far the is concerned, the As as preservation

only

per cent, 29.2 per

of the
cent.

children

were

born

dead

after version, and foi-ms of delivery,

that

perform prophylacticversion, individual case some particular danger oblige us all Tlie generally-narrow kinds of least to do so. are pelves if the conjugate is extremely favorable for version,especially the conjugate diameter Those in short. shortened only give the the best prognosis stances circum8 centimetres, below however, ; those in to are generaldeformity,because the analogous
we

should

therefore

hardly

ever

unless

in the

transverae most

diameter

then

favorable results

conditions.

into onlycomes and Exceptions show merits.

consideration

under

unlooked-for
case

able favormust

of version

only

that each separate

One

be

in according to is when which the a change of presentation becomes necessary head does not perform the usual rotation while passing through the pelvis, but being caught by a high, steep, anterior peine

treated

its individual

instance

wall, and impacted

conjugate, becomes occasionally happens and in the oblique deformity, asymmetrical posterior bone parietal presenting (posterior presentation),or parietal and low anterior when a pelvic wall retain high promontory trunk the head with the in an and the angle posteriorly, open Imds the anterior bone flat on paiietal examining finger lying the pelvic brim, and reaches the before one ear symphysis (anterior retention Here the the head oi presentation). parietal and the danger mother to child and require the rectification of the position oy podalic version, provided the pelvis be not generally A judicious when the narrow. applicationof the forceps, has passed the constriction head is in the pelvic cavity, or apa

low

promontory

with

narrow

in

the

of cavity

the

pelvis,which

Sears alic version.

to

enable

the

extraction breech-

of

more

Primary

and

livingchildren than pofootlingpresentationsgive

M^IMI X

and
better

Diseases

of
In

Women

and

Children.
version and

301 forcible

results for the children than when

the author givesSpieare performed. conclusion, the follows the one on as : On position subject, hand, gelberg's he supports and strengthens the reasons saries given by the adverof version, and on the other he advises prophylactic version, with a simpleconjugate but only in pelves when deformity,
extraction

the defective fixation or progress of the head lies in the unfavorable (anterior or posterior positions* parietal) just
the
cause or

described.

Contributions Knowledge our to Dr. F. N. Winkler, Jena, By

-

Human Placenta. Vol. IV., Part 2, pp. llbid.j

of the

238-265.)
the incompleteness of his former paper. explains The Texture,Structure,and Cellular Life in the Adnexa or the the Human in 1870," Jena, by Egg, difficulty sufficiently and nighly the method recommends hardening his preparations, used by him, and originally now suggestedby Eindfleisch. After slow of careful and a injection t"e foetal vessels with a decoction concentrated of glue colored with Prussian blue, while the placenta itself is in a hot condition, which is injected held in warm one-half in of an or three-quartere water, until, uls (eachcontaining about fifty cubic hour,six or eight syringef have the villihave been become injected, distended, centimetres) author
"

The

and

the

blood

has

the open
at to

vessels

96^

per

from the umbilical arteries, flowing cohol and the is placenta placed into alligated, the three is next changed, during cent.,which ceased
are

four

days,6-8
are

times.

Then of

cubes

about

1.5

centimetres for in
a

square

cut out

of the
a

placed in ice-water placenta,

few

minutes, then
when in
a

in

solution

gum-arabicand
one or

for glycerine

twenty-fourhours,and
weak

again

for
use.

two

days
are

alcohol,
foetal
in

for reaSy theyare finally solution of carmine

The maternal

sections but
no

to be laid

for 2-3

hours,when

the

portionwill appear
the architectural

the strongly,

tinted. slightly,

the Accordingto Winkler,

foetal portion has vessels ; he

part whatever
the

basis of the finished

which placenta,

is formed
qx-

by entirely

the

maternal

uses consequently

meaning the whole organ as it jplacenta, (gross-) the foetal porformed and and born, IS netto-placenta, deducting tion. bounded the is The cavernous of wards tonet-placerUa system the and towards the uterus the (serotina), hasaPplate by called The basal-plate, foetus by the closing-plate {sMuss-flatte), and others, consists simply maternal placenta, by Dohrn, Langhans, of small the of two layers, cells, uterus,composed one, near mQ^ioii"jBrutto

302

Quarterly Report
the

on

Obstetrics

the other, towards uterus,

spaces,
we

find in this between

of largecells. foetus, Looking from theof openings for the communication plate a number
sinuses be and the with

the uterine
are seen

bloodplacental
a

which The

latter

to

lined

thelium. distinct endo-

shuts off the superficial cavenisB closing-plate lies close of and in the tiguity consuriace placenta, to the epithelial layerof the chorion, beyc)nd which we The the amnion. find 'gelatinous opinion of matter, and finally consist of Virchow, that all vascular spaces of the net-placenta ectatic capillaries with consecutive dilatation,is a cavernous towards
the foetal shown
to be correct.
we placenta

In the foetal

of
and

three kinds things, villi : {a)those which have no are obliterated, epithelium, the end in the closing-plate without cavemce penetrating ; {b)

find, among

other

those

which

end

in the
as

only epithelium
which villi, into and of
numerous even

far

cavernsB superficial as they hang free

and

are

covered

with

are

covered and

the really ant import; (c) divide with epithelium, throughout

branches into and

penetmte

to

the

deepest cavemse,
are

through the

All villi basal-plate.

devoid

epitheliumas long as they do not hang free in the cavemse, wlien theyare surrounded tissue. This direct conor tact by maternal maternal between and foetal vessels is quiteextensive, and the of the protecting cient absence epithelium consequently affords suffithe of ces influenmorbid transmission for various opportunity and nereditaryimpressions, and facilitates the immigration
of

specifically impregnated
"

cells.

This

condition ovum." the middle

the heel of Achilles in the chorion

of the whole mitil about

may The

be

sidered con-

capillary

plexusesexist
and
are

then

replaced by lymphatic
traverse

which chen)^ the colloid latter and

are

spaces the interstitial cellular the

gestation, ducts or {saftcanair the of layer chorion,

the
" "

of

and layer,

of amnion, piercingthe epithelium

opening free into itB

with the is

cavity.
the

Tnese
fluid

saftcandlehen
tliese

arteries. and

connected extensively The origin of

with blood-vessels, principally from

amniotic

ries capilla-

according to extremely probable, of the capilwhich the persistence lary the the ectasia would of the exert on plexus or lymphatics of hydroamnios is sufficiently formation evident, and indeed ter Afand Winkler's investigations. demonstrated by Jungbluth's the first inspirations infant the new-bom we see frequently become violent aflFected with or suddenly pallid, asphyctic, this condition is of the the dyspnoea; owing to rapid filling

lymphatic Jungbluth,and the influence

canals

pulmonary
system, prevent
and

circulation

and

the

consequent

drain

on

the arterial

lasts until the

circulation

becomes

tliisoccurrence,

it seems

advisable not to

regulated. To the funis ligate

and

Diseases

of
also

Women

and

Children.
least nntil

303

until the
the

has placenta the cord

vein is

been

expelled,or
has

at

the

puLsationm
umbilical
the

has

ceased, its color entirelyempty, in

still pass the child
to

become
that

pale,and
a

order

certain and of

quantityof
remedy
seem

blood

may above-named

the

foetal circulation Schultze's

arms

deficiency.
by
treatment to be

method

resuscitation, by swinging
to

the

and

feet,would

employed for the removal of asphyxia pallida. regards the building-up of the the only point distinctly is the placenta, recognized by Winkler into the follicles of the growing-in of the villi of the chorion uterine membrane posits demucous ( UtHcuLardrusev), Cretaceous in normal, full-grownplacentae in almost every occur case, and not only in 5.10 Cams states,and occasionally per cent., as of extend thickness the placenta. The through the whole tissues are maternal more generallyprincipallyaffected, rarely and the villosities also, most unfrequently the villosities alone ; to as generally these latter are so little diseased very seldom
proper this As

be

the

endanger
o" the We minutiae of
course

the

foetal existence.
we

Nowhere
the

else

in the

foetal system

placenta do
been able

find calcareous
extract

deposits.

have and be

to

technicalities studied
in the

only principal points; the of the microscopicinvestigations must original.

Subjects.

Studies
vol.

on

Obstetrical
vol. {Ibid.^

By
p.

Dr.

IIeinrich

Lahs,

Marburg.

iii., part 2,

195-220,

continued

iv., part 2, p. 310-335.)

on

I.

"

Pressure the
uterine

the axis

of

the

ovum

or

general
oder

pressure

of

contents?

{Fruchtaxendruclc

allgemeiner
on Sjhatz

Inhaltsdmck The
the mode author

f)
opposes of action

the views
the
on

of Schroeder forces
ovum

and

of
the

expulsive
axis of

during labor,who
to

represent
of
the

pressure

the

of

the

be

the

result the

form-restoringforce
to

the

uterus, and

consider

of bom, in all normal confinements, except cases the of this axis-pressure of ovum.. hydramnion, by means the uterine thickness their oval the of Lahs walls, points out form and general equal shape during rest, and their spherical the head would which contraction during a pain, the direction child
be

take

'

expulsive forces on the vertical the injurynecessarily axis of the ovum, and resultingto the its if this the of child mode were expulsion,and by really of complicated and abstruse means reasoning and physico-meboth Schatz chanical explanations (a styleof writing in which and which makes and Lahs aca short are proficient, particularly
under

the

action

of

the

304

Quarterly Report
of the distinctive
and

on

Obstetrics

count

separate points of

their

articles
An
a

almost

1. impossible) arrives at the following conclusions: uterine walls is when equal spherical impossible shape of the
on

pressure

the

eveiywhere
pressure and can

foetal axis is admitted, because be touched alike the fundus cannot

the uterine

wnen

the

curve

is

by

the

general

of

contents, plus
a

the

therefore
2. The

lateral
pressure.

walls, which
of the

perform only

greater
to

amount

foetal-axis pressure, of work the than the

have

stand is

general-contents
gi-eater than the degree of arching

foetal-axis pressure

never

difference
of the

force,which
and the
rest

results of the

from

the

fundus

uterine

walL with
be

The
the the

smaller force
amount

this difference the of

is,the general-contents
foetal-axis

less will pressure,

it be and

compared
the

of
the

less will with

see

the

pressure

compared
We

the

amount

of

3. pressure. general-contents is the generalrcontervts pressure

le cases

then

that in normal

labor

where

the

uterus

assumes

an

expulsive force; that in all equal sphericalform during

can

the

pains, the

foetal-axis pressure
with
cases

compared
the

the

only a minimal and general-contents pressure,

have
to the mechanism

fluence inthat

latter in these

is essential

of labor.

II.

"

On

the labor

mflueriGe of the supports

^

in especially

cases

duritig of the uterus of deformed pet/vis,

walls without
the of taneous simul-

1. The

contraction
aid

of brim
uterus

the

uterine is

of
the the
mere

the

expulsive forces
of the

capable only

adapting
of the

the

head

to

bony
whole

with pelvis

the pressure

weight
head

of

with the

; the further takes parietal contraction of

of the configuration place only by means

of be the the
uterus.

of

resistance this the

the

lower

strongem
effect
on

resistance head.

is,the

segment greater will

a

The

configurative
the
mere

2. The

of possibility of

completing
the

delivery by
case

parietalcontraction
present themselves
is therefore pelvis,
to the total

only

uterus, in after the head

of the uterus.

of

obstacles

which the ferior in-

has
as

descended

into
are

present only as long

is

these obstacles

3. virtue

The'

uterus

weight in capable,by simple parietalcontraction,

of
its inferior

of

the

resistance the

segment,

and

in direct

proportionto

degree of

this
from brim

or resistance, surmounting much a

obstacles,arising greater ead and bony pelvis at the

4. The

broad

and
a

round
more

the disproportionbetween outlet. than its at pelvis into play at each ligaments come

of the

pain, and produce

of the uterus

to the brim

approach of the inferior portion of the pelvis ; we may say, the pressure
active

306

Quarterly Report
abdoiniiial muscles
on

on

-Ohsteti^ics
^x

The
a

by

their contraction

during
the

labor oriin

exert

general pressure

the

uterine

surface

above

of the

increase pelvis,
uterus

thereby the general-contents pressure, the in a firmlyinto pelvic brim, great measure
inferior

press the ing aid in fixwithin

the

the brim and the

segment
as

and

the the
as

contained

head

of the

bony pelvis,whereby
removed much

pelvis is

disproportion of the head of by configuration possible

between the

the frictional resistance and increase rormer, of the inferior portion of the uterus and the brim

pelvis.

III.

"

On in

fluid
This
as

com/pletedischarge of the amniotic uteri). of tetanus preternatural presentations (a c"iuse

the

effect of

the

affection of the
a

uterus

tonic

and

close

spasm of the embrace

of the

ed during labor is generally describwould firm which a organ, presume

foetus

by

the

contracted

uterine

walls.

This

does not take place, acof the womb cording spastic contraction the is the foetus so firmly embraced to Lahs, neither nor presenting part (generallythe shoulder) so firmly pressed into the pelvis, would be consistent with tonic spasm as ; besides, it would be impossible for tlie uterine contraction in tonic parietes of the various to to so adapt themselves irregularities closely the foetus as to allow of their being distinctly palpable. Lahs m gives the followingexplanation : Inasmuch as preternatural the lower of the uterus is but incompletesegment filled the by presenting part, consequently a premature rupture y

!)resentations
of the membranes flow is

more

common,

the

amniotic

fluid will of the

tents con-

gradually
abdominal and which

out, and
will

the voluntary finally

contractions

muscles

entirelyempty
the uterine and

the

uterus

of its fluid the

not

approximate
thus Kilian dimhiish contracted be
as

closely to parietes
"held
the

foetus,
stricted," con-

will

enveloped Gradually says.

in
to

fast, but
uterus

will will

contract

slowly
false
wall the

and

size,whereby
the spasm

its walls

examining hand, giving

; those

appear manently perrise to the the uterine

impression
which
are

of

tonic

of poilions
the
on

not

completely filled by
act
as an

adjacent portionsof
loetal surface
to

foetus will
an

then

aspirator
to

the

and cups We ;

produce
the other

increased
convex

afilux of blood
them

that

spot, similar

portions, completely occupied by

ana

the

fcjetal

members,
can

thus

compress explain the

on

will

empty
the

the

blood-vessels.
not
as can

and sugillations skin

ease

discolorations well

unfreternal in-

quently

found

the The

of with

as foetus,

similar be this

changes.
into is

which

the

hand

duced intro-

cavityand version performed at also therebyexplained. As this contraction and the

the uterine

time,

incessant

"

and
^

Diseases'

of

Women

and

Children.

307

"

irritation

becomes takes

sue tiscontinues,little by little the uterine and exudation congested, inflamed, finallyan which in a measure coagulates and leaves the uterus place, in the This form
now

of the foetus

solidified the
or,

in which is the

it

happened

to

be

enveloping

and

form of tetanus real,worst uteri, cojistrictw calls uteri as it, ^pastico-injlammatoria; Naegele here we of performing the aifliculty can easilyconceive foetus. the
ease

i
"

version, and

with

which

rupture of

the

uterus

may
"

thereby
IV.
"

be

produced.
tJie
cause

On

of the first inspirationof the new-horn infant.

the
to
reason

Schwartz the new-born and S. Schultzo

a

ascribes child the

for

the of

first
the in

of inspiration

the

interruption
want
oi

placental
the blood. oxygen
child.

culation cir-

consequent

believes
sufficient

that, before

oxygen the want

B.
has

of
the

reached
the

degree, the
in

fii-st inspirationis excited

of the cutaneous cooling-oflf by following up the changes

surface
the

of

uterus

by Lahs, occurring during

at
a

by experiments he thinks explanation, which

on

labor, and
the

animals, has gives us the

first
the

arrived immediate

third
reason
"

for

The
a

of the typical occurrence first inspirationof physiological

inspiration, viz.: new-born infant, as

rule, takes

the the

of and place in consequence immediately after the sudden or rapid expression by expulsive forces of the placental sinuses through the lunbilical vessels towards
and its further in
a

foetal heart
an

consequences

; the

conditions

for such labor

expression
for the

found
the where taken latter those

first time

are terminated, normal, not artificially during the passage of the cliild through

vulva,
the

or very soon sudden and or a soon

after

that

passage;
of

and the

in

all

cases,

place at
will for
cases

time

rapid expression placentahas not after the complete birth of the child,the Thus be in a state of apnoea. we explain
was

in which the

the child

bom

without

active

tions contrac-

of

and vessels, and section,

uterus, and consequent therefore remained for

the when

with

forceps
the

with

placental tractions apnoeic,such as exdeficient labor-pains. Cesarean

a

expression of the
time

foetus is born

with

caul.

V. A

"

The

negative pressure
that
met

in

the uterine

cavity.
that
uterus

negative pressure,
is
never

is, a lesser
in the

atmosphere,
normal
are

with

than pressure interior of the

of the
der un-

conditions
not

ever, during labor. Exceptions to this rule,howquite unfrequent, and intra-uterine negative pres-

308

Quarteidy Report
is met with in the

on^ Obstetrics
1. In
are

"

Bure

following instances:
the

cases

regular of irabove

contraction under
I

of

uterus, such

as

mentioned

and takes

IV., as therefore,of place within

labor in
uterus

tetanus

uteri,an

of the fatal aspiration

surface,

or a negative pressure quasi- vacuum course, in the uterus. 2. Operative interference

anomalous

cases,

as

well

as

the

"

walls power
roetus

In a pressure. will finally become

"

general, are the uterine labor protracted abnormal and will lose their inflamed, resistant, of and contraction If, therefore, the configuration. is operativelv removed at once, or piecemeal,the uterus
to

liable

operative manipulations of uterine produce negative intra-

will but

not

close will This

on

the be
vacuum a

removed
vacuum

part, as
and left, course,

it does

in normal

labors,
the
pletion com-

there

therefore,also,negative

pressure. lorcible

will,of
of

greatlyretard
if the the

of the
or

extraction

the

and, foetus,
of
ensue

tractions
mucous

be

long continued, hyperaemia

and
vacuum

uterine

membrane,
will fillthe which

finally haemorrhage,will
and

; this
"

haemorrhage
circumstance

facilitate the extraction

the points out a remedy to us, viz., the medicated or not, into the uterus, above of the detached operation. 3. The removal

injection of fluid, foetus,during the

ovum

in

abortion,

of
with

intra-uterine of

sponge-tents,
an

obstacle of tlie

retention

divided, of polypi the retained placenta,will occasionally meet The in the intra-uterine negative pressure. placenta is usuallysupposed to be owing to
after the

pedicle has

been

tion "hour-glasscontracpartialspasticconstriction below its seat but it is extremely probable that the violent contractions of of the uterus during protracted labors result in an exhaustion lies ralthe rest of the uterus the less muscular placental insertion, the glass hourthus find and contracts we more rapidly, again, 4r. In contraction podalic occurring without spasm. unfrenot we extraction, performed for deficient labor-pains, ing quently find the negative pressure during tlie operation expandthe lax uterus and simulatinga pain, which phenomenon short how generallydisappears when traction ceases, no matter
"

"

"

tne

latter may oedema in

a

have

been.

The

frequent
after such

lesions

of

the

child's

head,ecchymoses,and
and

infiltration of the
also to this

scalp and

pericranium,
less doubt-

of the
measure

brain,found
referable

are extractions,

5. negative pressure. seek The indications to be drawn herefrom are evidently (1) to the foetus, of fluids above to fill the vacuum by the injection and tempt while (2) to atplacenta, polypus, etc., operating, ovum, the adaptation of the uterus its to contents by pressure
on

the

fundus

from

above

; this latter

measure

should action

never

be

omitted

in difficult

podalicextraction.

6. The

of

nega-

and
-J

Diseaseslikewise

of
aids

Women
in

and

Children.

309

of the increasing the difficulty inverted reposition of an uterus, and, 7. In producing hying pertiemiaand capillary haemorrhage in the uterine cavity durtive pressure

the

uterine slight

contractions

at

the

menstrual

period.

On

Versions Treatment

and of

Flexions,

particularly
of the

on

the

Mechanical

Retro-deviations

Uterus. p.

By

Prof.

B. S.

ScHULTZE, Jena.

vol. iv., {Ibid.^ part 3,

374-417.)

After
oi

giving
versions

his views and

on

the

generalpathology and
laying especial
mechanical of

peutics theraon

and flexions, increase

stress

the
measures

value

of

the

combination
to

calculated
sums

the

tonicityof
"

supports, the parts, the

the bladder

v^rith

author
1.

The

: up the following conclusions normal the of position uterus, when or

is the

empty,
so-called

is anteversion

anteflexion.
of the

In

the

erect

posture

surface posterior and

uterus

points almost
anomalous

directly
when above

upwards.
2. Anteversions

anteflexions
or

are

only
in the

the uterus

is immovable

limited

in its motions

positions.
3. Abnormal tension
or

shortness of

of

Douglas's
and

folds

resultingfrom
cause

parametritic processes)is the

fixation
anteversion

most

(generally fi'equent

of
On of

anomalous

uncommonly

high degrees
4.
the the

of anteflexion. other

hand,

musculi

ation slackeningof Douglass folds (relaxretractores uteri) necessarilyleads to

a

retroversion 5. A

and

and retroflexion,

is their commonest without

cause.

flexion

of

the

uterus

almost
or

directlyin its
of
the

anterior originally
uterus

flexed
on

looks

more

to

exception occurs posteriorplane; if the body the rightthan the left, a rotation
is

its axis of the

whole

organ

present. Unequal

ening shortin
troflexion, re-

of
6. The the

unequal relaxation Douglas'sfolds in anteflexion, of this axis-rotation. is generallythe cause

normal is anteversion and

anteflexion

of the

uterus

when

bladder

empty,

the and

abnormal

anteflexion with

with relaxed

posterior
folds of
one
.

the fixation,

retroversion under

retroflexion

Douglas, are,
and

the above
normal is

all the result conditions, pressure.

of

the 7. To

same

intra-abdominal
the sound

recognizethe
a

of the

uterus

positionand reducible deviations bimanual only iusuiiicient; palpation

and

leads to

definite result.
anteversion

8. Abnormal

anteflexion

of the uterus,

its i,e,y

310

Quarterly Report
in that

on

Obstetrics

the position,demands causing absorption of the exsudation fixation

treatment

treatment

likely to

cause

the

fixation

of anteversions
and

and

anteflexions

; mechanical is useless and often

hurtful. 9. Eetroversions
are

retroflexions
not

should the

be reduced sound
;

when

they

reducible,but
to

manually,
the reduced
means.

by

necessary
10.

retain

uterus

in the

generallyit is normal (anteverted)

by position
The

mechanical

retroor keeping a retroverted of the vaginalportion. The reduced is retroposition flexed uterus intra-uterine generallyused, as a rule,do not effect this pessaries is attained by the vaginal pessariesrecommended object,which by S. (an 8-shaped pessary bent to an S form, in the posterior out responding corloop of which the cervdx rests, the anterior loop is drawn oval ring-pesto the length of the vagina ; and an sary,

only rational

way

of

bent

almost
more

double

on

itself like

cradle, the anterior

tion por-

being against the

with The

acutely bent towards cervix ; both pessaries are

must

rubber, and
soon as

of

course

to press so as posterior, of flexible copper-wire covered be adapted to each case).

the

intra-abdominal
as

version 11. the

keeps the uterus pressure the cervix is fixed behind.

intra-abdominal
a an

in normal

ante-

Rarely
is still

the

pressure

is not

able

to reduce

flexion.

If in such

case,

after

of the cervix, retroposition

pessary of hard be may rubber added
to

there the

trouble,

intra-uterine

vaginal support (a straightstem

to the

movably

attached

pessary).

The

SEizrRE Halle.

of

the

Feet

during

Version.

By

Dr.

Fritsch,

vol. {Ibid.,

iv., part 3, p. 483-498.

and illustrates

1873.)
normal rotation

The made

author

describes

the

by the child opinions of numerous

which foot the

the different during version, enumerates b oth obstetricians, livingand dead, as to

be

should
of

bring
fact From draws time
met

back
no

the

seized,the upper child forwards, and

or

lower, in
m

order
to

to

calls

attention this

the he

that
a

definite of
to reach

general
versions

rules

are

given
in and

respect.
ways
to waste

number

performed
upper

various

the in

conclusion,that it is unnecessary
the
to

wrong

trying
should

with

be the

used back

turn

foot,but that the foot first the child,as it is quite immaterial

forwards the
course or

whether

be

tm*ned

backwards

immediately

after the version

extraction, if it be

; during and not too carefully

of the

podalic

violentlyperformed,

aTld
""J

Diseases

of

Women
the

and

Children.

311

the

back

will

if generally, desired. tlie uterus and If

anteriorlyas and discharged,

of course, be

the is

deformed, turn fluid has long been amniotic firmly contracted,both feet must, pelvis
be
not

seized

brought

down.

Various

Information
STEiN, Berlin.

about

Old

PRDOPARiE.

By

Dr.

Cohn-

{Ibid,^vol. iv., part 3, p. 498-510.)

authors
of old and

According

to

various

hitherto, the
the age 1. The of the

confinements

30,

are

characterized the
most

general impression primiparte,i. e. those above of by certain peculiarities,

:
"

the

wliich

followingare
children

reliable

of
of
to

largertliaii those pi-ogressively up

The

as multiparae,are primiparaB,as their weight increasing young primiparas, the 44tli, their length up to the 40th, year.

old

well

largetransverse
soft

diameter

of

the

foetal head

attains 35th

dis-

size when proportional

the mother
less

has
and

passedher
more

year.

parts are labor, ruptures of the

2. The

and yielding

expulsion

perineeum, In therefore placenta, are more common. there may addition be anchylosis of the coecjx. 3. Deformed not that the advanced pelves are more common, with the capacity of age of the primipara has any connection for a time the pelvis, but that the deformity in itself may vent preconception, or the known dangers resultingtherefrom induce tlie woman to avoid getting into that condition. may caused 4. Face-presentations, by the disproportion between the capacity of the pelvis and the size of the child's head, are
of the
common.

disturbances

rigid; protracted during the

more

6. 6.

Eclampsic
A between

convulsions

occur

more

fi'equently.
occui-s

premature
favors

rupture
36th
a

of the and 40th

membranes years
; the

most

quently fre-

the

advanced the

age

of

primiparse

frequent change of position of

child

during
7.

the

last months.
not long sterile,

Women,
Old

unfrequently
liable
to

fall

victims

to

extra-uterine
8. to

pregnancy.

primiparse

are

more

puerperal diseases

and

mania.

Cohnstein from
30 to
:
"

has collected
50

the

cases

of

393

primiparae, ranging
reports the
of
were

years

(2

of the latter

age),and
duration

ing follow-

data 1., No 2. 29
=

difference 377

in the

course
=

and 37.13

pregnancy.
born

Of

children, 140
cent., died

7.69

per

within

cent., per the tii-stweek.

dead,

312

Quarterly Report
Of 389
"

on

OhstePrios

2 during 8 during mothers, 115 died pregnancy, labor, 105 during the puerperal state. in 42 per cent. found 4. Deformed pelves were ; of the 166 rachitic. deformities,61 were of operations in generalwas number 287 57.7 per 5. The mothers them 142 ! 83 forceps cases died, 136 cent., among still-bom children were pelves alone, 162 operations ; in narrow mothers 153 54 97.59 (in died, 90 persons) cent., per

3.

children 6.

were

still-bom.
and

Breach than in 4.07

quently fremore footling presentationsoccurred tions usual, in 2.54 per cent., also shoulder-presenta-

per
were

cent.,
born

7. Twins
remained 8. 9.
once

in 3.3 per cent. face-presentations 17 times, triplets once (thethird

child

living).
three deaths. six times, with pregnancy, pelves, prsevia 6 times, thrice with deformed
5

Extra-uterine

Placenta
with

10.

twins; Eclampsic died,

per

children

were were

still-bom,2
very labor

mothere in

died. 9.9 per

convulsions
most

common,

cent., appeanng
12
were

commonly during
children
with wide
were

motners
more

18

still-bom.

per cent.) ; (62.5 The convulsions with

narrow

frequent

(82 per cent.) than

were

pelves (18
11.
=

cent).

Deficient
per

labor-pains

very

common,

in

119

cases

30.2

cent., and

necessitated causes, in

artificial
were

mostly forceps. As pelvis 21 times, premature

eases,

delivery in assignable narrow

membranes 11.19
cases
=

84

rupture
all 44
19 of 4.58 the times

of times

the

22

times;

the

latter

occurred occurred

percent.
os

Spasticcontractions
alone
12.
was

(in 13

the

num inter-

rigid); 3 cases Prolapse of the cord of only in one-third

; manual

precipitousdeliverytook place. ceeded per cent. ; the repositionsuccases. was

13.
"er

Ilsemorrhage post-partum
removal

common,

38

times

9.6
more

cent.

of the

placenta 26 times,also
14

jquent than
14. 15.
16.

usual. of the

Ruptures
Mania
Besides

perinseum

times

3.56

per

cent.

5 times, with the

complete
external
an

deformed
of-the exerted
as

pelvis,various
and

recovery. malformations internal

on

and
org^ans

diseased

conditions
to

genital

appeared

have
; such

influence
the
13

the

late

period of

pregnation im-

rigidity of
external
os os

of times, rigidity firm

tumors

the

vagina and introitus 16 times, conglutination and

and
sarcomatous want

closure

of the the
uterus

external
15

times, fibroid
once, and

of

uterus

times, imperforate hymen,

each
various

of
ditions. con-

perineeum,

bicomis

similar

314

Quarterly Report
of less than
very
rare

on

Obstetrics
2"

conjugate diameter
be

7.67 centimeters

9'",is

to

regarded
of Direct from

as

exception.* (This
mother in

was

the

lowest

measure

the

206

cases.)
does puerj"erio after
a

danger the deformity of

139
not
cases

of life for the the

not

sult re-

pelvis alone
34

spontaneous
was

delivery.
Of
so

the

with

140

children,in
influence of the
; of

the
105

deformity
women

slight as
children
; 38

to be

of any
4

the died

with

106

remaining, fell sick,but

or

former
; of the

of

diffuse

tonitis peri7 died

recovered

children,but

during
The
nature true

labor

from
to

its effects. be drawn

deduction
more

therefrom

evidentlyis, to give
Where 2"
cm.

in moderate scope diameter is from conjugate

pelvic deformity.
7
cm.

the

to

9
cm.

cm.

(or
10.75

6'" to 3"

3"'),or the diagonal conjugate from 4"), artificial aid is not required by
A New
iNG

to

(3"

to

the

pelvicdeformity alone.
Pelvis
dlt"-

Case Labor.

of

Dilatation

of

an

Osteomalacian

By
relates
woman

Dr.

Theodor

Kezmarszky,
of osteomalacia
the

Pesth.

{Ibid.^

vol. The

iv., part 3, p. 637-547.)

author The the first had
case

published in
of the ease dis-

Hungary.

noticed

first

signs

: tliose sjmpl)efore, during her second pregnancy terminated which toms was during the third gestation, without much tending difficulty, contrary to the expectation of the atand in her fourth May, 1871, the physicians, pregnancy. of the walk such that she could condition bai-ely patient was without and move hausted emaciated, exor assistance, presented an found The be to was excessively pelvis appearance. the outlet, which assumed the shape had deformed, particularly of a stout, broad the point of the sacrum bottle, projectinginto its like the The distance bottom of a champagne-bottle. cavity from of the the point of the sacrum the arto narrowest point cus pubis, which presented the usual bill-shapeddeformity in

six years increased

the the

most

marked

degree,

measured

about

cm. cm.

1"
=

10'"

conjugate admirably proving the

external

diameter excessive tlie

measured contraction strait

19.5

of the is

7", thus ty. pelvic caviformed deseemed

to be

Considering
than the

that

superior
that the the

generallyless
fact
was

inferior

in these

cases,

which

confirmed
easy,

by examination,
and

last labor advent

judging
repeatedly
of

from

recent

of

the

unexpectedly disease,
ring by referof this 1,

That
to

it may the
case

occur

with

Buch
on

conjugate
p.

may

be

seen

Mehrwald,

reported

28,

vol.

vi,

No.

Journal.

and

Diseases
the

of

Women
ilium
see

and
to be

Children. bent, it slightly

the
soft

315

which
would while

allowed

crests
to

of the and

was

thought

advisable

wait

whether
the

bones

not

gradually yield
same

before

advancing
This

foetus,

at the

time Cesarean

the

inevitable
was

necessary section were

preparations for
made. could finger

wise the other-

expectation

fullyrealized ; for the examining the cavity gradually enlarging under

part,
after
a was

feel tne of the

labor

head

only hours, it passed the external The female by traction. easilyextracted

of
33 to

which

could

be

pressure recognized as the

pelvic ing presentbreach when,

orifice ; the cliild soon in

commenced

cry, but
were :

did

not

nurse,

and

died
=

five
oz.

days.

Its dimensions
28 chin

"

cumference weight, 1,682 grammes ; cirof head, foreliead occiput, neck, 27 ; forehead 9.5 Diameters : straight, ; small occiput, 29 cm.
" "

4 lb. 6

9.2 diagonal,

10.3 largediagonal,
cm.

small

transverse, 7
was so

large

transverse, 7.9
as

Immediately
to

after

allow

both

pubis deliverythe arcus into it ; 60 to be passed fingers

dilated
later it

hours

had
the
two

again contracted first phalanx of

branches of the died
woman

nearly to
one

the

size be

before

labor,and
between

only
the

fingercould

introduced

bill.

the ninth on day. At the peritonitis found soft, autopsy the bones of the pelns and the ribs were The most urements and easily important meascut with a knife. flexible, 27.0 ; trochanters, of the dried pelvis are : cristce ilii, 24.5 ; conjug. ext., 19.3 ; rightdiagon. diam., 20.7 ; left diagon. of the promontory from diam.,20.3; conjug. vera, 12.0; distance the narrowest part of the pubic arch,9.0 ; transverse, diam., 12.8. of the pubic arch, 8.7 ; the sacrum Outlet to vertex : point of to the narrowest portion of pubic arch, 5.5 ; point of sacrum 7.0 ; narrowest tubera portion of pubic arch, 1.8 cm., etc. ischii, De dilat. the ten With cases publisned in Kiiian's work, has author Dissert, inaug., Bonnse, 1859," the pelv. halist., of dilatation of a pelvisdefonned been able to find only 19 cases by mollities ossium, and birth of the child through the natural 2, Winckel, sen.. Feist, : Robert, Schmitz, Breslau passage tion), living child,previous preparations for Cesarean sec(forceps, ment instru8 times Carl Braun no ; Olshausen, Kezmarszky, the ; once, version forceps; twice, perforation ; 6 times The

of

"

and

extraction
to

; once,

extraction

employed
those
*

effect

bom

without
a

delivery : artificial aid, 3

by
Dr. Paul

; once, symphyseotomy, children still-bom 11 were

"

^were

were

; of 3 still-born.* living,

See

report of
where

20th

ca^e,

Journal,
trial with

Cesarean

section

the forceps resulted

F. Munde, p. 36, yoL t1 , No. 1, of this for, but a prepared anticipated and of a lining in the oomparatlTely easy extraction
was

child."

[Ed"]

316

Quarterly Report
Life
and

on

Obstet^^ios

On

Death

of

the

Fcetus.

By

{Ibid.,vol. iv.jpart 3, p.
FooTiNQ
the
on

lin. Cohnstein, Ber547-549.) Dr.

and

the

of Schroeder investigations
of

Winckel, that

temperature
that

the
the

uterus

is from

0.13*^-0.19**

Centigrade

higher than
heat
on cease

of the

vagina,which
child this
no

difference

is

owin^ to

the

produced
the
;

by
of

Cohnstein foetus,
the child

death

the

correctly,that argues will increase of temperature

because first, the

longer produces heat, and

its
own

second, because

uterus

gives part of
With that

heat

to the

now

foreign body
of
the labor
m a woman

within
uterus

it.

pregnant
of the

women

the

ture tempera;
tion exer-

exceeds

axilla
of

by

0.1''-0.29"

during
;

by 0.383^, in consequence in labor,however, whose

muscular been
uterus

child had
the

dead
was

hours, the increase of temperature in only 0.02" C. (Schroeder). Ilence, if the foetus
we a

for 17

in utero

is

dead,

shall little
a

find the temperature of the uterus no higher, or even the lower, than that of vagina ; to prevent the influence
the

of
we

possiblepost-mortem increase of temperature of should, however, control the first thermometrical by a second and third taken several hours later.
pregnant
organs,
to uterus

foetus,

ment measure-

If the
internal be
as

has
to the

higher temperature
of The
has
a we foetus,

than

other

owing
fot

presence

shall also

able

diagnosticate pregnancy
the
three montlis.

when

other
careful wall

signs fail,
introduction and
branes, mem-

during
a

of

small thermometer, between the into the cavity of the uterus,

to be

uterine been

shown

by

periment ex-

productiveof
or

no

evil

effects
as

the

thermometer
will

part
and

admit,

may be

be

introduced into the

far

(?). During the presenting as

labor
or
anus

placed

mouth

in

face-

breech-presentations.

CoNTRraunoN R.
The

to

the

Question

of

Sarcoma

Uteri.

By

Dr.

CuROBAOK, only
in
case

Vienna. of

vol. {Ibid.^

iv., 3, p. 549-554.)

the
a

uterus

case

of primary pediculated myo-sarcoma Winckel. Chroback by reports from the and which, judging macroscopic microscopic
a

has

been

described

examination

of tiie removed
tumor

tumor,
of the in the the

there
uterus

was

first an
all the this

ordinary
from

pediculated fibroid

proceeding
; at
to

the the

fundus,
slow

and

smaller examination increase

fibroid
of

cervix

events

microscopic

pedicle, and
lead
in the

relatively
conclusion.
a

primary and First,the largest

of the

tumors,

oldest tumor

fundus

underwent

and

Diseases

of

Women

and

Cliildren.
the cervical
it had

317

earcomatous

degeneration
short

; after its removal

tumor
so

became

similarly changed, probably by infection,and

tliat in the
a

grew

rapidly
the
sarcomatous

space

of five

months

attained
the

size of

completely nad proliferation only

the removal had of been
masses.

fist and

filled the
here latter

vagina, although the

there the invaded

and

tumor.

On

the
was

tumor,
termination

spot
with of

where

the

originalfibroid

found The

covered

soft,
case

medullary, sarcomatous is not known, as the operation.

The

the

patient

did

not

return

after

the

last

Liquor

Amnh

and

rrs

ExcEssrsne

Increase.

JxiNGBLUTH,
The final theories

Aachcu.

{Ibid,^ 3, p. part, iy.,

from
the author's

By Dr. 554-557.)

IL

deductions of the

are investigations

placenta exsudation the from or (Scanzoni),and by transudation refuted. The liquor surface of the foetus (Scherer),have been exsuded the is undoubtedly amnii vessels, or vasa by capillary the in of the found tal foeboundary-membrane propria,nonnally which gradually obliterate during the last months placenta,
The
uterina

origin of the

liquoramnii

from

the

of
the

and gestation,

must

consequentlybe
etc.

less obliterated

during

found hydramnios they are when than the liquor is normal in quanin greater abundance tity. the and in deviations foetus Other not were placenta chemical found ; physical experiments and analysis fully correspond the anatomical with ing conditions, and only by connectthese results can we satisfactorily explain the genesis and the liquor amnii. variations *ho frequent quantitative oi
5th month, 7th, fith,

In

Incarcerated Otto

FiBRoro

Tumors

of

the

Uterus.
v.,

By

Professor
100-

Spiegelbeeg, Breslau.

voL {Ibid.j

part 1, p.

117.)
By
not tal,

incarcerated

fibroids

Spiegelberg means
which of the

those

intra-pariethe
uterus

fibro-myomata pediculated,
occupy
riiore
or

grow
the

from

into, and
almost

less

cavity of, the

pelvis,

displace and
These
case

compress
not

wholly, if
tumors

its contents, obstruct immovable entirely,

passage, and are in any direction.

which

may

be

intra-uterine

and

in intra-vaginal,

favorable ; or subserous, principally prognosisis relatively and then constitute retro-uterine or cervical, retro-vaginal, be reached without as they cannot most affection, a dangerous opening the peritonealcavity. In either case the tumor may
the

318

Quarterly Report
from the

on

Obstetrics

spring

fundus, body, or cervix of the uterus ; of the the subserous body rarely descend tumors, those arisingfrom and become retro vaginal, and are mostly movable ; cervical
ante-uterine

myomata
to

have

not

as

yet

been the the

described. intra-uterine cervix

are

Those
and
more

tumors

intra-

operative treatment, which those arisingfrom of vaginal,

because
to the

amenable

favorable

easier

of access,

often

present considerable

for removal, impediment moved owing to their size and origin,and occasionally have to be reThe of tis, gradatim^ i.e., amputated. danger septicphlebithen and and is septicaemia peritonitis verylymphangitis, imminent. Spontaneous decomposition and septicaemia may also take place,generally proceeding from the lower portion of the

introduction

of the

instrument

tumor,

Avhich

is

most
cases

exposed
related

to

external

influences

and

violence. follows 1. into the

:
"

The

five

by Spiegelberg are
enormous

as briefly

Fibro-myoma
the

of the

fundus, of

size, wedged deep

vagina ; partialexcision from the vagina ; laceration of uteri and its serous sion cervix of the incicovering ; gangrene from septicaemia and peritonitisthree days after ; death

vical cermyo-fibroma of the posterior operation. 2. Submucous to the anterior wall,adherent vaginal wall; incarceration ; of the laceration of Dougaccount on only partial las's extirpation the tumor with fossa while tenacula drawing down ; foetoof the remainder in 15 days after purulent destruction ; death thrombosis of the complete closure of the abdominal rent, from veins of the leg and intramultiple pyaemia. 3. Incarcerated of the wall and fundus of the uterus ; parietalmyoma posterior destruction of death from its tonitis, lymphangitis,periseptic apex ; The first and distinct of septicaemia. septic symptoms

the

infection of the

came

on

about various from

18

hours
;

after

tumor

by

students
one

examination digital Spiegelberg thinks that the

4. Ketro-uterine

the

infection

proceeded
cervical

of them.
enormous

and

tro-vaginal re-

pelvic

myoma labor in at term cavity has found of

14

of

; Cesarean
cases

size ; obstruction section ; death. Breslau

was

of the

Spie-

felberg elaine, in all

mother cervical child and in

similar the

reported by
section
5.

and

Magto

which
were

Cesarean

fatal

the

; 7 children

saved.

Retro-uterine
at

incarcerated ture punc-

myoma (only bl(X)d

; unsuccessful

attempts
the
tumor.

repositionand
birth

flowing)during labor
elevation of the

after breech-presentation
taken

; spontaneous nipture of the That the

tumor

of the

membranes,

consequent
have the

this

happy
was

event

could
within
or

place only when

not

situated

and peritoneal cavity,

when

it

was

retro-vaginal

subserous, is evident.

and

Diseases

of

Women

and

Children.

319

On

Inversion

of

the

Uterus.

By

Prof.
aud

Otto

Spiegelberg.

vol. iv., {Ibid., part 2, p. 350-362, 1. Inversion of

sarcomatous

vol. v., p.

118-126.)

uterus,

by traction on the tumor inversion diagnosis, in supposing only a slight ; error and be the rest of the tumor this to a neous erropolypus ; unaer the removal of with the tumor impression ecraseur, of the exceedingly anaemic death hours later. woman thirty The specimen showed that the uterus had divided been little a above the cervix ; the removed 5^ centimeters portion was of and 4r the division. centimeters broad at point long 2. Complete months' of 18 irreducible puerperal inversion

partly produced
of

partly spontaneous, sician by the family phy-

duration

; ineffectual

attempts
to

at

reduction

with

the

hand

and

colpeurynter, according
one

various

methods, relieved, a

at intervals

during
and

mouth

tlie patient being extremely finally, and anxious the

to

ansemic

debilitated

be

placed

pedicle,to of the jacent adtwo subsequent operation (not to produce adhesion lapse, peritoneal surfaces); this produced vomitingand colwliich ceased after tlie ligature was loosened little ; a after 48 hours removed the boundary of the uterus at was with the galvanic loop ; the patient left her and cervix corpus and dismissed bed on the 15tn well. The soon was day, point
"

around

ligature was prevent haemorrhage during the

silk

of

inversion
"

in this

case

wiis

at

about

the
os.

middle The

of the

coUum of the

uteri

generallyit

is at

the

internal

advantage

loop is,besides arrestingthe haemorrhage, the oblique falvanic the stump irection in which the cervix divided, thus when
was was

reinverted,
not

aiding the
were

secretions

to

flow

into

the

vagina,
the
:

and

into

the

peritoneal cavity. During

made
mucous a on

menstruation
uterus

following observations
organ little
more

the

inverted

the
but

voluminous

; the

membrane

normal,

clear,gelatinous secretion ; the blood exuded slowly, as in parenchymatous haemorrhage, and coagulated immediately ; the largestportion did not come from the the uterus fundus, but from parts higher up {Le,y of of excised An brane memmucous piece being inverted, course). dilatation distention all and showed of an exceeding injected,and
covered the

with

blood-vessels,
colorless
at
an

small

extravasations

and

much

more

merous nu-

taken

non-menstrual

menstruation

found in a piece corpuscles than had been intermenstrual period ; the epithelium found in the S. considers these apalso wanting. piece was pearances the haemorrhage called to support his opinion that dation. principally takes place j?^/' diapedesin, by transu-

320

Quarterly Report
TO THE

on

Obstetrics
OvARlOTOMT.

CoNTRIBmON
WiLu.

INDICATIONS

FOR

By
S2ir

Db.
Ge-

Alexander

Freund,

Breslau.

{Beitrdge
50-62.

burtshvlfe uiid Gyndkologie^ii. vol., pt. 1, p. 1872.)

Freund

Berlin,

reports

two

cases

whicli were
of the

both

hesions, adcysts,with extensive punctured several times, one patient of which

of ovarian

refusing ovariotomy, in
cysts and
subacute

both

inflammation purulent

of temperawith increase peritonitis, ture and and debility(ichornight-sweats rapid general pulse, the obvious last resort, starting from As a rheemia), ensued. the suppurating and infectious tumor surgicalprinciplethat Freund followed the removed be should as rapidly as possible, and Veit, and performed ovariotomy. In example of Keith the peritoneal cavity contained of the two the worst cases a which ally continuserous was fluid, quantityof reddish,flocculent, In both from inflamed the exsuded peritonfeum. cases, C. down 38*^-40^ after the operation the temperature sank from threatened Case I. was C. to 36.9^ by dangerous symptoms of and both and but ered collapsus, rallied, patients recovperitonitis

perfectly.
Statistical
DURING

Contributions

to

the

Frequency
Louis

of

Menstruation Berlin.

Nursing.

By
in

Dr.

Mayer,

{Ibid,y

vol. Mayer many

515

ii., pt. 2,
found of whom

p. 136-142. that
were

1873.)
in 395 their women, children and

1,200 labors,occurring
returned
After
"

multiparse (685 nuraing

After

not

doing so),menstruation
t)ellvcry.
per
**

6 weeks 6 to 12
12 weeks

in weeks to in

62.82 1 in 4.85

cent,
'*

in
** *'

44

18.83**

per 16** 6
**

Weaning. cent,
** "

During in
** "

Nursing. per cent.

'* ** **

24.63 20. 81.84

4

"

year

*"

Before
After
In In

the

sixth

week

it returned

weaning, not-nursing women, in nursing women,

in*.

34 in 23.52 14.2

per
** **

cent.
" **

The
2.

result of
The

these

compilations

is

1. The

menstruation

during nursing is very most frequent period of

of the
menses

common

appearance climate. in our

of

the

reappearance menstrual

its return coincides with after weaning, and in notis therefore mentioned
not

women nursing

'after conlinement. flow

account

3. The

during

nutrition

normal, ab2 ; that

partlyon
partly
neither suffer because mother

of the coincidence

under

extensive
nor

practical experience shows us under otherwise normal child, conditions,

the
occurrence

any

injury

from

of

menstruation

during

nursing.

322

Quarterly Report
the hitherto
Hicks number where indolent
a

on

Obstetrics

greatlyimprove
and has
a seen case an a

unfavorable
the

prognosis of this
Wemich
which

plication. com-

Braxton

recommends

expectant treatment,
nessed wit-

of favorable doubtful before

instances.

abdominal

tumor,

had

existed

conception, was ted complicawith pregnancy. Shortly before deliverr,violent pain was had felt in the tumor, which caused nience never pain or inconveand occurred before ; rapid marasmus death three set in,
manner

in

weeks
be
a

after

delivery.
case

At

the

autopsy,
the
it
more

the

tumor

was

found
that

to

medullarycarcinoma
history of the
in the

of
makes
tumor

ovary,

partly decomposed.
than

The

probable

the

malignant change

took

place only after

tion. concep-

Cruveilhier, Eokitansky, Spiegelberg, Waldeyer, VirBraxton and HicKS himseli, others,have chow, Spencer Wells,
called ovary attention
to

the

connection and

of

colloid

disease

of

the

in which ovarian reported cases tumors rapidly increased during pregnancy, or where they were to be of cancerous unexpectedly found, at the autopsy after delivery,

with

carcinoma,

nature.

Martin, Winkel, Louis

said
to

Mayer,
on

and

Lucke, particularly
that pregnancy

have the

demonstrated
sexual

tiie fact

be may exercises a
not

positive deleterious

influence

hitherto

benign

tumors,

onlyof
of
this

organs,
in is

malignant growths
circumstance
with
tumor

is assisted

into whereby tlieir transformation The or importance produced.

a

pregnancy

ovarian prognosis of an self-evident, and, in the opinion of the making

the otherwise author, in a measure justifies extremely radical pate advice given by Dr. Alfred Wiltshire,of London, viz.,to extirwith ovarian tumor a multilocular together existing nancy pregif in the the is as soon as undoubted, possible diagnosis first months of gestation. Other remedial measures ture, puncinduction or or as a labor, prophylacticthe premature of sexual intercourse either useless or impracare prohibition ticable. of determining the tliere is no Unfortunately way
" "

cases

in which
; it

to

occur

liable malignant degenerationis particularly of the depends on a peculiar individual energy

the

formative

processes.

Spontaneous
OF THE

Reinversion
Uterus.

of

an

Old

Puerperal

Inversion
Breslau.

By

Prof.

Otto
v.,

vol. {Archiv.fur Gyndkotogie^ The

Spiegelberg, 1, p. 118-126.)
of and
her

normally delivered August 21, 1872; complete inversion patient was

by undue
traction
on

twelfth
uterus
was

child,
duced proat-

of the

the

child

placenta; the

and

Diseases

of
not

Women

and

Ohildren.
refused

323

temptedreposition did
f urtner trial ; two months

again ineffectually the clinic She admitted October to was attempted. 26th, and of complete inversion the usual ascertained condition by S. Ko and his two assistants. were made, attempts at reduction in order to keep the case for the beginning of the lectures,
November
was

succeed, and the reduction was later,

woman

any

4.

In
not

consequence

of
to

an

attack

Satient uring which

On
was

presented
no

the

class
or

of diarrhoea, the until November 14,

made.

time

examination

manipulation was

the latter found

centimeters least and

of all present, tlie uterus day, to the astonishment completely reinverted, slightly retroverted,soft,9 The woman had not had the in lengthby the sound.
of
was

consciousness the

the

fact
a

; the

womb

remained

in

place,

patient
this

dismissed there
are

week

later.

only nine others recorded : Lela Barre, Baudelocque, Thatcher, C. D. Meigs (tliree De roux, Rendu, and H. S. Shaw. cases), rather the one or Spiegelberg'sexplanation, given by Schatz in a communication to S.,is as follows : During the horizontal of the diarrhoea, the uterus in consequence in bed, and
Besides
case

Eosition less tumeiied

ecame

and

more

reducible easily the round

and been

; at

the

same

time

it ascended

and little,
than

broad in the

ligaments
erect

naturally became
;
a

shorter

they

had

sition po-

diarrhoea, with
pressure,

strong 1^ meters

frequent tenesmus, supervened, whereby mostly in the sitting posture, equal to 1 or

was

of

water,

exerted ;

on

and
the

depressed
and

the

anterior

and
became

posterior vaginal walls

too

hereby
the

portio vaginalis was

broad

likewise

pressed downwards,
short

round

ligaments

for such

degree

of descent

kept the fundus uteri in nearfy its former was pushed vaginalis gradually the portio
the organ,
version
was

of the uterus, and thus and situation,

over

the

fundus

of

fixea
then

near

the

outlet

of

the
its
own

pelvis. The
accord
or

total rein-

accomplished of

by further

prolapsus.
On
ON
THE

Ttjbeeoular
THE

Disease
of and

of
the

the

Female Female

Genttal
Generative
op

Oeoans,
Period

and on

Influence H.

Development

Progress

Tuberculosis.

Prof.
The

Lebert, Breslau.
of the

{Ibid,,vol. iv., 3, p.
are

By 457-470.)
:
"

following final
may
be

conclusions

drawn

by

the author

1. Tubercular

disease

internal

female

the

chief

localization

much as proportionally
or phthisis,

exist

developed as only secondarilyand

genital organs the affection, be or simultaneous pulmonary

of the
ot

in

an

inferior

degree.

"

324

Quarterly Report

on

Obstetrics
when
it

Sure

of recognition of phthisis sign's genitalium,even

-do primarily, disease in with
not

appears 2. The does

not

exist.
as

described

tuberculosis
least very

of the

cervix
the

uteri

realityexist, or
caseous

at

rarely, the
about

diseased
os

glands
3. The tubercular and 4.

contents epithelial

uteri

hayingbeen

taken

for.it. the puerperal state and of pregnancy the ages is exerted of mostly between
25
to
on

influence
disease

20

30, especiallyfrom
If in young

30,

and is

then

from

30

to

40. still be

girls the

process

arrested,

it will

takes by siibsequentmarriage, when pregnancy place, both during this and the puerperal state, occasionally after a later pregnancy. otherwise after the first, remain 5. Exceptionally, women formerly tuberculous may of and in spite in good health repeated prcOTancies puerperia; of these children in some instances, however, tne are sickly, of them die and at an a portion early age. 6. Advanced phthisis generally prevents conception ; early do not do so, and usually allow the pregphases of tuberculosis nancy reawakened
to

reach

term.

7. in
at

Abortion,
least and

pregnancy, three-fourths

and

puerperium,
cases,

on

an

average

of

the

promote

the

ment develop-

8. The

rapid progress of pulmonary phthisis. not puerperal state may only confirm
acts relatively still hastens commonly
a case even

an

existing

but predisposition, and

more

the

worse pregnancy, As an fatal termination.

tlian

exception,however,

of
take

which phthisis,
a

proceeded rapidly
more

during
course

pregnancy,
aiter

may

slower

and

favorable

deliver}".
pregnancy
tne
nor

9. Neither

puerperium
or

exert

determining
disease.
state

influence
10.
on

on

localization
of

form

of

tubercular
and the

The

evil influence

prej^nancy

puerperal

also

is most evident in hereditary predisposition, which phthisis favors the eruption of the disease during these materially

periods.
women parturient, tuberculous favorably pass through the puerperal state, they will still have but little milk, and their children, which can are only exceptionallynurse

11.

Should

very generally f stiU and ous,

and sickly, later

very

liable later

to

become

scrofu-

tuberculous.

Practical

aio)

Statistical

Contributions E.

to

Intrauterine

Therapeutics.

By

Prof.

Olshausen,
with

Halle.

{Ibid.^vol.
has pessaries

iv., 3, p. 471-482.)
The

experienceof

the author

intra-uterine

and

Diseases
favorable

of

Women

and,

Ohildreii.

325

been

more

of late than

during
with

former
Out
,

the
these
nor

productionof
and may version. be

evil results is concerned.

were cases

yeai'S, as far as of 297 cases of

stems ; to

versions

81 flexions^ added Of
were

treated

intra-uterine
was

in wliich
25
were

there
women

neither
who had

flexion
borne

these

86

cases,

children,
results

55

and nulliparae,
were :

6 unmarried instruments

of the treatment

the
;

nulliparae. The excited peri-or

on

para-metritic processes of haemorrhage or pain

continued
not 3
so

7 times
10

they were times ; they

therefore

removed
were

account

well
;

borne

and could

to

the

end

of

the treatment
were

66

times

they

be

kept
66

in

place, and
in which

not reapplied, finally

times. Of the
cases

the

treatment
were

was

persevered in, in
; in

17

only doubtful
was as

permanent
considerable
to

results and

obtained

18,

the

improvement
such Of
duration these
15

of

long duration;,
of
a

in

15, of
cure.

admit

the
w^ere

conclusion cured of

permanent
and the in

patients,11
In 8
under
cases no

their

by sterility

the

treatment.
cases

improvement
be ascertained The from in

ensued,
because

8 other

the results remain

could

not

did patients the

not

observation. carried varied

time

during
to
cases

wnich

struments in-

were

3 weeks 15

22^

months,
worn

with

one

to

three

interruptions ;

they were

from

6 to

22^ months.
useful particularly
; the

Stemanteto be

pessaries are
and

in

more flexions,

so

in

than

in retro-flexions their

benefit

in the

latter is less

likely

application is more dangerous ; also the of ameconstriction uterine and in certain of in cases canal, Their indications the are norrhoea; very rarely in vei*sions. sterility signs of obstruction in the uterine canal,with or without tle or neuralgia,occasionally metrorrhagia; very lax uteri are litCounter-indications are : all periadapted to this treatment. and para-metric complications,sharp, not neuralgic, pains m or
permanent
about the
a

uterus, firm
or

adhesions

adhesions (fax is

are

not
or

sarily neces-

neither counter-indication,

catarrh,with
Instruments
a

without

ulcera with 6
a

monorrhagia orificii extenii).

convex-concave cm.

uterine intra-

of hard thickness the

rubber,
of
a

flat

plate,
shorter them in

stem

of
the

the

No.

catheter,1.5-2
no

than

cavity of
the most the

uterus, with
will in
rest

support

to hold

place,are wall,and
pessary,

and convenient, reliable, button

least

anteflexions
thus

against the
the

In irritating. posteriorvaginal it will

more a

remain and

place y
a

in retroflexion

quently frelevertrivance. con-

slip out
with
or

necessitate

of co-application
or some

without

network

of silk

similar

Instruments

too
use.

firmlyfixed from

the

vagina

are

too

for irritating

continued

326

Quarterly Report
uterine slight catarrh is the

on

Obstetrics
"

A is not

rule
soon,

after and

troublesome,
after the
flow for the the the

diminishes

but application, disappears spontaneously of the

strual men-

the

removal

of

the
or

first two

Increase pessary. three periods is common

colic

blood

between of

regularperiods is generally
; uterine

; loss of location produced by dis-

occasionallyfollows its of hyperafter morphine, and the cases introduction, but ceases the relief often of their presesthesia most striking experience vious when Periand they occur, genpara-metritis, symptoftis. erally
pessary
come on on

during

the

first

sensitiveness

uterus, call for the

The
as

pressure immediate
must

during walking
removal
worn cure as

fortnight ; spontaneous pain, on or moving the

of the
as or

instrument.

instrument
seems

be

long
year
or

it is well

borne,
or

and of

it

necessary

for

(a

more),

relief

the

trouble and

(the same length of time, intensityof the disorder).

anatomical
results
"

according to
the flexion
"

tion the dura-

Kadical removal sacral

the any
not

cure

of

are

rare

of the obstruction, of the dysmenorrhoea,hypersesthesia, and of intercostal pain, hemicrania, and improvement
very common,
; hence

general health, are

other form

and the is

are

not

attainable
and

by

of

treatment

applicationof

stem-

in pessaries
to be

carefullyselected
any
more

discarded

cases, than numerous

invaluable,

ought

undertaken

for the relief of affections not Disturbance Conditions Motion

the

operations surgical dangerous to life.

with

Cases Dr.

of

of of

in

Connection
Sexual

logical Patho-

Female Transact.

Organs.

By

Mayer, {JSeitrdgezur Oeburtshvlfe uni

Louis

Berlin.

Ohstet.

Berlin JSoc.^

Gyndkologie^ vol. ii., pt. 2).

"

Paralysis, The patient, a Paroxysmal {reflex) 39 years of age, was chlorotic well-educated,respectable woman, carriages) in her at 25, and was youth, married pregnant 9 times (3 mis1.

General

In

her

25th

peculiar nervous
and
for

paroxysm,

she was year which she

suddenly seized
attributed and
to
nervous

with

a citement, ex-

which
next 14

was

repeated

the

state, Eeral haemorrhage y

or

when

years, the patient had

longer appearingusuallyduring
at

shorter
the

vals interpuer-

become

much

debilitated

much
were

she was post-partum or haemoptysis(to which addicted, although the lungs, neart, liver, kidneys,etc.,

influence, fear,fright, excitement, or tions, by examinaorgans micturition and defecation, had prepainful injections, ceded the attack,which in by an occasionally ushered was aura, distress, flushing of both palms, dyspnoea, general pulsation,
not
some

when or diseased),
local

external

irritation

of the

sexual

and

Diseases

of

Women

and

Children.
sensation the the

327

etc.

The

symptoms
spread
thorax

which pelvis,
to the

were, to the and

first, a dull,dead
left

in

the
cended as-

leg,then
body
were

to

and right, head

;

rest

of the

and

finally
eyelids
sciousness con-

all the
was

voluntary muscles
and

of the

body

respiration paralyzed,
half
to

slow

weak, complexion pale, mouth

but conscious
acute
even on

open,

half
move

closed, pupils dilated

a

inability to light,
and the

muscle and

direct

irritation;perfect
skin
to the

increased the

of the sensibility

tongue
count ac-

were

present during
of the

attack, according
attack lasted
to
return

subsequent
five minutes

patient.

Each

from

to

three-quartersof an hour ; the preceded by a flow of tears and

proceeding from motility

vertex,
attack with
and took

below

was voluntary motion the a closing of mouth, and brow the upwards ; pain m

sudden

general lassitude place during the

months the
aiter

for
version

24

hours the

followed. child for

One

of

placenta

prsevia.

Five

the seventh
the

(a miscarriage, delivery

ranch found uterus was month), enlarged, painful,immovably retroverted,the cervix eroded, the uterus various irregular adhesions were bleeding; around Under these pathological to be felt. ditions, conappropriate treatment which had much annoyed and debilitated the patient, and the patient restored to almost were graduallyremoved, fect perhealth. l)r. M. considers

twins, in

fourth

the
all

general temporary

paralysisof
of

pathology of this case the voluntary muscles

from the
diseased

to be

of the
sexual

body by
organs

means

reflex

irritation
not

to the medulla
were

oblongata;

only the voluntarymuscles

motor

of tlie trunk

but paralyzed,

also the

branches

of the

trigeminal, the
ana

oculo-motor, trochlear, abducens, hypoglossus,

nerves.

pneumogastric

The

of possibility

disease in
an

of

the
the be

system uro-genital

nerves irritating centripetal

anaemic

condition,and
denied.

this irritation
from

producing
ans"mic

reflex

of paralysis
cannot

centrifugalnerves
2. Paresis

the

central

organs,

lirnhs^ hy the from pressure \iterus. swollen retroverted and retrqflected 3. Paresis of the flexors and rotators of both lower lirrtbs^ and glutad muscles, of the hody^ psoas major iliacus intemus with the uterus of of retroposition rectangular tn consequence in the cutthe a/nd exsudations perimetritic body anteflexionof der%ac of Douglas. whioli raise and straighten 4. Peflsxparalysis of the muscles

of

hoth

the lower

tlie dorsal

rvSy

portions of th^e spinal colutnn, dependent condition the larged enan genital organs, of on a hypermmio but and aMeverted utenot painful, slightly anteflected, extensive catarrhalerosions with of the eerviXj and modeand lumbar

328
rate

Report on Quarterly

Ohststrica

sensitive infiltrations of the cellular tissue behind the WOfYlh, other remedies had been emIn all of these cases ployed various and the cases seemed in vain by different physicians, of the uterus by means of the sound in hopeless ; the reposition all eases immediately enabled the patients to walk (whichthey
unable totally
to do since their

had been the organ

but as soon as illness), abnormal allowed to resume its situation the was of the dislocation by hardreturned. The treatment paresis and in case 3 by an intra-uterine stem, and rubber pessaries, removal of the swelling for the remedies of the appropriate and the perimetritic in of uterus course tune exsudations, duced proin case cure a perfect 1, and a \'ery great improvem'ent abnormal 2 and 3. That tlie long-continued in cases pressure have the irritation caused and nerves a of, respective may on, which alteration in entire was them,by pathological recovery is quite retarded or prevented, probable. On Variola
in the

Fe^iale Sex.

By

Dr.

Lotiiar

Meter,

Berlin.
Out of in the '72, 19.0 per

vol. ii., {Ibid., pt.2,p. 187-198.) of

observed by M. from 1868small-pox the geiieml : females was mortality Hospital, Small-pox

3,221 cases

14.6 per cent. ; the mortalityfrom the males 5.3 per form 10.2 per cent., : females was hsemorrhagic absolute the thus mortality showing a greater cent., among pox, smallstill and a from haemorrhagic females, mortality greater to which theyseemed as well as particularly predisposed, to subcutaneous during the prodromic (purpura), haemorrhage from the sexual and otner organs. The and to haemorrhage stage, of small-pox the conclusions arrived at were 1. In the course : female sex is endangeredin a high degreeby certain peculiar and in every epidemicalways(abortion which partly conditions, after and and delivery delivery), partly premature haemorrhafje to the hsemorrhagic (the predisposition onlyin certain epidemics menstrual and rhage haemorabnormal to pseudo-menstrual variety, and on oophoritis, perioophoritis, hyperaemic depending tumefaction of the uterine mucous membrane),exert their full power and influence its mortality. 2. The difference in the mortality of the two sexes in variola is (with in their turn influencing to certain complications regard delirium tremens) the male sex, as, for instance, the whole on but rather vacillating in differentepidemics and not very large, favor of in of the in the other. and now favor now one periods,

cent, males

330

Quartet'lyReport
the

on

OhsUt/rics
of

of

head

and

the child
The

is then

length diminishes,and the superiorweight owing only to its embonpoint.

heads of
is the

weight being equal,the

are

and

the

length of
children

male

fants in-

still the

larger than
in the

those latter

female

quently ; conse-

oped, develmore proportionallj'^ body in the transverse and so direction, particularly owing to of the well-known adipose tissue under the sicin greater deposit tage of the limbs ; whereby the advanand the resulting roundness and in size of head length of body held by the boys is

compensated
has
more a more

for.
stout

well-developed new-born
same

a under-set, boy of the

girl certainly development a

which
cause

figure. It probable that the weight of greater average

is the

slender

same

influences children
is

the

the

of

vor multiparae also fa-

formation head
in of
a

of

adipose tissue.
in the

The
broader

first-born child

materiallyshortened diagonal,
the

generallyelongated in the but somewhat longitudinal,

that

transverse,
and shorter

diameter;
in

of

multiparous

child is smaller

the

diagonal,but

proportionally

longer
The

in the male

diameter. longitudinal,

offers more head, being relatively larger, opposition head, and consequently shows during labor than the female of the generative canal stronger signs of the configurating power than The
the latter.

general appearance

of

the

body

and

the relation

of its

is certainlya much different parts to each other correct more basis for the determination of the stage of development, i.e.,

age

of the

child,than
Tumor
zur

the

mere

weight
Sacrum.
und

or

length of

its

body.

Congenital

of

the

{Beitrdge
out. The

Oehurtshulfe
called

By Dr. Staudk, Berlin. Oyndkologie. Transact,

in which
was

Soc, Berlin,vol. ii., 2, p. 108-114.)

author
was

to

confinement
head
cause

the extraction
after

of the
considerable
a

body of the child, after the difliculty ; suspecting the

S. turned
the

born, presented
the child towards

of the trouble of

examination, and easilysucceeded in removing it. The cause of sacrum the dystocia was found of the size of a child's be a tumor to head, situated at the end of the sacrum ; during the extraction and it had burst vestigati dischargeda clear,yellow fiuid. A close inthe

careful

back

showed

that the
and the

tumor

was

situated

behind

the

tum, rec-

pushing the
and of
veins
ran over

sacrum

coccyx tumor, the

backwards

ganglia of
the

; the iliac arteries the sacral portion

mass

the

sympathetic

nerve

partlyentered

and

partly

and

Diseases

of

Women

amd

Children.

331

into the tumor. it,the sacralis media artery went and connection with had no the Bpinalcanal was closed,
ran over

The sacral
a

tmnor,

which

consisted

of

large

and

small

cysts containing
covered with

yellow,limpid,albuminous

the whole fluid, cells with

or

being
ovoid

fibrous,loosely-connectedcapsule.
fibrous cellular tissue,fusiform filled with small, round cords
cells. The
tumor

Under

the

microscope: nuclei,tubular
and

oval

doubtful, but it
sac.

undoubtedly was neither was certainly

cartilagea cysto-sarcoma, its origin hydrorachis nor a hernial

these the

bonecells,

There the lower

are

three end
of

pointsof originfor the meningeal sac,

of the
doubt
as a

cysto-hygromata:
osseous

and

laginous carticygeal coc-

termination

spinal column,
.it to
be

and

Luschka's
exact nature

gland
tnis

(there is still some

Arnold believes
to

to the

of

gland

convolute

of

vessels.)
but

Virchow

is inclined

consider
not

these

congenital cysto-sarcotissues

mata,

containing

as

whole occasionally under as coming

describes which it not
remnant

they do regions of
head the

only separate
body

the

(teratoidformations),
; development

the

of group

dunlicate of

Forster
thinks

them
are

under united

in Pygopages (monstrosities

twins

impossible

that

and coccyx), and by the sacrum they are of parasitic origin, a

foetal

melting
is very

the

patnologicalgrowth

and

then

pearing. disap-

in delivering a child frequentlysome difficulty if the tumor with be very firm and such a deformity, especially Of 79 cases collected by feraune, 22 not ruptured during labor. 40 18 delivered with great difficulty. of were cases by !m)hl, the plan followed If the cause of the dystocia is suspected, by

There

"

"

Staude,
the service.

of turning the child viz., of the

If sacrum, and then

so

as

to

get the
advise
be

tumor

into

hollow

will extracting,

be

found the
same even

of

Busch, Kilian, Siebold, and

necessary, still alive. the tumor

Horn
must

manipulation.
if the child be

ruptured,

Inteemittent

Fever

and

its

various

Forms und 1873.

during

hood. Child-

Jahrhuchfur KinderheUkunde VI. hung. Jahrgang. 2 Heft Konigsberg. p. 115-138.

The the of and age of
childhood the is much
more

Physische ErzieBy Prof. Bohn,

the

to susceptible

larious ma-

poison than spinal nervous

intermittens
are

adult

age.
to be

The

effects of the

system, wnereby

the

poison on peculiar phenomena

supposed
growing

rapid

in

the

violent produced, are more body, and the poison by its weight

332

Quarterly JReport on
near

Ohstetrics
of the
accounts

to hover appears inhalation facilitates its

alone

the the

surface

earth,and
for the
the

thus

by

child,and
a sure

great
be

frequency
of gaseous

of
or

the

disease

in children.

Whether

poison
absorbed of

vegetable nature,
is the
a

signof
malarious

its

being

by

the

blood which

intra-uterine few who instances had bom

infection
known. intennittent

the

fa"tus, of
children of

have

become

The fever

mothers

suffered with

from

during
with the

were pregnancy all the signs of malarial

skin, dropsigal effusions

accumulations the blood. viscera and

different organs,
after the
recover

spleen, large tumors the malarial cachexia, colormg of and hsemorrhagic ecchymoses in nal of pigment in the large abdomiof these children

of

the

Some

immediately
seemed
to be

birth

fell ill with of from

the

intermittent intra-uterine malarial

fever,which disease;
cachexia.
were

continuation for years

others In
a

did

not
cases

their

few
the
or

the

febrile

violent

of the paroxysms convulsive rollingand

to

foetus with
woman

discernible

bv

its

motions, the
that
must

type
be

of

fever
nating. alterwith
tain. uncer-

coinciding as
How intermittent

day
to

and
a

hour

of the of

mother,

long
fever

pregnant
cause

affected
is

the

infection
was

the child
in 465
;

Regular
from
number the

intermittent

fever

observed fifteenth second

on

children

tlie fii*styear

(21 cases) to the

69 Sex
cases no was on

the and

largest
up
to

observed
year. The
; most

was

in

the

year,

seventh

exerts

influence
the in the the cool

the

to liability

the disease.
and and

common

type
came

quotidian,then
hours between

tertian
noon

quartan

attacks

midnight, perhaps owing

tenth year in 64 per
cent.

to

night-airand

the

evening-fogs. Kelapses were

to the

rapidly ; closelyresemble tnose of gastricor typhoid fever,and their real be ascertained nature only by finding an enlarged spleen may of 40^ C. the first day, whereas and or more on a temperature would in typhoid fever these symptoms be more tardy in appearing.
the
verv

infection

the first extremely common ; from The disease follows (Griesinger). the premonitory symptoms very

The
attacks

abortive appear

variety,where
without

two

or

three

quotidianor
uncommon

tertian in

being repeated,
are

is not

children. Characteristic
the paroxysms

recognize; the generallyit is

exceptional in children ; are incomplete, fragmentary, often diflScult to cold stage may be entirely or wantmg ; very slight of the replaced by drowsiness, slighttremors
of the and
a

regular attacks

extremities, spasmodic movements the breast), pallid countenance,

The fever
is very

eyelids(in children
sensation
of

at etc.

cold,
the

variable

and

sometimes fiuctuating,

tern-

and

Diseases

of

Women

and

CJtildren.^

333

perature of only one-half of the body being increased,and the third or perspiratory stage is neither so intense nor so frequent
with A

children
constant

as

with

adults.
is the

symptom

enlargement
if the hot

of

the

times spleen,some.

but

but slight, is

always

present, and,

by
nal

acute

radiatingpain during
so common a

rapid, accompanied stage. A gastro-intestiof intermittent

catarrh

companion
a

fever

in

children,that
the time

it

maj^

be

considered

valuable

sign, diagnostic
or

if the particularly

most dejectionsoccur the and streaked or cliill, are is caused dangerous symptom

frequently near
with

after
sionally occa-

blood. the the

This

by

irritation

of the

spinal cord

through
of the

the

malarial

poison, and
and

consequent
catarrh

hypersemia
ai'e

intestine.

Jaundice

bronchial

occasional

concomitant
are

affections.
more

Children affected
the

much

rapidly, generally,and
A
lew
:

durably

by

malaria

than

adults. the

chills suffice to of the All the and

well-known

signsof
the

disease of

atrophy
skin.

produce panniculus
symptoms
race,

adiposus, and
of anuemia,
ascites and cervical 6-11
ctm.

pallid color
swelling

the

oedematous

of the

hands, feet

later

veins in

murmurs hydrothorax,systolic the of spleen,22-24 ; enlargement

in the heart
ctm.

and in

large

lengm,

breadth;

chronic

intestinal

and catarrh, petechife

the common are pui-pura, of the external

in

grene Gansymptoms of malarial cachexia. female genitalorgans occasionallyoccurs

exti-eme

cases.

The

youngest
any

children
one as

with

intermittens

served ob20

by Bohn days
his old
;

(or
cases

indeed
to

yet) were
says that age

10, 14,

and

contrary

Bouchut,
one

Bohn

two-thirds the

of
usual

twenty-one
was

under

signsof
catarrh
In

intermittent

fever
the

in

year older

of

presented
;

children

gastro-intestinal

present. generally
with

accordance

of the youthful greater susceptibility of

intennittent

system, the

varieties irregular

fever

were

more

and frequentlymet with in early childhood,, in derangements of the nervous chiefly caused

manifested

selves them-

system,
and

or

by
the

gestive-inflamma conare con-

by

processes. violent particularly

to

Of

the

former

which class, clonic and

malarial
are

infection sopor,

incident vulsibility

childhood,

tonic the
are

spasms, almost
membrane.
1.

neuralgia,vertigo,and

latter, caused

by vasomotor solely catarrh of the intestinal

sopor
oaa^

psychical disturbances ; the spinalcord, influence from

and

bronchial

mucous

InterTaittens
which
; hot

characterized
young

by sudden
can are

collapse,
hardly
the be best

from
roused

the

mostly

very

children

baths, quinme, wine^ musk, camphor,

remedies.

334

Qua/rterlyIteport on
L

Obstetrics
melanfiemia
cases

2.

conmdsiva,
of

caused in the

in

old

cases

by
fresh

and
the

acen-

mulation

pigment
by
the

brain, in
from

of most
or

children
time

to convulsions

at any
one

toxical

any influence swollen

liability condition, of the malarial poison. by

febrile slight
vulsions. con-

In

of the casejj)ercu88ion and

spleen caused violent Twice, periodical torticollis, spasmodic contraction

stemo-cleido-mastoid
was

of
the

the

scaleni

muscles

accompanied

and tertiary chills, 3.

/. neuraZgica
;. 9 in the

of the sensitive
12
cases

by quinine. in children,like all affections common fibres of the cerebro-spiual only system ; B. saw
is less

cured

regionof

the

trifacial

nerve

in children
once

from
in the

once sciatica, cardialgiaand years, once of the hemorrhoidal branches nerves.

1^12
4.

is very common : vertiginoaa connection in diagnostic symptom only

/.

the

vertigo
other

is

valuable

with

less definite

signs of
5.

infection. ment, excite-

/.

psychopathicay characterized by mania, nervous fear during the attack,of melancholy or extreme
is lost.

which

all

recollection
There the is

6. Intermittens
no

cha/racterized
and

pain
are

passages and 7.

coincide

chieflyhy hhody diarrhma. tenesmus, consequentlyit is not dysentery ; with the time of the chill, generallyquotidian,

only by quinine. I7vte7*mitten8 with croupy andla/ryngeal synvptom^^ and

controlled

8. /. vnth

pneumonia^
and the

I.

pneumonica^

are as

uncommon,

in

so

far

as

the croup
of the

pneumonia appear caused perhaps by intermittent,

to

sudden

tions complica-

the

mination repeated deter-

of blood

the

only as gradually,
are

the and

on pulmonary system. If they come sequel to an already existing catarrh,they more

less
or

dangerous
remittent

common,

and

present

an

tent intermit-

character. for

The
was

chief

remedy

all these

forms
in
two

of intermittent doses
hours

fever
centi-

quinine, generallythe tannate, (2-^12grs.)or more, every granunes

The Unity
of

of
or

12

to

60

oftener.

Vabiola Vienna.

and

Varicella.

{Ihid,, p.
most

By Db. Kassowitz, 160-175.)

incline towards clinics and
two

The

at present majority of psediatricians

the
in

theonr

of

while duality,
to

chiefs

of

dermar
the

still adnere tologists

the

unity of
aualists

the

diseases of
with five

question.
nature

The of

arguments
varicella

of the

in favor vesicles

cific spe-

(with well-defined

clear,

translucent
are :

contents,

1.

The

desiccatingin from impossihUity of producing

three
an

to

eruption

days) by

and
vaccination

Diseases
vnth

of

Women

and

Children.

385

the vesicular
and others
;

fiuid of varicella.
in

Steiner, in
a

Prague, Willan,
eruption

succeeded the

producing
of

general
owing,
fluid became
to

by
to

vaccination the fact

failure
vaccinated

others
with

is

perhaps,
instead opaque, the case prove
2.

that

they

the

clear

of when in

waiting till the

they
variola either
occurs are vera. more

contents

of

the

vesicles

infectious, as

is also

known

be

Negative
who

results

from

vaccination heen vacd-

nothing
VariceUa

way.

in children

have

never

attack of varicella affordsno im/mv/nity natedy and ajprevioits child tnay ha/ve varicella a/nd a even against vaccvnation: time. But, variola and vaccinevacdne-pustulesat toe same
"

may Sustules oumal., ii.,8,

milder

exist

contemporaneously (Priugle,in
169

Wilson's

enumerates

cases), the

variola

having
and
we

nature,

and

the

course or

of vaccinia

is also influenced

retarded
may with

by

intercurrent
a

existing varicella; herefrom

variola
occurs vera

deduct
vaccinia.

mutual The

of relationship

and

varicella

fact that varicella that

a

in non-vaccinated
not
one

children

only proves
in its severest

disease

need

always
child

affect
is taken

person catches its weakest varicella. with variola vera, another variety, in this order in and variola occasionallyappea/r 3. Varicella the
same

form,

and

that,while

person
to

at
a

diferent intervals.
second of
time
two

"

AH

exanthemata
times in the

are

liable

reappear
; vanola
;
an

under and

peculiarlyfavorable
three years
same

conditions

has occurred

individual
is

immunity

only a

few

after their

vaccination

quite common.
4.

and Epidemics ofva/riola

"

varicella

run

course

pendently inde-

^Varicella occurs before, during, and ofea^n other. cella, variafter also sporadically, and i.e.^ an epidemic of variola, of exists as the lightest form like most zymotic diseases, times all and increases times in at small-pox at large cities, favorable circumstances under to the height of an epidemic. vesicular exchisive occurrence the 5. 2he abnost variety in of and childhood. true, but to be explained by the tenderer ^Very the thinner skin of children,which more rapid propermits of duction
"

and

desiccation

of

the

vesicles

where

the the

skin

is

thick, as
retarded.
6.

on

the

soles

of the

feet,the
the

contents
course

of of the

vesicles

of varicella become The

purulent,and
the course^

eruption is eruption
may

in difference
"

temperature,

and

of
be

^These vary varieties. the two accompanied by high fever,and

almost has
a
no

exceedingly; varicella the other on variola,

hana,

by

increase

ly

prodromic

of temperature ; varicella not unf requentfever as well as variola ; the eruption in

eS36

Quarterly Report
crops,
seen

on

Obstetrics
is not varicella, is Bometiiiies eruption
are are so

Buccessive

said
in

to

be

characteristic
the last the date. other be the

of

nnfrequently 6-8 days in appearing, and

noticed
ent

where variola,

crops

not

so

much diflFershoald of

among and and

those

of older
of
not

There

many

degrees
vera

varieties varicella

exanthemata, why
two extreme

variola

degrees

? small-pox Both the

affections
the

have the

in

common

the

prodremic erythema
of would
on mucous

similarityin
over

anatomical

distribution

the be

thema exan-

cutaneous

surface, which
; the
occun'ence

most
branes mem-

singularin two
; the

distinct diseases
cause,

analogous

differing only in

duration of

of each

of the eruption, witli formation separate crop fluid exsudation, desiccation, decrustation, and

nodules,
the the the

cicatrization

(which analogy
cellular
cases

latter is allowed of the

for the the

vesicular

adversaries
in

unity);
structure

average of the

variety even by similarity in size; far as as efflorescence,

is shown in and

airangement
a

is

concerned, which
is

both

when the

tense

vesicle

punctured
the

only

small

portion

vesicle exudes, filled ; the retarding influence exerted continues by both on in of the development of vaccinia. severe Farther, case any be varicella vesicles will of which some found, the contents which show in the have become a depression purulent, centre, desiccate slowly, perhaps in two to three weeks, and leave a deep, that in confluent Hebra asseiis concave scar. small-pox vesicles the be observed at any period of the eruption. Then may of infection of variola from* and the undoubted cases varicella, the Ilebra, Thomson, Lebert, Rayer, autlior, reported by reveree,
contents

of

while

remainder

of

the

and

others. says is caused

Gerhardt which

that there is a disease

in occasionally,

exceedinglylike varicella,
and variola Would ated non-vaccinvera, and it not be

vaccinated

persons, which
better will
to

by

undoubted
varicella ? arrived
at

infection
true true

fi*om

again produce
from
versa

small-pox.

arise,and
The

say, vice

small-pox may
is
:

occasionally
result of
or

conclusion

by Kassowitz
person
one

The

the

whether infection,
vera,

the infected
the
to the

takes the

varicella

variola

depends mainly, on
of that person

hand,on

greater or lesser predisposition disease, and, on the other hand,

the had

on

the

greater
A

or

lesser who

intensityof
has
never

morbific
variola

agent, the
or

tagion. con-

person will,in ordinary cases, variola

varicella

fore, be-

in extraordinary varicella, infection instances,however, previous by affords the best protectionagainst a subsequent infection, variola. A

get varicella

from

338
"

Quarterly Report

on

Obstetrics
hours

aa. ij.,

fervid., 5 ij., a tablespoonful every

with
or

two

until

it

acts
nes.

; rneum,

without

carb., aa
"

3 bs., electuar.

magnesia, or pulv. rad. rhei,ma^The anis, 3 j. M. point of a knife

in

full
ad the

the or Mayr; I ij. Syr. spin,cervinse milk

two

Prof.

3He. panis laxans, inf. sennse If table- or doses. tea-spoonful

Monti
uses

contains

too

much

casein

whey

for children

under

to

uls a day ; for older children months, 2 to 3 tablespoonf i pint ; in obstinate cases nursing by a younger wet-nurse

the

adaition

of

a a

solution

of bicarbonate each
new

of soda

(halfa

drachm the be

to four

ounces, with

tablespoonful to
if it. it

bottle of

milk),to
should
of

milk diluted

in

artificial nutrition
water

is useful.

Liebig's soup
milk diet

or constipates,

with
is

veal-broth
service

substituted beef (breast,

children
3 2

Occasionally mixed -tea, spring-wateron an empty

have cod-liver

for

should

oil
font.

ij., pulv. gumm.

to 3

arab., aq.

stomach) ; rachitic or a (01.jecor.aselli, f. mixt, colat.,3 ij. q. B.,ut ;

mixture
;

a day) ; cool bathing, tablespoonfuls washing, enemata Kreuzlargerchildren,laxative mineral waters, I riedrichshall,

bruimen,
Nephritis

etc.

DiPHTHERrricA.

By
55

Dr. JSd.

L. LrrzEKiCH.

( Virchow^s

ArcMv,
The

Ibid.)

of L. on the fungous originof diphtheria investigations eine Monographic, etc., 1872) are known, and (Die Diphtheric, med. time time in the Berliner have been to published from Archiv. and A Virchow*8 new experiment is Wocherischrift from urine the following: If filtering-paper, through which has been with children is washed filtrated, tepid diphtheritic

water, dried, and

a

laid

on

the later and

mucous

membrane
same

of the

cheek

of
will

rabbit,
found

26 in

to

36

hours

the

be

the

urine,

later still the

fragments fungi diphtheritic specific

at

of

the system nephritis. The fungus entered the filtering-paper was applied ; the mucous nothingbut a slightmilky discoloration. At the autopsy of a boy 2^ years of age, and diphtheria, the urine who before had

the

spot

where shows

membrane

who from

died

of

ryngeal phaof

suffered
the

retention

found kidneys were much and incision friable; on enlarged, the capsule tense could cortical be the substance the not dullary medistinguished from of the it in was a dirty-yellow, shiny color; pyramids ; the striae. C)n r eddish near examination, papillse microscopical

fifty hours

death,

the

canaliculi
masses

recti

and

contorti

were

found

filled with
in parts

gous fun-

in various

degrees,the epithelium

entirely
its nor-

destroyedor

filled with

granulesand enlarged to

double

and
mal size. On

Diseaaea

of
the

Women

and

Children.

339

picking

of

fungous filaments and In the corpora development.

masses

specimens to pieces,a fine network was found, of various size and spores

Malpighiana
bodies,
in
some

there

were

black

filled with

bright
;

round the

which the the

could
spores

easilybe
were cumulated ac-

as distinguished

spores

in

pyramids
of

in
was

great quantity ;
well

tuouli

recti

the

filled with cent, translupreserved, others were epithelium bodies The fungous etc. (hyaline cylinders), cylindrical found but also to be not were only in the arterial vessels, spores the uriniferous of the tissue between in the interstices tubules, of have anived the where by way lymphatic spaces they may reach the The circulation of fungi by means {SaftkancUcheri). and their transmigiation into the renal the lymphatic vessels, in be particularly favored to epithelium and tubuli appears other. formed The in or manner some hyaline cylinders are and olent vithose tubuli where the epithelium has remained whole, and have taken exsudation congestion place. The croupous of the by the destruction paralysisin diphtheria is caused nerve-fibres by the fungi. intramuscular The
treatment

consists of the

in chiefly

the

chemical removal

and

cal mechanithe

destruction

and fungi,

their

from

system

by diuretics,warm
On Diphtheria.

batlis, lomentations, etc.

By
believe in

Db.

Senator.

( Virchow*8
of

Archiv^
the

66

JBd,

Ihid)
S. does
is
not

in the

nature specific

fungus which

found certainly parasite known well

over causes cause are

which diphtheria, generally is the vegetable thrives as leptothrix buccalis,and which very the and of on spread poison ground theria diphdiphtheritic may the and the circulation by entering poison all carrying the system. By itself it does not produce diphtheria. The given by S. for his non-belief in the fungus as the specific of diphtheria 1. The in diphtheria bodies found are: same also seen in other inflammatory processes in the cavity of
and

the mouth
same

pharvnx,
into chains hours

and

changes
for
as

if put into the urine undergo the and necklaces fibre retained ; 2. Muscular

several the

between

the teeth,presents the

fibres described In

same

pearance ap-

muscular diphtheritic

by Oertel,

minus

the and

increase

of of

nuclei tissue

; 3.

fragments
are

of

the

mucus freshly-expectorated the air-passages fungous or

elements

either real in

entirelywanting

very

scarce

; 4.

On

examining
find
leave the

the

fungi only

in the throat, we diphtheritic membranes the superficial layers,but less and less as we

surface.

340

Quarterly Report

on

Obstetrics

Degeneration of epitbelium with leptothrix buccalis may diphtheria,by causing decompoeventuallyproduce contagions sition
contagion. neuritis is a S., Paralysis diphtheritica, according migrans. S. of strong irritant does but not mends recomapplications, approve mild garglesor swabbing with chlorate or permanganate of potash,or other alkalis, and measures. antiphlogistic
a source

of

the

tissues,ana

thus

forming
to

of

SCROFULOSIS
AGAINST

AND

ITS

LoCAL Klin.

TREATMENT

AS

PROPHYLACTIC

Tubercular

Disease.

By

Prof.

IIueter.
49, 1872.

{Voli"-

maiirCs We
are

Sammluiig
surrounded

Vortrdge^ No.

Ibid.)

flammatio by various phlogogonous (producing inwe are influences, protected by the against which epidermic or epithelial covering of our body ; unfortunatelythis ces phlogogonous substancoatinghas defects, pores, through which called Certain who irritable or enter. can are individuals, this marked in vulnerable,possess a degree,and of this property class are scrofulous in whom an inflammation, especially, persons once started,has a particulartendency to spread and last to an
unusual extent.

The children

beginningof
of
tne

the

pores wide

are

the

tions terminasuperficial in filled wn'th nutrient with in

system
"

of
numerous

which sap-canals{SaftkaruUsyateTn) ducts

"

possesses

fluid,whence
childhood The
the

pastous

constitutions

are

chieflymet
a

; or, in other

words, scrofula
into reach the the

is

disease

of childhood.

sap-canalscontinue phlogogonous elements

is therefore
one

lymphatic ducts, and thus lymphatic glands ; lymphadenitis

of scrorula.

of the

first consequences

flamed, inlymphatic glands of scrofulous persons thus become but only undergo a hyperplastic, occasionally caseous, metamorphosis, rarelysuppurating. therefore Scrofula local inflammation, which begins witn is situated beyond the subsequentlyto be infected lymphatic culminates in the caseous glands, and finally metamorphosis of of these inflammatory conditions glands ; thus the scrofulous the skin and mucous membranes (eczema, conjunctivitis, rhinitis, reinstated their former to are prominent popharyngitis, etc.) sition.'
'

The

Caseous the of
same

inflltrations may
rare

heal
as an

by absorption,but
abscess, when
abscess
or

only

under
means

conditions

unusual

communication

with

the

caseous

deposit are
as deposit, a

developed. This is generally not the case, but and under rule,after long existence

the

caseous

unknown

conditions,be-

and

Difieases

of

Women

and

Children.

341

comes

the seat
to

of subacute
of

inflammation, which,
the
caseous

in most and

leads

the

elimination
to the

matter

cases, but cure,

frequentlyonly
duration. The unf

formation

of fistulous canals

of very

long

in development of abscesses requently accompanied by serious the subacute

caseous

infiltrations is not
which
occurs

general symptoms,
;

herald

before

state

developing tubercular disease suppurationhas set in. of the investigations, in we can

detritus of the
caseous

sometimes

this

Accordingto the sent preall conclude probability

to
bolisms em-

that the minute in the the

infiltrations leads

and capillaries

the

formation

of

miliary tubercles.

of scrofulous
the
.

excessive

to embolism persons dimensions of the

which sap-canals, give rise to The specialpredisposition of the sap-canalsis caused by

latter.

The of
caseous

of possibility
tne
cause

this

infection
out to
us

of the
a new

system by

the detritus

depositspoints
usual ternal in-

therapeutical
caseous as

indication,besides
remove

anti-scrofulous

to treatment, viz.,

the
the

of this of
the

infection, the
and
as soon

lymphatic glands,with
and possible,
to destroy the

ever knife, wher-

first link

produce lymphadenitis, early and energetic measures. The extirpation of the hyperplastic and caseous lymphatic is of and no is,under all glands generallyan operation danger,
which with circumstances
"

chain, the primary local inflammations

particularly when
"

the

caseous

infiltration

changes
-tubercular Besides
caseous

to

suppuration
disease. tlie
caseous

most

valuable

prophylactic against

depositsin

the

the epididymitis and orcliitis, of joints, the ischio-rectal of the synovial membrane of cavity, the medullary canal of bones, etc., are of equal importance. of deposits in the internal inaccessible to A number organs, abundant still remain as will,nevertheless, surgicalinterference,
sources

lymphatic glands, the caseous suppuration in

of

tuberculosis.

The

Injection

of

Perchloride

op

Iron

in

Puerperal

orrhage. Hem-

By A. B. Steele, L.K.Q.C.P., Physician to the Medicine Obstetric at the on Lying-in Hospital ; Lecturer Koyal Infirmary School of Medicine, Liverpool. {Obstetrical Journal and Ireland^ June, 1873.) of Cheat Britain
When
a

the of

means

of a powerful stypticinto injection controlling post-partura hemorrhage, pages of the

the

uterus,

as

in the

British

Medical

first gested was sugin 1869,* Journal,

"

BnU

Med,

Jour., 1869,

vol

L pp.

827, 888, 504;

vol

ii. p. 102.

342

Quarterly Report
to

on

Obstetrics

I ventured of

advocacy and the inexperienced practitioner,

those
and the
measures

fear that the Boraewhat my express this novel calculated treatment was
to

nnqnalified
"to mislead from

divert upon of
"

his attention

which

are

founded

physiological data,
obstetricians that the since cient effi-

upon of William time

means

the

accumulated
Hunter

experience
"

and

further

only

uterine
forms

contraction
of

is to secure hemorrhage useful in some so styptics, non-uterine hemorrhage, are, as a general rule,inapplicable to uterine hemorrhage."

of

controlling
; and

uterine local

that

Dr.

Barnes

at

that

time

stated of

his iron

belief
to

that

the

uterine intra-

of perchloride injection

arrest

post-partnm

introduced

improvements ever midwifery." An expression of opinion so strong, and from so high an authority,impressed me solved restrongly,in spite of my theoretical objections,and I finally the to put the plan to the test of practicalexperience on first opportunity. tion, observaAs I am in a position to speak from bedside now that the treatment and discussions recent finding from in question is still sub jvdwe^ I feel bound contribute to my of so important a question in obstetric quota to the settlement practice.
was one

hemorrhage

"

of the

most

valuable

into

the

practice of

circumstance
of
a

which

more

immediately
was a case

determined
of my Branch
at

adoption
to

this mode

of treatment

the

accident Dr.

my tening lisof of

graphic description of
given
the
at
a

by

Williams,

Wrexham,
the which been British

Medical

meeting of the Association,held

fortune
to

North
last

Wales
summer

Bala, at
who had

I had
attended from much

good by Dr.

be in

present.
several
to
a

lady

Williams

laboi-s

invariably
which
and rendered

suffered
caused each her

post-partum

hemorrhage
her immediate
a source

degree

anxiety
On
the

for

safety,and
of dread

approaching
friends.

confinement occasion

to herself

liams confinement. Dr. Wildetermined to try the eifect of the iron injectionas recommended done accordingly this was by Dr. Barnes, and immediately after the expulsion of the placenta and before of her last commenced. the

dread patient,notwithstanding of impending better exclaimed, "I am hemorrhage, at once I kuow and I shall have and no bleeding this time ; now, such excellent. was proved to be the case, and her recovery I This that resolved to adopt case so impressed me strongly the plan on after the first suitable which shortly sented preoccasion, itself in the following case: her usual
"
"

hemorrhage had completed than

No

sooner

was

the

operation

aTid Diseases
A

of

Women

and

Child/t^en.
of age,

343

patient of my

own,

nearly forty years

of

tender,

and ed delicate frame, deficient muscular tone large dilatenergy, and of which the the in latter veins, hemorrhoids, subject

months
their for
was

of removal

pregnancy time. and

became

so

aggravated
cautery,
uterine
was

as

to

necessitate in labor

by the clamp
Her

and

taken
a

the

second

first

confinement,
and

year

previous,

protracted rendering forceps delivery

effected without
was

difficult from
and

general inertia,

long

extraction not being necessary, forcible traction ; hemorrhage ensued, but a by the ordinary measures, continued, which, although not
a source

which

controlled

subsequent draining of blood in Quantity, was nevertheless excessive

in her

of

much

iety anx-

already
child
and

exhausted
a

condition.
and

recovered

after
was

tedious born

mately She, however, ultitroublesome puerperal died in

a

period.
from and

The

alive, but

few

weeks milk

diarrhoea
second

atrophy consequent
was

upon

loss of breast

general debility.
The
labor
was

almost after

as

difficult and
traction

as protracted

the first ; she

of
a

forcep" ately again set in immediafter the completion of labor. I at once injecteda solution of iron, one of liq. ferri perchloridi fortior. to four of part which in minutes all bleeding, few a completely controlled water, and firm caused of the uterus, contrasting general contraction' unreliable the imperfect and tion contracfavorably with
fine

delivered

livingfemale

child.

long Hemorrhage

with

the

so

common

under rendered

these her

circumstances condition

; and

which
a

on

the

former

occasion Her and in

critical for

ble considera-

time.

recovery,

although complicated by

constitutional

delicacy
than thrived The
iron in the A

able favornevertheless much more was feebleness, the child lived and her first confinement, and

well.

following case,
even

which
in

occurred

shortly after
of the

that of but

just
the
also

is related,

more

speciallyillustrative only
of abortion.

value

not injection,

puerperal hemorrhage,
of

hemorrhages patient about

at

twenty-fiveyears
of
one

looking woman,
a

the mother
times after

age, a fair,delicatefirst for consulted child, me

constant, and
many

profuse
an

loss of
at

blood, which
the

had

lasted I

for

weeks,

abortion

fourth

month.

the uterine cavity opened up the cervix with tents, and swabbed ferri perch, fortior. ; after two freelywith the undiluted liq. all applications bleeding ceased, and in a short time she was called About later I was her in conto see sultation a year quite well.
with her

medical of
a

attendant,
formidable

hemorrhage

consequence character,which

in

of had

partum postcome

344

Quarterly Report
about
an

on

Obstetrics

completion of labor, and had already caused great depression,approaching to collapse. The by compression, cold cloths, promptly checked bleeding was slow reaction in taking but and the other ordinary means, was for some hours in a feeble, excited place; the patient remained
on

hour

after

the

state, with
She

delirium
which

and

other

symptoms

of constitutional for two In

or

turbance, dis-

requiredclose watching
slowly
this she
but
was

three

days.
twelve her

recovered after
as

months
as soon

about completely. taken in labor, and I again

saw

and what someeasy pains set in. Her labor was rapid. Every precaution in anticipationof floodingwas adopted: a full dose of ergot just before the expulsion of the with the hand throuo:hout head, careful compression of uterus the and and binder, expulsive stage, compress subsequent to the and and
so on.

For

short but there

time
was was soon

after deliverv
recalled

all

went

on

well,

I left the

room,
"

patient told her once recognized

faint bed

the and

effects found

condition,
and in the

by the nurse, as the a good deal coming away." I at of hemorrhage in her pallidlipsand a large quantity of coagula in the
whence

vagina, from

fluid blood

was

still flowing.

doughy, and not readily respond to compression. prepared a solution tlie of solid perchloride (which fortunatelyI strong had and brought with me), and having cleared the uterus na vagiI from could feel the warm clots,during which process still flowing, I threw about stream a quart of the fluid, up checlked the and in minutes which the bleeding, at once a few ther furNo firmly contracted. uterus, and especiallythe os, was untoward followed, and the bleeding nor symptoms any better and quicker recovery than she had ever patient made a In the patients each done occasions. of these cases former on themselves appeared to appreciate the beneficial effects of the iron in its injection,and to acquire a feeling of confidence
The

uterus,

was flaccid, although not entirely

did

I hastily

power

to

control
a sense

the
of

bleeding in

few

minutes

after

its

cation applito

security which,
without used the iron
as

while

encouraging
emotional
a

the

accoucheur,
the
not
so

is not I

its beneficial in

eflect upon

interesting ; but in all the result has been and unattended satisfactory, by any of a disagreeable nature. appreciable after-consequences I therefore from assume own experience as well as from my that of others that this mode of treatingpuerperal hemorrhage is both safe and reliable, and under certain circumstances not but of the most only justifiable one as strongly indicated effectual means of rescuinga patient from imminent death.
so

patient. typicalnor

have

few

other
record

instances,
here

to

deserve

346

Quarterly

Report

on

Obstetrics^

etc.

repeat
will

one

condition
cause

insisted failure.
or

upon Before

by

him,

which
the

if fluid

neglected
into
stractare

probably
all be

injecting
portions
of

the

uterus,
must

coagula

remaining

placenta

carefully
was

removed.

A
to

woman

brought
abortion
tents

into
at

the

hospital
month.

literally
I
never

bleeding
opened
up the

death
cervix

after with

an

the

fourth

the

and

freely

swabbed

(I uterus)
but

inject
the

non-pregnant
with far
a

or

immature

parturient
ferri
to

out

cavity
so

the from

undiluted

liq. appeared
I
introduced

perchloridi,
flow
a more

the than fundus

bleeding,
ever.

ceasing,
resource

freely
to

As with

last

finger
a

up

the

and of

infinite

difficulty
after but which

scraped
the

off

minute

particle
ceased
and

placenta patient

structure,

hemorrhage

the

slowly

completely

recovered.

Reviews

and

Notices

of

Boohs.

347

REVIEWS

AND

NOTICES

OF

BOOKS.

The

Practice

of

Surgery.

By

Thoma8
507 984.

Bryant,

F.RC.S.,
delphia Phila-

Surgeon
:

to

Guy's Hospital. With Ilenry C. Lea, 1873. pp.

Illustrations.

book, and tains conis,as the preface states, an entirelynew in a moderately condensed all the surgical form tion informaIt is written in a spirit to a general practitioner. necessary consistent with the present improved standard of medical and valuable The and extensive records and surgical science. specimens of Guy's Hospital have been largely used in its preparation, the numerous and and excellent illustrations of specimens, manipulations, and instruments greatly facilitate the of the There various comprehension topics. is,in fact,a little of everything (and not always of surgery alone)in the book. and The type and general appearance is excellent, of the work
we
can

This

text-book

it readily recommend of surgical practice. Stirn-

to

those

in

want

of

modem

Die

Entstehung
Friedricii

der

ijnd

Gesichtslagen.
15

Von
und 5

Dr.

Med.

Ahlfeld.

Mit

Holzschnitten

phovon

tolithographischenTafeln.
Friedr.
In
are

Leipzig, 1873.
128.

Verlag

Wilh.

Grunow.
the and

pp.

order

to correct

inrpressionthat frontal presentations

very uncommon cases, besides the

from
of

of their
this

collected thirty unfavorable,Ahlfeld related so face-presentations, closely and made clinical reports in Leipzig, a careful analysis the and from statements aetiology, comparing quoting of fifty
the

Winckel, Freund, and other prominent authors on discussion of the various elaborate an subject. After causal influences of these with the presentations, conducted theory customary thoroughness of the author, omitting all mere the conclusions or as speculation,Ailfeld sums following up the result of his investigations :
Hecker,
"

1.

The
not

development
depend
on one

of

frontal

and

face-presentations
but in
most
cases

does

point, SBtiological

several

causes

aid
are

in

forining these

presentations.
or

Exceptions

considerable

enlargement

tumors

of

the

348

Heviews

and
thorax alone

Notices
and
to

of

Boohs.
also

upper wnich

portionof
are

the

the

neck, as

hemicephalus,
its normal
more or a

sufficient

remove

the chin

from

position on the thorax, and to tend to produce complete frontal or face-presentation.

2. As

less

yet

we or

do

not

know

all the

influences

which

may

duce pro-

tion observaaccurate face-presentations. Farther of labors the large fontanelle descends in which monly uncomA far will complete their number. served obwas rare case by A, in whi!;h the distended urinary bladder pre.ssed back the and the of child, a thereby produced position against favorable the child which, under have or circumstances, would frontal

complete frontal or face-presentation. influences are the same 3. The primary eetiological presentations. be An cannot exception is the hemicephalus, which frontal presentation. a
resulted in
a

for
bom

boti

in

4. in

The

the

known
a.

almost influences primary aitiological the uterus and its contents. fojtus itself, influences : are primary setiological
"

invariably lie
The

hitherto
the

The

formation
"

of

tumora

of

the

neck

and

upper

thoracical
".

region, as Struma congenita.

or

/3. Large coils

y. Broad

umbilical
of the

cord
uterus.

about

the neck

(hypothesis).

strictures

h. Abnormal
or

thorax, or
The
".

of both

of the head enlargement of the circumference with normal a relatively together, length fortified
hardness

of the child. influences

uncommon are
"

By i3. By
c.

of the
neck. of the

foetal head.

accumulation shortness

of

water

in the

cavity of

the

cranium.

Abnormal

of the

d.

Dolichocephalic formation
of

head

(a primary elongation

the diameter of head, particularly longitudinal of the lever,firstdescribed arm occiput or posterior by Hecker). cord forehead umbilical the The stretched e. over tensely (hypothesis by Winckel). the
the J. Abnormal

positionof twins
roof

to each

other.

of the g. Want A. Repeated i. Increase

of the cranium.
fluid. foetus.

pregnancy.

ot amniotic

k. Decrease
I,

in size of the and d^ath distention

Asphyxia

of of

the

foetus, particularlywhen
abdominal and

complicated w(th
cavities.
m.

the

thoracic

of Oblique position

the uterus.

Reviews

and

Notices
the

of

Boohs.

349

n.

of Oblique position

abdominal foetus, especially fluid in

the

sentation pre-

o,

Kapid discharge of
in abdominal

the

amniotic

oblique,particularly
in

J},

presentations. Rapid change of position of abdominal presentations.

in
course

woman

oblique, particularly

q. Tumors Btrait. 5. The

of

formation

above

the

superior pelvic
found
the
more

foetus, frequently consequently more presentationsoccur face, and less so frontal, frequentlyin to be sure, statistics, multiparae than in primipai-se.General

primary the more

influences setiplogical
motion is allowed

'are

the

give
6.

but The

little difference

in

the

absolute

frequency (Winckel).
proceed from
the of

secondary
and abnormal

influences setiological
constrictions
or

normal
An

arrest

of the occiput,
"

genitaltract. forehead, during the descent

of the

the
a.

head At

occur may the internal

os. os.

J. At
c.

the external

At

tumors,
the the the

which

laterally compress

the

lower

portionof

the
d.
e.

uterus.

At At At

deep-seatedplacenta. inlet (Imea innominata). pelvic

(if the

spine of the ischium. the ligamentum spinoso-and tuberoso-sacrum g. At of the ischium be unusually projecting or very spine the plane of the pelvis be but little inclined). and tumors h. At exostoses of the pelvis.

y.

long,or

The
chin

pelvis is,in
the
cause

the
the

majority of
farther
or

frontal

and

tions, face-presenta-

secondary deviation of the the development of face-presentations alone is due quency almost entirelyto the pelvis. The order of freof the development of the face and frontal presentations in dinerent 2. moderately forms of pelvis, is: 1. obUque; in the conjunarrow gate generallynarrow ; 4. slightly ; 3. normal and flat rachitic 5. wide. diameter, ;
for from
thorax
; the

i. At

the
the
more

hymen
vulva.
room

; and

k. At 7. The frontal

there of

is above

the

narrow

the foetus, the more passive themselves. face-presentations develop of the Consequently the brim pelvis is the most favorable into frontal place to change normal, or nearly normal, vertex
and 8. Frontal

motion

normal spot for an abfrequently do

or

face-presentations. are presentations

temporarilymore

frequent than

350

Reviews

and

Notices

of

Boohs.

face-presentations. They do not become permanent until either the primary or the secondary frontal presentation,develo|"ed of the head, becomes fixed in its position during the descent This fixation takes place by the surrounding organs.
"

a.

At

the the

brim

of the

S. At
c.

floor of the middle the

At

the

pelvis,and pelvis,by the bony walls of the pelvis. of the pelvis, not unfrequently by the os
of the foetus.
certain that of

contracted

about be

neck

9. It cannot favor almost the

said

pelvic varieties
are

exclusively
mature,
or

development
children
frontal of

With face-presentations.

mature,
a

those
and

pelves
the

most

favorable the
head

for the

development

which face-presentations size

present
and the

only
10.

slightdisparitybetween
of the

of

dimensions

Frontal

pelvic inlet. presentations are

brim

developed perhaps

with the

equal
latter

as frequency and the funnel-shapedpelves, case

at tie

at the floor of tne

pelvis. In
very

those with favorable.

of

ation inclinslight

and
11.
as

wide the

inlet,are
most extreme

the

most

In
as

degrees
but

deformed

pelves frontal
P.
F. M.

well

face-presentationscan

very

rarely occur.

The

Mineral

Springs
and of Sea-side
on

of

the

United

States

and

Canada.

With
and
a

Analyses
List

Notes

of

the Prominent

Spas of Europe,
E.

Resorts. Medica
York
:

By
in the

Geo.

Walton,
Med.

M.i).,

Lecturer

Materia New

Miami "

College,
pp.

Cincinnati, etc.
390. The
waters

D.

Appleton

Co., 1873.

somewhat

indiscriminate

manner

in

which

mineral

freare (or at least the various popular watering-places) a quentlv prescribed,both in Europe and this country, render
like the
one

book
a

under

discussion

medical

various

mineral and very

library. For in it we springs of the

the
most

very desirable find enumerated

a

addition
not

to

United

only the States, Canada, and

this country, historv,origin,and of

Europe,
but also

popular sea-side chapters on interesting

resorts

the

constituents, action, chemical classification, physicalproperties, of disease forms and therapeutics, application to the various the (only chronic diseases) of mineral waters, suggestionson

spring, the various kinds of mineral waters saline,sulphur, chalybeate, (alkaline, and tne purgative, calcic, thermal, and unclassified), anatomy of the the and therapeutical skin, physiology physiological the effects of hot, cold, Turkish, and other douche, sitz, baths, regimen
to be

observed

while

at

mineral

jReviews

and

Notices

of

BooJcs.

351

Under the description of each mineral foot-bath,etc. spring have and indications. its we therapeuticalproperties mineral Considering the frequency of the question, What ? and spring should I visit or use during the coming season sale on tne exceedingly common draught of Kissingen, Vichy,
" "

and

other

mineral

waters

at

our

drug stores, a
springs,as wqU

somewhat
and

more

definite
be

knowledge propertiesof
observed book

of
the

the
their

chemical

constitution
as

cinal medi-

various

the

regimen
Dr.

to

during
can

use,

would
a

seem

desirable. the

Walton's
manner,

fills this be read

in necessity with

scientific and

and

advantage by

pleasing physician as

well

as

layman.

BOOKS

EECEIVED.

Surgical

Diseases

of

Infants

and

Children. the of the Societe

By
de

M.

P.
'

Honorary Surgeon of Malades, Paris ; Honorary Member

GuERSANT,

Ilopital des
by Richard
C. Lea.

Enfants Chirur-

gie, etc.
GLisoN,

Translated M.D.

from

the

French

J. Dun-

Philadelphia: Henry
Differential
to

1873.

8vo,

pp. General with

354.
and

Diagnosis illustrations.

of

Ovarian

Tumors,
L. J. B.

Special Eeference
M.D. With Co.
the

Ovariotomy.
8vo, pp. 482.
Obstetrical "

Atlee,

39

By Washington Philadelphia:
Society

Lippincott"
Proceedings
OF of

1873. Dublin
:

for

Session
164.

1871-2.
of the

Dublin Urinary

Fannin Organs

Co.
:

1872.

8vo, pp.
Stricture
in the

Diseases

including

of

the
gery Sur-

of the Prostate,and Stone Urethra, Affections By John W. S. Gouley, M.D., late Professor
and Diseases Genito-urinaVy in the Med. of the
etc. etc.

Bladder.

of Clinical

City

of

New 103

versity Dept. of the Uniiellevue Hospital, York, Surgeon to illustrations. 368.

and

With 1873.
the

New

York:

Wm.

Wood A

6l Co.
on

8vo, pp.
Principles

Treatise
Austin

Practice
and of Students the

of

Medicine,
of Medicine.
the

designedfor the Use By

"

of Practitioners

Flint, M.D.,
of Medicine
and

Professor of Clinical

Principles and
in

Practice
vue

Medicine

Belle-

HospitalMedical

College. Foui-th Philadelphia: Henry C. Lea.

1873.

vised. edition, carefullyre1070. 8vo, pp.

352

Reviews

cmd

Notices

of

Books.

The

Science

and

Aet

of

Suroeey
and

being

Treatise

on

SarEric

ficalInjuries,
Irichsen, Hospital, M.I).,
and

DiBeases,'
Senior Holme

Operations.
to

By

John

Surgeon
Professor of A
new

University
Clinical

College

Surgery enlarged
by
C.
700 ings. engrav1873. and

in

University

College,
revised
two

London. the Author.

edition,

carefully
In

by
vols.

Illustrated

Philadelphia:

Henry

Lea.

Pp.

1988.

Teansaotions

of

the

Obstetkical 1872.

Society London:

of

London. Green

Vol.
"fc

XIV.,
Co.

for

the

Year

Longmans,

1873.

FiSTTTLA,
AND other

Hjemokrhoids,
Diseases

Painfttl
of the

Uloeb,
Rectum
;

Strictdke,
thedb

Pkolapsus,
Diagnosis'
of
to
and

Treatment.

By
of for

William

Allingham,
of
etc.

Fellow

the St.
revised

Royal
Mark's and 1873.

College
Hospital

Surgeons
Fistula,

England,
etc.

Surgeon

Second "

edition,
Blakiston.

enlarged.
12mo,
pp.

Philadelphia:
265.

Lindsay

THE

j^MERICAN

JOURNAL

OF
AJND

OBSTETRICS

DISEASES

OF

WOMEN

AND

CHILDREN.

VOL.

VL]

NOVEMBER,

1873.

[No.

3.

ORIGINAL

COMMUNICATIONS.

AREOLAR

HYPERPLASIA

AND

SCLEROSIS

UTERI:

RXPLT

TO

THE

RXPOBT
THE

OT

E.

NOEOOXBATH,
APPOINTED

M.D.,
BY THE nssr

T.
NXW

O.

THOMAS,
TOBS

M.D.,
ObOXXXBZCAI.

AND

JAMSS

L.

BbOWM,

M.D.,

OOBCMITTXB
TO

SoczBTT

Review

Db.

Skene's

Fapkb.*

Bt Professor of

ALEXR.
in the

J.

0.

SKBNE,
Oollege

H.D., Hospital,

GynsBOoIogy

Long

Island

Brooklyn,

New

York.

The

Committee

appointed by
report upon
a

the

New

York I

rical Obstet-

Society
at
a

to

paper
'*

which brief

presented
of the

previous meeting,
of
Areolar
to

entitled

Sketch

Pathology

Hyperplasia,"
views
to

etc., while
at

ing offersame

objections
time
"

the
me

then

stated,
before
the

the

kindly
and

invited facts The

been
"

bring

Society
"

the
"

proofs

upon
reason

which

my my
now

so-called response is the

theories
that that

were

based. has

why
until

to

vitation inno

delayed
sooner.

fact

opportunity
'*

offered

Dr. of

Skene's this

paper

and

the

report

of

the

committee

appeared

in the

ber num-

jonmal
23

for

NoTember,

1872.

354

Skene
the

Areolar

Hyperplasia

and

Through gladly
and in avail

space of

kindly granted
the

in this

journal,

I
;

myself
be
set

courtesy of the
the views
to

committee
in the

attempting
I shall

to sustain

presented

paper, the

compelled
forth

disagreewith
report.
in the that paper
"true

several

of

conclusions will
be the

in the that

It

remembered
statement

which areolar

submitted,

is made result of

as a hyperplasiaoccurs which SBmia a position

"
"

long-continuedhyperwith will

I reaffirm
are

emphasis,
be

and

trust to

that the

"

proofs
this

"

such

as

satisfactory
the

the In

committee.

reviewing
"

statement

in the

paper,

report

says

The
a

question here
and
at the

arises

whether
of

hyperplasia,
tissue, a
name,

namely,
process may
ever

growth

development
of

areolar

which

present time, lackinga better

one

be

properly called
as

injlammatory nature,
stated
; it is seen,

does

occur

the

result

of

hypersBmia."
be

In
not
a

answer
"

to this it may
"

that

hyperplasia is
the

process process that

of

any

kind be

merely by

product
to

of

; and

it will make

reference
that

the

paper, is But

I do

not

the

statement

the process

injlammatory
the committee
to

in its nature.
seem

determined
of

to

raise

the

questionas
which
to be content

the

precisenature
textural let them settle

the vascular
I shall
own

lesion
have ing. show-

precedes
to
'*

the

change, and
it
are

by

their

If
must
rest

the

proofs and
with
the

facts"

not not

it satisfactory,

mainly
first in

committee,
affirm
"

with
process

me.

In

the

place,they

that the
be

which
one

eventuates

hyperplasia
nature

may
"

properly called
in the very

of

injUmimatory

while,

same

Sclerosis

Uteri.

355

sentence, they raise the question as

occurs as

to
"

whether

it

"

ever

the it

result
to

of
me

hypersemia !
that if
we

Now

seems

are

to

accept the
to

generally
nature

received

views

of

pathologists as
of the confusion.

the

of

inflammation, the
in the
most

statement

committee

involves
we

them

perplexing
a

Can

have
as

inflammation
the
aware

in

highly

vascula?*

sPructv/re^
? may be
"

such I

uterus, without

previous hyperemia objections that

I

am

of theoretical
to this ; but

urged
that
a

in

answer

questionthe theory of

"

authority

appliesany

non-vascular

inflammation

to

structure

like the uterus. this

In

challenging
that
seem

strange, and, it
of of the

seems

to

me,

purely speculativetheory
aflSrm if
to
"

committee,

simply

is hypei'plasia

as infia/mrncUory origin,

they
the

then insist,

it logically follows,according to
"

most

trustworthy
of

writers

on

pathology, that

previous condition
A

the

hypersemiawas present further argument against the hypersemic theory of the is based on experiments of Bernard, paper
he induced
nerve.

in which

hyperaemiaby
We
are

"

disjection
such

"

of the

sympathetic
"

told that
or

hypersemia,
never

although
Now
I

it lasted

for weeks

months,

led

to

areolar

hypertrophy."
submit respectfully that this statement
shall

not

be

accepted as settlingthe question in controversy.

the
mere

Indeed,
settles

fact It

of

hypersBmia,as
be in
one

separate fact,
of
short of
or

nothing.

may

mild
case

or

severe,

long duration, followed

and in another

by growth

tissue
death

by inflammation,destruction,and
case

of

part

In the

cited

by

the

it conunittee,

would

356

Skene:
to

Areolar

Hyperplcmacmd
be
"

be natural
are

infer that the resultswould

"

sucli

as

of the symdisjection pathetic followed by protracted hypernerve, although d id of not produceincreased growth a part,ai-e semia, from natural causes, to infer that hyperseraia we arising of highly vascular tissv^Sj hypersBmia especially may not be followed by proliferation of connective-tissue

described. But because the

cells?
After these objections to the statement garding reraising the report a theory regarding hyperaemia, gives of areolar tissue. The statement development
" " "

the is this :

It is not the increase in the amount

of blood

but rather a certain districtof the body, supplies tation, irrithe peculiar conditions which we call, collectively, which are apt to modifyits affinities to certain constituents of the blood, or else the presence of specific

which

elements

in the

blood, upon
a

which

certain tissues

or

part of tissues exert

of which Now

in consequence attraction, special

the nutrition of the latter becomes

modified."

"

it appears that the somewhat " is no better than that of irritation process

indefinite term
"

the explaining

by

which

in hypergemia," is prohyperplasia duced.

own

say, the irritation. regarding theory

And, strangeto
what
one

report condenms
"

its

Hear
not least,

it says

on

this

: point

Until now,

at

exists to prove that by an experiment of ii^ritationapplied to the vessel itself a proliferation increase of the fibrils, be producedin or an can cells, the healthy body." If this argument holds good, then the theories offered and the paper must be alike rejected. both in the report

:rd

Sclerosis

Uteti.
"

357
in

Regarding
areolar

the

"

elements specific the

the blood

ducing probe
not

hyperplasia of
as

uterus, that

must

taken, of
seem

course,
to

purely speculative. It
that

does

reasonable

suppose

blood, which
other

maintains organs and

"

perfectlyhealthy nutrition
tissues

of all the contain

"

of the would

body,

should

elements specific
in tJieuterus

which
alone. The any
one

produce changes
states

of structure

report further

that
ever

"

It is doubtful followed up

whether the deveL

has gyneecologist

opment

of the

so-called second
tissue is

stage,where

the increase
could

of the areolar

and fullyestablished,

trace,

its genesis out clinically,

of

simple state
which

of
was

hypersemia
committed

of

the

neck.

The

common

error

consisted
in
one

in the

method

of

demonstrating hyperaemia
ing, assum-

patient and by
reasons

hyperplasia in another, and

on

based
nature

prevailingfaultyphysiological
course

views the

of

the

and
was

of

inflammation,
of the that

that

former
answer

condition
to this I

the

precui'sor

latter." the mode

; but to

In of

submit respectfully
in the
a

investigation given
of areolar

report is fallacious
case,

observe

hyperaemia, in
at

given

followed
lead

by
us

the
to

development
suppose,

hyperplasia,would
the
one

that least,

stood

in

causative done.

tion relaFor

to the other.

This, I believe,has
to
one

been

proof I

refer

you

of

your

committee,
On

for whose
283

opinionsI
find the with

entertain work

the
on
"

highestrespect
"

page

of

Prof. Thomas's

Diseases

of

Women,"

you have

will
met

: following

must Every practitioner

a

cases

in

which after

large, red, engorged, and

an

soft has

uterus, examined

interval

of several

years,

358

Skene

Areola/i^

Hyperplasia
have and

and

been

found,

to

his

surprise,to
aTumrvic^

become

small,

densely hard, white^ and

in size.
cuts
as

its

ished cavity dimin-

Such

an

organ

removed appears,

from

the

body

almost
and

like

and cartilage,

when

cut, almost

dense

bloodless."

Again,
"

the

report says:
the
cause

But

to

consider

co-existing hypersemia
of the

as

the

primary stage, the

admit. If
a caiisce

hyperplasia,we
the it
as

cannot

nescius rather

between

two

is to

be

upheld, we
than
as

must
cause

consider

the

consequence

the

of areolar in the

hyperplasia."
to me,

This

statement

report, it appears
can

may

fairly be
not

challenged.

It

be

proved,
has been
occurs

indeed been

will
ceded pre-

be

denied, that

areolar

hyperplasia
it has
not

by hypersemia ;
the

while

proved, in
without
a

report, that

areolar

hyperplasia

preceding hyperaemia.
If such
most

proof
at

can

be

be furnished, it will certainly

valuable in the
term

this
are

time; although
not

the

arguments
the
as

given
use

report
"

sufficient to overthrow
the

of the in the
to

that hyperaemia." Still,

is open idea
to

term,
not

used

paper,

objectionI

would

tend prebeen

deny.

The

would,

perhaps,
the

have

more

correctlyconveyed, by statingthat
of the

areolar result of

plasia hypera

cervix

uteri

occurs

as

ranged de-

in which nutrition, element. This paper.

was

hyperaemia
intended
'*

is the most

inent prom-

the
use

ground

to

be

taken the be

in
sense

the
in

The it is

of the term
in the

hyperaemia,"in
paper,
can

which
on

employed
that

only
find
a

excused

the

ground

it is difficult

to

word

which

360

Skene:

Areola/r

HyperpUma
the
met

wad

"Chronic

inflammation
uterus

of
never

substance

of

the has

puerperal non-

is is

with;
of the

what

been sue tis-

described

as

such

hypertrophy

connective

resultingfrom
In the

long-continuedhypersemia."
of the

Pathological Anatomy
on

Female

Seinial is

Organs by Klob,
made
"

page

129

the

following statement growth

of connective

The be

causes

of this diffuse

tissue must
cannot
concur

sought
in that
as

for in habitual

hyperaemia, and interpretsthe

be

explanation which
chronic inflammation."

process The

described number

of such

quotations might

indefinitelyit

multiplied.
in discussing areolar Pathologists,
occurs

hyperplasia
uniform,
as or

as

in other

organs

and

are tissues,

nearly
of

so, in their statements

that

it

occurs

the

result

chronic

inflammation.
of

Billroth, one
connective and that

the

most

recent,
in

states

that

"new

tissue is
the

developed
of
new

chronic

inflammation,

deposit

thus tissue,

produced,

is

called areolar

hyperplasia."
turn

Now,

if
we

we

to the

pathology
that

of

chronic
is
one

mation, inflamof the

invariablyfind
not

hyperaemia
element
are

most

important, if
these

the

only

in the based

process.
on

All
mortera

statements, however,
clinical claimed

po^U
it

and investigations

observations, and
that

may

still, therefore, be
areolar

the

process
not

by
been

which

hyperplasia

is

developed
the

has

demonstrated.
We made Thus may,
to however, by referring

observations information. cells has

.

obtain by ophthalmologists,

valuable

the

development

of

connective-tissue

Sclerosis
been

Uteri.

361

accuratelyobserved
The

by

tbe aid of the

scope. ophthalmofor
a

congestionwhich
the
increase

preceded, and
connective

time

accompanied,
also been For works the of

in the

has tissue,

clearlydemonstrated.'
truth of these
statements

I refer you

to

the

Iwanoff, Wecker,
seems

Nagle,
may

and
be

others. taken
as

This, then, it

to
we

me,
can

reliable is

proof, as
at least
an

much

so

as

obtain, that
in the

hyperaemia

important

element

production of
this
as a

are-

olar

hyperplasia.
report
"

The
:

next

quotes

from

the

paper

ment state-

True
to

areolar

hyperplasia
walls."

does
is

not,

rule,

extend the

the

uterine
who

This
"

objected to by
collides
of

committee,
the

affirm

that

This

opinion
those who

with

statements

of the most

trustworthy

writers

the present time ;

and,
while

above
to

all,with

have

thought

it worth

substantiate We

their statements
among

hy postrmortem
of the
not

examinations.
and

name,

them,

Virchow, Klob, Braun,

Seiffert.

In

the

experience
is
not

committee, true
to the

areolar

hj^erplasia
does, as
a

only
to

limited

cervix,but

rule, extend

the

body
If

of the

uterus."

it is true

(as the committee

to

claim
"

here) that
of
the

this

statement

is
it

opposed

the

most

trustworthy pathologists,"
views
most

certainly agrees

with This

the is

reliable clinical observers.

known
more

proved by
uteri

the well-" much

uterus.

fact
common

that disease of the cervix

than

is very
the

disease
as

of

the

body

of

Chronic

such metritis, is well

gives

rise to

areolar
to

plasia, hypera

known

by

clinical observers
as

be

very

rare

disease ;

rare certainly

compared

with

the

fre-

362

Skenb:

Areolwr

a/nd Hyperplasia of that trouble

quency
occurs.

with which

the cervical form

does affect the That areolar hyperplasia

body oi
the

the
parative com-

uterus has not been denied in the paper ; but

with frequency
made simply

which it affects the cervix

Further

is of

the basis of the rule. made

proof

the correctness of the statement be found

in the paper may

of Prof.

to by again referring

the work

Thomas, of the committee.

On page 274 the statement is that
"

The

habitat of

limited to the cervix, which is hy far the hyperplasia is represented commonest of the varieties^ by Fig.84 ;
"

and

on

ease page 275 he says : "Of all forms of the disthe cervical variety the most is decidedly mon." com-

Klob, one

of the authorities named

in

to opposition

the paper, is certainly misconstrued by the committee ; for he clearly at page 131 of his work, that prostates, liferation of the connective tissue of the cervix uteri does
occur
"

as

distinct affection.
"

trustworthy authors might be quotedto such as Bennet, Hewitt,and point, prove the same the on Simpson;but possibly to, theymay be objected ground that theydescribe what is now called areolar and induration ; but I reas enlargement hyperplasia, and the same submit that they mean one "spectfuUy thing. I may also state that I have repeatedly amputated the enlarged and hardened portions of the cervix, which were found,on examination by the microscope, to be principally composed of connective tissue. The
Other

.,-1

Scle7*08is examinations
is

Uteri.

363

were

made

by

medical of the

gentleman

who

thorougUy
In

skilled in the
it may

use

microscope.

these

cases,

observed, neither
the presence

physical
of any

signs nor
disease
The

clinical of the
next

historyindicated
of the in
:

body

uterua

statement

the

paper,

which

the

mittee com-

object to, is
"The
mucous

this

membrane

covering
the
"

the

indurated

portion
The

may

be, and

usually is,highly congested."

that
reverse

report cjaims
in many cases." this

of

this

is observed

Regarding
sclerosis
membrane
; but

point
the

it

can

only

be

said

that, in
mucous

irom resulting

the puerperal metritis^

covering
in of the it
"

cervix

is often

pale

and

mic anae-

sclerosis of

the cervix

alone, the

mucous

membrane

part is generallycongested.
be
"

However,
easy in
to find

may

safely affirmed
to pi'ove

that

it is not

authority point
It
is

the

views
or

expressed
the
mittee's com-

this

latter

either

in
a

the

paper of

report.

simply by

matter

servatio clinical ob-

Objections
in the

are

raised

the

committee
has

to

ment State-

in the paper,

which, by mistake,
of that of the the

been

left out I that of

printed copy
however,

report which
is made
occurs as

I obtained.
to

presume,
true

reference
uterus

this

hypertrophy
this statement

the

result

long-continued hypersemia.
To the
were same

objectionsare
the

raised

by

the committee areolar from

which

applied to
the neck Further

views
uterus

ing regardas sulting re-

hyperplasia of hyperaemia.

of the
on

in the

report

the

364

Skene

Areola/r

and Hyperjplaaia
"

is emphasized As yet it objection by this statement : is questionable whether a uterus, of normal originally does ever, out of pregnancy, assume true hypertro size, In confirmation of the several authoritiesmay be
"

ground taken quoted.

in the paper,

mative Klob, page 44, says : The result of excessive forconsists in an not altered in quantity, action,

of enlargement
of elements

the uterus,from increased

similar in character and

development to the disposition

tissues of the organ. physiological With the exception of an increase of its volume, the and we uterus retains all its other physical properties, call this condition Ityperplaaia nwmerical or hypertropliyP Page 45 of the same, the further statement is made,
"

that

"the

muscular

tis8V"

as

well

as

the connective

with the excessive simultaneously and thus the relativeproportion of both formation, remain normal" tissues in the enlarged uterus must Again, on page 220 of the same, "genuine of the uterus is an enlargement and intumescence hypertrophy of the organ, caused by a surplus of nutritive material received into its elementary parts;" of the uterus is rare, page 221, "genuinehypertrophy and dependent xoiih^ being generally accompanied upon, proportionate congestion^ Hewitt,page 363, says that the physical changes from chronic this most frequently tion inflammaresulting of the uterine tissue being undue sensibility, congestion^ and hypertrophy.
....

tissue must

be affected

"

"

.,"

'

Sclerosis

Uteri.

365

Meigs, while treatingof

uterus, makes
"

chronic

inflammation
on

of the
290
:

the the

following statement,
in these

page has

suppose character

texture

instances

acquired
without nated denomi-

the

of that
so,

of the

gravid uterus, yet

to

gravidity,and Hodge,
that

giving rise
of the the

what

may

be

hypertrophy
page is maintained

organ." following statement

many
an
"

51, makes

It

by

us, and

substantially by
is the result

ties, authorigestion con-

hypertrophy
the said
mucous

of

active

without
In

inflammation."
to statements

addition
may

of
cases

the of

authorities

quoted, it

be

that, in

desquamative
uterus
un-

dvsmenorrhoea,

the

membrane

of the

dergoes a
It this may

form

of true

hypertrophy.
out

not, perhaps, be
I have
"

of

place to

mention
cases

in
of the

connection, that
pregnancy
"

recently seen
one

two

extra-uterine
other tubal

and fallopio-ovarian

^in which

the

uteri

were

found

to

have

undergone
This
was

true

hypertrophy.
post-mortem. fact,that
in conditions that the We

demonstrated

might

also

recall the

well-known

mammaiy than

glands
of pregnancy.

undergo hypertrophy
This
at

other

clearlyproves
becomes least,

tive pa/rt of the reproducfrom

gestion. con-

system,

hypertrophied
"

Other who
occurs

"

trustworthy pathologists might

the the

be the

quoted
uterus

favor
as

idea

that of been

hypertrophy given
show

of

result

long-continuedcongestion ;
to

but

enough, I trust, has

ficient this
reason

good

and

suf
on

for the statements

made

in the paper

point.

366

Skene:

Areolar

Hyperpldsia
the
paper
true

and

The

next

portion

of

objected
with

to

in
of

the
tlie

report

is of

this: the

"Frequently
is foimd

hypertrophy

body

uterus

connected

areolar

hyperplasia of
show that

the cervix."
amount

Certainly a good
areolar

of

proof
the

has

been

given
occurs

to

hyperplasia of
of the uterus of the

cervix

alone

without
that

the

body

being involved,and
of the
two
uterus
occurs

also
as a

hypertrophy

body
as

distinct

affection; hence,
can

these

conditions
unreasonable There this is

occur

it separately, suppose that very

hardly
occur
"

be

considered

to

they

together.
"

surely
in the

nothing
However,
paper, have
on

extraordinary point, is

in

proposition !
It would facts
to

it is this

freelyadmitted
open in

that
to

the

statement

criticism.
with

possibly

been

more

accordance

have

stated,that

not occasionally,

frequently,areolar accompanied
from

hyperplasia of
enlargement
from The
"

the

cervix

uteri

is

with
perfect im-

of the

body
or

of the

uterus, either
or

involution

hypertrophy,
the
"

swellingresulting
istics character-

congestion.
report
also

objects to
the

anatomical is to be made
"

given
the
"

in the paper.

This

for regretted, the paper

garding re-

the

reason

that

statements

in

pathologicalanatomy
the Thomas

of these

affections

are

based

upon

authority
"

of

Klob,

Rindfleish,
that for

Noeggerath,
I

and

sources
as

of information
and

have

always
I have

regarded

"trustworthy," profoundest

which

entertained

the

respect
sug

Finally,the gested in
thus:

report objects to the

The

classification
on

the paper.

paragraph

this

point reads

368

Skene:
other

Areolar

Hyperplasia
from
not

amd of

of

morbid

structures, and

observations from
"

and general physical properties, researches." The

wa^
"

anatomical

report
used

also

states

that the term

the
same

"is not

but Tiew^'*

already for
me

etc affection,"

This, allow
more

to

remind
a

the

committee,
made that

is in the

little the
term

than

repetitionof
"

statement

paper.
"

It
"

is there
was a

distinctlyaffirmed
familiar
one

sclerosis
am

in the

medical
term

literature."
ever

not

aware,

however,
to

that

has

been of that

used the

heretofore
cervix of

designate the by
areolar organ

changed

structure
to

uteri
the and

hyperplasia, and
in which there

condition

whole

is areolar

hyperplasia
In

imperfect
the

involution

caused

by
"

peral puer-

metritis. defence
"

of

paper

it may

be said

that

worthy trust-

anatomical

researches
cases

have

demonstrated

the
uterus

fact,that, in certain
has

of uterine

disease,the
of

undergone preciselythose namely,

These

changes

structure

scribed, de-

areolar

hyperplasia
of
structure

and
are

volution. imperfect in-

changes
anaemic.

manifested,
in denser size, the

for instance, by the uterus

in

being increased
This
acute

and quality,
results

condition

of

uterus,
been

which

from
as
"

an

inflammation, has
metritis."
there the that

usually described
Now,
it is

chronic
that

quite evident
of

is not
case,

present
That

singleelement
these

injiamviationin
or

except the

products, events,
conditions

results

of

process. inflammation
structure

were

produced
that any

by

is
one

readily granted ;
of inflammation

but of

the kind

changed
I

is

deny;

To

call

such

Sclerosis lesions
to

Uteri. inflammation"
use

369

of
a

the

uterus

"chronic

appears

be

wholly
as

unscientific
much

of
reason,

the caU The

term.
a

We cicatrix

might, with
acute

show
Dr.

of

inflammation.
of

Noeggerath,in
very

American

Journal stated

Obstetrics, has, with

these

great clearness,
are

that

pathologicalconditions
are

the

ducts pro-

of
"7i"?
"

and "puerperal metritis,"

produced by
the

other

caused

And As
a

still he substitute

calls

disease
and

chronic
more

metritis^

for that name,

as

clearlyand
"

indicatingits character, correctly

"

the

term

sclerosis what

has
seems

been
to

employed
me

in the and

paper.

Having
reasons

given why
be

good
is
term

sufficient

the

term

chronic

metritis
the

objectionable,
sclerosis
more-

it may

again stated, that

the

correctly expresses
the

precisepathologicallesions
than
any

of

affection under

consideration

of the

terms

employed heretofore. areolar hyperplasia," which hasRegarding the term been employed to designate all that class of pathological
"

conditions various better

which
may in be

result

from

uterine

disease

of

kinds, it
than those

fairlyclaimed
use

for it that

it is

general
not
cover

; still it is

able, objectionof the

because

it does

the

whole

ground. hypertro*
of

While

it may

fairlyexpress
there

the

condition

cervix,in which

is

"

diflcuse interstitial that

phy,"
uterus

it

is

not

applicable to
from
acute

condition

the

which
cases

arises there

"puerperal
areolar

metritis."

In such also

is not
The

only

but hyperplasia,

sub-involution.
characters

difference

between

the

tomical ana-

of areolar

hyperplasia and
and

chronic be
re*

metritis has
24

been

stated in the paper,

might

370

Skene: it not
"

Areolar^Hyperpldsia^
that the

etc.

peated, were
That such

committee

has

raised
there

jections ob-

to the
a

anatomical

characteristics"
can

given. by
ferring re-

difference

exists

be

readily seen
"

to the

authoritative writings of Drs. Noeggerath

So

and
"

Thomas. of Dr.

long, then, as
and the
" "

the

areolar

sia hyperpla"

Thomas,
differ

chronic

metritis

of

Dr.
so

Noeggerath, long
name

in their

pathologicalanatomy,"
to

will
to

it be

impossible

correctlyapply

either

hofh affections.
the

With

view, therefore,of preventingconfusion, if

our

in possible, been

nomenclature, the
as

term

"

sclerosis
name

"

has

proposed
to

least

objectionable.
diseases ; and, if
true

The

is applicable
to
a

any

of the structural uterine

it

changes belonging employed

which
there in

that

class

of

generic sense,
of several the
a

represents the
of uterine

dition pathological con-

class

diseases

of

are

varieties.
and

for instance, Classified, according of the

to

extent

locatian
"

disease,there
and
the of

are

two

forms
are

of

sclerosis
two

circwmscribed classed

general.

There

also

forms

according to

causation;

sclerosis resulting from that form Jirstj which nutrition belongs to the order of affections ; and,
from

deranged
resulting
of

subacute

flammato in-

secondly
^

sclerosis

puerperal
any

metritis. other

If, by

the

employment
we
can

sclerosis, or
the

suitable

term,

simplify
this of
means

nomenclature

of uterine

and diseases,

by
use

harmonize
in uterine
must

views conflicting

regarding the
with
the this
same

terms to me,

pathology, practical benefit,it

therefrom. It
was

seems

follow

view

that I
it

at suggestedthe term ; believing, correctlyrepresents the condition

time, that

described.

Meadows:

Ovarian

Physiology
oppose
to

and

Pathology.
which

371

The used

committee without

simply
Until the

the
me,

term

I have
reasons

it giving,

seems

any

good

for

doing

so.

objection is

sustained

by

sonable rea-

arguments,
the

I shall feel

in maintaining justified

ground

which

I have
the

taken, notwithstanding the

high authority of

opposition.

REMARKS

ON

OVARIAN

PHYSIOLOGY

AND

PATHOLOGY.

'

BY

ALFBBD
and the

1CBAD0W8,
DiMaaes to of Women

M.D.,

F.B.O.F.,
and

Lood.
at

Lectozer

on

MidwUexy

Children London.

Bt

liMrfn Hospital

Phyddan

the

Hospital

f""r

Women,

{ConUniud

from

Vol,

yi.,No,

3, Augttgt^ 187a)
some

In

my

last

paper

I considered

points
of
the

in

nection con-

with
to

ovarian this head

physiology, prefacing what by

a

I had

say

upon

brief of

account

general
I

and

microscopical anatomy
reference
out to

the

ovary,

especially supply.
which exists

with

its vascular
the

and

nervous

pointed
between
source

how, by

free

anastomosis which
ovary,

the of

spermatic artery, supply

to

is the
and

principal
ovarian

blood

the

the

and

Fallopian branches
for
a more

of the

uterine

artery, provision
of blood
to

is made organ

equable supply
times
of

the
tivity, ac-

during
than and

the

its greatest functional

were no

would

result if there
in the
case

such

ment, arrangewhich
source.

if,as

of

the

kidney, with
one

the compared it, I

blood

came

from entirely

expressed
intended for

my the

belief

that

this arrangement of the

ovary,

must not

be

advantage

and

372

Meadows

Rema/rJcs

on

for

cither the

uterus

or

Fallopian tube, grounding

fact that

my

opinionpartly upon place

organs
in
"

the the

the anastomosis
not

takes other

or

upon

ovary,
account

and
of of

upon

the

^but

chieflyon
other

the the

logical greater physioovary,

are

dignity and
in

importance

to

which,
sidiary. sub-

truth, all the

generativeorgans
venous

only
that

In
same

regard
care

to

the
to

system,
the

we

saw

the

is taken between

provide
be
the

freest

munication possible com-

these
to

several

parts, and

pointed
of of the

out

what

seemed
venous

especial function
and above

several the

plexuses,over
return
a

that

ing secur-

due

of

the

venous

blood, namely, the

of erection
it were, and

production of by
the
means

certain

amount

rigidity
in
a

of which

the

ovary

is,as

held

so particularposition,

that

the fimbriated
organ

extremity
at to

of

Fallopian
the
thus the

tube

may of
an

seize the ovisac

ovum

that
take

point place,

where and

rupture
the escape
tube
next to

is about
and

of the
uterus

its safe

conduct

along

the
to

is secured.

Coming plexus,
"

the

consideration
out

of

the
the

nervous

arrangements,
which

pointed
has

the

originof
exclusive
nervous

spermatic
in the
munication com-

almost

the their

privilege of
"

supplyingthe
aortic

ovaries

with

energy, also
some

and

renal

plexuses,there
the

being
the

with which from

more

hypogastricplexus,by
fourth sacral

means

of
sent

particularly, through
second, third, and

branches
nerves,

the
are

the
and

ovaries
nerves
"

brought

into relation with the their other with the

spinalcord
as

^while, by

origins, they,
abdominal

it were,

hold

conmiunication

viscera, and

Ovarian

Physiology
the what

and

Pathology.
in this way be
a

373

with especially ventured

upon

kidneys.
seems

It
me

was

that
ex

to

to

probable
about.

planation of
of the also laid of
nerves

the

mode

by

which

the is

excessive

secretion 1

so-called

hystericalurine
upon

brought
the

great
which tube

stress

the fact that

ovary and

6ame

plexus
the

supplies the
and

supplies also
upper which

Fallopian body
of

the fundus
so

part of the
are

the

uterus,

that

the

parts

most

immediately
are

associated up,
as

work together in physiological in in

one

bound

it were,
also

circle

of

nervous

energy,

besides

being

direct

relation

through

the blood-vessels.

Having
to

discussed

these
some

anatomical
in the the

details,I

deavored en-

explain place in
also that I

points
vascular

physiology of
great changes

the

ovaries

"

referringespeciallyto
their
to

which

take
I

system
what

during
means

lation. ovu-

tried
the

explain by
of belief
a

it
are

appears

to

me

phenomena
induces

menstruation

brought
condition
of the

about.

expressed my

that the
and

activity
dilated

of the ovarian
of

circulation
the

relaxed

about capillaries
to
a

the

fundus

and

body
which

uterus, in obedience
functional
of my and

well-known

law

governs agency

nutritional

activity through the

and I of

the

vaso-motor

system;
that

further the

pressed ex-

conviction
uterus not

the

action

ovaries is

upon

the

in the

production
this which
some

of

menstruation
upon

and direct,

and reflex, facts

opinion I grounded
admit of the of the
more

definite anatomical

of

no

dispute.

Having, then, discussed

the
now

principal points in
I ovaries,
pass
on

anatomy
to

and

physiology
some

consider

of

the

important, and,

874

Meadows:

Remarks

on

instructive featuresin theirpathology hope, ; and it will be found that attention

details will otherwise be
to

I think

these much

physiological
that vrould

help us

to understand

and enable us to interpret clinical obscure, in future a more phenomenain such a way as to suggest than, I fear, satisfactory system of ovarian therapeutics The time. boast of possessing at the present we can

being made great advance which has been and is still

in and study, pathological
we now

the

more

which
motor

possess of the system of nerves, by which

knowledge of the vasophysiology

accm*ate
we

can, to
a

some

ex-

of blood to tent,estimate how the supply

part, and

with

of it,

course, the character of the nutritivechanges,

is or may be controlled. All this opens up an entirely new

fieldfor

tical therapeu-

means

that

I think, be the eventually, of revolutionizing so our systemof therapeutics, in the end we, or our successors, may hopeto see the

which observation,

must

treatment

of

more nothing placed upon

in too many instances, isnow which, disease, than blind routine, or ignorant empiricism,
a

basis which shall be definitescientific

as

and exact, appear to I

as some

else in nature. It may as certain, anything that this is a very Utopian and that idea,
more

it indicatesfar
am

of enthusiasm than
stand

judgment;but
is students

to prepared quite

which by the statement, that we, repeat

made

afterfull reflection ; and I

as we

of nature
as

we

cine to be,and practitioners of mediprofess to rest content until we are, ought never

have discovered the immutable

laws which govern the natural actions of the body both in health and disease, for we
may

be

sure quite

of this
"

that nothing isleftto

376

Meadows
of the

Remarks

on

some

lower

animals
two

hardly
even

any

difference

is observable and

in these

organs, in
man

in their
same

perfect

permanent
in the

forms, and

the

fact

is obsei-ved in their
;
are

early stage

of their

development points
with difference
of

Even

perfect condition
for

we

find many
covered
sac
. "

resemblance and

instance,both
in
a

are

peritoneum
between

enclosed

short

the

them
a

in this respect
cut

being,that
rest

whereas the
serous

the testis is, as

rule,
closed en-

off from

the

of
own

peritonealcavity,and
membrane,
"

therefore

in its

^the tunica
so

vaginalis ;
and in

the

ovary,

on

the contrary, is not

separate,
it
of

has, apparently,only a visceral layer of peritoneum,

those
rare cases

except

of

displacement
has
that
a

where

occupies the inguinalcanal, and peritoneum

to
:

distinct which
is

pouch
common

its

parietallayer is
viscera.

all the

other

capsule
which may the

of the
"

ovary,

we

Again, in place of the fibrous the tunica have albuginea of

"

the testis

its exact the

analogue
vessels

and
nerves

in the broad
to

ligament
ovary
we

carries

and

the

recognize the counterpart

testis ; while the is precisely similar

to

the

spermatic cord
the vessels In the and

of

dispositionof
in the two organs,
are

in the
more

gland
their
appear

cases.

essential

parts

of

these

those

in

by

which
not

proper

functions

performed,
to warrant
a

there

does

at first

sight much

comparison
the

; at

the the

same

time, there
of the

is a very
two

close resemblance between the

"

between
so-called

products
of

organs,

"vesicle
are

evolution," from
in the the
ovum

which
the the

spermatozoa

produced
evolves

and testis, from

Graafian

vesicle,"

which

ovary.

comparison, and studying Quitting this physiological

Ova/riam
the
note

Physiology
in their

and

Pathology.

377

two

organs
a

pathologicalrelations, we
in their morbid in this

may ities, affinin

again

strikingresemblance

however, differing,
the
case

respect,that
serious I shall

while

of the
to

ovary
not

some

of its most

diseases

appear

result

as infi'equently,

presently
same

show, from
result
not
even
occurs

action,the perverted physiological only

from

with the

extreme
same

and rarity, in the

case

perhaps
of the
my
seem

then

cause,

testicle ; at least if it

does, the

fact

is not

within

knowledge.
to

The

difference
at

in this

respect would
method

be

due, in part
their

to least,

thg different
are
"

by
for

which whatever
is
a

respective functions
there
"

performed,
no

resemblance

maybe
^between

and

doubt

there

certain resemblance
in the testis and

tion the vesicle of evolu-

the Graafian is
so common

vesicle
in the

in the ovary,

ovary, is
tremely ex-

cysticdisease,which
rare

in the

testicle. exists dissimilarity

to
an

But, while
organs
in

this

between

the

two

regard
is

those

more

formidable
resemblance

organic
in other

diseases,there points
to

undoubted
for

of

pathology. Both,
forms
descent of

instance, are
in

subject
case,

certain
the

malposition;
the

the

one

the

ovary,

from

f cetal position is original

carried too far ; in the

far

the descent is not other,the testis,

cases

enough
of the

; and

in in

both
some

the
of the

tion result is the deten-

gland

part
of

canal,and inguinal

consequent
organs
are

disturbance

its function. forms

Again,
and

both

subject to

various

of

inflammation,
tween be-

and specific

acute non-specific,

and

chronic;

orchitis and
or

ovaritis, simple,gonorrhoeal, tic, syphiliother form of there blood-poisoning,

due

to

any

378 is indeed
no

Meadows:

Remarks

on

essential difference, exceptit be

ia

the

of the ovarian form,owing, as I intractability greater of securing to the impossibility believe, physiological and consequentfreedom from vascular excitement, rest, in the. ovary
"

of condition which is at least possible

case

attainment in the

of the testicle. Again, in

are, I

the

neurotic affections, both simple

to
to

pretty much

the

same

diseases.

believe, subject So,too,in regard

a

diseased conditions of the

fact that the

it is now veins,

well

tablished es-

or pampiniform,

tubo-ovarian
as so

bulb of the ovary and is liable to become varicose, called, the plexusof veins,

it is also
to form
a

varicocele of the ovary precisely similar to that which in the case of the testicle. We know also that occurs haematocele be

is met

with in both cases, and may

same

indeed
ganic or-

producedin the
or diseases,

way.

in regard to Lastly, of distinct

growths, in this some thoughthere is undoubtedly dissimilarity the the difference is unimportant as against respect, fact that distinctgrowths do exist, and that, moreover, in many similar in the two cases they are precisely of encephaI need onlymention the occurrence cases. mors, loid and other forms of malignant fibroid tudisease, to and tubercular deposits, all which are common
the formation

remarkable, organs ; and,what is stillmore in all respects disease of the testicle, cystic resembling
the two

that which
met rarely

occurs

in the ovary, is occasionally though

with.
I hope, for thisseeming excused, digression of subject

I shall be from

this paper, because it appears to me, that,apart from the intrinsicinterest

the immediate

Ovcmcm

Physiology
to

and

Pathology.
many it the

379

Tvhich

attaches and
a

such
be

an

inquiry,
from

practical

hints
In

lessons may

gathered
of the

therapeutical point of view, undoubtedly

the
care

geon, sur-

to whom

testicle

belongs,has diagnosisand
of
Whether

the

advantage over
of the the ovary

the

who physician, in the matter

has the medical

charge
in

; for both

of

ready
be than

and

easy
to

applicationof remedies, the

boast

surgeon
cess sucor

should

able

of

far

larger measure physician.

of
my
own

falls to the lot of the

case

no

this is the

am

unable

knowledge
so, because
"

to

affirm,but
this is the

hope sincerely subject"

of the

it may
upon

be

and

ground practical
to the

which
we

justify
to

this reference

I think

ought

be

able, by
the male

careful organ

study
is

various advance

diseases to which
our

to subject,

knowledge by
the

of

the obscurer with

forms
we

of ovarian
can

disease ; and
and

ity facil-

which
on

observe

watch

the effects of
nally applied exter-

remedies
or

diseases

of the

whether testis,

administered
are

if only we internally,

observe

fully, care-

and
such and

free from

bias

or

we prejudice,

ought by

practicegreatly to
thus
to
remove

advance

ovarian

therapeutics,
an

what

I cannot

help feelingis
of the
I
we

opprobrium
state

to

science,viz.,the present gynaecological

treatment

of

diagnosisand
obscure

of

many

moner com-

but

forms
and

of ovarian

disease.
I

say

it

with
much would

all
to

humility
ashamed

candour, that

think

have

be

of in both
may

these respects, though I

fain

hope

we

fairlyplead extenuating
to

cumstanc cir-

having regard
which the
surround the

the

great

difficulties

diagnosis of

these

and affections, methods

of applying any impossibility

instrumental

380

Meadows:

Remarks

on

for

their

detection, such
every
case

as

are

applicable
of the

to

the
so

eases dis-

of almost

other
more

organ

body,

that,

except in the
we are

of the

serious
our

organic diseases, opinion

almost
tirely en-

perforce obliged to
upon
a

form

verbal
be

description of symptoms, by
such This
us

which
nation examiit

may

or

may
as we our

not

corroborated be

vaginal
the

may

able

to

make. upon

fact, while

enhances for

entails difficulties,
care

necessity
more

greater

in
we

observation, and
should

makes
from chance

it the
any

important
which
I
seems

that
to

seek

help

quarter
success.

offer
we

reasonable
such organ.
a

of

believe

that

have
male

chance

in the

study

of

the diseases

of the

In illustration of the
on
ence

pathologicalinfluence
the way in which
a

of the that

ries ova-

distant

parts, and

influfrom servation ob-

is

exercised,it

is difficult to make

selection
under and

the

many

interestingcases
; but

which

fall

one's

I will

for its novelty select,

ance, importupon the

treme ex-

the
nervous

influenceof pathological
I do
so

the ovaries because

system^ and
and interest,

partly

of

its

partly because

the

lessons which have

it
a

teaches, at
much

least

if I

coiTectlyinterpret them,
appears
a

wider
I the
me can

than significance

at

first

sight,

though
which Let
in
one

only

now

suggest
others
M. may

line
serve

of

thought

experience of
first relate
a

to illustrate.
me

case.

8.,set. 18^, consulted

and loss of The

September, 1867,
eye.

for amenorrhoea the

sightin
cata-

She

gave
at

me

followinghistory:
continued
she
was

menia about

first

began

and fifteen, At that

one

regularlyfor

six months.
of
a

time

stayingin
was

the

house

when fi*iend,

of

the inmates

taken

Ovaricm

Physiology
died.
M.

aiid

Pathology.

381

suddenly
at

ill and

S.

was

greatly frightened
at
a

this.

She

was

menstruating
in the
to the
course

the few

time, hours,

but and

the

dischargeceased
not

of of my of
was

had

returned
on

up

time

first

seeing her.
"

mediately Im-

the

cessation she

the

discharge
that time

indeed, a

little before
in the head

it ceased"

seized with

severe

pain
date

and

sickness.
both every

From these month but

to the

of her
at

consultingme
without

symptoms
:

had

recurred

regular intervals
without

occasionallyshe
she
never

had aches headin

sickness

headaches,

had

sickness ; the
be

therefore,seemed latter,

some

way

to

of

cerebral

origin.
of the

Almost

ately immediwas
ticed no-

after the commencement that her

and like
some
a

illness it
at times

gait was
friends
"

uncertain, and
remarked that
was

ing, stagger"

her

she walked discovered

then

just
until dent, acci"

blind

person

but

it

not

four
that

months she
was

afterwards,
blind fact that noticed with
the

and
one

only by
the
her

eye"

right

though, al-

from
of

the

in peculiarity

mode
tack at-

walking began,
that and

had

been

immediately
consulted

after the
also

it is

probable
She

that the

blindness
an

dated
list ocu-

from

attack.

had

eminent

two

their united
tumor
at

leading physiciansin London, and sufferingfrom a opinionwas that she was

of the
base of of the of the

the
tract

brain
side.

which With

pressed
this

upon

the the

optic

right
course,

opinion
so

prognosis was,
the
case

unfavorable, indeed

hopeless was
a

blister to the arm,

no

regarded,that, beyond ordering ternall iodide of potassium inand some

was

other

treatment

recommended. this advice

had been

It

was

some

few

months

after

382

Meadows I first
with any

HemarTcs

on

given that
never

saw

the similar

and patient,
case,

although
much

had

met to

and which

was

puzzled
tory, his-

how

explain the phenomena

to me,

this

presMited, it

yet appeared

that,having regard to its early

how in

remembering originated,namely,
menstrual that time

distinctlyall
direct connection

the

symptoms
sudden from of the

with

and hearing that suppressionfrom fright,

to

the present there that

at each

had

been

no

return

catamenia,
a

but

menstrual

slightaggravation of
the
as

the

symptoms,
could

period there was of pain especially

not

in
two

head in
some

and way

vomiting, I
intimately as

but
as

regard

the

connected, not merely

cause

coincidences,
effect
a

but As
one,

directlyand
the
I had
case

and

had

been

already pronounced
the
I the

hopeless
think

little

in persuading difiiculty
to

patientand

her friends to submit

I

any

treatment
as

might

sirable. deplained com-

argued, that

inasmuch

symptoms

of followed of
assume

immediatelyupon menstruation, therefore it was

if the
we

the sudden
at

tion cessa-

least fair

to

that about

return

of

menstruation
some

could

be of
strual men-

brought
them.
"

might hope for Accordingly I set to work

"

amelioration
restore

to

the

function

or

ought

rather
on

to

this say, for

more

nearly
before

expresses

my

thoughts
It

the

subject
"

^to

establish re-

healthy ovulation.
I
was

was

nearly six

months
the of

able to left eye

so

and accomplish this,

was

meanwhile
that

sightof
the

the

dim, becoming slightly

that The very she

right being
lasted

absolutelygone
darkness.

could

ly hard-

distinguish light from quite a week,

was

first menstruation

and

was

free.

The

mediate im-

result

to distinguishcertain ability

colors

384

Meadows

ItemarTcs

on

all such

as

those this
I

we

are

considering.
here and

I know

that
if

the the
to

contrary
views
the

of

is have

commonly

believed.
in

But,

which

propounded
and
are

regard

physiology
of

of

menstruation,
uterine

the

relative

portance imhave Tvith have

mere

the

ovarian
at

functions,
consistent that
to
we

any

foundation
then it

in

fact, or
be
too

all

reason,

must

admitted

hitherto uterine

attached

far

much
"

importance
^that

the

part of menstruation
and
mucus

is,to

the
"

discharge
and far ovulation

of
too

blood

from influence

the

uterine

surface

little to the process.

which

is borne
as

by

in the

Yet,

if it be

true,
are

I have very

again

and

that again insisted, in the

the ovaries and

the

central
rest
are

point
mere

generative system,
to

that

all the

appendages
the

them,

it

follows,I think, that, except

which
uterine may result

for the

purely

local
of

phenomena
proper
to
more

from

disturbance mischief
can

the

functions,no
parts from
of

serious
such turbance. dis-

accrue

distant
the

To

my
as a

mind,
mere

cessation

menstruation,
a

regarding that particular organ,

consequences any is similar
to

sanguineous discharge from

more

is not

to likely

be attended

by

evil

distant parts, than

the

would
or

be the arrest elsewhere. We

of
It

discharge from

bowel
to

different, however, with

seen

regard

the ovaries.
organs
are

have

these how, physiologically,

ble capaa

of

not influencing,
even

only particular parts organism, and

removal.

at

dis.

tance, but
are

the

entire
of

how

striking
and it is

the have

consequences

their

Physiology, as
that
a

I
a

said, is twin-sister
I

with

pathology,

law,

believe,in

the
a

animal

economy,

the

logical pathocom.

importance

of

part will bear

very

strict

Ovarian

Physiology physiology
system.

and

Pathology.
to

385

parison
effects
It must this
case

with
upon be

its the

in

regard

the

relative

conceded, I think, seeingthe

a

course

which
a

took, apparently as
that the of the the

result

as of,certainly

sequel to, treatment,

were

phenomena
any

in

question
or

not

consequence
nervous

serious
is

lesion

ease dis-

of that would

central had

system, it
the
case,

hardly likely
whatever which
I

if such

been

any

good
of

have
I

followed

the

plan
no

of

treatment

adopted.
cure

certainlyhad
treatment

intention
nervous

a effecting

by

any

of

the

centres, and

if

my in

remedies

did

so

operate, it is something quite new

which
I
can

for therapeutics, aim

take I

no

credit.

What
the

I did

at, and

what

I believe

influenced, was

ovariea
To the

ovaries,then, we
for
some

must

look, at least
the

in

my

judgment,
occurred
were

explanationof
I have

symptoms
my

which

in the

case

for they,in cited,

opinion,
amaurosis

alone

responsible. How,
It will be
to

then, are
that

the facts to be
the

explained?
was

remembered eye, the

at

first limited

one

right. Now,
the

this fact

I think,is opposed alone,

to the \'iew that

suppression
toms, symp-

of the menstrual for then

become

discharge was
one

the

cause

of the would

surely not
it were, which
also. other And
cases

but
on

both

eyes

have
result

whereas, affected,

the

contrary, the

being thus, as
is that
was

one-sided,the

logical inference
that result
out

the

cause

operated to produce
this view where
is

one-sided
to

fullyborne
nervous

by

reference
are

serious

mena phenoa

brought about
nervous

by
I

causes

acting at

distance this

from the

centrea

in short,that believe,

25

386

Meadows

Ttemarks

on

was

simply

case

of what
to

is called
one

reflex pardlysiSj
and bably pro-

the

paralysisbeing limited
to

optic nerve,
side is

that

one

opposite
such
a

the

of

the

affected need

ovary. I

Now,

that

thing

possibleI
occasion

not,

think, stay long

to prove.

It is

generally understood
amaurosis,
of motion their of
or

that

palsy of

the

optic nerve
other

will

just as paralysisof
of

nerves,

whether time
case

specialsense,
to

will

suspend

for the
a

special

function. due

Brown-Sequard
the frontal
was

relates
nerve.

amaurosis
records the
cases a

injury of
case

P6trequin
cured many
on

similar

which
a

immediately
; and

by
the

pulsion ex-

of

tapeworm
in

there

are

of

this

kind

mentioned
We

the

Treatise

Entozoa

by
and

M.

Davaine.

all know

how,
various
cases

in

tant childhood, disof

irritations will I have

produce
met

forms

paralysis,
and
paraof

myself
and

with

of hemi-

plegiaoccurring in
menstruation,
M.

young

at girls

the commencement
to

evidently due
manner,

ovarian
cases

irritationof alysis, par-

Nonat,
the

in like result the

records

several

of uterine
one-sided affection
was

disease,and
character

he

especially paralysis
one

remarks

upon the

of the
to

when

uterine

itself limited
that

side. of

It must
the
nervous

not, however, be

supposed
upon

affections

system consequent

ovarian

ments derangeThat fault

at

are

always, or
be
so

even

one-sided. generally,
one

they
I
can

will well

mostly

when

ovary be
a

only is

but believe,

it would

strong objection
former
were ame-

againstthe view I have advocated because, as invariablythe result,

noiThoea
are

if the
we

know, where

is at all

not persistent,
case

one

only but
is the text

both ovaries of my
pres-

defective.

In the

which

Ova/rian

Physiology
that both

and

Pathology.
were

387

ent

sermon,
one

I believe mucli
more

ovaries

affected,
it

but
was,

very

than

the

other,because

only

at the

time

of in

the

occurrence,

activelyand
ovulation. We

nently promiknow,

engaged however,
a

the work

of

that

the

preparation of
that

the Graafian
for the most

follicle is

work

of

time, and
a

though
are

part

one

only ripens at
The
ova

time, others
of the

always

in

prepai'ation.
But

sudden

arrest

development
and it was, I

of the less mature

even

is, however,

less mischievous

in its effects.

this tells in the

to tell in the
case

long run,
I have
care

believe, beginning
than this
:

related. different
eyes,

More times

I have

had

under

my

at

several about

cases

of

complete by
in the
one

amaurosis

of both

brought
of
both

entirely

gradual
ovary,
to

arrest

in the

process

ovulation, first
had

then

in the

other,until

completely by
absolute

ceased

act, and

this

was

shortlyfollowed permanently
the
utter

blindness, which

remained

and

hopelessly
exhausted

incurable, owing apparently to

of

impossibility
kind, and
these
I
to

restoringthe
stock of
no

ovarian remedies

function.
in
cases

have

all my know
treat.

of
more

of this

affections distressing

than

Admitting
attested
what any
to

these
a

then, facts, doubt,

be be the

and

they

are

too
as

well
to

allow

question
them. than that

arises
not

explanationcan
better
answer
can

given of
found
the
to
"

I do

think

furnished
all

by

Brown-S6quard, viz., that

cases

paralysis in
a

these

of

reflex

originis
of

due

contraction

of bloodvessels,

and

to the

of insufficiency

nutrition
In

that follows of M. 8.

this condition which

I have

the vessels."

the

case

related,most

careful

ophthalmoscopicex-

388

Meadows of the eye failed

or

Hemarhs

on

animation

to

discover

any

lesion of the
with

optic nerve
is found in

retina,and
of the

this

exactly agrees
I and
or

what

cases

reflex

amaurosis. of bile

believe

that,

just
mental

as

arrest

of
be

secretion

consequent
other
severe

jaundice
ovulation
we

may

produced by fright
in

impression, so
may be
no

like

manner

the
; and

function
as

of
can,

suddenly

arrested

there

believe,be
of the

menstruation

without
the ovarian

ovulation, the
influence
; the

arrest

latter

suspends supply

blood-vessels
reason

which

the

menstrual
manner

secretion
I have

by

of their dilatation

in the

already discharge
of
a

explained, are
ceases.

suddenly
same

contracted
sudden

and

the

At

the

time, this

arrest

most

important
crisis of the

function

(ovulation), just when

causes

it is at

the of

its

development,
at
some

rapid
the

contraction

blood-vessels

part of
to

spinal cord, the

distal
one

effect of which and be

so a

is transmitted

some

extremity,
spot should

paralysis is produced.
rather than another
a

Why
;

selected
to

why

the

optic in preference
not
a

the

auditory,why
are

sensitive and
at

motor
we are

nerve

; all these

questionswhich
But
so

present

utterly unable
has

to answer.

experimental physiology
much
we

of

late facts

years

thrown

light upon
may is at

the

scurer ob-

of
to

pathology, that
much
that I

in time

hope
I have does
more

to

be in

able

explain
which

ed present shroud-

mystery.

do not
our

think, however, that

present
be
so,

stated
not

anything
; and

knowledge
know of than
no

warrant

if this

interestingsubject in
the influence

ovarian

pathology
the
are

this of

of the

ovaries that

upon

nervous

system,
of

because

it is obvious

if

they

capable

thus

Ovaricm

JPhyaiology
system,
may
not

and

Pathology.
is

389

the affecting
in the

nervous

there

hardly
under

any

organ

body

which

be

brought

fluence. their in-

Turning
that of

now

to

another

I subject,

have

already said
its size, that
of
an

the

ovary

during the performance

to at

of its function

ovulation

increases

least double the and

seat

it becomes

intensely vascular, is
into its

actual
a

haemorrhage again
local any from

substance,
"

finallyhas
all and

tinct dis-

laceration
occurs

of

its tunics

^and
once

this, probably, then,

any but

and

again, not
without

now

month

by month,
or

giving

rise to
in

bance, distur-

general; without,
whatever, except
The in
some a

fact, occasioning
of blood the

symptoms
the is well in my

discharge

uterus.
seen

degree
Under local

of

vascularityof
these

part

injectedmicroscopic preparations
circumstances

possession.
all of

we

have

probably
to
a

the

phenomena
the

usually single
will it

attributed

state
"

inflammation, with

exception oipain,
local

there is of

and probredness,swelling, ably

"

elevation
say that

temperature,

yet

no

one

pretend
does,
it

to

inflammation
the kind

exists ; at
we

if least,

is not

of

which

derstand ordinarily un-

by
ence

the term

ovaritis.

Where, then, is the

in the
what I have
one

diflPercase

What does
not

constitutes

inflammation
other ? And

which have
is not This
we we

exist in the

grounds
described

for
an

sayingthat
difficult

the state
one

which

inflammatory
is
a

?
to answer,

question
more,

and

the
we

more

think
to

upon

it the
that there

shall believe,

be

clined in-

admit

with is

the

singleexception of pain

and

tenderness

absolutelyno

sign or

symptom

390

Meadows which

Remarks

on

by

you very

can

between distinguish of

the of

two.

But,

then, the

fact

the

existence

pain implies granted

is
a

something that
that

is abnormal, for I may of

take it for

the

performance
which
is

normal, healthy
from

ovulation

process

free perfectly
?

pain.
can

Upon what,
this
to what

then, does this pain depend

we

If

we

determine

shall

probably by
the
a

have

settled
ovaritis.
must

the In
be

question as
the
first made between

is meant
me

term

place,let
paiii
women

say

that

distinction
I

and

tenderness.

have

many

times

examined

during
in the

menstruation
or

for the the ovary

I have have

singlepurpose
is tender
been able

of ascertaining

whether
no

not

at that to reach

time, and
it with than
der, ten-

case

in which

fingerpjer vaginam
even

I found
no

it other

in and

persons in whom

who

made

complaint
from
and for

whatever
to

oipain,
end
manner. was

menstruation in
a

beginning

performed
condition

perfectlyhealthy
may take

natural

Tenderness, therefore, we
usual

granted,
But,

is

of the ovary
the

during ovulation.
the so-called unites
a

then, this completes

; it is the
an
"

signs of
"

tion inflammanormal
to

missinglink
"

which
we

abnormal

condition limit well

as

only that
latter

find it convenient
to

in

practiceto
pain
as

the

term

those

cases

in

which
cases

tenderness is

is present ;

that

is,

in which

pain
touch.

exists and

perceived by
is further
of

the patient covered dis-

independently of tenderness, which

by
moreover,

only

There

is this the

difference,
as a

that, admitting
of

fact
occurrence :

tenderness
is limited

usual

result
to

its ovulation, of ovulation This

tirely en-

the

time

when

that is over,
noted

aU

tenderness

disappears.

also I

have

in the

392

Meadows

Rema/rks

on

of there is no history either of gonorrhoea, or tis, menstrual

acute

be of parturition, which can or suppression, referred to as a starting-point. met Again,ovaritis never occurs, at JeastI never with or heard of a case, after the climacteric periodor that is to say, itseldom or never before puberty, occurs

before

or

after the establishment of the ovarian function

of ovulation. This fact seems

inasmuch
as

the

menstrual during

implythat, is met with only disease in question life ^inother words, duringthe performance
to
me

to

"

of the function of ovulation

"

it is ^therefore

that highlyprobable

nected way or other it is conI have noticed further, with functional activity.

in

some

that

women
or

who
never

are

married

and

families h"ve large

on that,

seldom

suffer from

ovaritis ; but

the

its frequency is in inverse proportion to the contrary, number

of

pregnancies, beingmuch
or no

more

in frequent

those who

have few

children than in those who

all

have many ; and in the unmanied

that it is most frequent of further, between

the ages of 30 and 35, and in the married but sterilebetween the ages of 20 and be drawn What from these 30. can then, inference, of the explanation last mentioned, which is found in books, that in the is, results from the married of this class the sterility
more common

facts? simple

The

ovaritis and
"

this

no

doubt

is

so

far true; but then

this

onlyremoves
we
are

the

one question

pointfarther back,

What inquiry. of the ovaritis is the cause ? Obviously, of the cause the inflammation i% the tbue of the sterility. ca'me which I venture to offer is, The explanation that itis

because

stillconfronted with the

"^

Ova/rian caused
flaw and

Physiology
flaw in the
sanie

and

Pathology.
of ovulation of

393

by
which

some

the

process

"

hinders
at

development
time,
in
some

healthy ova,
way

which,

the the

leads

to

inflammation

of

ovary: in itself

the
be
a

non-development
sufficient
even cause

of of

healthy
normal, part
that froin of

ova

would have

sterility. We
and

already seen

that

in

ordinary,
of
that

healthy ovulation, the

whence the ovule

condition is to escape
to

the ovary

is such

it is
an

difficult if not

impossible
But, in
if I the may

it distinguish
course

inflammation.
all this

usual
so

of
pacity ca-

things

and, activity,

say, this and

for

mischief,subsides
of the of process,

by

the

happy
the of

timely
time,
are

termination
and and

in the

rupture of the ovisac

at
same

the

escape the
same

the

ovum,

while,
vessels

by

process,

the

the

part

relieved

by

slight but compatible

of certain

effective also

haemorrhage.
the
more

This

explanation
have the

is

with is

other
common

facts I
in in the

that mentioned, viz.,

ovaritis
age
;
more

immarried
who

uncommon

married

have

large families;
is

and the of the

that

quency its freof

in the married pregnancy; in the

because

inverselyto
mere

frequency
is

the

fact far
as

frequent
woman

nancy pregcerned, con-

married

is,so

evidence
to

of normal view
I
am

healthy ovulation, and, advocating,this

in those is fair to
my
own

cording ac-

the

is the

best

while guarantee against ovaritis,*

who, being
assume

married,
*

are

seldom
to my
own cases

pregnant, it
"

that

Bef
"

erenoe

^and
to

it is from my

experience only that frequent gestation

is in

speak

demonstrates
a

condusively against

mind,

that

some no

way other

gnarantee
than and

oyarian

inflammation

; and

can

explain it in
is

way

by supposing that in them

is
no

the ovarian
as

fonction

healthily

performed,

tJareforethere

ground,

it were,

for Inflammation.

394

Meadows:

Remmk%

on

defective ovulation may at least have somethingto do in the unmarried, with it Lastly, those of especially
that in a highly know the ages I have specified, we of civilized and luxurious age, and among a population

given to habits of self-indulgence, in ovulation, errors arisingnot a littlefrom moral,or perhapsI ought rather to say from immoral causes, are very aptto occur, and if thej I have said, do occur, I believe, that inflammation, as is very likely term inflammation, to raeult or what we
the lower

who class,

are

very

much

from it

But, if this be granted, important thoughit

is

as

fact in the clinical of this affection, history pathological it hardly for it scarcely touches all the ground, covers

the

root

mitting It may be said, of course, adthe fact of the defective ovulation as a principal
of the matter.

cause

the of ovaritis,

remains question
And

as

to what

is the

exact nature of thisdefect ?

;

thisisof primeimportance
be
at all
casea

if the disease is to because, obviously,

to treatment
; if we
are

amenable
upon

to treat these

peutics, exact system of theraany sound and scientifically the it will not be enoughmerely to recognize
one

disease as

of inflammation and
must

to seek to combat

that alone ; and

we

tryto

go

into deeper

the matter,

to discover that upon

:

which
must

pends the inflammation de-

in other

words,we
restore

endeavor

to findout

the
we

cause

and character of the defective

and ovulation, action, h

me

try to what,then,may
once

must

ovarian healthy Let

this defect consist?

now

say at

that

am

in the land of

and speculation,
should be

should

wish

therefore that what

I say

Ovcuricm

Physiology
so

cmd

Pathology.
is

395

and, rigidly criticised,

far

as

possible, tested
facts,
I court
one

by
and

careful Hitherto
I

clinical observation I have

dealt
one

and

experience.
with chiefly,
them
to
: now

only, or
to

challenge any shall inquiiy, and

facts
or

dispute
thankful
or

be in

any

for ojHnup

arguments
we

proof

disproof of
in order
to

my

ion. this

What
most

especiallywant
"

clear

question interesting
the
mere

^for its interest

or

is far

greater

than

existence

non-existence
have
we

flammat of in-

it involves

also,as

we

seen,

the

vitally
of

what important questionof sterility"

want, I say, is
histories

careful, accurate,
cases

and

minutely
I may
so

recorded
term

of ovarian

if life,

it,together with
the ovaries
after

exact

microscopic
And of
a

examination

of

death.

here

I would

say, in

that passing,
mean a

when

speak
the

history of
We

ova/rian

I life^ of

complete
life of
and of and
our

biographical sketch, as patient

few should

it were,
note

the

ovular

every

minute

detail

of menstruation,includingthe particular

occurrences

the
in

days preceding

the menstrual should

all the upon

discharge;
while have
as

noting these facts,we

gaze

mental central

steadfastlyfixed
in

the

ovary, the

the

point
sets

the

menstrual

system,
At in

mainspring
same

which while

the

machine
the

in motion.

the

time,
is

inquiringinto
should in
and is the

mode

which

its function view

the

performed, we
which

keep steadilyin
the uterus the

process

going on
ovary

it,and the relation which

on one

exists between
and
nervous

hand

its

anatomical

connections,especially through the

other and
our more

arrangements, with
We
are

distant

parts.

in apt, I fear,

studies, gynaecological espe

396

Meadows

Rmuji/rk%

on

cially in
mucli The

all that

relates

to

menstruation, to
and
too

pay

too

attention
uterus
our

to the
so
"

uterus

little to the
that

ov^arv.

is

accessible

to observation

it is

no

wonder
and well

attention upon the the

is diverted

from

the main
we

point
do
as a

fixed
to

subsidiaryorgan
habit with of
whom

; but

should
uterus to

get into

regardingthe
we are

species of coquette
the face of the
more

not
we

in flirt,
to

serious work
to

which
as

have

do.
or

But,

to

revert nature

the

question
defect

to

the

possible
of

probable
which
at least
to

of that

in the
an

process

tion ovulaor

is the
a

of starting-point

inflammation,
of the which
organ is

of such

hyperaBmic condition
train of

as

occasion

all that
to

symptoms
have

usually
that its

attributed

inflammation, I
of ovulation

already stated
with follicle, from the the in due

in the process

the Graafian its way

contained
central

ovum,

works gi'adually

more

portionof
it may

the ovary

to

some

point on
there

surface
course

whence of its
escapes

escape

; having arrived outer

maturation, the
into

covering bursts, the

tube
or

ovum

the
up

Fallopian
to this

oviduct,the
been and relieved,

vessels, bloodcreased in-

which

point have
are now

enonnously
their be

in size and

number,

they
vices ser-

speedilyreturn
are

to their

wonted

quietude until
has

again
by
the

called

into

requisition. It
a

will
an

membered, re-

too, that the ovary

surface
;

free and
it were,

attached the posterior is

latter

it

adheres, as

to

aspect of the

broad

ligament
of the

Its free

surface

probably
organ,
so

about

four-fifth
see, there

whole

of the superficies

that,we

is about

one-fifth of the ovary,

for the
no

perhaps more, which its function, because

is not

available

purpose
can

of

from

this surface

ova

escape.

Ovarian

Physiology
not

and

Pathology.
or

397

Now,

we

do

know
it
comes

why,
the

rather

we
ova

cannot

explain exactly how,

as a

to pass
to

that

should,
whence
its

rule, make
may escape

their
; but

way

free surface
no

they

there is almost
we

rule without
may of

even exceptions,

in

physiology,and
the ovary
were

well ask how

it would

fare with
ovum

if,instead
to

going to
to

the its

free
d6but then

surface,an
at to

attempt
How the of the
are

make

the

attached

border..
What ?
can

the

vessels,
effect
to
we

be

relieved?
local

ovary
two
ovum

quiet the
may

excitement

One

courses,

suppose,

will be taken

; either

will

die,

the
to

follicle their
on

gradually shrink, and

state, or
else may

the
now

vessels
morbid

return

normal

the

action

will go

and increasing, very

lead to disease in various will be

ovaritis.
a

forms, the
such
as

mildest

of which
the
term

condition This
may, be fective de-

is described
one

by

perhaps, be
and But other
we

method

by

which result.

ovulation

may

an

inflammation

can

readilyimagine, also,that
similar
same

there

may

be

methods the
that which of the

in

kind, but
may be

in detail^ differing

by

which

result
are

brought
or

about.

I
ditions con-

believe

there

constitutional hinder seriously At

diathetic

at times

the due

ance performtime, for

ovarian
a

functions.

the present
my
care, two
a

instance,I have
menstruated nineteen of for
two to

patient under
seized

who, having
years,
severe

regularlyand properly for

twenty-one,
was

from
attack

with
the

rheumatic
five years

fever,after
with with

which

catamenia

ceased for

entirely. They
more

then
or

returned, and
less

years

continued

but regularity,

and scantily,

always

pain ;

in

these

respects dif-

398

Meadows: from
On

Renmrks

on

fering

what

they

were

before found
the

the

rheumatic

tack. at-

examination

left ovary

very
not

tender,but
be

little if at all
was

enlarged ; during
that

the and the

right could
before
the

felt

Pain

constant
seems

cata-

menia.
state

Here interfered

it

evident

constitutional
functions

so

with seriously since

has been

the ovarian

that

they
the

have

never

properly performed.
under my for of age, and

In another
care,
many

case,

which

been quitelately

patientwas

twenty-three years
almost been since

years

ment

of

^Zri^, she had

was

past, indeed

the first establishin

subject to pain
worse

tie
a

right groin,which
few

always

during

and

for

days
For

before
a

the

catamenia
my

; the

discharge was
the and

fuse. proin

year

previous to
had been

seeing her
worse,

pain

the ovarian

region
had

much

for the
pation. occu-

last six months

She

it had
been

quite unfitted
treated

her

for any

for ovaritis
on

by

very

tinguished dis-

provincial physician, and

there could be
no

examination
a

doubt

that
was

that

was

correct

nosis. diagwas

The
very
more

right ovary
but
not

plainly to enlarged.
found walk

be On

felt ; it

tender,

much

inquiring
five and
a

minutely
years

into the
she

I history, took
a

that
one

half
the

before,
at

long
her

evening, damp,
and That

weather

the

time
been

being
on

cold for

and
two

menstruation

having

days.
; and

night she
morning
the

felt feverish ; the catamenia

she
was

ceased
to

in the

unable After

to move,

owing

the
were

pain

in

right groin.
with
to

this the catamenia

absent

for six montha

They
severe

then

and recurred,but irregularly, As

a

always subject

pain.

child,
she

she had

had
most

been
un-

strumous

abscesses, and

400

'Meadows

Renta/rlcB

on

healthy ovulation, and

the

that, making

use, to

as

it were,

of

follicular

vascularity, they give rise

which
can

inflammatory experience of
with,

states

of the ovary

only

be

bated successfullycom-

by
others of this

constitutional
no

treatmetit

The

will,I have
sort.

doubt, furnish
all

them

example:?
culosis tuber-

We

know, for ingtance, how

ovulation.
In the

interferes

with

early stage of
and
no

pulmonary phthisis, menorrhagia, both

is of
that

in time I have

tity, quandoubt
as we

frequent
to it,

occurrence,

and

this is due
term

to excessive

ovarian ovulation. the

activity, or,

might

tubercular advocated

I have

elsewhere

ing great importance of givin the

treatment

heed

to diathetic

tendencies

ease, of dis; and

in regard to especially

the diseases of children becomes of

seems,

although

in adult

life diathesis

less
as

ance, importit were,

apparently because
to over-ride

the vital force

and

to

conquer

constitutional if
we

defect, yet in
be successful

many in
am

cases

this is ndt

so, and

would

we therapeutics

must

recognize this peculiarity.I

it does
to

satisfied

that

where

exist, no
state

treatment

which the
grasp mark upon
to

is directed

merely
We
must

any take

local
a more

will

be

of

least avail
of
we

comprehensive
shall for
miss
a

the aim

whole
at

condition, or
And

we

the

when
term

we

reflect

while

the

meaning
sometimes
as

of it

the

and diathesis^

endeavor that
centrated, con-

take

in all that

implies, we
with

must, I think, see

evil will
be

though

the

constitutional

it were,
or

especial malignity
the whole
energy

upon

some

one

organ
a

structure, yet that it will assuredly

influence
upon

exercise

certain the

nutiitional
of the

and activity,

entire functional

body.

Ova/rian In

Physiology

cmd

Pathology.

401

the

diathesis,for instance, syphilitic every

single

vital act is

performed

under

the

influence of the master

poison. Every
all

secretion

carries the virus ; all

its influence.
"

nutrition,
very

is governed by repair,

The

fact

that

these
"

diathetic
are so

states

and struma, tuberculosis,

syphilis

stronglyhereditary, proves
But if this be
so,

how

nant domitions operaat

they
in the

are.

surely those
or

body

which

depend
excessive the
to

upon,

are

least

always accompanied by, pre-eminently subject

and
.

will vascularity, of
can

be

operation

this
be

law;
more

there

is,perhaps, none
than

of which

this

truly said
-

of the function

of ovulation,
to

I have

said,then, I think, enough

of ovulation is

show

that

the
ditions, con-

performance
and
as

governed by
inflammation

local
such
a

by

constitutional

in peculiarity,

way

that

it may

give rise
defect
"

to

an

due

simply
lation re-

to

functional which

^thus

the illustrating

intimate

exists between

action physiological

and

pathological process.
The
to

following details
the

of

case

of ovaritis will of that

been

serve

illustrate

leading features
of age, has but
one

disease:
teen seven-

lady, thirty-nine yeara

years,

married
years

and

has

had

child,ten
married

ago.

During
suffered somewhere

the
more

greater part of
or

her

life she
as

has

less

pain, described pelvis.

much

vaguely
was

being

about has

the
been

Menstruation

but excessive,

more

and
On

at times

it has

amounted

to

always since she married, so severe haemorrhage.

that the

it questioningher closely,
been
worse

appears

pain

has
and is
a

always though

in

the

left ovarian from

region;

seldom
26

absolutelyfree

pain there,it

402

Meadows:

Memarks

on

good

deal
It

aggravated
is

few
"as

days

before

menstmation
were

begins.

described

though
the

something
heavier first

that situation; it gets gradually filling-in

and the

heavier, and

remains
as soon as

so

during pain

day

of

period,but
down but the

the The

discharge becomes
seldom
or

very
never

free,
goes ovary,

relief is obtained."

leg,indeed
to go

is not

felt lower towards

than

the

it appears
most

through

the
the

sciatic

notch,
of the form. uniboth

and

of all

upwards, exactly in
of
nerves:

direction
and

spermatic plexus
There

this is constant
on

is always tenderness

deep
also

pressure, the in

and and externally, internally

to

this

causes

pain
both For

shoot

upwards.
it is
has it has been

There

is

generally pain
in the deal

breasts, but
years she but

certainlygreatest subjected to
been
a

right.
of

great
to

ment, treat-

always

directed
to

the uterus, and

lias consisted

of chiefly

leeches
same

the

cervix,the application
abundant has nal vagibeen have

of caustics to the

place,and
say that

injections. I anything
been The
occurrence

need

not

the result

but

satisfactory ; it
be

could

hardly

indeed

otherwise.

points to
of

noted

here
I

are,

the systematic first,

menorrhagia.

have

explained how
to
a

in

ordinary healthy ovulation, according

law, the vascular

lished well-estab-

activityin
vaso-motor

the

ovary

leads,
tation to dila-

through

the

influence

of the

system,
in

of
uppejr

the

uterine

blood-vessels of the uterus

nerves as
"

the

fundus

and

part of the body

same

the

parts supplied
ovary
"

by
so

the

plexus

of

supply

the

and

occasions

menstruation.

If this takes
as

place in healthy by

morbid vovulation,

such ovulation,

is characterized

Ovwrian

Phyeiology
or activity excess

and

Pathology.

403

excess

of

ovarian lead to

ovarian

will vascularity,
; thus

probably
that The I

also in menstruation in the

occurrence case

it is

explain that symptom point to

note

just
of

related.
one

next

is the

only
wife

pregnatio im-

during a
husband
all outward that many

married

life of seventeen
the

years, the

being perfectlyhealthy,and
appearanca those

also,to
ova

What
years
as a

became ? The

of
answer

all the

escaped during

is,that
of morbid

probably perished
;

consequence be
one

ovulation

menorrhagia

itself would
coitus

bar the

to
ovum

pregnatio im-

by preventing
had

until

after

escaped altogetherin
life of this
A
seat
over

the menstrual fatal to the

discharge;
occurrence

the

ovarian

lady
and

was

of

pregnancy. is the
most
exa^t
severe

third
and

most

important point to note,

of the

character

pain :
to

it

was

always
; from

the

spot occupied by the ovary

that

point
about

it

was

referred
situation

through

the

back

of

the

hip,in
"

the

of the left sacro-iliac the left broad

drosis synchon-

in fact,where ^just,

ligament joins
ovarian
nerves

the
enter

pelvicwall,and
the

the where, therefore,

to

broad

ligament
the in the

join the
of the

ovary

; thence

it

ascended

exactly in by
such

course

spermatic plexus,
renal

namely, upwards
Now, others, of

direction
as

of the these

region.
will
we

symptoms
of less this

(there
believe
I know

be may
none

course,

importance), I
condition,and
any be

invariablydiagnose
others

of

which

are

nor reliable,

affection

presenting
Morbid
in

symptoms
conditions
some

with of

which
the

it

can

confounded.

broad

ligament might, perhaps, it,but

of
the

respects resemble
downwards instead

pain

of

the

latter the

goes

upwards, following

404

Meadows

Ovarian

Physiology^
;

etc.

course

of

the and

sacral

nerves

and,

moreover,

there affections
of

are

symptoms
the broad and

local conditions
which
are

peculiarto wanting

of the

ligament
vice

in those

ovary, But the time close.

to

verad.
at too

I have has I
can

already written
come

great length, and

those remarks
to
a

when express

I must my of the

bring
regret
morbid

but
so

at

having been
conditions discussed
of

able the

consider which

very

few

ovary much have

might, perhaps, have advantage.

consider
some

been

with

profitand
been

In

I particular,
more

should

glad

to

of the in their

important
pects, as-

organic

diseases

of the

ovary, of
a

pathological
the

those especially r could have shown

cysticcharacter, for
most

I think
quence conse-

that

of these

are

of
in

action. perverted physiological

My difficulty
from
any

compassing
of

what

I wanted

has

not
an

arisen

lack

material, but rather from

of crowding impossibility,
even

I might inability,
a

say the

into

communication the
more

of this kind

the

leading features
and subjects,
to

of

portant imsider con-

ovarian

diseases ; I have
many

preferred rather
to take

to
as

few
best, in my
ovarian

than

such

serve

judgment,
be

illustrate

the

principles of
suggest
some

pathology; hoping, thereby, to

which
may useful be and

thoughts
which
some

and by interesting,
to

may,

perhaps, they
have

enabled

treat,
a

more

successfullythan
cases

hitherto
the
more

done,

class

of

which

often

presents

in greatest difficulty mistakes

if
our are

about practice, than

which

I believe from

made

with

any

others,and
the

which,

successful, we
and patients,

shall
the

deservedly earn

gratitude of
a

pleasure which

arises fi'om

duty

well

done.

'

White

Chronic

Inversion

of

the

Uterus.

405

CASE

OF YEARS'

CHRONIC

LNTVERSION
SUCCESSFULLY

OF

THE

UTERUS REDUCED.*

OF

SIX

STANDING,

Bt

Pbov.

JAMES

P.

WHITE,

M.Dm

Buffalo, N.

Y.

Mrs.

H., wife,aged 35, native of New

at

Bedford,
She
:

first
at

menstruated

her

thirteenth birth
as

year. foUows

married the

fourteen,and
years

has

given
She

teen fourfirst,

after first.

marriage ;
was

the

second, eighteenmonths
in

after the

attended
an

her

last

ment, confine-

six years the

ago, the

by

practitioner. After irregular

the
on

delivery of
two

child and
a

medical his

attendant

left the
to

patient for
remove

hours,

return

proceeded
hurried
ner. man-

the For

placenta in
three
was

very

rough

and

weeks then

convalescence
taken

proceeded

as

usual The

she

with

profuse hemorrhage.
intervals
called.

latter

continued

in

varying quantity and

the

for several

weeks,

when

family physicianwas
it.

Upon
and and the of the
a

examination surgeon
was

he

diagnosticated uterine
to
remove

polypus, Accepting
The wire
about

summoned

confirming the opinion of operation was

the 6craseur
was

the

attending physician,

immediately
with
some

undertaken.

applied difficulty
traction it

but pedicle,

upon

making
of

parted. Upon
ascertained

close that

inspection
the
case was

after the
one

accident,it
uterine

was

inversion,originally
the
at

but partial,

rendered

complete by
was

previous manipulation.
the time.

Nothing
1872,
Dr.
*

further F.

done of

June,
was

George
Reported

Hough,
H.

New

Bedford,

by Geoige

Bixbj, M.D., Boston, Mass.

406

White Dr. H.
she

Cdse

of
to

called. where

found
been She
was

the almost

patient confined
and
to

her her

sofa,
last

had

continuously since
chlorotic; time, but
of

confinement had suffered been from

thin
as

tion menstrua-

regular frequent
were

profuse.
in

She the

attacks

hemorrhage
exertions
as

which interval, that of

provoked by
the
room.

slight as through
times A

walking

across

Frequently slight hemorrhages

the there
entire
was a

continued
at

interval

of

menstruation;
of the
"

other

complete
revealed the less

absence the

same.

vaginal genitals
its

examination
normal
;
more

following :
a

^External

within
or

vagina
the

round, regular, conical

constricted
at
perior su-

body,

movable,

and

extremity. Upon
Dr. diagnostic signs.

of application

the
case

usual
one

Hough
of

pronounced
Not

the

of
sure
was

chronic
of his

inversion

thfe uterus.

feelingquite
Bedford,

Dr. diagnosis.

Johnson,
Dr.

of New

called

in consultation.

Hough's opinion was

Dr.

confirmed

by

Dr.

J.
P.
was

In

June, 1872,

Hough
On

sulted con-

Prof. James

and White, of Buffalo, by letter, called

to
see

later. Dr.
sixteenth

White
of Dr. of

the

case.

the

May,
White,
the

1872,
in the

an

examination
presence and

was

taken underthe
sistance as-

by

with

following gentlemen:
of

Drs. in

Mason,
the

of

Norwich, Ct., Professor

Medical and

Physiology
and

Buffalo

College ; Hough,
of
New removed teeth

Johnson, Hooper, Vermyne

Hayes,

Bedford,
and Mason.

Bixby,
drawn

of

Boston.

Artificial commenced

urine
When

; etherization
thetized, anaes-

by Prof.
the

completely
the back
a

patient was
the

placed
near one

upon

across

the

bed

with

pelvis

side,in

favorable

408

White:

Chronic

Inversion

of

the Uterus.
and

Gentle

but

unyieldingpressure,
the

rendered

equable
little

manageable by
without
force any

action for

of

the

spring,was

continued
more

variation
than

thirty minutes, required to

being exerted spring.

Thirty
:

that

compress

the

minutes
in in

after

the

commencement ;

of the

ration ope-

Patient
tumor

good
from

condition
still

nificant; hemorrhage insigconstriction

of
more yielding. un-

vagina

firm;

One

hour

commencement

the operation:

Hemorrhage tendency
and
ounce

tumor insignificant;

soft;

to

collapse,manifested
combated in the

by by

retarded

tion respiraan

pulse, was
action
"

the

injectionof
to
"

of clear

brandy

rectum,
The

which

the

heart's

promptly responded.
now

Egg-beater by
a

repositor
slow One
and

was

continued, its action varied

of
:

to-and-fro
a

motion hours

the

body

upon

the
the

spring.
erated accel-

half

The

patientbears

operation large-size
of the tion constricits
mal nor-

well ;

hemorrhage insignificant ; pulse somewhat

; tumor
more

soft and

compressible;
for
"

gum-elasticrectal bougie
Two hours and
and
ten

substituted
:

Egg-beater.''

minutes

Under
the

the pressure the fingers, assumed the

bougie

manipulation
The

with
the

suddenly relaxed, and position.

in less than
a

organ from

patient rallied
an

anaesthesia
took

quarter of

hour.
this

Reaction

place
jured. in-

slowly. Notwithstanding
neither
the Dr.

prolonged manipulation,
in any
to

vagina Hough

nor

perinaeum were
writes in

way

thus

regard
"The

the

quent subse-

condition

of the
were

patient:
of

day

after

the
idly rap-

operation there

symptoms

which metritis,
treatment.

disappeared under

appropriate

There

Engelmann

Prolapse of

the Umhilical

Cord.

409

were

no

bad

symptoms
after from
month she

following the
suffered
to

operation,but slightattack
of cold has of air at
sat up,

two

weeks

from
a

pneumonia, night.
has
a

exposure

draft

One

after the

She operationp: and

good appetite, sleeps well,

examination

gains strength
the
uterus

daily ; vaginal
normal

revealed

in

position."

ON

PROLAPSE

OF

THE

UMBILICAL

CORD,

ITS

CAUSE

AND

TREATMENT.

fBT
Master In Obstetrics

GBO.
of

J. the

ENGELMANN,
of

A.M.,
Vienna

H.D.,
of

St
the

Loaiei, Mo.,
London Obstetrical

UnlTendty
of the

; Fellow

Sodely;

Member

London

Pathological

Society, etc.

INTRODUCTION.

The

subject of prolapse of
to

the cord

is of

as

great
it is

an

importance
interest
treatment to

the

practical

obstetrician
its

as

of
and

the
as

scientific

accoucheur;
been

cause

have

yet

not to

clearlydefined. ppint
no

Though
extensive,

the literature the

the

devoted reached

this
are

is most

conclusions
results of
to
me

by

means

satisfactory, differingin
a

obtained

by

various
the
cause

authors of this of

number
seems

points,and
to lie in

disagreement

the

lack

extensive sufficiently

and

compiled carefully
the

statistics. of

Upon
claims

continent

North it does

America
in

this

dystocia
the

less attention

than

Europe,

where

410

ExGELMAinr

Prolapse of
upon
as

ffie
the main

deformed

which pelvis,

I look

cause

of

prolapse
for

of the cord, is
our

by

far
do

more

frequent
suffer the from frame poor and the

tunately for-

people they
which
classes
so

not

the
of and

wretched
women

conditions
of the

often

affect
"

lower

in

Europe England

^f ood

scanty, mostly vegetable,tenements

with of
a

narrow

close,
N^orth

damp
German

climate,such
offer.

as

and

Germany
In

hospital
is of rather

and

policlinical (city poor)

rence, occur-

prolapse practice,
and in which
to

comparatively frequent
far been
an

the the

and unsatisfactory
so

superficial ivay
lead

subjecthas
and

must treated,

the

favorable

reception of
valuable
of the Berlin

based investigation
materials
as

upon

such

extensive

that

lected col-

in the annals my

Lying-in House,
the

which
chief

worthy
that

teacher

and

friend.Prof. Martin,

of
The

institution, so
of
"

kindly placed
"

at

my

disposal
and this way

large number
one

cases

^the largestat the command

of any

author

^the careful

notes, and
the

the

exact

complete measurements, question in

than has
a

permit

of investigation

much been

more

precise and pointa

methodical
a

yet

and possible,

promise

satisfactory
consider
have of

solution
I deem the been

of the doubtful
it of

prime importance carefullyto

which
to

conditions

under

the
a

results

here

given

obtained, and
material
upon

gain
of

thorough knowledge prolapse

of
the

the

which
cases

our

investigationis based;
served funis obof the

this consists

of the

in the of

royal Lying-in Hospital

the

University

Berlin,

and

policlinical (out-door)department
October, 1858,
to

of that institution from

August, 1871,

ZTmbilical of

Cwd.

411

two

classes

cases

between

which

we

must

carefully Lying-in
decisive

distinguish.
The

records
are

of the 63

cases

observed

in

the

Souse
for of

alone

perfect in
abnormal from

all their

and details, With the

all
13

points under
of most
inter

consideration.
and the

exception

cases

ported complex labor, trans-

partam
have been

city into

the

institution,
from
the
was

these

cases

observed conscientiously
measurements

ginning be-

to
were

end;

careful
case,

of

pelvis
con-

made
upon

in every

and

the

treatment

duicted Owr
were

scientific

principles throughout.
on

out-door

(policlinical) cases^
and
are

the

contrary,
stances. circumof

observed

treated

under
or

less favorable
cases

They
among the poor

difficult
of the

prolonged
which the
later

labor

to city,

the

despairing

midwife It
that the is of

summons

the

aid of
at
a

necessity only
cases come

stafi. Lying-inHouse stage of parturition when

these

under

observation, mostly

prolapse of
even

the funis has

it has ceased

already taken
to

times someplace,

after

pulsate,so Among
aid
to

that

they
the

are

but
we

imperfectly recorded.
find
notes

these

out-door

cases

upon

302

prolapses; though
can us

number
a

of

cases

is

large,they
of

in

solvingbut
upon, such

few
the

of the

questions we

propose

enter

as

relative

frequency
302

prolapse
the

among

primithe
have

parse

(I. p.) and multiparae(M.p.),or

Of
these out-door from that
cases

of position

child.
been

98, however,
to

carefully observed
made,
those
so

beginning they
in may be the

end

and

measurements

considered

equivalent to
and have
been

observed

Lying-in House,
the

classed

together with them, making

412

Enoelhann:

Prolapse of
with

the

number

of

our

prolapse cases
shall and
as

pelves measured,
as

and

deliveries
As from

carefullyrecorded, as high
as

160.*
365
cases

far
the

possibleI
would
to

refer to the total

out-door

Lying-in House
be,
the relative

department
of

bined; com-

this with

have

already

mentioned among

regard
and

frequency
the and

prolapse

Lp.

M.p., the positionof regard

in the
must to treatment

etc. foetus,

With

prognosis the
and

results partment de-

achieved

Lying-in House
be

in the out-door

considered

the separately,

conditions
so

under

which

the obstetrician

labored

being

very

ferent. dif-

A.

"

FEEQUENOY

OP

PEOLAPSE.

However

many

obstetricians

have

given

us

their

experience
data
very
we

with
as

find
as

regard to prolapse of the funis, the to the frequency of its occurrence vary
that

much,

it is natural

they should, being

class of

pendent de-

upon The

country, climate, and

cent,

population.
is supplied

highest per.
the
a

is that

given by Michaelis, who

of Kiel, which

finds that

Lying-in Institution
country where

from

the rachitic

pelvis abounds,
"

produced
Scanzoni
of
699
cases

27

prolapsesamong
cases,

2,400 deliveries
collected from

1 to 90 ;

cites 178,043
a

the

cations publiwhich
254

large number
it is

of obstetricians, among
"

of
As

prolapse occurred
customary

prolapse
the

to

liveries. deand
are

that

statements
or

figuresof
Table 160

one

whether authority,
measurements

right
and

wrong,
histozy of
number

I.,oontaining the pelvio

will
appear at

condensed
a

these

cases,

the

dose

of

our

in article,

later

of the

AsMfrioan

Journal

of

Obstetrics,

Umbilical
f aitlifully copied in each from

Cord.

413

successive
we

work, and
find about

translated
the
to
same

language
made
in

to

language,

statement =1

by Saxtorph,who Churchill,who
188,730
the

gives 480
finds
or

116,272
of

243, and

816 1 to

examples
231^.

prolapsed
are

funis among
from
one

cases,

These

gathered
French,

obstetricians
to

of all

the countries,

British
the

having
finds

prolapse
; the

23 2

cases

of labor;
.

1 in 373

German,

1 to 521

262f
cases.

Boivin All

but

one

prolapse to

these
are

calculations, even

if based

upon

bers, large num-

and exceedinglysuperficial,
us

of value

only so myself

far

as

they approximately give prolapse

the
in

the relative
; and

frequency of
I
am

the also
to

institutions lying-in

unfortunately compelled

to confine
we

my
no

calculations
control
to
over

Lying-in Hospital,as
of normal
of

have

the

relative number
cases

deliveries
be

which

the

out-door I must observed

prolapse might
state

referred.
the

simply
in the years,

that, among
of

5,900 deliveries
the last

Berlin
were

Lying-inHospital within
cases

twelve
one

63

prolapse
per

of
a

the

funis,

prolapse to
is

94

1.07 deliveries,

which

exceeded

only by
in Dublin

the

frequency Lying-in Hospital of

cent,
1 to 168.
were more

Kiel, the Eotunda

Even inter if
we

giving but
13
cases

disregardthe
to the
cases

which for

brought
serious
"

partimi

Lying-inHospital
of
a

50 complication,
or

prolapse stillremain
similar
to

1 to

118,

0.85

per
1 to
we

cent. 120.

"

ratio

that

found

by
wide
of

Nagele"
Should

desire to make of
course

generaldeductions,a
given, in

margin
these

must

be and

the consideration

to figures,

social

to geographical conditions,

414

ExoELMAinr

Prolapse of

Ae

tbe cbaracteristics

of the various
the
are

ooimtries

mod

diiaate?!.
aziK'Lz

and,
whom
Ah
rare

above

all,to

class

of the

populAtioii
mocli

the Btatistics
I have in this

collected.
more

already stated,the prolapse is

country,
housed
as

well

as

among
"

the

hig-her

cla-^-^ dt-

"

the better
the

and

fed abroad
all

^where

diseas"e
occurs:

forming
where
we

above pelvis, the

seldom rachitis, of

rarely find
walls, or
the

flabby condition
of the

the

af"-

dominal
so

early escape
The class of
as

liquor
as

amnii poorer

frecjuent among
are.

hard-working
often such

women,

the

of the Gei*mans

women

which

frequent
from of
izi

Lying-inHouses,
in proltt])He

have
make

before
the

suffered

com])licated labor, naturally

Huch institutions
the

frequency
it is fact

much

greater than
that

general [)ractice.On
is
a

contrary, the
confined
we

there has
no

very

largeproportion of Lp.
upon
these
as figures,

there,

influence

shall

hereafter
laid

see,

notwithstandingthat great stress this point by many authorities.

We

has

been

upon

must, in short,seek
extremes

the true

proportion

between

the various

given.
Frbquenct
Rbbsentationb.'

Table

II."

Rblatiyb

of

tsb

yabioub

416

Engelmank

Prolapse of
must 6 face

the

face

presentationthat
of the maternal that

we

look

upon

as

causing
have record

the

prolapse.

In 5 of these

presentations we
of the sisih
been
no

distortion
is

pelvis ;
have So

given, so
B.
"

this also may

"

deformed.
tation; presen-

Other
that

Presentations.
all

much
"

for head

other
"

presentations ^perfect breech

should
tend size
more

presentations excepted
of the

to

prolapse
of the the

funis

is but

natural, as
its

and

shape

presenting part prevents

lower

thorough adaptation to
thus

segment of the womb,

which the funis
the presentations but

leaving an

open

space in

through
all these We

readilyglides;
funis lies
table
to
nearer

moreover,

the

os.

need

refer to

our

see

that
cent

facts of the
come

verify
total under

these
number the but these
ft

theoretical of
cases

deductions, as
of

43

per

prolapse here
under the

recorded

latter
6 per

while class,
cent

normal
ai'e

condition delivered

at

most

of

children that

in
we

one

of

so presentations,

as malpositions, more

might
among

almost
cases

call

them,

are

7 times

frequent

complicated with
Presentatimis.
in
toto

prolapse.
"

Breech far

Of

all these the head

so presentations,

contrasted

with

the presentation,

breech

presentationis
The
sum

least often
our cases

complicated giving
every the
36
us

with
not

lapse. promore

total of

than
"

one

breech
which but

presentationto
little exceeds
when
we

cases

of prolapse
"

normal that

ratio

and

seems

but the

natural
so

consider
to the

size and
a

shape
able suit-

of

breech,

similar

cranium, permit segment of the

with

of configuration Foot Presentations.

the lower
"

uterus.

It is far different

the

ly near-

allied foot

the irregular small presentations,

parts

ZAnbilical whicli
OS

Cord.

417
the of the

first
not

press

downward the
close

through adaptation

yielding
cervix,

do
we

permit
this

and

find

presentationmost
I may that the

frequentlycomplicated
it is
least be

with

prolapse,yet
this very this not

add, incidentally

fortunately in dangerous
the
terror ;
were

case

prolapse is
2.7 per
of foot In the

so, foot
; with

must presentations

of obstetricians

but

cent,

of

breech

we presentations

find 19

per

cent,

tations presen-

among

our

cases

of
25.4

prolapse.

Lying-in
the been

Hospital they even

more

reach

per cent, of all cases, much

; in the

than of

in the out-door in-door

"

department
the the

former has

number

patients under
and normal

treatment

comparatively large
the foetus
as

longitudinal position of
action of
a

produced by

healthy ment, departpractice,

the

strong

uterus

naturallypredominates.
Presentations.
we
"

Trajisverse
where the number axis

In

the

out-door medical

deal

more

largelywith

of

foot

in presentations (presentations

normal the
6.4 to

of the

uterus) is smaller,only
14 positionlarger,

18

percent,
cent, to

number per cent the

of transverse
in the

per

Lying-inHospital ;
tissues, uterus,
so

this is due

mainly
wall

laxityof
the

the

and

abdominal of the
per
28

in

multiparsB ;
Of

not

much of

to distortion

pelvis.
cent
curred oc-

total number

prolapses 12.9
cases
"

in transverse Class
mother
"

positions (47
the 11.

of

the

I.

the
; 19

head of

of
the

foetus

in the

left side of the

of

Class, the head

the

foetus in

the mother's Shoulder which

a are

rightside).
PresenUUions.
almost
"

Shoulder
transverse
as

presentations, positionsas
a

identical with
so

cause

of

in prolapse,
27

far

in both

presenting

418

Engelmann

Prolapse of
is

ike

part, which
cent,

closes
cases
"

the

os,

lacking,constitute
in the

8.5

j"er

of

our

equally distributed department.

that

Lying-in

Hospital
the

and

out-door up,
we see

Summing

among

head

presentations
face presentations,
more

prolapse of
but

the is

funis

rarely complicates vertex

with
I

sentations pre-

frequently found
as

caused, however,
deformed breech with

have face

proved,

by

the such

pelvis

than

the

presentation;as
shoulder

presentations also
transverse prolapse,

are

but

rarely complicated
tations presen-

positionsand
and

much

more

commonly,
other.
n. FGBTAL

foot

presentations

oftener

than

any

AFFBNDAOSa

Having
shall

seen

what

share

the

foetus in its various

sentations pre-

has
now

in

we favoring or causing the prolapse,

consider
but
as

the

foetal

appendages
any
as

in their shaU

casual be
as

relations;
and positive
me

in

order

that

results

minutely exact
other I points,
"

thorough notes
here confine

enable

to

give

upon

must

myself
centa plawas

to DQWich smaller 1.

numbers. ^Thus the

35

Placenta. is

"

place of
cases,
"

insertion of

of the
it

given
down

in

but

in 16

which

found
cases

low
as

in the

uterus

I consider i.e.^

all such the

adherent in from
not

unusually
membranes

near

the

os, in which 4

rupture
distant
I have

the the

is less of the

than

centimetres
these the
"

margin
of of

placenta. Among
cases

eniunerated

the extreme

in which
treatment

placenta presents;

such,

15

were

under

givingus
cases

one

case

placerda prmvia
unusual

among

every but

24

of

prolapse, an
these and

frequency;
to

garding disre35

ourselves confining,

the

other

Umbilical
ca^es, it is of
an uncommon

Cord. in 16
so near

419

certainlymost

that striking

the
the

hesion ados,

the

placentashould
occurrence,
women as

have

been

in the very

large number

of

autopsiesupon performed, I
I have almost

and shortly after duringgestation I have but either witnessed

or

confinement, which
have

myself
;

rarelyobserved
found
the
seat

these conditions
of the

always
often
to

ward placenta to-

the fundus

usuallyupon
the location
seems

the

wall posterior
to

of

the

uterus,
That

more

right than
of the evident

the

left. the of

this unusual
the
as

placentafavors
; but

prolapse of
this is not,

cord

the it
;

reason

the authorities
so

state,because
nearer

bringsthe
the
reason

insertion of the cord

is
a

much
"

the

os

different totally of the

one

it is the

mechanical passive,
of the the

action in

large, though yieldingmass

of in

ta placenclose
to

preventing the normal course part through the pelviccanal, and adaptation of the lower segment foetal head impossible.I have laid
as point,

presenting
the
the

making

of the uterus
some

stress upon

this

it is new,

and

I deem

it of

considerable

tance, imporat

certainlytheoretically very
events, I
trust

interesting ;
to

all

I have

said

enough

stimulate

farther

observation
In
cases

and

investigation. placenta praevia, complicated with

of lapse pro-

of

of the

funis,the prolapsebecomes
the dangers threatening
attention
;

portance, secondary im-

the here

life of the mother

state

claiming our by

yet I may

that

the

placenta presenting the

caused
are

difficulties before
the inferior
zone

mentioned,
of the
we

its insertion upon

rus, ute-

greatlyaugmented, and
so near

in addition

have

the

insertion of the funis made still easier.

the os, that

the

prolapseis

420

Engelmanw Funis.
to

Prolapse of

the has
but

2.

"

little ^Unfortunately,

attention

been

paid
the

the
cases

placentalinsertion
noted the lower
cases

of

the

funis^

among
was

few

we

find

two

in which

the

cord

attached

to

margin

of the the

placenta,the
internal
be led
more

latter
to

being
these
the

in both

situated
we

near

os, and

conspiiing causes
we

should
find

to

attribute
plications com-

prolapse,did
in the

not
case

by

far

serious

one

(Lying-inHospital,20)
other of which I consider

in

deformed shoulder

pelvis;
and

in the

(Lying-inHospital, 34)
as

both presentation,

most

important
It

primary
an

causes

of the

prolapsecases

is not
a

alone

analysis of
small the of various

the

I find above

corded, re-

comparatively
that

number,

but

all

careful which
or

consideration convince
the
me

points involved,
of the
a

the insertion
of the

funis
matter

upon of

near

lower

margin
on

placenta is
before

very

little

bearing
most

the

subject

us,

standing notwith-

that

each authorities,
a

copying

his

cessor, predeto

consider
occurrence

it

complication very
great
the deal

favorable

the

of
same

prolapse.
way
a

In the laid upon

of
^

stress

is

generally
idea,
the

the

lengthof

funis

with

vague

which

seems

natural, that sufficiently

the

longer

cord, the

more

readily will

it

come

down.

Length of
In
"

the funis in 92
less than
more

cases.

20

cases,
"

56 56

cm.

72 37
35

than 56

em.

"

"

betw.
over

and
cm.
cm.

70

cm.

"

"

^0

Average length,65

Umbilical

Cord.

421

"W^e other

have data this

one

the
are

length of
wHch

the cord

in 92 cases,

in which

all
not

carefullyascertained^thus giving us
fact alone upon its is worth very

only

Kttle,but
a parison com-

enabling
the

us

to

decide

importance by
In
20

with
cases

other of

complications.
the

of
the

these

92

length
56
cm.

funis

is less than other

normal

average

of

; whilst
cases

in the

72 it is above
is very erable, considthe
cm.

this, and
over

in 35 70

of these
cm.

the
the

length
average

;
cases

so

that

length of
65
cm.
"

cord

in

these the

92

of

prolapse is
I

longer
item
seem

than

normal
a

average cai'ef ul in

accept.

This

is

an

which
to

claims of

consideration,and
the

would
us.

be

importance
so, and

question

before

Yet

this is not

shall
an

justifythis apparently
of the
extreme
we

paradoxical assertion by
cases

examination

of
our

very
cases

long
of

and

very

short

funis which

find

among I may of such

prolapse.
a

call certainly
we

funis of
in 10

over

80
cases

cm.

very
we

long,
a

have

18 ; but

of these

find

formed de-

and pelvis,

this,as
and

I have

repeatedly stated,I
of

consider

the

primary

pre-eminent cause
8
cases

the prolapse
the prolapse
a

of the
of
an

funis ; in the other

in which

uncommonly
find
as

long cord

took

place in
cross

normal

pelvis, we

in 5 instances
we

footlingand

tions, presentathe lapse pro3

which,
"

have

seen,

greatly facilitate
even

only

vertex

and presentations, other

these

vertex

presentationsshow
very
we

complications
a

which
In
one

tend
case

much
a

toward very small

producing
foetus ; in

prolapse.
head

have

another,a premature
was

rupture of the membranes

in the fast pelvis, upon

while
the

the

still high

brim

; and

in the

third,a

422

Engelmaitn^

Prolapseof the
uterus,as proven

condition pathological

of the

by the

that there see preceded ; we is not a single be said instance of a prolapse which can of the cord, to have been caused by an abnormal length its occurrence. facilitates though this undoubtedly To

difficult labors which had

these

we

must

contrast

the 6

cases

with

an

usually un-

short
we

of cord,

find 2 normal
one

less than 45 cm., among which both with vertex presentations : pelves

in

instance the foetal head

remained

in stationary

the

for some which prestrata of the pelvis time, higher vented of the thus close a nd sioned occaa cervix, adaptation the prolapse a very short cord ; in the other even down without
to
me

came

any serious

cause.

This

seems

sufficient to prove, what

am

that great length of the i.e. convinced of, thoroughly funis is by no reason the causes, to be classed among in but that, with a direct bearing upon the prolapse, it may be looked connection with other circumstances,

Although upon as an item favorable to its occurrence. is of the funis in cases of prolapse the average length a short funis is by no means a congreatertlian usual,
'

and an uncommonlylongcord tra-indication, itselfcause An

will not

by

with

prolapse. item which is frequently mentioned in connection is the coiling prolapse, of the funis around the
as one

neck of the child ; is an coiling

seen

of the main the in

reasons

for this
we

undue
rare

of length
occurrence

which cord,

have

pect we prolapse, may exaround than usual looped to find it more frequently and this proves to be the case. the neck of the foetus, of the cord is mentioned in a number of the Coiling
no

to be

_J

424

Engelmann

Prolapse of

tke is still
womb it

vertex

presentation, yet
and pelvis,
to

the

presenting part
segment
amniotic
the

high
so

up

in the

the

lower

of the

little conformed

it that

fluid,as

capes, es-

drags
The
even

down

with

it the funis.
is
a

rupture of the
at
a

membranes

dangerous moment, fully dilated

the
waters

time

when

the

os

is

more

and
are

the

presenting part
and
cause

farther

advanced, if

abundant
The be
women

escape

suddenly. bursting of
the sack will

of

premature
severe

found of

either the

in the

physical exertion
are

to which to

working
of

classes

subjected up rupturing
the
in chronic

the

very

commencement

labor,so

branes mem-

by simple
of the

mechanical
and

strain,or
seem

tions affecthe them

vagina
as

cervix,which

to corrode

membranes,

it were, I have

by

their secretion
upon per

and

make in

less resistant.
cases,

notes
over

this

point
the

128
^-

in 65 when

of
the

which,
os was

50

cent.,the

waters

caped
silver

not

dilated
4 cm.,
a

beyond
very
rare

size of

or half-dollar,

about

occurrence

in normal The

labor.
cases

greater part of these

naturallybelong
cii'cumstances accidents.
has been said
are

to
so

the

out-door
to

department,
the in
occurrence
a

where

favorable To

of these words
causes

review

few
as

what of

about
seen

the foetal

appendages
to

prolapse, we
of the

have

that, disregarding placenta praevia,the

the

adhesion
uterus
"

of

placenta
the

the

inferior

segment
upon

perhaps
of

the insertion of the funis

"

the lower

margin
cord,
the

placenta
the

and

an

unusual may
means

length of
tend
to
cause

the

especiallywhen prolapse of

concomitant, cord, but by

no

to

favor

it directly

Umbilical

Cord.

425

more

dangerous
seems

than

any

of the circumstances
membranes

here

tioned, men-

to be

the rupture of the

at

an

early period
The
causes

of labor.

of from
or

prolapsewhich
the foetus and

we

have

so

far

discussed,
either
to the

emanating secondary

its

appendages, are
we now come

of minor

importance ;
due

chief andprvma/ry
ni.

causes^

to the

maternal

parts.

ABNOBMniBB

OF

THB

WOHB.

To

begin with
these

the less

important, I
and

shall first consider

the

abnormities
even

of the
are

shape
cases

positionof

womb,

as

in most

only secondary changes ; as produced by

in
a

malposition pendenSy
the of

of the uterus
was

as

the

venter

jproamong

which of the
H.

observed

few

instances

M.p.
the

poorer
more

classes in the

out-door

department
with
a

L.-in

frequently,in
and hand
a

connection

deformed
The

pelvis.
venter

propendens, mostly
go

the
in

anteversio

uteri from selves themfavor

tex ver-

gravidi,
their
most

which

hand,

aside

frequent
to
cause

cause,

deformed in
so

in pelvis, far
as

tend
transverse

prolapse
the

they
even

and

shoulder

and presentations, descent of the of the

in

retard presentations The

head.
the
door out-

repeated department

occurrence

prolapse in
normal

among

mth multiparsB,

pelvis
to
us

and

full-sized
a

foetus in vertex

presentations, proves
diminution a itself,
this accident.

that

flabbiness
power,
are cases

of the uterus
may

of its

muscular

provoke

They
the

in which

the organ

has been

weakened who
work

in laboring by frequent child-bearing women

to

last;

unable

to

nurse

themselves, they barely

426

Engelmann

Prola/pBe of
hours

the

keep again
in the

their
take very

bed up

for

few
a

after

deliveiy,

and

work

with

tender, impressible

uterus,

beginning
most

of involution. endometritis the

out-door colli
cases^

So

also uterine

diseases,of which

is found

frequently
its close
"

among

destroy
organ,

the

and elasticity
render

muscular

of contractility

the

and

adaptation to
effect of
as

the

presenting

part impossible,
weakness
or

^the

same

is

produced by

entire cessation

labor-pains.
"

Lahor^ains.
Normal in 62

One

Hundred

and

Eighteen
58
cases.

Ceases.
Pains

cases

in pathological
40
cases

weak

or

ceasingentirelyin
in 16
cases.

spasmodic, powerless
in which
were
nor

contractions Thus the

we

find that in but of the

62

of the 118

cases

character in
a

is given they labor-pains of

mal,

few

instances
of
to

great intensity ;
in the
other

the
56

gical patholocases was

condition

the

pains

mostly owing
of the
"

deformed

pelvis,malposition of
membranes,
this
as or

the

foetus, premature womb,

a so

rupture of the
that
we

disease

must
"

consider
as a

cation compliof mity abnorwith

form

concomitant

rarely
with

primary

cause

prolapse. Equally
in

often the

malposition, an
uterus

shape
the
or

of cord

pregnant

is linked
the

prolapse of by
a cross

; either the

loss of

ovoid
the

shoulder

presentation,or by
a

unusual
foetus
or

expansion
Twin
we

of

the

womb

plurality of

hydramnios.
cases
are

; frequentlycomplicated with prolapse

our

find 15

upon

1 twin records,i.e.^

case

among

Umbilical

Cord.

427

cases

of

prolapse,whereas

the

usual

ratio

is

about

1.80.

In three of the four in

eases

of twins
was a

treated

in the

Lyingin all any

;
so

Hospital
we

the
a

mother

patient; lying-in
without pelvis, before foetus
as

four
of that

have

well-formed

normal

the
we

pathologicalconcomitants
may
cause

mentioned
the

look of

upon

the twin

cated uncomplithe fourth other

with prolapse,

the

exception of
we

case

of

lying-inpatient,in
favorable
to

which

have the

cumstanc cir-

the breech

prolapse in length
the

transverse

position of
child, and,
and
Of

one,

and

the

of presentation

the other

if

we

will add

in the

of the

cords, 70

74

cm.

respectively.
eleven twin-births
in
a a

the
one was

among

out-door

cases,

only
is

observed
with

and lying-in patient,

but

one

complicated
the

deformed

pelvis;
the

whilst

in two lapsed. pro-

instances

cords

of

both

of

twin

children

The

reason

of the

tendency
action
;

to

prolapse in
power

twin
the
a

births

lies in the
due
to

diminished

and
we

of

uterus,
twofold
uterus

its unusual
"

distention
the other
one

have

in fact

disproportion enlarged,on
somewhat All this
we

on

side the foetus and

cavity of
its

the

the

the in
true

presenting part
in hyd/rcminios^

smaller
also have the

than

singlebirths.
for
cases

holds

of

which
with and

farther

complications,in
which
the the

the

difficulty position,
of

which
in the

presenting head
space
to

finds its proper

ample

superabundance
of

amniotic heavier
I may,

fluid

offers

descent

the

specifically

funis.

perhaps,

add

that not

unfrequentlyhydram-

428

Engelmakn

Prolapse of
twin foetus.

the

nios is found
we

with conjointly few

cases

Unfortunately
as

have

but
cases

of

hydramnios recorded,
not
come

the

out-door tion
until

frequently did
the of
escape

under
;

obsei*vaamong the

after

of

the waters
treated in but

sixty-threecases Hospital
of these
seem we

prolapse
of

the

Lying-in
in
one

have does
the

three the

hydramnios,

only

cases

superabundance
circumstance condition
of

of amniotic

fluid

to

be

only

leading to prolapse
abdominal

(Case
and of

41.

Healthy

parietes
.

the womb,

normal

vertex pelvis,
an

presentation of
cord of
64
cm-

and well-developedfoetus, with normal

umbilical

insertion).
IV. FBBMATUBB LABOB.

will

finally mention
of the
and

the

comparatively frequent
deliveries
where

occurrence

prolapse in premature
foetus
are

both
to

uterus

in

an

undeveloped state, unfit

which
find

enter

upon

the each

normal other
;

relation
we

they
a

should

sustain

toward of the

mostly

premature
of
a

rupture

membranes

and

malposition

quently fre-

but

of

fact theoretically, interesting little practical importance ; thus of the premature

lifeless

foetus, an

births
even

here in the

enumerated,
sixth month.

some

were

in the

seventh, one

Of

the

twenty-eightpremature
funis

labors

in which far

pro-

lapse of
number which
labor
us a

the

occurred, relatively by
were

the

largest

(twelve)
is induced

observed

in

the

Lying-in Hospital,
cases

quite natural, as
on

in many

premature

was

account

of deformed

pelvis, giving
have

complication of
part
true

circumstances.

It is in

of premature

deliveries, as

we

Umhilical

Cord.

429

seen

it to be
have

of
been

so

many accused

other
of

of complications

labor of

which the
a

causing

the

prolapse

funis, that

in

tracing the
of the
cause

evil to its
osseous

originwe

find

pathological
canal
as

condition

vic part of the peltrouble.

the

primary
V.

of aU

PKLVIS.

That the

the

pelvis
the

and

its abnormal in

deviations

is of theories evident careful

highest importance regard

and
to

our establishing

with

prolapse,
a

have

made
and

enough,

it claims all the been

most
as

thorough
it in

consideration,
has

more

considerable
to

tance imporcausal

always
to

attached in
a

its

relations
way
"

the

prolapse, but
them.

vague

and

careless
or

^general statements
to

without It is

measurements

numbers

substantiate of the

owing

to the

ful care-

records
exact

Berlin
of the

Lying-in Asylum pelvis

need
so

and

the

measurement

conscientiously
am

taken
to

in

every

single instance, that

facts,
and
not

here

enabled
to

deal

with

limit

myself

theories.
The of

laws
the

here

expounded
of
we

are

the

well-weighed
the data"

sult re-

study

160

cases

of

prolapse of completely

funis, pelvic

concerning which

have
62

all the

desirable

dimensions, etc.;
cases
were

of in the

these

recorded
maining re-

observed
98

Lying-in Hospital,the
cases.

among

the the

out-door

In

determining
dimensions
are

capacity of
used,
and

the

its pelvis,
.

nal exter-

here

I must

necessarily
still in
to

say for

few

words

in

explanation of this, as, unfortunately pelvimetry

almost

child-bearingwomen,
in

is

its
our

and infancy,

this

country

untaught;

430

Ekgelmakk

of ike Prolapse

shame be it said, that the average accoucheur is entirely innocent of a science upon which the life of mother or
child not The

is the

unfrequently depend. of the pelvic with the finger exploration cavity in this country and in England, method practised
an

whenever

attempt is

made

to ascertain its dimen-

to determine irregularities sions, upon the

as

inner

surface,

When of the diagonal length conjugate. it gives the skilled examiner,and to executed, properly of the pelvis him alone, a very goodpicture ; it is rarely

well

as

the

and is definite,

of little value

to others ; it cannot
:

be

recorded and precisely concisely internal

measurements post-mortem

very different are the of the pelvis.

have always been made; but explorations of the pelvis I have confined myself for a classification to external measurements,which can be more thorough]/ made and recorded, and afford us a very good estimate of the cavity. Internal The ineasv/rements
1. The

givenare
the

distance between

the periores,

inferiortransverse

iliianterioressuspinaB diameter (inf. transv.)

cm. or

which in the standard

2. The

is 25 pelvis

9 J''.

distance between

the cristaeiliiat the widest

transverse part of the brim, the superior

diameter
or

in the transv.), (sup.

3. The

standard the

28 pelvis,

cm.

lOV

"

of the spinosus last lumbar vertebra to the symphysis, the antero-pos20 terior diameter (ant. external conjugate, or post.), distance from
processus
cm. or

^\'\
the diagonal to determine, possible conjugate,

4. If

432

Engelhakk I

Prolapse of
not to

the remain
satisfied but in

but distortions,

beg

the reader

with each

the

general distinctions
case

given

in this

table,

individual I.
160

to refer to the

pelvicmeasurements
normaZy
19

in Table Of the

pelves,I regard
above both

65

as

i.e. the
cm. or

external
more,

diameter antero-posterior inferior above

transverse

being
25 cm,,

the

the
22.5

superior
or

transverse

28

cm.

oblique
to theib

over,

Tab.

ni.

Pblyes

clabbbd

according

Antebo-fostkrios

DiAMETBB.

External

antero-posterior

diameter

in cm.'

Na

of

pelves.

peroCTt.

-" ft

19

andJ than

^ over
over

20 go ^^

10 54 80 10

10.0 33.8 500

-J^g

i i

70 90

43.8p.c 56.2p.c.

Leee

10

j ,^^1^^

6.2

and

the

pelviccircumference
be

89

cm.

; 16

of these

must,

however,
the

grouped separatelyas moderately eidarged^

whose
posterior antero20

pelvis sequabiliter justa major,

is above
cm.,

with

the transverse

diametei^

enlarged. especially
The
are

way

in which among

these
our

moderately enlarged pelves

cases

distributed and
I

of

prolapseis

istic, character-

might

almost

say self-explaining.
we

Only

two

in whom belonged to primiparae,

and

must

ness expect the firmthe effect

of elasticity

the
"

tissues to counteract ^these two affords

an

of
were

very

spaciouspelvis ;
births, which
among the

exceptional cases explanation of

cases

twin

the

prolapse;
many

remaining 14
very

of

multipara, mostly

of them
cross

having

borne, we frequently

find the

have footling presentations ; and here we simple explanation of the conflicting opinions ex-

and

Uhibilicdl different authors

Cord.

433

pressed
both
to
an

by

"

^as

is

so

often
error

the

case

"

parties are
others

the partiallyright, of the

being
If

due

incomplete study
consider

subject.
of the

Scanzoni

and
a

the
to

moderately enlarged pelvisas

funis, they
are

contra-indication
in
so

prolapse
the

right
formed
passage

far

as

the

pretematurally large,regularly
same

pelvis
of
the
as

affords normal

advantage
in
a

to

the

foetus
standard

vertex

or

breech
cannot

presentation
be called
a

the

pelvis (yet

it

[if there is too contra-indication) disproportion between pelvisand cranium, as

of

great
in
cases

premature

delivery
"

or

unusually
other

small

foetus and

enlarged pelvis] ; opinion,

the and the
causes

on

the

hand,
in

the

contrary
of
of

that of

the

moderately enlarged pelvisis one

cases

is justifiable, as prolapse,
an

cross

or footlingpresentation,

unusual
or

extension

of

uterine

cavity (hydramnios
circumstance
I

twins), then
to the
occurrence

it is of

certainlya
the the
As

favorable
can

prolapse,though
causes.

by

no

means

class it among

standard
19 cm.,

with pelveSj
20 cm., 49
"

an

diameter antero-posterior dimensions

a

between
I have and
even

other

corresponding,
"

enumerated
among
to group

less than
are some

third

31

per

cent.,
been
ternal ex-

these there under

which
reason

I have of

forced

this head

by

their

dimensions,although abnormity
the present
as
on

I veiy

much
or

suspect
let this

some

account

of

difficult
;
we

labor lingering
must

in

or

previous births
me

pass,
cause

it is

impossiblefor
Pelves.

now

to determine

the

of the trouble
2.

ContTdcted
28

"

^We

now

come

to the consider-

434

Engelmann

Prolapse of

the

ation

of the

largestand
/ and imder

most

important class, the general head

those I less than of the
19

tracted con-

pehis
whose external

this
are

place

all

dimensions

dard stancm.,

whose pelvis, be

anteroposterioris
or

less than

they distorted
59

simply(uniformly)contracted.
pelvesmeasured
in the per
cent
are

per cent those

of the 160
observed

contracted per
cent
are

among

the
62

L-in

H.,

52

contracted
door in the Even
cases

(33
show

among
63

whilst births), of
contracted

the

ont

pelves (62

98

deliveries).
if
we

bear

in
on

mind

that

of

the

13

cases

ported trans-

inter into the L-in

partum^

account

of most

complex labor,
a

H., most
even

every

singleone

exhibits
account

highly
of the
on ac-

contracted outdoor
count

pelvis;

taking into
some

that made

measurements,
of
an

were

merely

evidently deformed

nevertheless pelvis,
a

the
one,

number

of contracted
we
can

pelves remains

very

large
mind

which

to only appreciate in recalling

occurrence

the

comparatively rare
Michaelis, in
describes
72

of the contracted
work
on

pelvis. pelvis,
has served ob-

his excellent
cases

the contracted which

he

of

this

deformity
"

among

liveries 1,000 deliveries, ^Lying-in Hospital de; this

be it remembered in about 7 per

cases

gives a
"

contracted

pelvis
we

cent

of

the

cases

6 per

cent, if

regard dis-

brought
the
a

inter

partum

into the
of

institution. which
is

Although supplied from

may
even

Lying-in Hospital
rather I
am

Kiel,
of

greatly from country suffering

a

rickets,

show
think

large

number

contracted that about

pelves,I
7 per
cent

that

in saying justified

of the the

women child-bearing

in the possesses

northern
a

j)art of

European

Continent

pelvis

Umbilical

Cord.

435

varying
the
term.

so

mucli

from
of

the
a

standard

as

not

to'

permit
at

ready delivery
the

well-developed
is obtained

foetus

full

About

same

result

by
hei

Dr.

C.

Martin

(^Zur Kenntniss
who finds among

der

Engen-Beckens
somewhat

Geharendm)^
in the 7 per
19
cm.

2,034 pelves measured

Berlin

Lying-in Hospital, 135,

with
we an

less than
less than

cent.,
If
an

external
to

of antero-posterior

add

these

the

oblique and
of
over

nan'ow

pelves with
cm.,

diameter antero-posterior contracted also reach

19

the

number H.

of
will

pelves
7 per

observed

in

the

Berlin

L-in

cent.

Notwithstanding
malformation,
we

the

very
as our

rare

occurrence

of
in

this
labor
59

have,

tables contracted
one

show,

complicated
per of
cent,

with
cases

prolapse,a
12

pelvis in
case

of the
to

(thisgives us
cases

of

prolapse

the

funis

every

of

labor

complicated they
sively conclumain
a

with

contracted say
no

pelvis).
more

I need

; these

facts

suffice ; be
one

prove
causes,

the contracted well

as

pelvisto

of the

directlyas by
to

of indirectly,

the

prolapse ;
for the

truth time

which, though, often surmised,

proven the the

is here

first

logic of
dates
16

numbers.

According
of

of the

L-in

H., the frequency

contracted
all in vertex

the

prolapses is
normal
we

times

greater in the
it is above

than

in the

and pelvis, shall

as a cause

presentation,as pelvisasserts
We
as

see,

that

the

pathological pelvis
to

itself
so

of the

prolapse.
contracted in order

have

far with

only
the

considered

the

contrasted

standard the

; but

fully
"

understand

its

bearing upon

dystocia in question

4"36

Engelmakn: mechanical

Prolapse of
"

the
\he

purely

one

^we

must

study
forms

frequency
the pro
95

of

the va/riou8

contractions the
a

and

distortions

to which

as pelvis is subject, cess

different
very

affect Of

the the
or

of

parturitionin by pelves,
24.2

different way.

contracted
per

far the

largestnumber, 69,
called

72.6

cent., are

contracted,jlattened antero-posteriorly ves. pelper

23,
these

cent.,I have

simple contracted
the flattened

it is often but

difficult to separate from

of them
are

pelves,as

few

uniformly simple strictly antero-posterior being

the scope in

contracted,the diminution

in the
than

usually somewhat
and it is

more

other
which

diameters,
I

owing

to

this

unusual

give the
are so

simple large.
The
our

contracted

pelvisthat
is

its numbers

here

oblique pelvis

rare

distortion;
have

and
2

among

number

of contracted

pelves we
as

but

which
show
a

are

distinctlycharacterized
difference
diameters. In
a

which such, i.e.^ dimensions of

considerable

in the

their

lique ob-

number

of

instances
noted

I find

lateral
of

dislocation
found made

of
in
more

the

promontory

This

was

course

the

digitalexploration of
the

the

pelvic canal,
of
the
are

especiallyfor
and

determination the
statements

diagonal
too

conjugate; unfortunately
as

eral, gennot

the

external

oblique
am

diameters

do

show such

sufficient variation,I

not

in placing justified have

pelves

among their

the

oblique,but

classed

them

according to
dislocation
But
was
one

external

diameters,mentioning

the

of the promontory.
na/rrow
"

^transversely compressed
this is

"

^pelvis

found

complicating prolapse;

clearlymarked

Umbilical

Cord.

437
and the

as

such
the

by

the external
as

dimensions,
as

conditions

of

present
prove

well
have

the been

birth history of previous childa

it to
that

serious

obstacle.

We
most most
plicate com-

have,

seen

the

flattenedpelvis is
; not

for

us

the

important
common

of
of the

the

contracted

only
the

is it the

malformations
also in
a

of

pelviswhich
average

prolapse,but
most

general

it is the

frequent of
was

the

pathological forms
who

of the
finds

pelvis;
70 him
a

this
cent,

first the

proved by Michaelis, pelves

;

per
to

of

72 contracted

described
my per result
cent

by
is
of

be

contracted .antero-posteriorly
one.

very
95

similar

have

shown

72.6 with

the
be

contracted

pelves complicated
enumerated
very
as

prolapse to

tened flat-

; I have

flattened

pelves only
diminished

those

which

were

decidedly compressed
those

teriorly, antero-posin

excluding
all

pelves which,
more

diameters,

were

somewhat

contracted
me

antero-

and posteriorly,
the

notwithstanding placed by
"

among

simple

contracted
more

which the

in their

general pelvis.

features We
see

they
that

resemble among the per

a

than

flattened

contracted
cent,

pelves complicated
flattened

with

lapse, prothan

of

pelves is greater

ordinary ;
the
narrow

fact
nor

which
the

as readilyexplainsitself,

neither

simple

contracted

pelvis provided
"

that the diminution

cause
as

in their diameters

is but
normal

moderate descent

"

much

obstruction
as an

to

the

of

the

presenting head
if

antero-posterior shortening.
between and the the
transverse

Even diameters
the

the
of the but

disproportion
fcetal cranium

conjugate

of

pelvisis

the slight, with

head its

descends, the

vertex

as usual, but presenting

diameter longitudinal

438

Ekgelmann

Prolapseof the
the head position of the cavity entering

in the transverse is held fast for the

of the brim ; in this

some

time before

pelvis ; itcannot descend upon the os and the cervii though its elements be strong and active; cannot fitto the fcetal part held fast adapt itself and closely oval mass so highup in the pelvis ; the comparatively of the cranium, placedin the transverse axis of the brim or superior of a flattened pelvis, part of the cavity leaves the sacro-iliac fossae unoccupied, and this is the in which the cord glides locus minoris resistentiae down. number 60 of the 69 flattened By far the larger diameter of pelves have an external antero-posterior
" " "

9 are so very much remaining their antero-posterior contracted, being less than 17 for the prolapse cm., that they lose their importance of the cord the life of the child being by endangered other and more serious complications. I should liketo to the CBtiology add,with regard of the flattened j^lvk^ of scientific than of practimore thoughit is a question cal i n this that among the 69 antei*oimportance place, in 28 the distortionis posteriorly compressed pelves, the result of rachitis. This leads me to an clearly opinion contrary to the one expressed by Michaelis, vrho takes the pelvis mon complanaDeventeri to be more than the pelvis plana rachitica. The 28 flattened which I have called rachitic, either such as are pelves show the characteristics of the rachitic pelvis in a ver/ marked in which it is especially way, or theyare cases stated in the histoiy of the mother that in her childhood she suffered from the as this Englishdisease,'^ affectionis popularly termed in the north of Germany.
cm.

from

17 to 19

; the

"

"

^^A

440

Engelmaj^n

Prolapse of
to
us

the PresentcUion.

3,

Melationa
to

of
Table

the

Pelvis shows

the

"

Reference

IV,

that

by

far

the

greater part, 78
occurs

per

cent, of
with
head

the

contracted

pelves
the

in

combination

presentation of
breech
22

foetus;

transverse

shoulder in the

and

presentations
per
cause

are 1x)gether

found

remaining
that

cent.

It

must

be

understood distinctly
is not head
to

the
an

of

this

combination
nimiber
more

be

looked
"

for in

overpowering
that
we

of
head

presentations
have that

^itis not

have

presentations
we
seen so

combined
many little
more
over

with head

contracted

pelves,because
We of
our cases

tions. presenta-

have of

half,57 percent,
the head of the

prolapse
the
in

were

with

foetus almost
stress 101

presenting; equal
upon them

other
number.

presentations combined,
If
we

lay
the
in

the

main

the

presentation, we
73.3

shall
among
"

find that
160

of the
sured mea-

head

presentationsobserved
"

pelves,74
with

per

cent

occurred of the 60
cent
are

tion combinaof all

contracted

whilst pelves,
35

cases

remaining presentations only

malformation the contracted
in
cases

per

linked
shown

with
that

of the

pelvis.
found
we

I have with
now see

before unusual

pelvis is

frequency
its

of

prolapse,and
as

that it attains of

highest importance
head who head cord with

primary

cause

prolapse
to

in

presentations ;
was

fact

known ali^eady
the

Michaelis,
of
849

led

to

the

conclusion,by

study

treated presentations in head

by him,
ten

that

prolapse of
more

the

presentations was
than been

times

frequent
7
cases

contracted

with

normal

pelves; by
him

of
776

prolapse having
cases

observed
7 among

among

of normal

and pelvis,

73 contracted

pelves.

Umbilical Here
cause

Cord.

441

the distortion of the

of the
but

pelvisis
are

in itself the direct

cases

prolapse;
to

there

other
about

in still,
same

whicb.

it tends
I refer

to bring indirectly

the

mis-

liap.

the venter
of the

propendens, to
uterus

the
so

tions malposi-

and

deformities
the the

which

frequently
themselves
The fact

complicate again
that favor

contracted
occurrence

pelves, and
of the

in

prolapse.
so

malposition by
should

of

the

foetus is

frequently engendered
of
no

contraction
be inclined
us a

of the
to

pelvisis
of

great weight ;
this

we

lay some

stress two

upon veiy

point,

as

it

gives
of

combination

important

causes

prolapsa
here
the in

Though they

each-is

dangerous in itself,
from

when
I

concomitant
must

lose in effect
a

diverge
have
I

moment

my

subject to
a

establish

point I
which

justtouched
that

upon,
concur

disputed
in

question
views foetus than
case,

most

thoroughly

the
the

of Michaelis, who
are

says
more

malpositionsof
found
to be

by

foui* times

frequent with
this I have held

contracted the

with

normal

pelves ; ground

contrary
that

to the

by Naegele, who

tains main-

such

positionsare

never

brought
Pelvis

about

by

distortion
4.

of the

pelvis.
the Cont/roGted
wpon

Injluence of
in

the Prothe lapse pro-

lapse

Lp.

and of

Mp.
the

"

^We

must

consider finally
in
cases

distribution
among

contracted

pelves
is

of

primiparsB and
a

as multiparsB,

I must

here

again
with

refute that

theory

which

quite freely accepted,

but

namely,
that it upon

the

contracted

pelvis has
the
cord

little to do

causing only
the

the

prolapse of
of the second

among

LparsB,

attains its full

importance
child.

in this respect

advent

443

Engelmann

FrolapBe

of

the

Umbilical

Cord.

Now,

we

naturally
statement

inquire,
harmonize

how

does

this
data ?

commonly
What
are

accepted
the

with

our

facts

Per

oent.

Per

oenL

Among

44

T.p.

we

find

80

oontr.

pel.

68.2

44

Lp.

30oontr.peL

=68.2

"

65

M.p.

"

85

"

=58.8^^^^^-^

-^

Only
cases

27.5

per

cent,

of

the

160

women

in

labor

(our

of

prolapse
these the
come

with

measured

pelves)
per
cent

are

primiparae,
contracted

and

upon

31.5

of

the

pelves, large

same

quantity
of

which

is
32
"

distributed
cent,

among

number and

secundiparsB
in
cases

per

of

the

160

prolapses;
in

of

prolapse
is still

among
more

multiparsB
rare

general,
have

the

contracted
of

pelvis
the

;
cent

thus of

we

malformation of
68.2

pelvis

in

56

per

all

cases

prolapse
per
cent

among
are so

multiparse,
affected.

whereas

of

primiparse

(To

be

oontinaed.)

Trandations.

443

TRANSLATIONS.

THE

DIAGNOSIS
REFERENCE

OF

OVARIAN
TO

TUMORS,
OVARIAN

WITH

SPECIAL

CYSTS.*

By

FBOF.

otto

BPIEGELBEBO,

Bredan,

Oennany.

The
of

two

patients,F.
term, and
excellent

and
at

E., whom
the

you

saw

first at the whom you which

ning beginwere

the
are

operations upon
of the Let

present,
attend
them.

instances ovarian

difficulties
us

may

the

diagnosis of

tumors.

recapitulate
for ovariotomy,

F., an

unmarried

woman,

of 44

years,

was

sent
one

to

us

with
ovarian

an

uncertain

that diagnosis,

of

physicianbeing
liver with ascites.

it disease of the cyst,others considering

as

So but

far the

percussion went

the

signsof
a

ovarian

cyst were
that

present,
neither

exploringneedle
nor

gave

doubtful

in result,

chemical discovered

microscopicalexamination anything
as

of

the

fluid obtained

characteristic.

Employing, therefore,the
by Simon, I found
the
a

rectal examination
sac

I'ecommended lately
between of the

of ovoid and

form the small

pressed in
promontory

posteriorsurface
in the

of of

the uterus which

were

sacrum, in

walls

secondary cysts, and

was

which
A

fluctuation broad
On

produced
connected

from
the
was

outside
tumor
more

perceivabla clearly
the

band
the

with

left broad
but
even

ligament.
here

right there
not was,
*

free

space,
the

the hand

could

be

pressed

up

towards

abdominal

cavity. The

diagnosis
the

therefore:
Translated from

segment
the

of

cyst lying posteriorto

Vortrage, No.

uterus, M.D.,

KliiuBohe

66, by

L.

Wheeler,

Worcester, Mass.

444

Transldtioiis.

either the

stronglyadherent

or

wedged

into

the

superior
found

strait

of

and probably springing from pelvis, confirmed essentially

our

the left ovary.

a

otomy Ovari-

We diagnosis.

bilateral
into

cyst, the left portion with

abdominal
recent

long pedicle reaching far

the

up

the

cavity; the rightdivision

smaller,of decidedly more

left

growth, coalescingwith
broad the

portion and
the
uterus

having
; adhesions
*

short

pediclein
and

close

proximity to

with The of

uterus

in the

rightiliac
very

fossa.

patient E. presented a

smooth large,

tumor spherical to

uniformly
and and

elastic structure,

reaching upwards
fluid. The foi-ward and
was a

the

trium epigaswas

into laterally

the limibar

regions.Fluctuation
cervix

distinct, in-

puncture yieldedno
and crowded

of the uteruB

was

drawn
uterus

upwards
and

to the left. Behind

the

rather to the

there left,
into

round

smooth

ment segand
way

of

the tumor that it It

pressed down
was

the

pelvis so

deeply
by
it

immovably
of this tumor,

impossibleto
therefore
a

force the hand

by

the rectum.

was

impossible to
was

decide

whether
or

feelinglike

soft myoma,

of

uterine it
was

uterine extra-

and origin,

in the latter

case, whether
was

secondarily
more
was

attat;hed to the uterus. from felt from

to

The

decision

all the

sible imposnot to be

the fact that the fundus

the
an

of

the uterus

outside.

Under

these circumstances
the

I determined

make

since exploratoryincision,

patient, a young
her

woman,

wished

by all

means

to be

relieved

of

tumor,

which

her incapacitated

for work. the

You
was

saw,

after
to

opening
the tumor

of

the
either

abdominal
from

cavity,that
or

unable

separate

the uterus

from
and

the left abdominal

that I was,
not

from wall, i,e,y

the

parietalperitoneum,
to close

in consequence, determine what

compelled
the

the

wound,

since

I could
meme

difficulties of the
in

extirpationquand
that the

might be, and

afterwards, we
as

during
remained
the

eight weeks just as

patient

lived
ever

great uncertainty as

to

the

originof
made

tumor,
the

notwithstandingthe frequent
When
the

examinations poor
woman

during

secondary illness.

died finally

of marasmus,

followingintra-peritoneal

Diagnosis of
retrovaginal suppuration and
the left
the it side,
was

Ova/rian
the

Tmnors.

445

development of phlegmon
autopsy
room,
as so

on

even diflScult,

in the

to separate

foreign mass
its sole

from

the

pelvicorgans
the the

to

be

able to of the

demonstrate

originfrom.

uterus, its invasion

parenchyma
of
Cases
means

of

the left broad

ligament,and

tion non-participaby

both

ovaries. the This

in which very
rare.

diagnosis thus
may the
seem

perplexes us
to you

are
view

no

strange

in
tumor

of the
is made

certainty
in other

with cases,

which and

diagnosis of

ovarian

of the

examination superficial

upon

which

it is often

based. of you
may,
as

Many
no

perhaps,

tliink

certain
as

diagnosis of
ment treat-

great importance,
to

it is all the
the

same,

regards the
a

be the

adopted, whether
uterus, there
certain
a

patient has
to

tumor

of
in
a

the

ovary
case.

or

being nothing
is demanded

be may

done
be us, and upon

either

Under
but where

circumstances
cure

this

proper omy ovariotour

view,

radical
the

of

desired,then'
answer

diagnosisis
Indeed

the element
it
was

which

essentially depends.
the

justthese
and

difiiculties
no means

in

diagnosisof
of the

abdominal
in

tumors,

the

by

rarely resultingmistakes
the
way

which operating,

for years
as a

stood

in

acceptation of ovariotomy
various methods
come

legitimate

operation.
Let
me

then, the recapitulate,

of which You
you will

of examination
a

by

means

be able to
in

to

clear of

standing. undercases

will

find

that alone

the

great majority
of intricacy the

these
at

difficulties exist not

in the
on

in the
as

question
I
am

issue,but
to say,

lack

of

care,

well
I

as

knowledge,
shall ovarian

sorry
manner

the

part of

observers.

not, after the

of
will

books, detail the different

rather
take.

signs of
the
will learn may bo

tumors,
the

but

follow
has
to

the
In

course

which you
tumors

physicianat
and have

bedside

this way ovarian

all essentially been

the conditions mistaken. For

for which

instance, a

patient comes

to

you

who,

on

account

of in-

446

TransloHana.
size of the and
tumor

creased
ous

abdoraen, with abnormal

symptoms,

resistance herself
to
a

and

van

unusual

troublesome
and is will

believes

to have
one.

an

ovarian
your
at all.

suspected by
be
to determine

her friends
whether

have
tumor

Here

first task

ists ex-

You

will

arrive easily

at

an

affirmative
mass

answer

to

this

tion quesfrom the

on count ac-

when the

you

find

well-defined It is very

separated distinctly

neighboring parts.
is not

different, however, when

contour

and distinguishable,

palpationis
of
no

fruitless

of Here there

tenderness, and
may be
a

the

tension

the
means

abdominal

walls.

there
are

cyst, but
in
a

by

for necessarily, with

a

two

conditions

which, particular,
cyst that they are
ascites. ascites is the
tumors
more

superficial

examination, so resemble
for
viz. it,
:

not

rarelymistaken frequent error,

tympanites

and

The
as

confounding of cyst and

ovarian

would

naturally be expected,both

being
appear
the

fluid.

The

mistaking of
to you,

cyst for tympanites

when I tell you

will

ble inexcusahas

perhaps, but
to
a men

that

mistake
may

happened
therefrom of others. abdominal

of

the

greatest experience you

severe

gather

warning against too

criticism

of the failures

Simpson*
walls

mentions

six

cases

of incision
and
names no

through the
tumor
was

where

tympanites only
I

found, and
neuve,

in this connection

might

cite the and

a

of MaisonI have

Lizars, King, Smith, McDowell,

had
two
cases

Dolhof.

myself
of of the
are

of
to
me

tympanites, and
for

still

larger number
the it

pregnancies sent deception is

case

ovariotomy.

Indeed

danger
does, in
walls

not

at all

remote,

arisingmostly, as
distended

of
tense

whose hysterical subjects and

as hypersesthetic

abdominal

so

to

tion. palpaprevent satisfactory

in the abdominal

In

such
of

it is

impossible to
no

press

walls,

and

change

positioncauses
even

alteration

of form.
the

Sometimes
m

singlemuscles, or
such
a

separate portionsof
one

contract recti,

way

as

to

remind

of

secondary

lobes

upon

main

"

The

Works

of Sir

J. Y.

Simpson,

1873.

Vol

iii., p.

426.

448

li'anslaiions.
be

may

rendered
walls.

very

difficult

by

thick

layer of
cases

fat

dominal in the absuch

even

Atlee*
been

mentions

several ovarian
the

where
^^here

masses

of fat have

held

for

tumors,

operationwas
this collection
a

proposed. Especiallyat
of fat oftentimes
as

climacteric both
in the

age

is

enormous,

form

of

diffuse
the

layer and,
naveL away

it

now
masses

and
are

then

appears,

isolated touch.

lumps
The
and be is be

about

Such

elastic to the definite

motion

edges

fade

in all directions
a

without

bounds,
which
may

percussioncauses
mistaken

trembling, swaying
fluctuation. The
since flat, entirely

for

indistinct
or

percussion
intestine

sound
must

dully tympanitic

the

percussed through
exact especially

several

inches

of

fat.

Bepeated
of the

tion, examina-

bimanual

examination after proper of

a

internal of

tal genitestine in-

organs

deep percussion
to the

emptying
; the

the

; attention

presence

general development growths

of

fat,rarelypresent
of the
the lifting

in

case

of abnormal

possibility
regions, points
fluctnais essj

cushion

of fat from of the

the muscular

layer beneath;
lumbar
to

comparative thinness
the fat is

inguinal and
"

where

always
such

less abundant
cases

attention

these

will suffice to make The

clear.

mistaking of
shown

ascites for

only where cyst is possible

the distinction
and be

tion has where

and

the presence
tense

of fluid ; and
sac

the filled and forth

under

can

grasped
be

moved

back
the

the abdominal

walls,or, conversely, where

can

fiuid, being nowhere

in the in lower

sharply bounded,
to

felt to

slop about
change
lection the cola

and portions, the

change
A

its level with

met

every

of position has
one,

is patient. Difficulty

only
smaller

when

become

extensive.
one

large, simple cyst, or

other

ple multiif

of consisting
be thin and

large and
no

members,

the walls is

has flaccid,

defined
a

contour, fluctuation
course,
so

easily produced, and

of

the

waves

take
so

long

that the

existence

cyst

walls

is not

easy

to

distinguish. In such

General

and

Differential

Diagnosis

of Ovarian

Tumors,

etc.

Phila., 1873,

p. 899.

Diagnosis of
cases,

Ovarian

Tv/mors.
In ascites
on

449

the

followingsignsmust
find the abdomen

guide you

you
two

will

generally
the

equallyprominent

the

sides,

lumbar

regions distended, the umbilical

itself is

while flat, relatively

the the

umbilicus
other

frequentlyprominent.
is is
more

With

cysts,on
at least

hand, the abdomen

umbilicus

conical

in

form, or
is not

cask-shaped, the
prominent. unequal,
is
one

and relatively higher, distention than

imduly
is

Not
side

the infrequently

of the abdomen the other.

being

more

prominent

There
be

nothing
the

distinctive in
case, and

enlargement of
account

the veins ;

they may
connections

swollen
with

in either
vena cava

on since,

of the

ample

porta, any hindrance

to the

circulation in (Edema of

either

vessel

causes

distention of the abdominal

be sure,
cause more

veins.

the lower

to extremityis,

frequentin ascites, depending

; still this is
a

generally upon
real

the

same

symptom
of
the

of

no

worth,
on

since

cysts

too

may

cause

oedema

legs by
may exist

pressure without

the

pelvicveins,and
The
most

conversely ascites
are

anasarca.

important distinctions
In ascites

afforded

by palpation and
every flatness while
remain

percussion.
the most

the fluid

gravitatesin
the
area

towards position
on

dependent part, and

the

of

percussionchanges with encystedfluid

positionof the patient,

resonance

with

the territories of

and
no

flatness
what

or approximativelythe absolutely

same,

matter

position

the

woman

takes.

In

the lumbar

dorsal

decubitus,then, supposing
be

the fluid to be

free,the
the

regionswill
will be the brim

dull,and
in
case

the umbilicus

resonant, and

converse

true

of

cyst,since
he

those at least which

anterior

rise above

of the

pelvis

againstthe
and

abdominal

wall, crowding the intestines

in ascites the bowel

upwards

backwards, whereas,
of the fluid.
are

floats

on

the surface

there Still,
it is
even

various

which points ascites

may

deceive. easily

First,
and

by

no

means

infrequentin
is often
a

to find the

rightiliac
is

lumbar
csecum, in its

on region tympanitic,

account

of the presence with

gas,

of
fined con-

the

which

widely

distended

positionby

short mesentery, and adhesions.

is sometimes
now

still then

farther fixed by abnormal

29

Again, we

and

450

Translations.
fold of intestine

find

lyingin
in the its

front of the lower

it is
narrow

anterior and

border
eaii"^

of the tumor,
a

when eBpecially
tone

below,

this

dull

tympanitic
I have

hypogastrium.
also
to the

As

regards
as a

tuation flucin be

mentioned
your

greater distinctness

rule
may

but called ascites,

attention

fact that it
in and
a

equallydistinct
when may very be the

under

favorable

circumstances
are

cyst ;

more, furthertion fluctua-

abdominal
in

walls

thick

fat the

indistinct

and ascites,
be

if the amount

of fluid be

considerable
a

it will

uninfluenced
be

by change of position.
use

Here

point in diagnosismay
at

made

of to which

the
:

late in
a

Professor

Breslau, of Zurich, first called attention, viz.

ceases

cyst fluctuation

the

point when

percussion becomes
sac

tympanitic (lumbar
a

and

the epigastric regions),

wall

ing affordis free

complete separationbetween
cavity,if
fluctuation
it flows will be all about
even felt,

them among
in

; but the

if the fluid intestines

in the

(ascites),
intestine

then

parts where

the

gives a tympanitic sound.

An fail
to
use intelligent

of all these

signswill sometimes, however,

there
is excessive distention be
so mous, enor-

establish
abdomen. the

when diagnosis The

of the

collection of ascitic fluid may

walls
so

abdominal
in
contact

prominent, that the

on

intestine

not can-

come

with
or

them

account

of the
be

insufficient and

length
fluid In

of

mesentery,

the

mesentery

may
a

thickened
amoimt

shortened
the
a

by disease,so that with

intestine
case

only

moderate
wall

of
cavitv. with
a

cannot

reach have with

the

anterior
on

of

the

such

you

might
meet

flatness

as percussion,

cyst.

we Conversely,

ovarian

cysts so large that they

force their way

with arch that

into small

every

available below
so

space, and

crowding
behind

the

stomach

folds of of
tlie

intestine

it into

the left
intestine there

diaphragm,
discoverable
or

and
on

compressing the large

percussion,when tympanitis
lost in the

it is not be

of

course

would
as

flatness

indistinct
not

lumbar
that
a

region,
cyst
may

in

ascites.

It is abo the
result

to be

sightof

contain
or

gas,

as

of

communication

with

the intestine, for

of

decomposition of its contents

(after puncture,

instance),

Didgnosia of
and wall. the
you

Ovaricm

Tv^mors,
the

451

hence Under

may such

arise

tympanitis of

anterior alone

abdominal
can

embarrassments

puncture

reveal As

truth, and
are

this in the great

I hold this to be
not

majority of
one

cases

it will do. valuable

aware,
; and

of the

most

aids to
has

diagnosis
dark side

though
common

devoid entirely
many

of

danger, it
from where

this

in

with

another

diagnostic means.
us so

The

results

of

exploratory puncture* have

that

saved

many I have

dangerous
any
the value

miscakes

I continue

to

practiseit

doubts, notwithstanding the

of the information
to be

slightrisk.

Its

importance,
to proper

gained by turning it
little acknowledged
contents

account

however, is,

in

general so

(forproof

need

only refer
Wells of
in

to

the

description of cyst

given ])y
book;t
to

Spencer
and last that

his

lately published and

a work,:]:

excellent

Peaslee,
;
or

in his

book
so

fullyequal
that

that

mentioned

to

West, who
of

betrays Women,

a slight knowledge

of the here the

subject in his Diseases

to go
more

I feel it my
our

duty
the

into

since details, especially

it is

with clinic,

assistance its

of

Professor

Waldeyer,
of

which

has

brought

subject to
Puncture

present degree of perfection.

be

may

the
the

means

obtainingmost
the

formatio important in-

through
the

partialemptying of
tension

abdomen

and

diminished resulting after this that it is

of the

of

its walls,for it is oftentimes percuss

only
after

to palpate and possible

the
; but

tents con-

abdomen

with
if the

any

degree of satisfaction
fluid has
been

even

the

puncture,
has

dischargeof

small, if deep
down

the tumor
in

or parietal

visceral

adhesions,or

if it lies

the

abdomen, the physical examination

All

may

still be

without the
ex-

practicalresults.

the

more

important,therefore,is
estimates

Atlee

alone

of the
but

more

recent

authors

the which

exploratory puncture
he

at to

its proper
the

worth,
of the of

the

description by Diysdale
researches. their

gives

is not

up

mark

Gterman the

f
1872.

Diseases

Ovaries:

Diagnosis

and

Treatment.

London,

Ovarian

Tumors: New

their

Pathology, Diagnosis,
1872.

and

Treatment,

especially by

Ovariotomy.

York,

452

Translations.
of
Should
or

amination

the

fluid

both itself,

chemically and
decided

inicroecopiother

callj.

such

examination is

give a

whether result,

negative

it aflirmative,

reliable against all absolutely

symptoms.*
The
contents
a

of ovarian

cysts vary

from

vratery light-yellow,
or

clear fluid to
green clear. substance
mass.

dirty-brown tough, colloid, stringy,

Ascitic
to

yellowishof

fluid

is

always thin, and

two
:

comparatively organic

According
are

Eichwald,
cystoma

principalsorts

found

in the

mucin, the so-called colloid

substance, and
so

albumen;

but,

more

pai-albumen, particularly,
the
tents con-

called

by Scherer, of which
the Graafian

substance, by the way,

a

of
This poor

follicles is
is
never

pure in

solution ascitic

(Waldeyer).
is

latter

substance

found

fluid,which

in solid ovarian

constituents

in

general,and, in
a

farther
a

distinction

from

it deposits, fluid, as
states

rule,

copious, delicate
seen

coagulum
from
he
an

of fibrine. Virchow ovarian

to describe

\ that he has

the

fluid
; but

cyst coagulatespontaneouslyin the air

the the

omits

character

of the

coagulum,
fluid.

whether
in

it the also
no

extended usual
manner

through
of

whole

or fluid,

whether ascitic

it formed

the

coagulum

of

Klob:^

mentions

spontaneous

but coagulation of cyst fluid,

gives

particulars.These
Wells

statements,

therefore, to
he

which the

Spencer
presence tioned above-men-

probably refers, when

ovarian in

speaks

of

of

fibrinogenin
fluids. Far
more

cysts, cannot
the chemical

invalidate
constitution

the

difference

of

the

two

important
upon

than

this, however,
I must

are

the

cal morphologisideration con-

differences of

which

lay particular stress, in regard

to

the

false

views pp.

prevailing in
132-133.
we

them. f. of

(Compare Spencer Wells, Gynak., i., p. 421.)

in Schetelig,

ArcL

In ascitic fluid

find

the

endothelium

S. meine

MittheiL
des Ges. 1

im

Aroh.

f. Gynak.,
zu

iil,S. 271-83.

Verhdl.

Geburtsh.

S. 217. Berlin, ill., S. 857.

X Path.

Anat.

d. weibL

Sexoalozgane,

Diagnosis of
the In

Ovarian

l^imors.
from
the

453

peritonseum,
that derived

and

wandering
ovarian of

cells derived have

latter.

from
states

cysts we

cylinder epithelium
of

in various

change, remnants
process

cells, large fat

or

granules, swollen
colloid cells
there the
"

cells in
and

of

paralbuminous, mucous,
element. In
;

degeneration,
and
are

oftentimes

well-preservedcylinder
addition, then, too,

this
masses

is the

most

important

of

detritus, crystals of cholesterin formation, now

of
never

products of
fresh

dermoid
or

and

then red
and

puscles, blood-cor-

changed, masses
cells
are

pigment,
found

pigment
puration sup-

granules.
of Peritoneal

Wandering
the

except where

cyst-wall has

taken

place.
which the

fluid,then, supplies the elements

from
a

would other

naturally be expected
hand,
when
it is

lymph
This

sac

cyst, on
is

formations. epithelial

difference Notice of
the

radical, and
The

clearly present, decisive.

were

the

patient F.

cylinder
its
and

cells

the

only result published

have
a

ination, microscopicalexam-

speaking for
reliability. I have
on

ovarian

cyst,and

the

operationestablished
cases

similar able the

in

the
a

ArchiVj

different occasions
between and and

I been

to make

diagnosis
in the

of communication
a

cyst

and

cavity,or peritoneal
co-existence

complication of cyst
fluid of But

from ascites,

the

same

lymphoid
not

forms. epithelial
the examination is often is not

you
If
a

must

forget that
be thin and

always
to

easy.

the

fluid
time the

clear,it

necessary

search cells often

above

long

before

finding the
examination
a

characteristic also result in which

we

epithelial
time, it is
;

; and

since

chemical

takes

several

days before
that

decided
occur

is reached the need

and,

remember all,
are

cases

distinctive

features
in

not

discoverable.

Where

most

ever, aid, how-

the

diagnosis from
leaves
us

ascites,the

exploratorypuncture
elements
are

very

seldom is

in

doubt, and, if certain

covered, dis-

reliable. absolutely this also

as

Should
rectal

fail, we

have

left

as

last

resource
we

the
use

examination
case

practised by Simon,
It often throws

which

made

of in the

of F.

lightupon

the case, and

454

Trarislatums.

will

describe

it the way
tumor

more

fullywhen
tumors.*
you

speaking
have

of

the

differential

of diagnosis If
you in the
a

various

described

convinced before

yourself
you, then

that you
nates ema-

have
to

and

probably a cyst
it is is not

have

assure

yourselfthat
the

ovarian, i.e.j prove

of
uterine

that For

it

from
tumors

pelvis and

origin.
of the

since gether altothat

can

of

the tube, the

be
same

parovarium, the
from
as

broad

ligament
ovary
in

cannot

differentiated

those

they
and

have

the

basis, and
into
account

tumors
reason

of

osseous

origin
question

be scarcely easy

taken

for

of their extreme
this
one

rarity
to

diagnosis,we
case

have

reallyonly

settle in
*

of
make

tumor
the

of the

whether pelvicorgans, viz.,

more

it is

In order
I hare

to

exploratory panofrnre

accessible and

to

the

pzactifinida

tioner and

placed side by side the comititaents

steps for showing
FLUm.
are one

of oyarian
:
"

ascitic

the

necessary
OVARIAN

their

presence

ASCtriC

FLUID.

Color

and
the

consistence

in

direct

Commonly Anid,

light-yeUow, thin, dear Specific

gi"T-

ratio;
the

lighter the
It

the
a

thinner

slightly sticky.

other.

is generally
or

cloudy,
thick
a

i^y* 1010-15.

whitish-brown fluid
sp.
mass

greenish-yeUow

(like barley water), with

or

gr.

of 1018-24 Chemical

higher.
Ch"mical Fibrin lum
sure

Constituents,

Constituents,

Mucin

(CoUoidstofl,
and

Schleimpeppa-

delicate 12
yery to

jelly-like coaga48 hours'

expo-

ton), albumen,
ralbumen

particularly

forms
to the

after air
"

(metalbumen

albumenpep-

characteristia

ton).

Microscopical Constituents,
Cells of

Microscopical Constituents,
(more
rem-

cylinder epithelium
than the

Amoeboid

corpuscles
in

and

payement
espe-

important
nants

anything
same

else) ;

epithelium, both cially the

latter,

abundance,

of

colloid
mucous

spheres

(swollen

cells

undergoing frequently

generation), de-

cholesterin and

crystals, red
blood

blood
and

corpuscles
in
case

pigment,
on

of

ration suppupus

inner

surface

of

cyst,

cells. The ascites fluid of

enlarged
and

Graafian pure, with

follicles may few

very

dosely resemble elements, but

that of besides

; it is dear

morphological

456

Translations.
and

verted

lying behind
in this way

the cyst,but
obser\'ed

this is it but
tumor

one

of the

rare

ik" It the

sitionsjCruveilhier
comes

having
:

three

times.

to pass

the

ovarian

rising from
then
sacrum.

in pelvisgains a position

front of the
the

uterus, and

growing
The

rapidly downwards
uterus

presses may,
in

body against the

and

tumor

addition,be
be

firmlyadherent.
since the

The

retroversion

may,

however,
the

only apparent,
with

although
the wards. downuterus

the

uterus

lies behind
be the

ovary,

fundus

against

sacrum,

it may

anterior is

surface

which

is directed with axis. the

This

dislocation
tumor

produced when,
on

firmly adherent, the

it Still, is not

is turned

its the

long
tumor

always possibleto
be very

reach folds

from

below slide be
as so

the down

pediclemay
under

long,and

of

intestine

may

it toward

the

pelviccavity,or
or so

again

it may

crowded
to be

against the utenis,

On
a

firmly adherent
it is often the

thereto
case

not

isolated.
of ill

the other

hand,

that the
so

connection
or

uterine

tumor

with

the

womb

is
trace

slight,
it with

at

least

defined, that
now

it is and

impossible to happens
into

certainty. Finally,it

then

that the

peritoneal
brim of the

growtlisor cysts of pelvis.

the Here
are

the

kidney

slide down

the

important
absent
to you,
or

criteria

of

the ovarian
I have had the

nature

of
times
to

disease

either
cases

unreliable.
and you have

several

presented
learn of the
this cases, in the

such

opportunity

of the diagnosis and great difliculty

to be
are

unreliableness

signs held
as

characteristic
recounted in
are

of the different disea"es of

the text-books. In
some

class
to

they

be

sjire, these ones,

signs
you
a

present, often
seen

not, however,

complicated
Let

and
make
a

have

that

it is sometimes

utterlyimpossibleto
us,

diagnosis.
moments

however, for
which
in

few

give our
has
we

closer
to be

attention liable

to to

the

conditions
to errors

experience

shown have

most

giverise
the

diagnosis.As
are

already remarked,
as

the and

principal of these
sometimes soft,

the uterine

tumors, such

pregnancy
and

cystic, myomas,

cysts of the kidney

times I have had

omental

and

peritoneal growths. Several

preg^

Diagnosis of
nant sent patients
reverse

Ova/rian
the

Tmnors.
ovarian

457

to
never

me

with

of diagnosis
to me.

cyst, but

the

has the

happened

This
cases

experience is supported
where the

by
was

existing reports of
and its execution You

several

ovariotomy
occurrence

proposed
confinement.

prevented onlyby
such and auscultation

of

will

probably think

an

error

hardly
ex-

excusable amination

iii these have

davs, when
so

the bimanual
does
not

been

perfected.But they are

it

auscultation
not

ways al-

give decisive
foetal extremities I must
and say when

and results,

palpationdoes
such
must

always reveal
happen,
to

when

there. Notwithstanding, really

a

emphaticallythat
it does
or occur

mistake ascribed

must

not

be

either

the

carelessness When you

have

the

ignorance of the physician.

and external

by percussion recognized
the
a

and

vaginal palpation
tumor

rounded regularly tenselyelastic,

be

from rising

always pelvic cavity,

auscultation you will

of suspicious
able

pregnancy.
to

By

means

of

generallybe

satisfy
If the

or yourself either positively negativelyin regard to

it.

foetus is alive you

sounds be may ; should
to
an

will almost

invariably hear
not

the

foetal heart-

careful
excessive In the

observation
amount

discover

them,

it may

owing
be

of
case,

anmiotic the

the child or fluid,

dead. and

latter will
or

bimanual movable

examination, extremities,
fluid is
dle mid-

external
and

combined,
the the

discover

the

ballottement

head

breech.
not

If the amniotic
advanced

superabundant or
period, it
direct
the

pregnancy easy
to trace

beyond the connection, and

with

will be

the close
tumor

the
of

continuityof
In

the

abdominal

the cervix

uterus.

the first half

of

pregnancy
can

the
be

anteslightly

verted,more
and difcculty, will have
and

uterus rarelyretroverted,

palpated without
Then
the you cervix of

in the

second

half the
on

more

easilystill.

further

signsin

posteriordirection
the anterior

the
less

resultingtension
important than
most

roof

of the
and

vagina.
ing deserv-

Not

either

of these

symptoms,
the

of the
all the

careful

attention,is
which

peculiarsoftness
pregnancy,

of

internal

genitalorgans

attends

their

the irregular color, thickeningof the vaginalwalls,the beating

458

Translations.

and

not

nnfreqnentlywhirring (to the finger what

ear) of the
uterine
arteries

the
and

uterine lateral excited

sotifiie is to the

of
,

the

anterior

vaginal walls,the
by

souffle itself the of the

menses

contractions
; and

palpation,the
minor

cessation

then

the

so-

called

signs (" kleine

Zeichen

")

such

as

hypertrophy
of the

of

the abdominal

condition walls,the resulting

out out

of the

navel, which,
walls,
is

though nearly smoothed

still lax and
can

by

the

distention

be

drawn

with the color of

the swelling fingers, the

and
as

secretion their

of

the

mammse,

the

areola, as
the
so

well

glandularand
the doubts

muscular And

development,and though
of
in

frequently
all these

occurring chloasma.
or signs, even

doubtful
are

cases

majority
may

them,

almost after the

never

present,
careful

and

though

still remain

most

examination, if
be

pregnancy
at least
a

exist

some

of its
your
or

signs

will

surely
restrain

present, enough
from

to arouse

suspicionsand

you

giving
until
a

decided

opinion
of events
will
are

adopting
sufiSce.

any

decided

treatment

the progress interval

has cleared

the

obscurity,

for which the

may results be

short of

always

Conversely, if
for the
tumor.

examination

absolutelynegative, pregnancy
The
same

excluded. definitely
a

hold principles
with ovarian has been

diagnosisof
In under and ovary the
a

complicationof
cases an diagnosis,

pregnancy

reports of
false

where

gastix)tomy
is

done

important part
For
in have And
a

played by
solid
tiunor

fibromas
of the

myomas is rare,

of
it

the

uterus.
once

although a

happens
such, and
60

while, nevertheless.
post-mortem,
the other
an

(I have
ovarian the

extirpated
fibroma
myomas, like with and

two

seen,
on

weighing
such
as

lbs.*)
saw

hand,

soft

you

in the

R., are patient

of
to
more or

often

deceptively
filled

cysts,may
fluid. We

indeed
shall

enclose
not

spaces time

less extent the

serve

have

recount

symptoms
to

signs peculiarto
them In certain from
cases

uterine

tumors,

and

which

entiate differ-

ovarian

growths.
all be

these

signs may
t Qebvtak.,

wanting, whether

de-

Hon.

28 Bd., S. 415.

Diagnosis of
rived of form the from the

OvaHan

Twmoi'S.

459

historyof the

case,

age

of the of

condition patient,

menses, and

pelvic symptoms,
of the

form
its

the

position, belly,
relations
may
to not

consistence

tumor,

mobility or

Burronnding
be

parts ; or, if

not

wanting, they entirely

;

prominent characteristically
or,

complications may
certain in

conceal
stances circumeven

them,

in

fact, they may

of
ovarian

be

present under

in uterine myoma,

cases

tumor,
and In
not

which, indeed,

the of

valuable a souffle,
has been observed.

infrequentlyfound
cases

sign

such

careful

and

repeated
doubts,
best
perience ex-

manual
but

examination

will do
now
so

much

toward leave

clearing up
the
man

will,however,

and

then
a

of of

undecided,
excusable

that

certain
to

number

mistakes

are
an

when
or

not

carried it

the
at

point of undertaking
all

operation,

carrying
of the

through

hazards, before
In

full
cases

understanding
we

case

is reached.*
two

such methods

obscure

have
our

at

our

command
"

additional
per

of
with

ing advancthe

knowledge
hand,
was

the examination the

rectum

half

or

whole Simon

and

exploratoryincision.
teach

the

first to of

the

proper

execution

of

the

first-mentioned organs
to

method

examining
how

the

pelvic and

abdominal the results Simon

and self him-

per

rectum, and
from
made
use

to show

important were
of

be

derived I have

it. of its

Since

seeingit practisedby
my
a own

it in several

cases,

will
;

add

my you

testimony
saw

to

with usefulness,
was

however restriction,

for
cannot

that here

this, too,
upon

unavailingin
details in

the

case

of

R. of

1 the

enter

the Mitth.

of the Arch,
etatement

execution
ftlr klin.

method

(See Simon's
Atlee's

the

Chirurg.,
that

Should

(L c., p.

378-79, 464, etc.)

on

be to

proyed,

the
it

fluid of
contains

ovarian

cysts invariably coagulate

and here with farther also
be

ezposore

the

air, becanse

blood-semm,
shonld

that able

it contains
to sort
no

spindle-formed
a one

fibroiu

tissae-cells, we
I have to
never

establish where

diagnosis by pnnctore.
would the feel called
on

yet
and

met I
can

cysts of this
express

pnncture,

therefore
more

opinion upon

statement
as

; the

matter

is,however,

the

worthy
which

of
are

farther most

investigation,
often in^"**^^""

it is

jnst

these

fibro-cysts of the
are

nteros

for ovarian

cystomas, and

first reoogniied after

indsion.

460
S.

Translations.

XV., but

99,

and

in

the

Deutsche that
the

Klinik, Ur.

46,
be

1872,)* deeply
over, more-

will

merely
and

mention

patient must patientthat

she have will

narcotized be
some

placed in lithotomyposition. It should,

the

previouslyexplained to
few
or

there
have

will be
to

lacerations slight
a

of the anus,

that
may

keep
cation defethn?
troducing in in-

quiet for
far

days, and that she

12

trouble

with I have

for 10

days

even.

In 6 called

cases

in which have

thought this
the

examination hand

for,I

succeeded
without

the whole

without

and difficulty,
or

ing enlargincisions
a

opening farther
anterior

than

by
anus.

one

two
one

very
case,

shallow
that

on woman

the

edge
never

of the
been

In

of
tore

young

who

had

pregnant,
healed

the

incision

through
it
was

the

sphincter ;
before other

the

wound
of

and by granulation,
was

12

days
the
very

continence

fseces

fullyre-established.
in
an

In It is of

cases, recovery

was

complete
to have

3 to
exact

days.

necessary

for the the

operator

knowledge

the

topography of
the
; and
contents
one

pelvicorgans

before

he

can

feel at hor.e
tlie

among touch
no

of the whole has

never can

pelvisthus presented to
method
can

who

the practised

have of

idea

how

admirably one proof

of the
saw

feel

over

the

whole
structure

contents

the

pelWs, and
Even

recognizechanges in
presence
in the
was
case

their
a

and

tion. posiof the

of

tumor

is often the

greatest value, as
of
some a

you

of

F., where
the
tumor

segment

tumor, felt per rectum,

cases

decisive of
the

diagnosis.In
and directly,

you

can

feel the
an

originof
be

thus be able to
the

make

absolute may

diagnosis ;

in

others, where
same

result is

negative, you
In
one

able to do the
was a

thingby

exclusion. between

case, where

there

difference of of
an

opinion

several

gentlemen as
it
was

to the character
or a

ante-uterine

tumor, whether
and

ovarian
in doubt

fibro-myoma
the
usual

of the utems,

where

I also

was

after

examination, I
the
tumor

felt, easily by
the fundus desired But and
such

this

method, the
was

connection

of

with

of the utenis, and

enabled

to advise

the against

proposed operation.
a

result it is
*A]so

to possible
Jour.

obtain

only in

case

you

can

Amer.

Obet, Vol

V., Feb., 1873.

Dia-gnosiis of
isolate
the tumor
tumor

Ovaricm

Tumor
from
the

8.

461

from

the

uterus,
down

or

broad

ligament
must to be

(if tlie
be able If

extends

deep
and it),

into the

pelvic cavity, you

able
to

to dislocate

it is of the

greatest advantage

assist the rectal

with
not
or

the other fulfilled

uterine

hand, externally applied.

where
"

these

conditions

are

(and
tumor

the

question

is

between
not
"

large ovarian especiallyif

then tBft the

they

sometimes

are

rectal

hand

cannot

reach

around

the

growth),
as a

examination, too, may

you

be ineffectual.

Finally,
"

last resource, incision

will have

the

incision exploratory
to

i. e.y
admit

an

through
the the

the abdominal whole

walls,long enough
for

four
the

or fingers,

hand,

the purpose

of

determining
this cedure prothe

origin of

tumor.

Understand, however, that

an

involves
case

always
the

intention

of

should extirpation,

be

found

and suitable,

that every
in the

preparation must
event.

be made incision

to

proceed

with

operation only
when

this

The well

is,

therefore, allowable
is resolved upon
a

patient,as
Under

as

surgeon,
stances, circumis if in

radical

operation.
become
a

certain
one.

the. position may

of coui-se, with
way
mere

diflScult
the
to

All

done,
any
a

the

purpose

of

removing
not

tumor,
so

and possible,

still it is necessary
to

proceed

far,in
make

as investigation,

produce injurieswhich

will
case

radical
proves

operation

necessary,

notwithstanding the
be

finally
it

itself unsuitable.
in itself, order

Every point must

the

weighed, as
the

sents pre-

that
or

whether decision,
be

operationis
before
juries in-

to

be

desisted
are

from which

completed, may
the

reached

done

endanger

life of the

patientwithout
is not

the offering With these

as

chance

of radical

cure.
so

cautions,the

incision exploratory Of 24
cases,

gerous dan-

most

people think.
recovered p. without I

cer operated on by Spenwere

Wells, 17

injury, a few
made

better

after

7 died (1. it, c,

4 times. In
one

464).

have

the

incision exploratory
u.

case

S. 75 (Arch. f. Gynak., i.,

in the

omy 62), ovariot-

followed
I discovered
a

immediately ;

second

S. 272), (ibid,iii.,

echinococcus retro-peritoneal

cyst

on

the left into

side,
the

excised

portion thereof,and

sewed

the

remainder

462

Translations.
The

wound. mentioned healed

patient recovered. beginning of

the

The

third

is the whom

patient
the

K^

at the

the

in lecture,
or

incision

well, but

patientdied
fourth
a

in two
case

thre^ months

of

toneal peri-

suppuration. The
It
was one

has

not

yet

been

published
nearly
be the

of man's

lady with
head,
on

firm, irregular tumor,

size of

the
was

right side.
easy to
move

It could it in it"""ld any

reached

from
but it

the

vagina,and

it

direction^
the Sth

slippedback
was

again immediately

into

position;
On the

uterus

"ee, the rightinguinalregion resonant. 1870,

1

of

November,

made,

with
a

the consent

of

the

patient, an
cod-

exploratoryincision,and
nected

found of the
to

tumor retroperitoneal
nor

neither

with

any

pelvic organs
the
had made

with

the the

tine, intestion, operathe

belonging probably
several
folds
was

kidney. During
their way
were

of intestine

through

wound,
the

which

3i inches
The of

long.

These
a

replaced, and
covery, re-

opening
with

closed.

patient made

relatively speedy

symptoms
the latter wound.

merely

local

confined peritonitis,

to

the

vicinityof
the

During
1871.
Of
cure

part

of the the

winter
woman

the following, died

in

tumor

creased in-

rapidly
No the

in size and
was

the

summer

of

autopsy
four

made.
led
to

incisions, then, one

one

ovariotomy,one
in
no

to

the

of
one

an

echinococcus,
died
thus

resulted

essential

injurv,
from be
pared com-

while We

of
a

disease

in itself inaccessible that number

(thepatientR).
obtained may

have

result cases, The

tumor
so

corresponding with
far
as our

Spencer Wells's
with and
that it
no

small

his.

result in

of
the

my

incisions, ovariotomy three, will

prove

in
to

one

ovarian
not
cases

other the

you

I did

enter

carelessly upon
the of
more

operation,but employed

only in
our

where
means

diagnosiswas
; and

exceedingly doubtful.
the fact
that cases,

With
will

present
more

diagnosis this operative procedure

rare

become has

and

Spencer
while F.
the

Wells

made in
some

incisions exploratory few

in 24 of 600

Bird, who,
ovary*
can

published

cases

of of

extirpationof

refer to 40

unpublished cases

incisions exploratory

464

Translations.
well said

been

by Spencer Wells,*
the

but in the later

to it of

stages neither
intestine uponlie
an or

the

positionof

tumor,

the
are

relations

the

functional
I have in the ovarian shown median

disturbances

absolutelyto
that
a

be the

depended
kidney
the

f elsewhere
line and may laid
even

tiunor

of

may

may

reach

down

into
to

pelvis like pelvic

that oi^ns.
such
as times some-

tumor,
also

have

adhesions upon
over

the fact

have

emphasis
intestine
ovarian

the
it
or

tumor

may

have
with

by
may

its

side,

happens
motion

cysts. We

have
be

freedom
in
one

of

in

tumor

of the The

kidney, and
seat original

it may

wanting

of ovarian
as
a

growth.

of the disease

is available

point only in diagnostic

the

first

development, and
cases

then

its will

discovery is merely

accidental.

In

many the

puncture
in the

give

valuable

information, through
forms

presence

fluid obtained
or

of the of the

of

epitheliumpeculiarto
have been

the ovary
and in

ney, kid-

salts and
as

deposits of the urine,urea,

never

ecliinococci the

(which, so far
But
are
even

know,

found elements

ovary).

these

results may
in

deceive.

The

of the urine
may

not

always present
in those

cysts of

the

kidney, and
observed may I has the

possibly
in

be

present
when

of the ovary
are

(Naunyn

allantoin

such) ;
as

echinococci of

present they

escape

detection,
narrated
been
;

in the

case

exploratory incision
not

which

have

and

again
but

in

hydronephrotic sacs
paralbumen
such

only

cholesterin
ovary

found,
1. c, S. with
it is

also the

peculiarto

(Schetelig,
examination

417).

Under hand
say

circumstances

the rectal

the whole
to possible

is of the greatest whether

value, since

by

its

means

the cyst is of
serves

pelvic origin;
up
matters

and mensely^ im-

this

piece of knowledge
even

alone

to

clear is

when

the evidence
and

obtained
the
so

purely negative.
can

Tumors

of the omentum

peritonceum

give rise

to

confusion
to
or

only when
the

they are
brim

of of

large a

size

as

to reach

down

into

upper has
p.

the

and pelvis,
in

when especially

fluid peritoneal
*

collected, forming cysts

Dublin S. Jomn. Med.

different

parts,

L.

a,

222, and

S., Feb., 1867.

Arch.

Gynak., 1,

146;

iii, S. 272.

Didgnosis of
as

Ova/nicm
and The may

Tv/mors.

465

takes

place in lymph
and ovarian

sarcomas

cancers

of the omentum, of such

a

the
to
a

intestine

mesentery.

resemblance
be

tumor

multilocular

cyst

very

deceptive indeed,
walls men, of the abdo-

since

they

lie like

them

against the
may intestinal have

anterior
even

fluctuate
to

and indistinctly,
or

be

secondarilyadherent
may
a

the

uterus

ovary,

while

resonance

be
case

present
of
coma, sar-

superiorly and
which in my

posteriorly. I impressed
vol. all who

such i-eported it
as an

examined and

ovarian
two
as

cyst,
other
to the

Archives,
cases.

iii., p. 277,
vrill

I have

seen

similar
nature

Puncture

probably always decide

fluid is to be

of the disease
cases

wherever
examination

obtained,as

in these

reported
of
of

where

proved
thus fluid,
to

the

lymphatic instead
any

character epithelial
ovarian
cvst

of

the
no

setting aside
be

idea

Where
must

fluid is

obtained

the

means

already
The
it
was

mentioned distended

be relied
has been

upon.

bladder

punctured
cases

in the

belief that
of the

an

ovarian

in cyst, especially

of retroversion
men

gravid

uterus.

That
to you

this

error

has befallen

of the first rank

the bladder

w^ill indicate

the

of emptying necessity Old collections

before

making
have favored such But

your

examination.

of faeces in the colon this

not
error

been

mistaken

for ovarian
that

cysts,and

is

generally
exist in

by

the

fact

does constipation
on is,

always

cases, that

diarrhoea
to tumors

the contrary, relatively frequent.

more

it is unnecessary
as

speak

in detail

of these

and

other

such conditions,

of the liver and have led

were

tions, pelvic exudaspleen,

errors

hsemometra, etc., which

more

to

in

diagnosis,
have
to

when especially ascites. In and

so

the

tumors

large and
Careful

complicated
you attention

with heard the

doing

I should

only repeat what

lecture.

again

againduring the
of the

general condition
and

patient; careful and

and

repeated

cussion per-

of palpation
in view

the abdominal

pelviccavities, keeping
tion connec-

always
or

the

importance of determining the

of the tumor with
is the

non-connection

pelvicorgans,
rectal

the
amination ex-

exploratory puncture
with
30

where whole

fluctuation

found, the
of

the

hand, and

in

case

incinecessity

466

Translations.
will be sufficient to establish few
in
a cases

sion

"

these
In

means

an

accurate

nosis. diagwill
at

the

where

this

is

impossible they

least
a

place you
abdominal

of to deny decidedly the possibility position you

and protect diagnosis, and

from
tumors
case

dangerous operative mistakes.

do
occur

That
is

pelvic

where

diagnosis
shown

the absolutely impossible,

where it
was

of

the

patient R.
autopsy,

has
to

you,

very

difficult, even

at the

find

the

originof

the tumor.
word uniupon
or

a Finally,

the

of diagnosis

the character
of

of ovarian

cysts,whether
ovary, and

whether multilocular,
or

the

right or
the

left

whether

adherent is easy
to

not.

When

marked
the

locular multi-

character
formation of the
masses

by distinguish

uneven,

lumpy
the

the discovery surface,the indistinct fluctuation,

of firm

side

by

side with

largercysticspaces.
the fact
that of

Not
a

so

unilocular
chamber found

form
are

; aside
rare

from

cysts with

single
I

quite

cases (in twenty-eight

ovariotomy

and only six), still

more

the

simple form

without
out

papillaryproliferations six), they may

as

infrequent(onlyone
a

of the

be
one

simulated

by those of
with

reallycompound
point is
is of it is of

structure, such
or

large cyst
cavities the

small, deep-seatedsecondary sacs,

side. This
no

two
as

large
regards

side

by

importance
in the

results of

but extirpation,

weight
this

prognosis of
in

and injection which

treatment

drainage
increases

and

just

uncertainty
the latter StiU and

nosis diagof
we

the

unpopularity of
to

mode
can

and

gives supporters
to the two

ovariotomy.
the disease
so naturally

less

arrive

at

certaintyas
The

origin of
are

the location

of adhesions. and
a

ovaries may
so

close

together,
the

tumor

of

one

side
on

obtain easily

position in
the

median

line,or
often

even

the
one.

opposite side,that
If
tumor

question of
learn which
a

origin is

difficult
side

it is
was

possibleto
first
in felt, in

with guinal in-

certaintyon

which
it

the

region
spot during
swollen its

appeared,

that

pain

was

present
one

certain

early development, or time, such

"

that

of the
as

thighswas
indicating
to

at this

information

is valuable
"

with

probability

but

only with probability

the side

whiti

Tltei^ine and
the disease All

Vaginal

Sarcoma.

467

belongs.
to the

experienced operators

agree,

scliematic any
ment state-

demonstrations
as

that contrary notwithstanding,

or

to

adhesions

length of pedicle must

be

conjecture

merely.

UTERINE

AND

VAGINAL

SARCOMA.*

Bt

prof,

otto

BPIEGELBERG,

Bredan,

Germany.

The

interest

manifested

in the

above

disease

since

the

lication pubme

of Professors

Gusserow
have

and
come

Ilegar, has
under my and

induced

to

report
which

few

cases

which
as

observation,and
from locality any

are

different

to their

course

hitherto

published.
recurrent

I. Local
the
uterine

and sjpindle-form and

roundrceU

sarcoma

of had

cavity,cervix
three
took times and

vagina.

Mrs.
several ago. occurred three

B., aged 59,

times. She
was

given

birth

miscarried

Her in

last

confinement health
several until

place twenty-six years

menstruation

good July,

1869, when

profuselyfor
In

then periods, she had

ceased

entirelyfor

months.

1870,
induced

frequenthemorrhages
her

of variable

duration,which

Jier to consult my advice.

family physician. She subsequently

this

sought

Upon
ana3mic the

occasion,with

the

exception

of

bearing-down pains,she complained

incident An normal. old clots.
to her

of little else than

the symptoms

condition. did revealed

not

examination

of

abdomen

reveal

anvthincr

abwith
was

Vaginal
From

examination

that

cavity filled
the much

the

stronoc utdrine
neck of the

contractions womb
was

fundus

exceedingly firm.
*

The

distended

Translated

by

Dr.

J. J. B.

Vermyne,
From

New the

Bedford,
Aichiv 1870.
fur

Mass.,

and

George

Holmes S. 344

Bixby, M.D.,
1872. Archiv.

Boston, Mass.
of

Gyn., B. IV., S. 2,

Gynaecol.,B. L,

IL

468

T^analaiions.
its walls thin. The
From uteri the with os,

and
with

ob

was

three centimetres extruded

which
two

in widtL villous able fri-

sharp edges.
masses, into

latter there clotted

and

interwoven

blood,
about

extende"J
centimetre?

upward

the

internal

for

along

the

posterior wall
in

of the
a

uterine of

cavity,where

they
The

bled resem-

placentaltissue
the womb
as was

state

decomposition.
from the

body

of

retroflexed.
mass as

I removed dared

uterine

cavity
rhage hemorwere

much

of the
which

to, on
the

account

of

the

followed
I

; but
was now

from

cervical

cavity they
that the

removed. entirely

able to ascertain
was

anterior
urated sat-

wall

was

free. with

The

hemorrhage
found
nucleated

arrested

by

tampon

liq.ferri susquichlor. removed, and

them

Prof.
to

Waldeyer
consist

examined
exuberant

the

masses

of

containing granulations,
and blood-cells
internal and

cells of

different

forms,

fat

connective

tissue. after

The
next

orifice closed
it
soon

removing

the

tampon

on

the
newed re-

day,

but

opened again, with

In the order uterine
was more on cavity,

distinct

pains
remove

and

hemorrhage. growths
November from the
was

thoroughly to
the 13th
with

the 14th of

within

and

fundus
attended On

dilated

sponge-tents.
on difficulty

This

procedure

with
the

considerable 15th
I

account

of the retroflexion.
the index

succeeded
uterine
a

in

introducing
after

and fixed

middle

fingerinto*the lip with

of the and fingers

cavity, and
was

having
with
mass

the

anterior

tenaculum,
a

enabled off the

at

the extremities attached

to

curette,

to

tear

the
was

posteriorwall.

The

uterine

wall

the

point of

attachment

extremely thin.
The
a

The

rhage profuse hemordoubtless

was some

necessitated

the

and greatest expedition,

portions were
The
were

left behind.

hemorrhage
to

arrested

by

and ferri susquichlor. liquor,

tampon

the

cervix. of marrow, and

portionsremoved composed
of round

were

of the consistence

and

cells. spindle-shaped
very and slight, the

The

reaction

followingthe operation was

ansemic,
recovered in
a

patient,though

comparatively short

time.

During
on

the
the

were following days small particles

and freelyexpelled,

Uterine
26tli I found

and

Vdginal

Sarcoma.

469

the womb
OS

much
was

smaller,and
closed.

capable of being
to her

vated. ele-

The
to

internum

The

patient continued
home in fair her

improve, and
At the
return

earlyin
end

December
the

returned I
was

health. of
excrescences

of

month

infonned of the
On the looked

by

sician phyof

of the

hemorrhage,
the
me os

and

appearance 19th much

extending from
she

uteri.

ary, of Januworse

1871,
than uteri when
was

called

upon her

again.
was

She

she

and left,

color

quite
extruded

cachectic.

The

os

widely dilated,and
the
was

there

therefrom month.

large
The

villous
cervical

masses

size of

placenta at
seat

the fourth
was

canal

free,the
the

of the

growths
that

again in

the

posterior wall
The

of but

uterine

cavity,causing slightinversion.
the parts in the

organ

was

retroverted,so slightly
be

posteriorwall
the

could

easilyreached

by manipulations above

pubes.
On the
as

20th much

of

January
of
the silver

again removed, with

as

the
a

and finger
its

curette,
base the

growth
thaler.
a

could, also

piece of

size of

Microscopic
uterine
were

examination

by
round

Prof.
and

Waldeyer

revealed

layer of
latter

tissue,also
found between

spindle-form cells.
fibres and
"

The

the

muscular

also in the
sarcoma

lymphatic vessels. of
and

Diagnosis.
form
The

Diffuse
the

the

uterine

cavity^in

the

of

villi, containinground
was same as

spindle-formcells.
the first operation ; the organ

result

after

diminished
An borne.

in size and

the

os

readilyclosed.
iron, made
a on

of injection The

chloride

of

the the the

27th, was

well

strengthimproved
a

little.

On
at

ary 1st of Februof

use

I discovered anterior

small

white

tubercle

left side

the of in
turning re-

lip.

At

first I took
on

this to be it had remained she

the result

of

the

the tenaculum size. The

; but

the 6th
uterus

materiallyincreased
the
same.

fundus home

of the
in the in the

Upon
to

to her

country
and

commenced

experience
she

lancinatingpains
never

back

hypogastrium, which
the

had

before

felt.

Fourteen

days after

last

exploration,I

found

the entire

mucous

membrane

of the anterior

lipand

wall

470
of the
cervix

Translations.
covered free.
with At

granulations and
the the left size of
to

infiltrated. of
the

The labia-

posterior lip was

there
was an

commissure
a

isolated tumor
the

that protnidfni filbert,

somewhat

over

posteriorlipand
A

greater
was

extent
on

upon
the In

its

vaginal connections.
of the fornix
both
no

smaller

tumor

found

right
sistence con-

in close
tumors

relation
were

with and the

the

anterior

lip.

soft On

compressible.
24th I

There
with

wa?

swellingof
able the

the

glands.
of the

removed,
wall

knife
as

and
I
was

much as scissors,
to

entire

anterior

of the
and

cervix bladder

do

without
at

injuringthe peritoneum
the fundus

also

little

tumors to the

and vaginae,

applied

the

actual

cautery

wounded

surfaces.
the

Upon
from the muscular

examination anterior tissue.

by Prof. Waldeyer,
cervical wall
was

portion

removed

everywhere
the excised and

coimected

by
of
a

The

surface

of

part

was

lightgrayish-redcolor,nearly homogeneous,
strands
was

traversed

by

of

yellow
to be

tissue.
a

Upon

cutting oflF a
The
removed

small

it jx)rtion,

found
same

of

fibrous the

nature.

microscope
a

showed

the

elements

as

specimen

month

before,
from the

January 20th, from

fundus
were

the of

posteriorwall.
the
same

The
;

tumors

vagina3 were entirelyabsent.

nature

glandular

elements

The and

disease in the

soon

recurred wall after

at the

fornix

vaginae,at the cervix, cavity.

a

anterior

of
the

the

uterine

On

the

2d of
dition con-

March,

eight days
in

operation,I found
a

thickened left half of

Douglas's fossa,and
the
os.

tubercle
was

at the

the

lip of posterior
with the
an

The of

latter villous

widely dilated,and granulations.

vaginae was
covered anterior anterior On
a

filled 5th,
of

extruding
left

mass

the
state

entire

portion of
the

the

fundus

in with

ulceration,and
There
were

wall densely posterior

tubercles.
more

tubercles The
in
a

present

also

in the the

wall,but
wall of

isolated.
cervix was

remaining
state

portion of

of

the

of

ulceration,and
masses

the seat extended of

the

wound the

was

covered

with

medullary
os, and

that

through

patulous internal

upon

the surface

the anterior

wall

472
and growths, "The two following cases development.
a.

Translations.
the latter for cancroid will

for fibroid

degeneration.
mode of

fullyillustrate their

ike size of a walnut^ at the inferior JFtbrO'sarcoma^ portion of the anterior wall of the vagina. Excision / cure,
"

I had She

was

consulted
sent

at L.,whither by Countess L.,residing

she

been

for

She paralysis.
weakness

had

borne

four

children.

some experienced

of her limbs

after the third

until after the not complete was pregnancy, but the paralysis fourth confinement, which took place about a year ago. During and with frequent the last pregnancy she suffered from dysuria, desire to micturate. At the delivery the midwife discovered a
tumor

in the

vagina ;

the latter

was

no

obstruction
a

to

labor.
at the

For the last six months introitus vaginae. She

she has been conscious of

was a

tumor

delicate woman. frail, Upun examination the uterus was and bound found to be retroflexed, down side by old parametritic exudation. the right The on uterine cavity sensitive. At the inferiorpartof was extremely the right and near the anterior wall of the vagina, the on I detected a hard, the size of a median line, ovoid tumor elastic, The latter was that extended to the urethral eminence. walnut, and was movable covered by a smooth, to a limited degree, cular vasmucous

membrane.

few

weeks

afterward I removed
in
a

the

tumor

the by incising
tumor
was

mucous

membrane

longitudinal

direction. The

from its loose cellular separated easily

attachments. ceased upon

some

The

the closing

and hemorrhagewas insignificant, attended with The healing wound. was years
return

but was not delayed. Four suppuration, and there has been no since the operation, elapsed

have of the

disease.
The
to have tumor
a was

examined

elastic soft,

and by Prof. Waldeyer, and proved to consistency, cells.

was

found
a

be

sarcoma; fibro-

rich blood-vesselsand

The

more

dense external
a

of layerconsisted solely

and fibrous tissue,

formed

separate

UteriTie and

Vaginal
The

Sa/rcoina,

473
and

capsule

aroimd

the

whole.

cells

were

long,

long

spindle-form.
b.

MedvUary Excision;
seated

aa/rcoma

of

the

portion of inferior

the

vagina,
"

death

from phlegmonous inflammation thigh.

of
borne
a

and

deep-

abscess in the

Mrs.
married

H., aged fifty-eight ; wife

at

landed children.
a

proprietor ;
She had

twenty-two;

had the

never

enjoyed
which

fair

health,with
at
an

exception of
age. At

leucorrhoea, slight

commenced

early

forty menstruation
In

ceased, quite suddenly,without

her

any

particulardisturbance.

fifty-seventh year

she

began

to have

hemorrhages
and

from
at

the

genital organs.
but intervals,
soon

They
after

and appeared slight at first,

were

long

frequent
she
was

more

pecially profuse,es-

after
that she

fatigue.
was

In

1868

informed

cian by the physihe

from suflFering
nitrate
not

spongy of

growths, which
The
treatment

treated gave
the

with

of applications

silver. the

her great

pain, but did

occasional
were

arrest

hemorrhage.
she

With

exception of
the

nocturnal

pains

felt

quite well,
her in

and

functions
She

regularlyperformed.
pale, but
the in other the

I first saw

June,
On

1868.

was

respects locked
of vicinity
were

well.

examination,
and

I found

parts in
The

the introitus and rated, indu-

vaginae hard
and The

infiltrated.

labise

everted

elevated slightly
were

about with

the level of the

and granulations,

healthyparts.
bled
a

parts

covered

at

the

touch. slightest
cancerous

The

which infiltration, entire

resembled
left side of

superficial
the

ulcer, occupied the

the

inferior

portionof
of the
meatus

to canal,extending posteriorly

the middle

portion
from the in

wall recto-vaginal

anteriorlyit

was

separated

by
parts

stripof healthy tissue, appearing again

near

in

spots

other

the

urethral of
The

opening.
the

From

this in less

point it
urethra of

tended ex-

to the
on

rightside
side. vertical the
a

vagina, but
parts
the

degree than
were

the

opposing
in

inferior of
The

of

the

free, but

centre

posterior wall
was

the

vagina I

found

flat

growth.

vagina

short, apparently

474

Translations.
free
On from the

senile ; the uterus

and infiltration, 22d of It from down

atrophied.
the

The

pelvic organs
were

were

inguinal glands

not

swollen.

June
was

I excised
not

the infiltrated
to

portions, under

sia. anaesthedisea"ed

difficult

separate
the

accurately
fact of

the

the
and

surrounding parts, from

quite
accessible.

their
was

being

low

The
three

hemorrhage
vessels
on

profu"e.
of the

the ligation of necessitating

introitus.

the left side

near

To
a

excise

the
wa^

portion located

the

urethral wall the

eminence,

catheter

introduced, but of the posterior

was

only

its

mucous

membrane

left
was

after

removing

all

diseased
the

parts.
surface
of the

The
of

hemorrhage
the wound

controlled

by covering
tannin.
a

entire

with

powdered

amination Exture struc-

specimen by Prof.

Waldeyer
"

revealed
same

of scattered the wound

small-cell

medullary
the
to

sarcoma

^with

the

elements reaction

through
began
acid.

healthy tissue. granulate,under

the

After the the

use

moderate

of

injections of

carbolic became ensued

On

eighth day
of the
a

left

inguinal glands
The

inflamed,
in the wound
'

and

subsequently deep-seated inflammation

inner
was

siu^ace
covered

corresponding thigh.
exudation

vaginal
thin pus.

by

gray

that
of in the

secreted femur.

There

were

soon

evidences
was

of

necrosis

July 11th, a deep-seated abscess

"and

discovered
was a

the

thigh,
took

freelyopened.
in the

After

this

there
and the

decided of

ment improvewound

condition, patient's
The

surface
in the

on

healthy granulations.
and discharge, it became pus. tlie exit of

abscess

thigh

continued

to

necessary This

to make

repeated incisions
but the the

to favor

kept the patient weak,

At the the end of the still

vaginal wound
wound
was

continued

to heal.

month

entirely healed,
the

but

abscess

discharged;
she
was

nevertheless,at
to go

urgent request of the patient

I learned

mitted per-

home.

afterwards
she died

from from veins.

her

husband,
would

that
seem

few

weeks
been
was

after

her

return

what

to have

thrombus
not

of the

femoral

An

autopsy

permitted.

Etiology of

Uterine

Fleadona.

475

CONTRrounON
BASED ON

TO

THE

AETIOLOGY

OF

UTERINE

FLEXIONS AND

ANATOMICAL CLINICAL

INVESTIGATIONS
OBSERVATIONS.*

By

dr.
in

LUDWIG
Breslau and

JOSEPH,
Bath Landeck.

Physician

The

of aetiology

uterine

flexions in its present scientific the hitherto Virchow

shape

culminates

principallyin Kokitansky
The
has flexions.
ten

uifdecided contradictory
on

opinions of

and

the

point of

genetic
has

origin of
lasted
views
once over

reasons

why
yet
been

this

which dispute,
are,

years,

not

settled

that

the
at

expressed directly oppose

each

other, and

therefore

preclude any compromise

of histological exploration

; that the

practical importance of
has
not
mere

the

the

uterus

been

ciently suffi-

realized
account to

who by anatomists, ; and that

generally givea

tive descripbeen
tent con-

of the organ

have gynaecologists

without adopt these descriptions

specialindividual

tigations, inves-

although
importance, logical
the
two to
case

the
but

subject
the exact and time

is not

only of

the

highest setiostate

knowledge
one

of the true
or

of

would

even

annul
some

invalidate
it has

the

other

of the
me

theories.

For the

seemed the

to appropriate

attempt

reconciliation

of

difference
the

of

opinion
point standI instituted

between

JRokitansky and
and

Virchow, from
For

combined

of anatomist

gynaecologist
time
women

this purpose

both

and macroscopical investigations on histological

at

the dead

and subject,

the

same

kept
with

this

end

in

view, during

clinical examinations inasmuch

utenis
as

of

and

without

disease, genital
flexions other the

the

exposition of the
the

of aetiology
numerous

of

the

necessitates

of investigation

tant imporuterine uterine normal

points besides
tissue.

the

of histological exploration
the mode

Before
is

enteringon

of

formation
consider

of the

it flexions,
*

to carefully surelyjustifiable
the
^^

Translated

from

BerEn F.

Beitrage

zur

Gebnrtshiilfe New York.

und

Gynakologie,*'

Vol

2, part 2, 1873,

by Paul

Munde,

M.D.,

476

Translations.

of the uterus and its anatomical relationsto shapeand position of the neighboring as the accounts giventhereorgans, especially in the principal works or anatomical and practical are more less contradictory and unsatisfactory.*

body none is so variable a" that of the pelvis.This variability, however, is not merelyan pending deindividual one, as in the other cavities of the body, but also,
Of all the cavities of the female
as woman one

it does

on

the

different conditions incidental

the

to

of the
;
so

genital apparatussituated in

a tempopelvis, rary

to according pelvic organs of the female, the period of her life, presenta differentaspect.f In order to become acquainted with the topographical tions condi-

that the

pelvicorgans, we must therefore observe them the three chief phases of female existence ^before closely during sequent and subpuberty,duringthe stage of possible conception, to that period. As the anatomical relations of the pelvis here, in the second phase life of female interest us chiefly will begin with them. we
"

of the

If

we

of the

and seek to gain a view virgin find the pelvic inlet occupied of the pehas,:}: by we cavity open the abdomen

of

coils of the small intestine and

*
"

the iliac flexure ; the latter lies

the Determination

0. Orede, in Only lately Position of the

^*

his

Contributions to

of th^

Normal

Arohiv healthyUteros,*' relation of the been

fttr Gynakologie,YoL
to the The

1,pu^

1 , 1870, says

The

normal

healthyutems

and tlie pelvis result of

topsies, aues*

adjacent parts has hitherto

amination of living women,

not

ascertained. definitely
the information

the sections of frozen

and subjects,

obtained

by

the

do not coincide.'*
case

f The neglectof
of
the

this view of the

is the

reason

why

uniform

tation represen-

female

pelvic organs

oould

not

be obtained

by topographical

anatomy, whence
1870, page

the complaintsof the conflicting results of pelvicexaminaThe V. Hiiter, Flexions of the Uterus.

tions (see previousnote, and

Leipziigi
of the

23).
of the pelvisis higher than
iliacus intemus

X
and

The

brim

in the

skeleton, by
on

means

presence

of the psoas and

muscles

the wings of the saxarum

elevated

and the iliacfossa,

therefore also larger and somewhat

to

posteriorlj

and No.

laterallya
"

fact

alreadyreferred

1S69, Klin. Wochenschrift, (Berliner

ureters.

the anatomy of the female 47) while describing

_^-i

Etiology of
either the than
in the

Uterine
brim

Flexions.
the and pelvis,
to

4t77

cavity or

at the

of

belongs in
the

latter case, with the

small

its

largercircumference, more
The
course

largfe

pelvis.
to be

of this fold of
; I will reaches

the

testine large in-

is known here side

exceedingly variable
with

only mention
to

that
of the

its angular deviation occasionally

the

right
covers

pelvis,and
upper and

moderate
the

degree
If
we

of fulness
now

the iliac
small

whole
flexure

entrance

to

pelvis.
to see, the

remove

the
in the

all the
are

folds of small

intestine

contained and

we pelvis,

astonished
or

bladder

the

tum rec-

being entirely empty

space
If is left for the all the
entrance

but in

distended,how slightly
the small

large a

intestines

pelvis.
divided
at
tents con-

coils of intestine into the

have

been

ligaturedor
if the
we see

their

small

pelvis,and removed,
contained
at
or

intestinal

of the small

pelvisare

then

the considerable We The

can

length of
best very
trace

the small

intestine

therein.
csecum.

it from

its termination

the within small

ileum

rarely
from
a

descends the

immediately
csecum

few

centimetres
as a

distance

into the

the

pelvis ;
and

rule

it the

forms
iliac it

large loop
close
over

above the

ileo-csecal valve
of into the the

lies in

foQsa

to

beginning
line

right colon,
small
on

thence

passes
into

the

terminal

scends pelvis,dethe in
we

Douglas's fossa,and
the

ascends

again

left side.
the small

If

we

develop

folds
them

of

small

intestine

lying

pelvis by detaching
they
a

from

their

mesentery,
and
measure

find

that

constitute

almost

the entire

ileum,

extended half of
I the

quarter, tlyrd,even
small
intestine

half,occasionallymore (exclusive of
and 450

than

whole found
the shown

the

duodenum);
of
small

have
in is

140, 230, 325,

small

centimetres is

intestine

pelvis.
the

The

length
of the

naturally very
is

variable,as

by

and preceding figures,

always dependent,
on

spective irretents con-

of the of

condition

other

pelvic organs,
the greatest
is the
case

the

the intestine itself.

was

I found

length when
in this
on

the intestine
carcinoma

empty

and

contracted,as

cholera,
case

and ventriculi, the

pulmonum. phthisis
to

In

the

folds

on

rightside belonged

the

lower, those

the left

478

Translations.
half

side to the upper,

of the ileum.
the

The

of raajority
the

the

folds
and

lay in
broad

the

posteriorportion of
on

between pelvis, the

rectum

uterus

ligament
on

the

one

and
:

and
on

vic posteriorpeland find

a

wall side small and of

the

otlier hand

but

few

folds lav

at

either of

the

urinary bladder.
the

Very rarely do
anterior surface

we

fold

intestine between
the

of

tlie corpus

uteri rally gene-

posteriorwall

of

the

bladder, as

both

organs

are

closelyapproximated.* Although

Bawisch

(Klin. Yortrage,
numerous

Prag, 1849, Bd.

folds of small

II. p.

2, 51) frequently speaks of

intestine

surrounding
give
a

both

ovaries

in the

lower

pelvic cavity,the According

late Iliiter
to

latest repoits

totallydifferent
folds

account.

Luschka

f there

are

usually a few
this the

in

las's DougOf

fossa,whilst " has

Claudius asserted

considers :{:

exception.
small

that,although folds of
the fundus and

intestine upper do tion pornot not

undoubtedly

always

suiTOund and

the

of the anterior
descend be
to

posterior uterine
of

they surfaces,
can

the bottom
in the

Douglas'sfossa,and

therefore

felt there

livingsubject!

Yirchow

(Ueber die Entstehang 4), Luschka

B.

dei

Utehisflexionen,AUgem.
des

Wiener

med.

Zeitnng, 1859, No.

Bd.

(Die Anatomie

Menschen, peculiar
consider to

Tubingen,
Women,
IL

1864,

II., Abth.

II.

355),

and

Hodge
hand

(On Diseases
appear to

Ed.,
as

Philadelphia, 1868), on rule, and

the

other

the

exception

the

accordingly giye coiresponding

360. med.
the

diagrams.

t L.O., p. t Allgem. I
As

Centralzeitnng, 1864, No.

latter

82.

"
I

I'- c^* P- ^^
ceeded suc-

regards

assertion, I

must

reply that

have

repeatedly
the

(by verbal
intestine contained the
The

communication,
an

also

others), particularly when

small them my does

abundant

in distinctly feeling quantity of fseces, and

even

through fingers.
not
more

posterior laquear vaginss,

reason

in

indenting them

with

why
sounds
than

the is

palpation of probably
lower the

these

intestinal that gas is

convolutions

produce
in

gaseous upper

fact

usuaUy
At

contained
aU

the
I

in the

portions of the intestine.

with the
was

events,
of the
or or

before

became

well

acquainted
come across

the

topographical diagnosis
to

conditions
of
an

pelvis
other
two

I have

frequently
behind
the

mistaken found

ovarian
a

tumor,

the

uterus, which
of

have thus

disappeared
was

day

later after

administration

laxatives, and

proved

to be of

fsBcal

origin.

480

TraTislations.
find the
in the
to

tions,we

uterus

rightanterior portion generally right side

in
an

and deviating anteriorly its

the

of

the

median

line,
and the

long and

transverse

axes

running
the
an

oblique direction,
axes

thefefore

not

coinciding with
them
at

corresponding
acute

of

pelvis,but
horizontal

crossing
sections

angle. Sagittal and

strike the
utenus

of the
axes.

pelvis never
Tlie in the
uterus

in its stands La

long
with

and its

transverse

therefore
with its

usually
its

longitudinalaxis

the

second,

breadth

the first diagonal axis of

its right-anteriorly,

pelvis,so
orifice

that

fundus

points

external

the left-posteriorly,

right
left-

border

of

the

uterus

the right-posteriorly,

left somewhat

anteriorly.*
As the the

vaginal

canal the

runs

in the median in the

line

of

the

pelvis,

lower the

portion of

uterus

descril"ed

position must
one

indent lateral
mere

laquear vaginsB obliquelyfrom

above, whereby
narrow

becomes laquear, generallythe right, whilst slit, the other is wide foetus small and and

and

like

spherical.
new-born

The

pelvic contents
contracted its

of the

infant

occupj

different totally still so

in the

relations.
as

The
to

is then pelvis, particularly,

not

allow

any
even

folds of
the
rectum

the small

tine intes-

cavity;t indeed, not

with the

urinary bladder
alone

and
the
as

uterus, which
have pelvis,

distended
room

occupy

small

quite sufficient
the

therein, inasmuch
and

the former anterior and

the

over projects

symphysis pubis
the found
and

touches of
the

the latter

abdominal
tubes and is

wall, and
ovaries
are

upper
in

portion
the

large pelvis. The

it were, between
a

uterus, which
bladderand inclination iliac flexure

wedged
here

in

elevated,as
lies

rectum,

already

extra-median, with
to

slight
The

of the fundus

and anteriorly

the

rightside.

generallylies greatlydistended

over

the uterus in

The of

embzyologioftl investigatioBBof Dohm,

MttUex Ues
more

aooordiog
whioh

to

which

the left

dnot both

aateiiorly than
the above

the

right,in

oblique podtioB

xunaUj

unite, aapport
1. c,
p.

aasertion.

f Lnsohka,

9.

Etiology of
the

Uterine

Flexions. f found
in in the

481

large pelvis.*
female infant
the the between towards

Once
32

only M. days
old and

B. Freund

ture ma-

the iliac flexure the

A.

small

pelvis,
former
romaiium
on

uterus

bladder, and
has Steffen:}:

pushing
found the

the
S.

sacrum,

whilst

in the small

pelvis both
left side.
the

when From

the rectum
the very very

descended

the

rightanrd

on

the

beginning of
the

extra-uterine evacuation
to

when life,

pelvisgrows
and

fast and the

ular reg-

of the urine

faeces opens
the

pelvic cavity
commence

the

neighboring organs, portions of

into
22

intestine

descending
12, 21,
and

the

small

pelvis. Freund
numerous

" foimd

in

girls
in

days of

age

folds

of small

intestine

Douglas's cul-de-sacl
The We here

pelvic relations

in

senile
state

women

are

again
the

different.
erally genthe

rarelyfind
The
above

normal

of

the

uterus, because

alterations pathological

have

changed
of

positionof

pelvic
the
same

organs.
as

intestinal

contents

the

small

pelvis are
tumors

if uterine,ovarian, or described,

other

have
often

not

displaced them.
in the small

Besides, the whole

covered pelvis, with

iliac flexure folds

is testine in-

found,
and

of small

contiguous

to the

posteriorportion of the left wall

can

of the
to

and pelvis(excavatiosacro-iliaca sinistra),

be

exposed
from

the

sightonly after

the

removal

of the

small

intestine

BouTvart,

De

la mtnatioii d^nn I"ie

anns

de

Tilique

ohea

le nouveaa-n^
de

dans

sea

rapports

ayeo

retablissement

artifideL

Th^ der

Paris, 18. Atlot 1873. eta,

p. 80.

M.

B. Freund,

Lageentwicklung

Beckenorgane,

Bres-,

Ian, 1863.
X A. Steffen, Beitrage
biicher fiir
sur

Physiologie
p.

nnd

Fathologie des Mastdarms,

1872.

Jahr-

Kinderheilkmide, 98, 04

12a

Y.

Jahrgang,

"

L.

o., p.

I The
showed

post-mortem
the

examinatioii
:

of The

girl of 12 urinary
very

years,

who

died

of

variola,

following condition
to

bladder

much

ing distended, reachthe

almost

the

os

sacrum

; the uterus left of

the
os

small, doeely approximating

line (a
rare

bladder, and
the
rectum

situated descended

to the

the
sacrum

median
on

instance), whilst
A terminal distended fold iliac

along

the right side. and pelvis, the

of the

ilium

lay

in the

right side of the small

fleznze filled its superior portion. 31

482

TVansldtions.

the small whole minalis

After

pelvis.* Very rarely(onlytwice) have

with the vermiform process, below

I
the

fonnd
linea

the
ter-

caecum,

in the small this

pelvis.
the

of description

general topographical illations

the

of

the

female

a close pelvis, inspectionof

embryological
is of great portance imh^

conditions

of the

and position

form

of the utemff flexions.

as

in the discussion been

of uterine descent

The

utems

shown

to make

similar

the

ovaries

and

tnbe^,
in

which form

descent and

is

connected intimately the

with

the

variations

the

of collapse
the
uterus

urinary bladder, to
The the short floor of

the

po5teri"."r

wall of which from fundus

uterus

is attached.
to

bladder, changing

the

elongated fusiform approaching

with
it.

ovoid the

shape,and

its the the

a

thus

the

pelvis,draws

downward

This the

happens alreadyduring
vertex

first year of child The of

one

for I found life,

year
not
no

of

the

bladder

in

longerprojectingover
exerts
a

the
on

symphysis.
the

bladder

alone

decisive

influence

siologica phyit has

development of
reached
its
own

the uterine also

uterus

but position,

after
the

growth, it
of
the between

influences, materially

graphical topo-

condition
This

during the
and
clear and

whole

life. bladder
manner,
was

relation

the uterus
in
a

urinary
He

first
and the

represented by Virchowf
for the

correct

employed
cervix

of aetiology
but

flexions.

has

shown
attached

that
to

uteri is

closelyand

slightly movably
A

the

posteriorsurface of the bladder.

the cellular tissue

careful organs

examination
to be

proves
*In
women

connecting
have smaU had

the two
aeyeral

firmjf

in the pzime of Uf e, who

in the

we ohildien, a

also almost

regularly find the iliao flezore fonnd, in

whole of the
a woman

pelvia. Onlj
month lower
I
men.

short

time

ago

who

died

of variola

in the seventh

of pregnancj,

Uie

iliac flexure
uterus

in the

smaU the

pelvis, although
whole in the

the

enlarged
even

segmeDt
witneBsed

already fiUed

pelvic cavity.
small

have

this position of the iliao flexure

pelvis in

Transactions

of

the
p.

Obstetrical Wiener and

Society of Berlin, 1849, vol

med.

p.^. iv.,
].

Collected

Writings,

8^.

Zeitung, 1859, No. Allgem. Wiener

4, 6, c
med.

fBokitansky (The
1859, No. 18) and

Uterus

its Flexions.

Zeitong,
f iir Gthtissue is

Luschka

(Topography

of the Female
assert

Ureters, Archiv
that the oeUular

akologie,voL
loose and very

iiL, part 8, p. 879),however,

yielding.

Etiology of
but little
and yielding, muscular,

Uterine

Flexions.
with

483

plentifully supplied
fibres and It is therefore
bladder

elastic
nerves

and and

diffused

organic

sympathetic
not

inicroscopical ganglia.
the because in
uterus

quite

easy the

to separate

from cellular

the

with

the

or fingers can

knife,
tached de-

the

tissue

is very

firm, and

only be
is but

layers. Even
in existing the

in very it.

fat persons
firm

there

little tissue the

adipose
extends

tissue between
are

This
and and

layer of cellular
the urethra

bladder

vagina ;
form
all
one

and

vagina
The
the and

inseparablyunited
uteri

single thick daily evolutions

the the bladder.

wall. of

cervix

thus

accompanies
the

the

bladder urinarj^ descends

as

; it ascends

with posteriorly of collapse, of the whole

distention,
asmuch In-

with anteriorly

the cervix
as

is the base
as

uterus, this

applies

to

the

latter
uterus

well
a

to the

former.

The

is in

much

less

degree dependent
is less intimate

on

the and

rectum,

partly being
rectum

because secured

their

connection

direct,
the
the

by

arched less

ligaments, and frequent changes

uteri and upper

partly
of

because than

undergoes
"

form

bladder.
smooth the

The

plicsesemilunares
fibres (m. retractor
between the
uterus to

Douglasii, which Luschka), and

the

contain

muscular

form

connection the sides

meet os,

rectum,
the

proceed
cervix

from

of the
at its

rectum

the

part of

and uteri, internal As both

posteriorsurface, immediately below

thus
cover a

the

forming
do
not

transverse

convex slightly

ridge.*
the

organs

each

other, but

lie that

in

nal diagoin -the

on

diameter which usual the

connect

of the
them

pelvis,it
are

is self-evident

the

ligaments

of
on

unequal length,and
the

that

positionof
left The

the

uterus

right
the
or

and

of

the rectum
is shorter

side,the right sacro-uterine

ligament
cervix
below the

than

the left.f

specialpositionof
of the rectum
above When

is influenced

by

the distention of the

*

the rectal inseition

upper
aa

peritonealduplicature.
(1. a,
Frennd
to p.

portion
concave,

of the

Losohka M. B.

860) incorrectly deacrlbes

p.

this ridge
meana

(1.c, unequal

95) has

already, by
the

of

measnrements,

oaUed

attention

the

length of

semUunar

folds.

484

Translations.
is filled, whereby the and its folds
or are

rectum

cul-de-Bac

of

Douglas
uteri

\"

encroached

upon

stretched,the cervix

is

pushed push

rectly di-

forwards
the

simultaneouslysomewhat
lower

downwards,
will
a

whiUt the tention dis-

of filling forwards
of of the

the
and
rectum

portion of the
In

rectum

cervix

upwards.
is

any

case,

considerable
marked

required to produce
dislocation which

tion dislocatakes

the

cervix

uteri, a

normally
the
iliac the

place temporarilyonly during defecation,as

occupies
bladder
reservoir the
same

flexure
urinarr the

place
fasces.

in

the

chylopoetic as
that

does for

in the the
so

uropoetic system, namely, Long-continued

found
in habitual

of

real

fsacal

accuniulationf pation, constithe

in tlie rectum,
exert
a

commonly

obstinate
on

considerable

pathologicalinfluence
are an

tion posi-

of the

uterus, and

therefore

important setiological supplied

so

point of
The muscular
lax that
as

uterine

flexions.
are

other

which peritoneal duplicatures

round way and broad

with and

the fibres,

are ligaments,

long
the

they long
uteri

in
as

no

impede
not

the free
an

mobility of
as all, they are

corpus the

uteri cervix

it does

reach

extreme at

degree, whilst
A

is not

influenced and fundus ascribed

by

them

attached

only

to the

body

of the uterus.
to

great importance
the

has,however,
of
the

been

them Since
a

in the

determining
time

tion posi-

uterus

generally.
firet became
these
was

of

the

Eeformann-

tion,when

anatomy
of

Bcience,the
was

remarkably
observed,
of

equal length
shorter the uterus with

uterine
to

ligaments
possess the

the

of which

supposed
end
were

power
one

drawing
this

its upper

forwards

and

to

side.*
to

sequently, Sub-

however, there
who of denied
any

plenty of opponents
these

view,

influence The

of

ligaments
the

on

the

position
rotunda

the uterus.t
*

question whether
p.

ligamenta
Ant

Biolan, Anthopogzaphia, ParisiiB,1626, pathol.,etc., YenetiiB,1676, a 25, p. 46, Patavii, 1719.

of Anatomy of

228.

Molinetti, Diaseit
Advezs.
anal

snat

12,

p. 829.

Moxgagni

IV.,

animadv.

Winkler

(Demonstiator
p.

De Haller),

dta

obUqno

ntezi,Got-

tingen, 1746,

18, "

48.

Etiology of
and is not divided

Uterine

Flexions.

485

lata
even

are

the

cause

of the extra-median

positionof the
on

utems

settled
into
two

to-day, and

the

authors
as

the

subject are
Klob,t greater |

parties. Some,
that the of position
on

such

Tiedemann,*
a

Htlter," allow Spiegelberg,:}:

or

the

ligaments exert
uterus, while
the

less influence
no

on

the

Luschka

expresses considers
as

opinion whatever
whether
uterus

subject,and
strisB which

Henlel"
extend
as

it doubtful the

the
to

muscular

ligaments from
whether

the

adjacent parts, such

the

the

ligamenta teretia,are position,or

flexion. M. B. Others

intended

to fix

organ
not

in its rather and

straight
induce

tlieir contraction

does

again, Brehmental,**
any

Bernutz

Goupil,tt
the
the
uterus
cause

Freund,:}::|: deny
and consider

action of the

ligaments on
be not

whatever,
but the

their of

unequal length to
extra-median demonstrated

consequence

the

position of by
numerous

the

uterus.""

Freund

has particularly

that investigations, erabryological

the extra-median

situation

of the

the uterus

results necessarily

from

changes

in

of position

Fr.

Tiedemann,
Driisen des

Yon Weibes

den

I"ayeTney*8cheii, Bartholin'schen
der

oder

Gowpei*Gebar-

schen,

tind

schief
p.

en

Gestaltimg

and

Lage

der

mutter, Heidelberg

and

Leipzig, 1840,

34.

L.

c.

p.

50.
to

X Spiegelberg (according
15
minntes

Hiiter, L c,

p.

19), in
seen

woman

26 years

of age,

after
the

death

by decapitation, has ligaments

become tense

the
means

aterns of

rise from the

induced

the.
rent cur-

sacrom

and

round

by

passed through

the

womb.

"
**

L. c,

p.

19.

I L.

c, p. 354 formam maladies

and et des

seq.

% L.

c,

p. p.

454 17.
"

De

obliquitate uteri quoad

sur

situm, Bonnsd, 1858,

ff
538.

Clinique m^dicale

les

femmes,

Paris, 1862, tome

II., p.

ttL. ""
In

a,

p.

76.
the

place of

expression, '^extra-median
or

position,*^the quoad situm,"

term
was

^^oblique formerly
common,

position,situs
used.
in which Klob

obUquus,"
,

**obliquitas uteri 44) distinguishes

of two

(1.c.

p.

43 and
axis

varieties,one line,but
the
runs

more

the

uterine

is outside

the

median
which

parallel with
is not
the
are

the pelvic axis, and and both

organs
cross

the

other

less

frequent, in
Both

latter

case,
genital con-

each

other.

varieties, according
above,
p.

to

him,

anomalies

of position (compare

7, Note

2).

486

H'cmslations.
and the
than

urinary bladder
of who
divided the

rectum,
the

both

of

which

are

of earlier
ficiency the inef-

embryological date
them

genital canal.
been

Besides,

round
in

ligament has
the of

proved
Without

by Manncl* wishingto
supports, still
clinical
orer-

dead
all

subject.
value
as

deprive
their

the

ligaments
seems
a

uterine

importance
of This
as

to me,

after the
years,
to

autopsies and
have
the been much

observations

immber

of

estimated.

much
do

appears
in
a

that certain,

round

ligamenta,
arch from
as veneris,

extending
the
uterus
as

they
their

large outwardly
in
a

convex
mons

to

point of insertion
such the

the

well

the

broad

ligaments,show
in

degree
the
the
not

of

relaxation,
the

that their
uterus amount

importance
a

securing
connection

noimal allow

of position
uterus
a

is but

very

slightone.
In

Both

lai^e

of

play-room.
has been

with

broad
terminate
as a

ligament,
simply

the
at

point
the

forgottenthat
but pelvis, into

it does

wall of

of the
some

that
the

it extends

wing-diaped
tenninates
the
as

process
there.

breadth the which

uterus

large pelvis,and

Hereby
around

acquiresa greater mobility, as

rotate

radius

it

can

is

large one.

Inasmuch

only

Ilenle

f mentions

this process
of

of the broad
the

which ligament,

is the
moreover,

natural
a

continuation

ala

and is, vespertilionis, I will add

items
a

constant

anatomical

occurrence, in
some

few

words
Ilenle.

on

the
Whilst from

as subject,especially

I differfrom

the
the

lower larger walls

half of the broad of

the small

ceeding proligament,

lateral

pelvis,terminates
and latter,
its two

slightlybefore
layers extend including
the into

the
to them

frontal

middle

of

the

anteriorlyand
ala

the upper portion, posteriorly,

the
at

extends vespertilionis,

along
this

and

over

terminal
the

line

height of

5-6
to

centimetres

out) (spread
lateralend of
Uartinabo,in

large pelvis. According

des

Henle,

Die

Tomoien
on

Donglas'schen

Batimes, Marbuig,
atems,
held

1864. the

leoture

prolapse of the vagina and

before
not

Hafelt"dflcbe
th" toojA

GeseUschaft and
broad

(BerL klin. Wooheneohrift, 1872, 80) does ligamente adapted to the support of the
467.

oonslder

uterus.

tL. o.,p.

488

Translations.

broad is drawn

ligament are
upward
to

thus and
to

formed, by

means

of which
much raised

the ateni?
out

occasionallyso
the
caecum,
or

of tk k

pelvisas
more

lie close

descending
wall

colon, and
than

easily palpable through

vagina.
"

the

abdominal somewliat

throngh

the

^Of

exceeding,

hitherto

est interneglected,

for which

the

positionof the uterus,

the
uterus

is the It may

peritonaealduplicatiire
not

enfolds the

itself.

be

to superflnoos

repeat here

course

and

relations of

this

uf duplicattire

the

peritonaeum, since, notwithstanding its unchanging

various incorrect
accounts
are

condition,

in

and circulation, of

quaintance thorough ac-

with
its called 20

it alone

is

capable

ing sufficientlydemonstrat-

practical importance, to

which

Virchow* has

has

alreadjr
the last of the

attention.

Although
the
most

Virchow

repeatedly for
of the
course

years

given
to be

definite
in the best
at

accounts

peritonaeum,
views
naeum are

still

even

text-books
admit
os

entirelyincorrect
that
to

found. front
are

All

present
internal of

the

Y^niiy

passes

in

from

the

the

bladder.!
the

Widely
on

different
to

the accounts

the passage
word the and
rectum

of

naeum peritothe

the rectum.
as

Ilenle,:]: by extending
to

diagram, represents
at

the
same

peritonaeum
as

about

height covering

anteriorly. Luschka"

describes

the

peritODSPnni
the

as

not

only

the

cervix
to to

uteri,but
the upper

also half of

posterinr

laquear vaginae,coiTCsponding

theposteri""r
cavation ex-

lipof

the

cervix. descends

According quite
of low the

Virchow
the

the cervix

recto-uterrae

behind

generally uteri,
#

to

about

the

region
med. here the
to

even vaginal portion, occasionally

Allgem.
1

Wiener

Zeitung, 1859, No.

correct
a

4. made
to

merely wish
to

etatement extends

by Elob
uterus

(L c,
from

p.

50),that

according
surface of
the but
on

Langer

peritonaeum
at the

the

the

posterior

of

the

urinary bladder
yesic89.

lowest
to my

point corresponding investigations this

the

to tfael"^

trigonum
the whole anterior
oent.

According
a so

is neter

the

case, Ues

trigonum, with vaginal waU,

above

portion of
that the

posterior waU

of the b]"3der"

the

anterior

laquear vaginasis found

and above the bottom

from

1.5-2

the
is
as

base

of
as

the from

trigonum,
4-5
cent,

of the

vesico-uterine

excavation L. c, p. 456.

far

the

trigonum.

"

L. c,

p. 260,

Etiology
from
of the 3-4 centimetres is

of

TlteriTie Fleodona.
"

489

lower, so that
from

in the latter

case

portion

vagina

separated
Klob
the it

the rectum
lets the

by

prolongationof
some

Douglas's
cases

cul-desac.
over

also

peritonaeum in
of the
the

spread
says

posteriorfornix
the

vagina, whilst posterior

of
to

Hyrtl*

that

covers

upper
two

portion of
different

vaginal wall.
course

Hiiterf

gives
in the but

accounts

the

of
to

the

peritonseum,in
and

one

of
to

which
cover

it is said the upper

reach

only
of

the

vagina

other

portion
in saying

the

fornix
the but

vaginse. All
from the

Henle, therefore,concur
not

that

peritonaeum does

extend

to the

rectum

from should
or

the' uterus
be called

vagina, wherefore

the excavation

as Eokitansky occasionally recto-vaginal, does,X

recto-

vagino-uterine.According
peritonaeum
to

to my

numerous

investigations
at
a

the

extends

to

the

vaginal wall
the

point
the

sponding corre-

the

lower

border
as

of

posteriorlip of
the
the

cervix,
even

generally lower
helow
distance cul-de-sac the
a

far as still,
line drawn

below from

external
anterior bottom
; in

os, and

horizontal

laquear.
of
a

The

from

the

laquear posterior 1.5,2.6

to

to the

Douglas's
woman

measures

3.7 centimetres
even

in

seventh
no

month

of pregnancy,

5.8

centimetres. the
uterus

Of

less

importance for the position of

the and
extent

than
manner

the

knowledge
The

of

of
nature

the

peritonaeum
the

is the

of
tissue. terior pos-

its attachment

the

of

subjacent

cellular

uterus, whose
vesical wall

cervix

is

tolerably firmlyattached
2.5 to 3 cent., must
must

to the not

for the of
the

length of

only
to

follow

the

motions

bladder, but

also

adapt itself
or

the latter and

lie close

to it in accordance

with

its greater

less

degreeof
which the is

distention.

That

this accommodation

of

the

uterus,
in

materiallyaided

by

the

muscular

fibres contained

ligaments,actually takes place, is easily pubo-vesico-uterine

J. Hyrtl, Lehrbuch
c, p. 9 and

der

Anatomie

des

MeDschen.

Wien,

1867,

p.

719.

f L.

12.

\ Cul-de-sac
1866. Paris,
tonsum

recto-yaginal. Gourty, Trait6

G.
on

pratique des maladies

de

rut^ros,
peri*

p.

11

giyes

an

excellent

dia^am

of the

course

of the

about

the

uteruB.

490

Translations.
in the dead been

demonstrable when
we

and subject,
as a

even

in the

pelvicorgans
the

they have
vesico-nterine the fundus I could this

removed
see

whole the

from

bodj. If
forming
it

injectthe bladder, we
excavation
uteri
see

how

peritonsenm
distance

the and

and rises, diminishes

the
;

between

thus

the by largely filling 1 centimetre. the ftrndns The

uterus

bladder

the

excavation
we can

gradually rise
further
observe

During
uteri

experiment
forward

that

inclines

and

touches the

the bladder. bladder

when it with

therefore

closelyapproaches
then
above see,
at

the
a

latter is

largelydistended, and
the

lies
os

on directly on

of portion
we can

body

the internal

the

other
the

hand,
bladder

quently fre-

autopsies,that
and in
a

when
in

is emptr, touches
cavation ex-

stronglycontracted
the bladder

diminished

size,the

uterus

only
uteri the the

very

slightdegree,the
the internal os, and

vesico-uterine
a

is situated

below

portiononlyof
of the bladder. distention the
on a

the cervix Thus bottom

in

approaches the posteriorsurface

extreme

most

degree
excavation

of

vesical
is not relation proves
to the

of

vesico-uterine

level with

the internal
between

orifice of the uterus. the litems

of and

This

tion of accommodaalmost
uterus
a

the bladder

priori
be

that the of
a

attachment

the
*

peritonaeum
says with

must

peculiar kind.

Ilenle of the
the

quite correctlyand
the muscularis

distinctlj,
is less firm

that the connection

in

serosa

front

than

on

posterior wall, while

From
the

lately Chrobakf
the

asserts

the

contrary.
the

middle

of
to the

vesico-uterine
for

excavation
at
most

peritonaeum

is attached
a manner

uterus

1-1-5,

centimetres,in such
the

that

it may

be separated
some

with

knife, but
connection the bladder

in

the upper here below

part
to

already with
that between
os.

The difiiculty.
cervix tissue

is similar

the

uteri and
is very

the internal in

The

cellular

tense, detachable

only

and layers,
as

containsbut
as

little fat ; at the sides of the uterus, however,

*

far

the inser-

L. c, R.

p. 456.

t
S.

Ghiobak

in the

"

Handbnoh

der

Lohie

von

den

Geweben,"

l7 edited

Strieker,Leipzig,1873, Chap, zzxvii,

p. 1169.

Etiology of
tion

Uterine
it

Flexions.

491

of

the

round

ligament,
of

can

easily be
obtuse

detached; the
the

inseparable according
above. is At
to

connection

the

peritonfleum with

uterus,
open

Henle, forms

anteriorly an
of the

angle

the

posteriorsurface

uterus, the

peritonaeum
to

firmly and
of whilst
of

inseparablyattached
the
uterus

in its whole down

breadth
to

the

substance OS,

from

the fundus

the

internal uteri

from

the

point where, through \he

it forms
a

retractor

muscle
becomes

Luschka,
and

transverse

ridge, it gradually
the
bottom

looser

easily detachable
the cellular

towards is less

of

Douglas's fossa.
more

Here

tissue

dense, contains

fat and From this

more especially

blood-vessels. infer that the

descriptionwe
so

peritoneal covering
in

of the uterus,
is used increased

far

as

it is

capable of being detached

of the bladder
the
as a

front,
its

during

the distention that

covering of

and -surface,
means

hereby
and

approximation,already
uteri with the
the

by existing

of the of the

connection

of the cervix

posteriorwall

bladder

by

pubo-vesico-uterine peritonseum
the

ligament, is augmented.
uterus

But, while
the

the

of

the

in

measure

becomes

peritonaeum of
convex

bladder, posterior
of We
the

the

uterus

not

only closelyapproaches the bladder,

in but
a

surface fundus possess influence of

of

the

the

forward

inclination

uteri
a

increases

corresponding degree.*
which
exerts
a

thus

second
on

important point
form

determining

the

of the uterus.
with the

The

connection peritoneal

the corpus
not

uteri

bladder

is therefore
uterus
on

portance, of great imbut also for its

of the only for the position

and configuration,
as

particularstress
on,

is laid

this

point because,

will

be

explained farther
fiexions.
on

it is of

value specialaetiological

for uterine The of

opinions

the

shape of
somewhat.
os as

the

uterus

and

its

manner

development
at

differ

Some

describe

the

angle
(140").
curva-

formed
As

the

internal

larger (165") than

above the

others uterine

have

already

mentioned

Yirohow, Allg.

Wiener

med.

Zeitnng, 1859, No.

4, p. 87.

492

Translations.
is discernible
in new-bom

ture

female

infants, a

fact
and

already
Freund,

noticed

by Boulard,* Lorain,t Sondry,:j: Goupil" Virchowl and Klob^f deny

possesses that
as

whereas
uterus

the foetal and

I
am

infantile

any flexion.
to
"

As

far

aware,

Eokitansky
uterus.

**alone

has

sought
to

explain
the

this curvature and

of

the
mass

According

him,
forms
at

dense, firm

mighty
and does

lar of cellu-

tissue which

tlie cervical the

mucous

membrane,
not

which is
terminate
some

appreciablythicker
at

posteriorwall

the internal os,

into

but, graduallybecoming thinner, extends

corpus
as

distance
on

the

uteri,ascending considerably higher

a

the

posteriorsurface
mass

dense

submucous

cellular
the
utenis

is layer,

the basis

supporter of the
of
its erect

of

the
a

body

of

and

the

position with
this

slightanterior

inclination."
the bnli

nis

opinion is,that

layer of

cellular tissue

forms

of the cervix. deduction

with and

the Virchow,tt however, particularly as regai-ds

adaptation made

by Eokitansky,
Henle

does

not

cide coin-

this anatomical

and description,

XX ^^^ Hyrtl,?,?

"

BoTdard,

De

rant^flezion
but

(Revne

m6d.-chir., Jnin, 1853, voL Paria, 1853.

1853 i la Maternity. de Tut^ms. femme" 4. Tom.

xin.,p. U\]

et

qnelqnes

mots

Tut^roB.

Th^,
en

f Begistre X Quoted

des

autopsies faites
sur

by Aran, LeQons
mMicale Wiener
sur

les maladies
des

Paris, 1858.
ii

" Clinique I Allgem.

IT L.
**

les maladies

Paris,1862.

med.

Zeitung, 1859, No.

0., p. 58.

L.

c., p. 457.

Lately in

session

of the

Obstetrical

Society of Leipsg.

Nov.
on

20, 1871 (ArchivfOr

**

Gynsecol., vol. ii,partii,p. 312), Hennig,inapap"

of the

the

architectural
corpus

development
uteri is
a

uterus," expressed
of its contents pass, that

the
and

dai opinion of the narrow

in
a

the shape of the and

tortuous
sense.

consequence it has to

genital canal

which

is, an

heirioom

Dtf*

winian

tt
the

Klob

(1. c,

p.

60)

makes

the

inaccurate
stratum

statement,
under

that

Tnchovr

denies
vii-

occurrence

of

thick

submucous Flexionen
"

normal

conditions,
Wiener med.

ohow,

however

(Ueber

die
:

des

tTterus, Allg^m.
mucous

*a*

tung, 1859, No.

fibres
means

21), says
and
we

Towards
a

the

membrane but

the mnscalar

diminish, thick,

find

tolerably dense, distinct,

normaUy ^7^

submucous

stratum."

tt^L. c,

p. 456.

""

L. c,

p.

715.

Etiology of
regardless
of
the

Uterine
value
and

Fleocions.
of

498

of

the

anatomical

tjiis

point, make
the

totallycontradictory statement,
submucous

deny actually
described and of the under

existence

cellular
as

layer

by

Kokitansky.

Others

again, such

Luschka,* Klob,t
The

recentlyChrobak,J finally settlingthis

that

directly support
anatomical considers the

it.

importance
from
tissue
a

question
mass

is evident

fact

Kokitansky
its the
mal nor-

of cellular the

in discussion, upon which

condition,in
of the of which
as

lightof
to

framework

mainder re-

substance it has

of the uterus

is built up,

and

the direction

follow, in
the

its

quently pathologicalstate, conse-

the

basis

for

development
which
in all

of

uterine

flexions.

Consideringthe
holds
to

intimate

relation

pathologysetiology
theory
which
plains ex-

the importance of therapeutics,

causal

any

the As the the

conditions
not

of

disease the

becomes

self-evident. of the
causes

treatment

only includes

removal

of
and oughly thorroom

disease, but also has the objectto prevent the formation

the morbifacient

of activity
the
we

agent, the
disease

more

and accurately the

more more

of aitiology

each

is settled and

find

for

therapeuticalinterference, the
it become

important
disease.

and

influential does

for the

treatment

of the

It

became, therefore,absolutely necessary,

and
the

consideringthe
institute should

quency freand

often

exceedinglyimportant, troublesome,
of uterine of the
of
or

annoying

consequences

to flexions,

special
the

exploration histological
correctness
or

uterus, which

prove

incorrectness

Kokitansky'sanatomical
his
for

tion, descriporigin of
1

and uterine

thereby confirm
flexions. For of uteri

refute

theory of
some

the

that purpose,
at different

time

made

vestigati inthe

stages of development, from

found that

foBtal to

the

senile

condition,and

Eokitansky'srepdoes
own

Lnschka

(1.c,

p.

371), adopts Rokitanaky^B view, and

he has
an

not
on

show, while
the

quoting
or

it almost

yerbally, whether

opinion of his

sabject

not.

f Klob,

1. c,

p.

60, Note,
on

is the this
most

only gynsecologist who question.

has

made

cal histologi-

investigations directly

L. o., p. 1178.

Likewise

gynaecologists, cunong

others

Martin.

494

TranslaiioTis.
of
was

resentation which and

the existence

of
to

strong stratam
the
mucous

of

cellular
membrane

sue, tis-

supposed

constitute

its submucous

is entirely without layer,

foundation.

The

macroscopic
the
"

appearance

of the

uterus

refutes already decisively

cellular
a tissue,

presence

of

submucous

layer of

so-called
piratory res-

tunica

which nervea,''
tract

is found

in the whole Its

and digestive

and

in the

nrinarybladder.
between membrane of the organ
to

object is
and

to

act

as

loose

connective
to
as

substance
mucous

the

muscular
to

mucous

coats, and

permit the

become it

folded

and

wrinkled, require.

the functions
can

which

belongs may
the the of

It

easilybe
coat.

lifted np
With It

and

dissected

off from

subjacent muscular
uterus

the
is
a

mucous

membrane and

the

case

is diffei*ent. that
we can

well-known lift up
nor

generally
off the

admitted uterine
more or

fact
mucous

neither and
coat to
a

dissect such it.

membrane,
muscular
uterus

that

at

every with

attempt

less of the

is removed

If
obtain

we

subject the
the
constant

microscopicalexamination
in all the

we

that result,
mucous

phases of development
of its

of

the

uterus, the
to

membrane muscular

of the whole

cavity
into

closely adheres
the latter without

the any

coat, and
innermost muscular

directly merges layer of

the

link, the
of

muscular in does

coat, which
various
not to
even

consists

strong

fasciculi, miming

directions

and

each other, profuselyintersecting

mucosa,
mucous

stop short

at the

but

in large bundles projects

various

deptlis into
the

the

membrane,

and

in

adults
cous mu-

envelopes

glands situated

in the whole

thickness

of the

membrane.

Occasionally muscular
membrane
as

strise

so project

far into
naiTow

the

mucous

to

reduce

the latter

to

mere

border.

We

therefore
into

see

the

mucous

membrane
coat.

merging

in

unequal thickness
conditions
uterus
are

the muscular

These

microscopical
non-puerperal

visible

both

in the

puerperal* and

in the most

manner. indisputable

The

Btady of the puerperal

oonneotiye tissue does

ntems

in

itself necessarily prove

that former

sab-

mucous

not

exist ;

how, then,

could

the

theory

496

OPf^anslations.
membrane consists of first basal
of substance, acetic
or

mucous

homogeneous
the

which

distinctly appears
fluid,*etc.,and
closely

on

addition
small
are

acid,
rather and
cleolus nu-

Moleschott's
nuclei

of innumerable

cells

arranged without
a

order,which
power show

mostly oval
nucleus the and

spheroidaland only under

in their
mucous

high

interior.

The

membrana
a

of pi-opria

uterine
a

membrane,
cells with

therefore,is
but like

tissue

of consisting
or

large

quantity of

little intercellular

basal matter, and

consequently looks
which
it has been

granulation
"

or

glandular tissue, with

The

compared by Virchow, Ilenle and Lusclika.

the addition

homogeneous designatesit
whereas

intercellular substance, on
a

of the above

reagent, presents
as

swollen, gelatinous appearance.

or

Luschkaf

homogeneous

at best
as

but

imperfectly fibrous,
here and

describes llenleij:
or

it

finelygranular, or
of
soft substance. the connective
or

there,after brushing out

fibrous.
Both anatomists should
to
means

the addition
call it
a

liquor potassie, finely

Were
we

to

we classify it,

place it
of this
is
no

among

tissues,and
ive connect-

liken

it

mostly
By

the

so-called

formless

embryonic
membrane,

tissue.

embryonic composition
mucous

it is
to

bly proba-

also

adapted, as
and easy

other

rapid

change
The
at

and proliferation

regeneration.
varies,and
from is

thickness the the its

of

the
os,

mucous

membrane

est great-

external

gradually decreasing comparison

with the

that

point
lar muscu-

towards
coat

fundus. diameter
uterus

In
is

subjacent

extremely sniall.
the
uterus

According
substance

to

this

descriptionthe supporting tissue

the

contains
preserves

in its muscular

"

the'
to

which

given shape originally

organ.

This

shape

of

the

partlydepends
of each

on

the

miztare
water two p. p.

of acetic

acid and
a

Btrong alcohol

one

volame,
"

and

of distilled

volumes,

modification

of darkens

fluid.

Trakbl.

t L. X g
L.

c, c,

869. 459. here remark

I would

that the intermuscular

increases somewhat

oonneotiye from the

tissue in the
mucous

uterus

is very

and inconsiderable, the

serous

membrane

towards

covering.

Etiology of
circumstance the

Ut'"rine
of the
to

Fleodons.

497

that,by
it is

means

attachment
accommodate

of its cervix itself to

to

bladder,

compelled
wherein
a

the

changes

in that organ,

it is assisted

hy

its

peritonseal
of in its the
out
cular mus-

covering, and

partly on

congenital arrangement
are

layei's. The
wall
most

latter

thiimer considerabl}^
has been

terior an-

than

in the

posterior,as

pointed
certified

by
curate ac-

authors

and (Virchow,* Luschka, f etc.),

by
of

measurement.

This

difference

in the

the thickness
uterine

the

walls
of wall

becomes

most

apparent
the

during
and

development
the

pregnancy,
attracts

when

thickness

weight
even

of

posterior
quency fresue tis-

attention,and particular
ascribe
to this

caused the the

Rokitansky "
greater
muscular the

to unhesitatingly

circumstance

of retroflexion
and of the the

after

parturition. To

peritoneal covering,therefore,is owing

shape
sideration con-

uterus, and
in the

they, consequently, come

question
of of the in

into

primary

origin of virgins

flexions.
and
women

The
who of
troflexions re-

greater frequency
have
never

anteflexions
or

borne in
women

children who

have

only miscarried,

and

have

been The
in
an

confined,especiallyvery
retroflexion is

thus explains itself. frequently, in that the one, organ which becomes would and

paradoxical
to

flexed

opposite

direction

its

natural of the

hardly

be

possiblewithout
its

relaxation

muscular

tissue

yieldingof

peritoneal envelope.|

"

Die

Krankhaften

aesohwttlate.

BerUn,

1887, vol. iii., p. 176.

L. c., p. 358.
own

X M7

xneasnrementB

entirely agree
anterior and

with

those

of

Lnsohka.
nterus
are

Htlter of

(p.

23) maintains

that

the

posterior walls
this to be

of the
common

equal

thickness,and " Allgem.

appears to be

incorrectly
med.

supposes

the

impression.
1. c, of
p. 459.

Wiener of the of

Zeitung, 1869, No.

that

18,

and

Rokitansky posterior waU

opinion
the

the

greater

thickness

the

is only the

result has
to

development
the

incidental
that

to pregnancy. uterus

I Virchow
contributes

expressed

idea

the

peritoneal envelope of the

in

the

preservation of
i

its

shape,
Wiener

his paper med. tissue

no means

*'

Ueber

die Entste-

hung
One

der

Uterusflexionen,"
suppose

Allgem.

Zeitnng,
is relaxed the

1859, No.
the easier
case :

4).
an

might

that
ensue.

the

more

the uterine
is

anteflexion

would

This, however,

by

for

the

32

498

Translations.
The

Both

occur, of

however,
the

in

the
uterus

puerperal

state.

serous

velope en-

pregnant
also
not

which, particularly,
the assistance
condition of

besides the until

by

is hyperplasia,
" ligaments,

formed
return

through
to

broad

does

its former

long
of the

Bfter

and deliver}',

gradually regains its facultyof

corpus uteri
to

aidingthe

approximation of the bladder, which

do of
most not

the

wall posterior
if
are

it had

lost
it.

during
Such

pregnancy,

fluences disturbing in-

prevent

influences

turbance disprincipally are,

puerperal involution.
found in
women

Retroflexions
with

therefore,
involuted

commonly

imperfectly
influences of

puerperal uteri,which, by
are

means

of
chance

their

general relaxation,
their
a roundings sur-

completely subject

to

the

(weight of normally
That
the the the

the

full intestine,etc). Of
a

course,

troflexion re-

generallyneeds

longer
uterus

time is in

for
an

its

formation,

cause be-

puerperal

anteflexed

tion. condi-

greater development,
exerts
a

and

consequent

greater
oa

weight, of

posteriorwall

determining

influence

ateroB
serouB

veiT*

rarely becomes

relaxed ;

without

coincident
in senile

relaxation
as

of its
as men-

covering taking
or

place also

and, therefore,
or

weU

Btmal

reclination pnerperal relaxation,

actual

retroflexion

ensnes

with

ixomeasarably
*

greater facility.
to

Here
the

I desire

rectify

an

error

of

LuBchka,

that

the

peritoneal enT^ope
the
I

of the

gravid

nterus

is formed After Eiwisoh

by hyperplasia alone, without

numerous

assistance
am

of

broad

ligaments.
with broad

accurate

investigations

obliged,
miinutera"

in oonjimction tain We that

can

and

Klob,
are

to

contradict
to
women

this assertion, and

cover

both
best

ligaments

largely tised
from

the who and

gravid
died

demonstrate

this in specimens the

a

ly immediateThe

after latter the the

confinement,
with
not

by examining
middle
in the

ovarian short

Ugaments
distance rather
a

the tubes.
the

extend

their

portion
median

along

lateral wall of

uterus,

exactly
of

line, but
The

little behind
are

it,nesrer

posterior surface
to
a

the

uterus.

ovarian

ligaments

duced generally reas

slight length, having

and

often

entirely lost their character wall,

womb.
so

distinct middle of tlie

round

cords,

lie dose ovary the

to

the the

posterior uterine
lateral wall of

that

the

portion of the puerperal

but
in state

touches ovarian after

the

Outside in

ligaments

measure are

2.5-6

centimetres

lengthy
long.

the

first week the

parturition they
are

only S-16
on

nullimetEes
m

Usually, like

tubes, they

of

unequal

length

both

Etiology of
the formation
as

Uterine
is

Flexions.
be

499

of

the

retroflexion
occur

hardly

to

denied,
of
the

pecially es-

similar

inclinations

in consequence

creasing in-

size of eral

the of

posterior wall

through
as a

tumors.

That
cause

gen

relaxation

the uterus, aided

proximate
of the
not

by

mechanical

influence

(own weight, pressure

cause

neighboring
peritonitic pelvis,is

organs), is the usual

adhesion
most

of
to

and retroflexion,

of

the

uterus

the

posterior wall

of the

clearlyproved by
the
uterus
can

the

clinical be

experience, that retroflexion

of
but

generally

easilyand
care

completely reduced,*
be
not

very

frequentlyreturns,
does
not

if proper suflice
a

taken. the

single elevation
in its normal

always

to preserve

uterus

situation;generally
lefrain from

suitable

recumbent

position
example
with

cannot I
as

remarking
the in
a

here, that, following

with
the

the

of

Frennd, hands,
the

never

elevate

ntenis

sound

but

always

both

described

by

me

previous
of
these
^*

article, ^^Betentionsblutungen,'' in Beitrage."

uterus,
as as

first

part of the
of
:

I. volume

(This method

reposition
*-^

of

the

retroflexed
even

described in

c,

p.

86,
one

is

as

foUows

The into

finger (or
the

two,
the

is other

possible
hand
on

puerperio) of
the

hand and

introduced
fix the cervix

vagina, and
them.
the Then

abdomen,
it to

seize

between

the the

internal

finger leaves
behind lie
as

the
as

external

hand,

and
case

pushes
the time
to

body

of

uterus

from

far

up

possible, and, line, at the

it is often

in

latter, as

rarely happens, should

the
the

quite in the

median
because

same

laterally toward
pass

ilio-sacral

qmchondroeis,
The external

difficult cervix

it

over

promontory.
the

hand

holding
over

the

is then

pressed
or one

deep
of

into the

ately pelvic cavity immedirami

the
as

(symphysis pubis,
far
as

superior
the the
which

of

the

pubis,
sacrum.

and After back

pushed
this

possible posteriorly towards elevation, the Hfting-up

the

cavity of the
and the

first act

of

of

corpus

pushingbi-

of

the

cervix
The

uteri, comes

second

step,
was

is also

performed

manually. portion below

the atiU

finger in the vagina, which

for the the

introduced of

behind
up

the vaginal the

the

Douglases oul-de-sac passed

in front

purpose

raising
and

body

of

uterus,
more

is

of

vaginal portion,
saomm,
uterus

pushes

latter the
ternal ex-

towards seeks

the
to grasp and
a

cavity of the
the
press

whilst
a

simultaneously

hand the whole

elevated
it forward

little the

higher

up,

low slightly beThe

umbilicus,
is

to

towards

^ymphykis pubis.
executed

procedure
As
a

somewhat there

compUoated
are no

lever-action
or no more

in of the it

several men, abdocan

steps.
the

rule, when

adhesions

tenderness

whole

manipulation
^

succeeds

easily and

rapidly than

be

described.''"

TSANSL.)

500

Translations.

or

supporting

instrument
to retain

(Hodge's pessary,
the

Frennd's elevated

wireuterus

loop "),are
in its normal

required

relaxed

and

posture, and
a

give
curative
extreme
can

permanency
treatment

to the

complete

volution in-

which relaxation the law

I will of is

proper

has

induced.

The

generallyso

that

the uterus
at wilL
occurs
as

freelyfollows congenital
pends dewalL
flexion ante-

and gravity,

be

flexed

here
but

remark, that retroflexion

in

anomaly,
on

extremely

rare

cases,

and

then

probably
With

retarded

development
The

of
on

the the

uterine posterior

I have

no

post-mortem
case

experience

subject
is either
on

the

is difPerent.

latter

congenitalor
an

acquired.

The of

former

varietyalways depends
wall, which
assumes a

arrest

of
mally, nor-

development
and

the anterior

is thinner

than

the uterus

therefore
is most

snail-like
in

curvature.

Congenital anteflexion
in sterile women,
most
common cause or

frequently found disposed

to

virginsand
is the quired Accomes belatter terior pos-

in those of the

miscarry, and

so-called
a

habitual

miscarriage.
uterus, which
The
the

anteflexion
more

occurs

in

normally formed
mechanical

flexed by strongly adhesions peritonitic

or

influences.
uterus

are

either

uniting the

with from

vesical

anterior

pelvic wall, or
existed condition

pressure

above

(obstinateconstipation, large fsecal accumulations, tumors).

For
some

time

there and

of

antagonism
the former
a

tween besessed posterest. in-

the antemore

the

because retro-flexion,

of

the pathologico-anatomical,
as

latter

clinical

Carl attention young

Mayer, however,

Virchow

states, already called

to the

fact,in the Berlin

and those

Obstetrical
never

Society,that
than

in

women, is the

who

have

borne

flexion children, anteflexion, retro-

also decidedly more clinically

frequent

frequency of
or a

which

gradually increases
friend. Dr.
the

first after

the

puerperal state
the

miscarriage.
of my my

Through

kindness

Freund,
course

I of

have
more

at large statistical figures

*

disposal. In
Society for

45th

Annual

Beport

of

the

Sileaian

Home-Coltnre,

1868,

p.

183.

Etiology of
than
nine

Uterine

JFleodons.

501

years

there

occurred

among
:

4,305

cases

in his gynse-

the followingflexions clinic, cological

ANTEFLEXION.
"i^

BETBOFLEXION.

1)
there

Of
was

these
even

42, only
one

fonr

carried

their

children
went to rest

twice term

to

the onoe,

end four

of

pregnancy,

among

which

immatnre
to
a

five i)irth,

only

had

premature

deUveriee,

and

one

gave went

birth

dead to term

child.
once,
were were

All the
and
one

miscarried

several

times.

2)
8)

One Of

entirely 24, only

twice.

these
these

eleven five

unmarried. unmarried.

4) Of

18, only

If

we

compare

these
:

with figures
*

those

of other

authors

we

get

the

followingtable
this and

From

compilation Iluter, both

whilst

we

infer

that, according to Rockwitz,

of C.
flexion
occur

Valleix

varieties

in

almost

equal numbers,
and

according to
are

Mayer, Ilennig,Saxinger
the

myself, the anteflexions

G.

double
even

retroflexions, with
more

Scanzoni, Ilolst and

L.

Braun the

considerably
varieties does

; with

Mayer
but

the

proportion of

two

not

differ

so

much,

nevertheless
are

it is in favor

of anteflexion.
common

Anteflexions,
retroflexions

therefore,
at

not

onlv

much

more

than

the

post-mortem
table taken is based both

table,but
on

also

in

practice.
(1.c,
p.

This has

the compilation and versions

hy Hater

86).

ever, Hfiter, how-

flexions I

together, which
to

explains the

high

figure of Valleiz, which

changed according

F. Ohurchill

(Traits pratique,

Paris,1866,

p.

452.)

In the

preceding
of the

pages,

above

is demonstrated all,

the and

portance imits

peritoneal envelope
in the has
a

of

the

uterus,

conditions pathological circumstance

development

of flexions, to which
very

Virchow
As

ab*eadj repeatedly
it

properly

called attention.
be advisable and
on as

prophylacticmeasure
cases

will,therefore, particular

to

watch
as

all

of

perimetritis with

care,

much

fluence possible guard against their injurious inof the be the

uterus.

the

shape

On

the

other A
as

hand,
short

the

puerperal
of 1. and

condition

must

watched. carefully
is investigations normal is
texture

mary sum-

the results

of

above the

follows the

Rokitansky'stheory of
the

of

uterus
as

development
substratum

of

flexions
upon

inasmuch fallacious,
it
wsas

the
not

anatomical exist. the

which
that

founded

does

The

opinion
possesses

of
a

Virchow,
submucous

the

mucous

membrane

of

uterus

layer,is likewise
Virchow the
not
as

incorrect
the

2. The of 3.

theories

propounded by
are

to

ment developfacts.

flexions

sustained

by
are

above

anatomical

Anteflexions,when development of
to principally
.

they
the

caused uterine

congenitally by
walls, owe
are

defective
existence either cicatricial

anterior

their ated situ-

mechanical
uterus
or

which influences,
are

outside

of

the

caused

by perimetritic
in
quence conse-

contraction
relaxation

; retroflexions

generallyensue
tissue

of

of

the

uterine

resultingfrom

perfect im-

puerperal involution.

504

Transactions

of

the

CURIOUS

ACCIDENT

FROM

THE

USE

OF

THE

F0KCEP8.

At sound time

o'clock

A.M.

sleep by

the

young of escape

primipara was
her
waters
"

roused
os

out

of
at

the

uteri

that

into tne finger. She immediatelj went barely admitting with and infrequent. By labor, but pains unusually feeble the tlie had but 10 o'clock become bead, A.M. OS dilatable, tlie left with the which to ilium, occiput presented transversely had contraction The not undersized, a woman engaged. being in the was was suspected, and the brim conjugate diameter measured and therefore carefully by two fingers. The swept obstacle of descent found the to pelvis was am]"le,and, as no head could and
were

the

be

discovered,

tlie the

delay was

attributed

to

the

feebleness
enemata

infrequency of
she but

pains. Friction, stimulants,

without any

accordinglyresorted to, but

As

response
was

whatever.
at last

given,
the

strongly objected to with barely any increase

vectis
was,

the

forceps,ergot
severityof

in the

the

pains. Finallythe
in over

without

her

knowledge, slipped
it affected she felt clined in-

neither

trial with occiput ; but a half-hour's the pains nor the position of the head. As for she left three 3 hours. At to sleep, was

o'clock
to
an

p.m.,

no

progress and with

having
great
lock
ease

u)eantime

been

made,

she

consented

strumenta in-

were delivery. Hodge's forceps

" "

accordingly applied
head,
the female under the

to

tlie sides of
and

tlie child's up the

blade

being
The

first introduced
looked

rotated

sis. symphythe
as so

towards directly concerned.

left

ilium, and
in far

therefore,became forceps,
the

virtuallya straight one,

The
but the

pelvic

curve

was

handles,
interval

very rather the

firmlyupon
greater
wiis

the

than

coccyx, the when

of course, pressed tliem was between In isgi'as^jed. of the divergence

was

diameter biparietal this

absence

handles made

of any other manifest cause, attributed to a large head. the

Traction
came was

at

first vals, interquency. fre-

during
and

without

pains only ; but as these gaining any progress, it

an

at

long

increased

in

After

hour the

hard

work

the

head but

traction,to
now

bear
to

upon
rotate

floor of the
the hollow

pelvis;
of

began, difring the occiput as

and,
G. in

tended

into

the

sacrum,

fact,had
to

reached end that force the view could

the labor the

left sacro-iliac with sacral the vectis.

was

synchondrosis, Dr.
first removed It
the
was

cided de-

With

blade
could

; but

no

Erudeut hard body, which y

some

release the

pubicone.
just be

firmly

held

touched

by

tlie

finger,

and sacral

which blade

The evidently projected through therefore reapplied, the occiput forcibly rotawas

fenestra.

Philadelphia
ted
to the left

OhsteU^ical
head The

Society.
with
of

505

delivered
now

in

acetabulum, and the that oblique position.

the

much

difficulty
cause was

disturbing
the

evident

hand

enough : the dorsal lay against the cheek, and

raised up from
the the

surface
in of in
concave

child's the

right
count, ac-

elbow,
contact

on bein^,

this

body

and

with

head,
The

had

been

noosed

by
was

fenestra

the the
the

anterior

blade.

tip of the blade

deeply buried

wrist ; the proximal portion of its the soft tissues of the inner surface of the
arm

palmar aspect of the edge seemed lost in

humerus
two ;

of

while

all

and

forearm

lying

between

these

points
radius

the fenestra. through

was

The the

humerus, just above

jected promidits dle, had

broken

in

two, and
none

epiphysis of
The
child for the

the

been

separated from
seemed been

its shaft. the

worse

cried

and, lustily,
to which

otherwise,
it had

rough
in

usage

union,
The

without

mother

use subjected. By was any deformity, the catheter required

the

of card-board

perfect splints
seventeen

gained lor four

days.
made
on a

days, but
out

prompt

recovery eighth day. In conduct the in this

in

the

usual

time, being
Goodell open,

of bed

the his
to

conclusion.Dr.
case

remarked

that, as

laid

him

perhaps deservedly so,

offer refusal
in

he would charge of carelessness, unique cliaracter of the accident,the take ether,and the great sensitiveness he Had
was

extenuation of his

the

patient to

of her
hand

unable
he earlier

to

introduce

his

whole

into

tissues, whereby the vagina.

would have

recognizedthe
detailed

cause

of the

delayhe

delivered Dr.
labor a. from

by version.
H. SMrrn
two briefly
cases

of obstruction

to

the

intervention

of the

hand. of

Both the

of the
should In

forceps. In the introduction be kept closelyhugging the

this
not

required the use forceps the blades

child's head.
care

sides

of the
median

doing
Dr.
was

by incliningthe handles
them
too

outwards,
the

should

be

taken

to carry

far from
case

line. tory his-

Parry

referred

to the

of

clitoridectomywhose

at the last meeting. She applied given by Dr. Goodell to the Presbyterian Hospital,after having been operated upon having failed to keep her appointment by a surgeon of this city, with In the operation,which attended with Dr. Goodell. was the internal had freshened edges of hemorrhage, the surgeon the labia minora, and, bringing them together,put in three or four stitches, thus making a sort of capsule out oi the nymph". but the external The uterus was anteflexed, genitalsnormal.

She

still masturbates.

Dr. which The which

Parry
he had Museum
was

showed
not

specimen
described

of

post-laryngealabscess, following appeal^

found
to be

in the books.

Committee

presented the
:
"

ordered

printed

506

Philadelplda
OF
THE PniLADELPIIIA OF GYNAECOLOGICAL A MUSEUM

Obstetrical

Society.
BOCIETY FOR AID OBSTET15

APPEAL THE RICAL

OBSTETEICAL OF INSTRUMENTS. DISTORT DISTORTED

FORMATION AND

PELVES,

At

recent

meeting of
decided
and
to

the

Philadelphia.
a

Obstetrical
for the

ciety, So-

it

was

establish

Musenm,

collection

of deformed Obstetrical
new

distorted

Instruments methods

preservation of ing possessing historical value, or illustratPelves, and

for the for these
interest
reasons:

of treatment.
the

The

1st. No

Societywas led to take this action subjectat present possesses more

than of and

to

stetricia Ob-

their

mode

study production, their influence

the which principles is

the

of the various

deformities
on

of tlie Pehis,
of parprocess turition, the accoucheur

the

should

guide
more or

when The

operative interference
Profession
of the

is deemed

necessary. and
more vinced con-

gradually becoming
of contractions, more and
diflicult of

influence

less marked, also the in

in the

causing
of labor.

not

only

tedious

but label's, many

and production of mal-presentations

of

accidents

present there does Female Pelves, by which

At

not
a

exist

any

extensive

collection

of

comprehensive study of this subjet-t undertaken. be successfully can Feeling,thererore,tlie importance of such to establish observation, the Society purposes a and would in this therefore Museum view, nestly earobject having in Pelves solicit such specimens of contracted be as may of the Medical the possessionof members Profession, who mav be willing to yield the pleasure of individual in order pc^ssession
to
more

assist

in

forming

collection of
or

which this

will

allow
If

wider

and

comprehensive survey be sent, casts specimen cannot certain cases, possessingunusual to offer a pecuniary recompense,
2d.

subject.

the

original
In

photographs are
should various for the this be

solicited.

the Society is prepared interest, desired.

Recognizing
in Uterine

the

fact that

Manipulations, or Surgery, having been only an historical improved models, now possess instruments to collect such Society has determined of the this branch them, as illustrating progress also warmly urge We the would America. upon
new or

for Obstetric

Instruments, designed performance of operations and superseded by new

interest, the
and of
our

preserve
art

in

inventors

""f

modified in

instruments, and

Makers

general,the
of

Surgical Instrument upon of presentingto the Society desirability

specimens
contrivances

Instruments, Pessaries, and special mechanical which they may be desirous of bringing before the

profession.

Quarterly Meport
All
"Will be

on

Obstetrics^etc.
in the

507
I

embraced objects,whether conspicuously placed in

been

first

or

second

class,

the
an

after
with

having
the
name

labelled with
donor.

Societ)^, and explanatorydescription,

to

Museum

of

the

of the
also be

Thev
of and All the

will

carefully preserved, open

support
and advancement

the

inspection
Obstetrics

all interested
the kindred

in the

of

branches

of Medicine.
may No. be 1342
sent to the

objectsfor
who

the Museum

Secretary of
wil

Society,Dr. J. V. InghAm.
will at
such the
once

delphia, Si)ruce Street, Philatheir

as

acknowledge
information
Wm.

receipt,and
may be

gladly furnish By order of

additional

desired.

Society.
Goodell,

M.D.,
President.

Wm.

F.

Jenks, M.D.,
M.D.,

J.

Y.

Ingham,

^ Committee.

Horace

Williams,

M.D.,

QUARTERLY
AND CHILDREN.

REPORT DISEASES

ON OF

OBSTETRICS
WOMEN AND

Quinine

as

an

Oxytoxic.

By

Robert

Gray,

L.K.

and

Q.C.P.J., 1873.)

Medical

Officer, Armagh of
Great Britaiti

stetrioal Journul

and

Dispensary. {The OhIrelanH^ September,

increase uterine contractions drug that would of powerless or tedious in cases labors,in lieu of ergot, has owing to the uncertainty of ergot and tlie risk to long been felt, the cliild's life,unless as pointed out by the late Dr. Beatty delivery The
want

of

was

effected

within

two

hours

after its administration

and

in some besides,as is known contraction, thus adding to

case.
9

instances, it has caused

the

hour-glass
the

danger
drawn the fact

difficultyor
of
our

Some

time

ago

attention

was

by

one

tal continen-

brethren, I
decided

forget whom,
on

to

that

quinine produced
and

oxytoxic effects

pregnant

women,

also tlrat in

508

QttdrterlyHeport
hours
and

on

Ohstet/rics
female
in labor it quickened

two

after its administration increased

the

to

pains.
tnis the
case

Soon which I

after

reading
The
the
a

administered
result. 5th
woman

occurred in quinine, a case quinine with this intention with the

abont
was as

happiest
On

follows

"

Sunday,
to

January last,I
whom the

was

requested by
as as

her

husband
in her
more

visit whole

he described
and
never

having been
attended

lal)or in

the

of

night before,
and had

I had been

her

three
a

confinements,
11 o'clock

detained

than

couple of hours, I anticipated a

a.m.,

short

delay.

On

my

about arrival, She

I found

my

patientcomparatively
severe

stated easy. the night and part intervals very irregular

to

that she of the

had

very morning, but

had

ing painsdurthere
ten
were

that

between
was

half

an

hour.
labor

Pulse

each, varying from calm, tongue clean,

"

minutes

skin

slightly

moist

and

cool, occasional
almost
the

vomiting
the

^in short,every hour On about motion

appearance
her seeing
amination, exvaginal

of natural the

except that for

os

prior
the

to

my
a

pains had

disapi"eared.
dilated
to

making
size

found
soft membi-anes

of I

crown,

parts cool, rectum

empty,

had

before

saw

her,

into unruptured, and a feeble pain caused protrusion at membranes As she was vagina. very large,I ruptured the of liquoraranii. In 10 P.M., lest delay should be due to excess of this, however, I was although a large quantity disappointed, fluid came Shortly after this the pains ceased. I away.

waited

until I

4 o'clock

p.m.,

and

no

appearance
a

of the

repeated on pain came slight the came steadily,

in
8

fifteen her grains of gave About the dose at 5 o'clock.

; in ten

sulphate of
quarter

returning, pains and quinine,

past five a
noir paiijp

minutes between

another.

The

intervals

creasing degradually but steadily force, until

length,though increasing m strength and o'clock when she was safely delivered P.M.,
any of the

of

a so

fiue
monly com-

healthy child,without
seen

blanched

appearance

and

child

taking of ergot during labor. Mother event progressed favorably without any untoward
after
the
case was a

occurring.
The
was

other
a

multipara,who
and and up
to

had

four
month

children.

Ste

nervous very of the head neuralgia

of

excitable

temperament,
a severe

to subject to her prior

face.
with
a

About

confinement
;

she

was

laid

very
of

attack

gia of neural-

it, however, yielded

remained well until
set in with

bromide

She
false

ten

potassium and aconite. when her before delivery, daj^s

50 ^in minims

pains of opnim produced

seemed
to have

such
little
or

severity that
no

of tinctnre

effect

"

short, no

medicine

any

control

over

them

whatever.

I should steto

arid

Diseases

of

Women

and

Children.
had her

509
bowels

opiate on the next morning I chloral hydrate, cleared out with an aperient ; I also gavener and opium), and stupes, opiates (morphia belladonna, poppy this acid,but without effect. By the eighth day of
that

after

the

hydrocyanic patientwas suffering my

pains, her simple.
my the stomach I
now

greatlyreduced,
not

addition as, in

to

the
fected efOn

would concluded would

retain

that

any unless

kind

of

food, liowever
were soon

delivery
from

patient

mixture containing a evening of the mediately imthree grains, and quinine in solution ; each dose contained her to swallow I directed after taking the medicine thus the size of a bean, both to be taken a lump of ice about arrival next On morning she stated tliat third hour. my every and she had passed an easier night than any of the preceding, been greatlymitigated. She that the severityof the pains had it times or twice, the omer once had only rejected the medicine in labor, as a slight thought she was remained, and she now

probably sink eighth day I gave her

exhaustion.

discharge of blood and before my seeing her.

time,
for and she On

mucus

had

come

away

about
were

an

hour

The
more

pains

now

present

regular in
she had done

felt much

comfortable

than

the os making a vaginal examination, found her of the finger. Visited uteri would permit the passage labor progressing fairly. Membranes during the day. Found that labor retarded, but was unfortunately ruptured early, so of a healthy child. o'clock safely delivered she was ten at

days.

Mother the

and

child

did

well.

In
was

this

case

the

mother about

continued

quinine until before delivery.

In

quinism
I directed
cases

produced,
then
to

four

hours

both from
the

these that
same

the it

which

stop taking it. uterus presented a very different does after ergot. Quinine does
her

pect as-

not

produce

as ergot. persistent state of contraction in natural does it labor, just as the contraction passed off, each objections the uterus and quite flaccid and soft. Some was the that time for instance might be raised against quinine, as

In

from elapses suit in

cases

its administration

requiring quick administered the forceps, etc. Again, when of quinism, irritability produces, besides
have
after found
a

would it acts, which delivery ; but for such we until in the stomach

not

have
I

large doses, it
; but

that

time

ice prevents this without leaving any

quinism unplesantness behind.

latter,and

passes

off

Hydrate

of

Chloral

in

Obstei^rics. has

{London Lancet.)
the in last number which

Dr.
the

Dujardin-Baumetz Medicalede

recorded, in
cases

of
use

Gazette

FariSy several

the

510

Quarterly Report
hydrate
albumen the of

on

Obstetrics
nl. of In the firet lids, eyedavs

of
case

remarkably sncceBsf oedema (priniipara, protracted cephalalgia,

was

chloral

urine) a with one An enema labor,and lasted ten minutes. drachm of chloral was administered, and the patient fell asleep. On the day of the accouchement, to avoid a as a precaution and of of the with chloral drachm two one recurrence tit, enemata, Xo lit"x:houre' interval. in each, were administered two at curred, and, furthermore, the contracti^^ms were quite painlesN and intense even more though they were frequent than normal.
before In there chloral
tne

in

tit ot

legs and eclampsia supervened two

second the

case,

where

albumen
for

was

found

in

the urine,

existed
was

usual

conditions
as a

administered several and other

eclampsia. preventive, and no

the

Hydrate of
fit occurred. extitachloral
to
one

Lastly,in
ble, nervous
with drachm,
moreover,

cases,

the

weak. Dr. in greatest benefit,

it

patientswere Dujardin-Baumetz gave

doses

where

of

from

one-half

alwavs

had

the

effect of

soothing the
of
labor.

and, pain,
but

of

the accelerating
to

much raends doses

chloi*al prefei-s that it should

even

process chloroform administered

Dr. liannietz
rewm-

in

eclampsia,
in

be

sufticientlv

stronf'

(two and

three

drachms).
Woman.
of
a

llK-fiMio Eclampsia
Cksakean gres Section. Medical

m
"

Pregnant Extraction

"

Coma.

"

Death."

Living Great

Gniu).

(/^/^
and

and

Obatet.

Joum.

of

Britain

Irelayul^Sept, 1873.)
A and had she
on

WOMAN,
was

had aged thirty-five,

the end the
was

seven

normal

pregnancies,
when flie

at

of the

eighth

month

of

pregnancy
la

swellingof
had her fits. arrival
was

legs and
removed
to

face.
to
a

After the
state

losingeousciousneffi
and Pitie,
stertorous

She

Ilopitalde
of coma,

found The

be in loss

with

respiration
heart
fatal
was

and

complete

of
was

consciousness.

The

fcetal
As
a

heard.
was

issue

highly albuminous. made anticipated, preparationswere

section, which
child
was was

urine

Cesarean

effected three

two

for forming peralter minutes after the

death,
mother's
M. and

and

the

extracted well.

minutes

death, and

throve
whilst

Yvon but

analysed the urine, which

the

contained contained
a

much

albumen

little urea, of the amount of

blood

certain

fied speci-

acters kidneys presented all the charmarks parenchymatous nephritis. The author, M. Mac^, re-

latter.

The

that and

this

was

case

oi

urcemia

and

lowering of temperature,
calls it that in

by

tne

name

according to the works of M. Boumeville, he of eclamptic ursemia, because it is known

612

Quart"rly Report
occasionallyrising to
more

on

Obstetrics
tuations fluc-

and

105^ in

and
most

even

106", subject
fevers.
milk odor and

to

marked

than

other

JJiminution,

and the

after

day

or

two

latter of which

complete acquires a peculiar offensive

tissue,and
be
so

suppression,of

lochia,
that it its
curs oc-

suggestive

of dead (like patchouli) ought in my opinion to own,

characteristic

which
at

might

be

kakolochml.
sometimes

by an distinguished Vomiting frequently

latQr
; and

adjective of

the

outset, and
odor. iliac

diarrhoea, easily

induced
the

if not

spontaneous, the motions

Abdominal

kakolochial the

in ])ecially Often than

a

regions,but
Sometimes been

partaking of distinctly tenderness, espain and not constant or persistent.

delirium, but
one

intense

headache.

less my

quently frecsLses,

miglithave
dulness and

degree
and

of

expected. In stupor, accompanied

of

of

head

deafness,

powerfully suggestive

by noises in the typhus. Tongue

loner clean,but, if fever continues generallymoist and tolerably in the middle, and eventually enough, becoming dry and brown Thirst generally great, appetite dry, red, and glazed all over.

bad, but food

seldom

entirelyrefused,
in
severe

and

often

taken

surj)risacute

ingly well.
ditis in
one

Tympanitis
of my I mention the last cases, here link

cases,

independently of
as

which general peritonitis, which Finally abscessesj and

to

sometimes and

occurs,

did

also

].)ericarin

pneumonia
to
me

in another. in two
occurrence

occurred
because in the

cases
seems

1S71,
Uj
me

which furnish

tlieir chain

gradations comparatively trifling puerperal disturbances I pi-opose first to refer (see Diagrams I. and those to which as II.) thus afford and with the most to a strictly pyaimic cases, very I think confirmation the sympof tne presumption, which strong toms connecting
such

of

insensible

]ust enumerated
the that
more severe cases

warrant, fairly
are

alike of the

they depend
of
in the
uterus.

upon

as slighter which septicorigin, by the into absorption general

that

the

well I
mean

as

tion circulathe

decomposing
from
"

fluids and
the

deposits from disintegrating

to

veins
word
"

Passing now purghw

"

disease

its treatment
more sum

; tlie

single
tliaii

shorter, plainer,
would
serve

and

home-bred
up the

principal and ary secondprimair treatment, part and practice. 1 do, however, meanings both my theory my all the steady exhibition also rely upon, at events of or practise, doses three of soda in i. four lioura 3 3 or ss, or sulphite every to keep up carbolized a throughout the case, and I endeavor of McDougall's powder placed in suiall atmosphere by means in recommended the and about Johii Wood. Mr. bed, as by bags I have also given lately McDougall's fluid carbolate in drachm
of my and indicate

elimination

roughly to
by

its

and

Disedses
of the

of

Women
I

and

Children,

513

doses
upon

instead the

sulphite.

ventured scarcely I
am

to say I relied

because sulphite, it does much

in truth

I good or not. all the cases in which I theoretical grounds, and though nearly have ing watchgiven it have done well,I am inclined,from closely their course, to ascribe the good result principallyto the

whether

entirelysatisfied adopted it mainly on

not

pwrging. The purgative agent

which little Dover's
in
3
or

gave

I have which omel, mainly i-elied is calupon combined with a at firet in 5-grain doses

powder, as originally suggestedto me, but latterly Its popularly received doses with extr. col. co. 4:-grain
commend it
was

Qualities

it of

course

as

an

eliminant,
to

but and

first because
to
use

suggested originally
I felt
sure

me,

I gave I nave

it at
tinued con-

it because
course

that that

saw

it do be

I do

not

of

recommend
case,

it should

good. given
rule

criminately indisto

throughout a

but

make

it my

never

there is diarrhcea / when repress leave well there is no alone / when lose no time in settingit up. I

improvement without improvement without

is much

it,to it^to

ought
and

to add

that

when

there

pain

and

tenderness

of the belly I
chloral in

linseed-meal einploy

that i

find it advisable occasionally

a

anum, poulticessprinkled with laudto give a dose of of

; very

rarely indeed
with calomel. in these

dose

opium,
have

and
a

never

except
dread and

combination of

Indeed, i

great

opium cases, believingit to be capable of and masking dangerous symptoms. elimination checking salutary I give as generous the patient ate, will bear, with a modera diet as of stimulants. and occasionally allowance a liberal, I endeavor and attach of course, to secure, great importance I aim at economizing the patient's and to good nursing, strength child breast the the frc"n as as soon really by withdrawing
distrust

serious
of and and

symptoms
thus the treatment

show
a

themselves.

Having

given
views

generalview
advocate,

of the
now a

cases

am

I will
to
common

proceed
few
ones,

to

speaking explain
cases on

support my
nrst
more

by

reference
more

illustrative and

taking
to

the

and slighter
as

going
on

the

severe,

being
to

and

corresponding best
And

lucid both the most flie growth of my own

arrangement
views

the

matter.

"

friend to my acknowledge my obligations who C. first of Mr. former J. Kilbum, Whaley, partner, recommended he had which the practice, to me long followed, of giving five grains of calomel of Dover's and ten powder whenever woman. high febrile syonptoms set in in a lying-in I had begun practice with a horror of active treatment, espefirst let
me

and

33

514

Quarterly JR^port on
active and purgatives, the last ; but
a an more

Obstetrics
of calomel^ espeeially and

of cially
should

have occurred under of

been

person
seen

to whom

sueJi
cases

an

idea of

would

have
fever

I had

several and

fatal
I did

puerperal

different
older

treatment,
when
I

not

traditions of
had
a man

school

confirmed

I could led
to

trust.

accordinglytried
very shall

by the it,and found,

symptoms
the

despise the experience

a"

been

expect, that
the
to which

ugly febrile
refer

sided sub-

rapidly under
The that of lirst
a case

influence, apparently,of
I named and

dose.
of her this is fourth
on

in illustration

young child,in whom third the

woman,

with English, lying-in

severe

rigors
tenderness

headache

occurred

the

day, with
some

milk,
32,
seven

resp.

and

of discharge,retarded establishment with and of a pulse belly, 124^ of three of dose calomel A grains temp. 1031^"^.

diminished

of the

with the

of

extr.
were

col.

co.

was

given at
very short

once.

Three
in

sive loose offenthe

motions
woman

passed

at

intervals

night:

found
went

next
on

better mimediately,wa5 expressed herself as reeling with pulse 88, resp. 21, temp, narfnal, and morning quite well afterwards.
was

This time

woman

wretchedly poor

and

out

of condition

at the

labor,and lost a good deal of blood during the fir"t of the uterus; twenty-four hours owing to imperfect contmction conditions which favorable are both, and the latter especially, of puerperal fever. to the occurrence The is that of a young named next case woman Mills, lying-in
of her with her third child.

She

was

also

rather

out

of

conditioD

had been a tlurough prolonged attendance upon of pain in the right iliac region. She bad a good deal suffering labor, but apsharp aiter-painstlie first day, after a rather severe peared well up to the morning of the foui-th day, to be going on when About live p:m. she had a pulse of 84 ancja cool skin. she was seized with intense pain in the back and right ilium, fulness violent and of exand of numbness head, tremities, rigors, pain pulse 116, resp. 30, temp. 102^^. Milk and discharge almost ordered linseed-meal a suspended. She was poultice and took five grains of calomel with tr. opii, and eight of liover's There not much was powder within an hour. change by 11 p.m. fall in temperature. In the night,however, ^e except a slight had three loose foul motions, and next morning the pain was all but

sick

child,and

gone,
still
some

although

some

tenderness better.
rose

remained.

expression,and
was

felt much

The
104"

high, 1034", and

lieadache the all

to

good temperature, however, there by night, having

a

She

nad

been

day.
and

The

bowels

continued

to

act

also several times in the night, day, frequentlythrough the motions offensive character,and bv their graduallylosing

and
the with
had

Diseases

of

Women

and

Childi'en.
much
still the

615

following morning (the sixth) she

a

was

very but

better,
scanty
cretion se-

free
of

and discharge

an

increased still

though
116,
to

milk.

fallen to 20, and

rate

normal
was

96, the
It
was

respiration lOlf", reachmg the temperature the pulse the following day (the seventh), .when on respiration20, and all going on well.
pulse was
the

The

the like these,to overlook scarcely possible,in cases and the purgation accompanied improvement, borne and the natural from inference was so surprisinglywell, this was in which confirmed by the recollection of two cases diarrhoea had accompanied severe alarming febrile symptoms all my efforts settingin a few days after labor,and, after resisting fact that active

it,had subsided in two repress fever without doing any harm.

to

or

three have

days along with

notes

the

I
on

of

one

of

in which and

severe

rigors occurred
of thei
noted
on an belly,

the fourth

night,and
and also
a was one

these, pain

tenderness 120
were

anxious

countenance,
There
of dose

pulse
severe

of

the

fifth

day.
a

vomiting,and
and

grain be purgative. powder, milk The and lochia almost were suspended by the entirely enth morning of the sixth,and disappeared entirelyduring the sevand on eighth days, showing some signs of reappearance the ninth, and the ttie but tenth purging being restored by ; sedulous did until the of in not cease twelfth, spite entirely
five of

diarrhoea

set in after

of calomel

Dover's

not

intended

to

efforts A

to repress

it. illustration
to me,

very

similar it
seems

of

the

usefulness

of

diarrhoea
where

is

afforded,as
continued

for five

by the following case, days, after giving,as I now

under similar also of
course

ing purgto

began
"

do,

decidedlyaperient dose
to check

circumstances,
: a

all

attempts
Mrs. labor
the

it
a

being

given up
had

McKellar,
terminated rather

young primipara, by the forceps. The uterus

for the

long

and

severe

contracted first two

on on

allowing
The
the

profuse discharge
which large clots, fell below 100, and

formation

of

passed
was

pulse

never

120

badly, days, and the second day. the second day,

temperature being lOOf **. On the third day the pulse had and there risen to 140, resp. 32, and the temperature to 103|^**,
was was

much
also

in pain, especially

the four

where right iliuin,

tenderness
and five of

present.

She

took

grains of

calomel
on

Dover's

powder, which had to be repeated twice vomiting,and sharp purging set in in the course Next 140, and day (the fourth)ner pulse was
about 30 both

account

of

of the the

night.

q^orning
to

and

evening,
morning,

the

having
in

fallen

lOlf

"

in the

respiration temperature, however, arid only reaching 102^

and

the

evening.

Tjie

abdominal

pain

tenderness

were

616

Qua/rterlyJReport on

Ohatetrics

There tendency to tynij)aniti8. Bome unabated, and there was of milk secretion at was a slightattempt ; very little discharge. Laudanum the to was belly. applied on poultices and The continued went at on iiitervals, purffinff frequent unabated all tnrongh the night and the next day (the fifth), dition, improvement in her general conduring which there was some the pain abating somewhat, the tenderness though sisted, perthe and the to turn. reappetite beginning tongue cleaning, There
milk.
was

also
and

rather

more

discharge and
124,
32 in the

trace

of

morning, the and and I** was 132, 30 in the evenmg, just. temperature than and botli the preceding day, on higher morning evening. The little diminution continued with diarrhoea during very sixth and motions the next two seven being days (the seventh), pulse
were respiration

The

noted

between

my The

two

visits

on

tlie
to

latter

day.
and

tongue
abdominal

continued

five on former, and clean, the appetite to

tenderness

the prove, imde-

the

pain
maintained
on

and

steadily to day,
traces

ci*ease.

Tlie

the

milk

discharge quite disappeared

noted
on

itself
the

to

slightextent, but
The

seventh

however of

again

the

eighth and
ii
we

ninth.
one

being pulse and

of
on a

respirationaveraged 122, 29,

except

observation exertion fell from

pulse

evening on lOO^^^j^^
a

of the the

140, probably occasioned by some The sixth day. temperature

the
to

102f"

morning
rise
or

of
one

the

seventh
on

temporary
99"
on

degree
was

the

reached
an

the

eighth, and

did not

day, and, evening of that day, again exceed it,though

ing notwithstandnoted till the eleventh

normal absolutely

temperature
some

not

day.
There the ninth
was

still

diarrhoea

on

the exceed

eighth day, but

two
to

the
on

motions, though
or

still

loose, did
the bowels till

not

in
at

number all from

a

tenth,and

ceased

act

the

morning of the eleventh aperient was given. The poultices were continued
the

the

thirteenth,when
the gone,

gentle
when

until all but

eleventli
and the

day,

abdominal
This

tenderness
100. is remarkable

was

pulse at

last fell below

case

for

temperature
so, unless for
case

began
is
an

to

there the

nm up omission

in which the pulse and way from tlie very fii-st, and still more in mv notes (which I rather suspect)

the

absence

of

wluch rigors,

occurred

iu every

otlier

without The

exception.

as

of range in those which

temperatureis
follow, but days shows

not

nearly
occurrence

so

the

high in this o| a pulse of

of

c^ise

140

on

three

several

it to

have

been

considerable

gravity.

cmd
Before

Diseases

of

Women

and

Children.

517

for a moment to anticipatean passing on, I pause which t)bjection possiblybe urged to the argument founded may such last ; the objection namely, that the the cases as upon central fact in them runs really be the diarrhoea, which may milk and that the and febrile with txie to so speak, lochia, away, being relieved by the diarrhoea, are in symptoms, so far from realitysecondary to and dependent upon it. This is of course of the facts, for it is evident that the a plausibleinterpretation diarrhoea is conterminous in point of time with the failure of
"

milk
cases

and

lochia.

But

this

theory takes

no

account exist to

of

those

where

looseness relieved
no

of
when

the

precisely similar symptoms indeed bowels, and appear

it is set the which up
: cause case

without be

any

manifestly
it offers it

explanationof
ours, in

it ignores the of the diarrhoea it is

and rigors,
"

unless, indeed,
;

accepts

virtually suiTendered

for

if admitted to be count sieptic present, will, we know, acpoisoning, 140 tor a pulse of and a temperature of 104^, whereas diarrhoea the severest will. hardly
....

The

first two

or

three

cases

to

which

I referred the
name

were

haps per-

hardly
time

grave

enough
the

to

be

dignified by

of
up
to

though
of

symptoms

whicli

they presented

septicemia, the

did differ in any way not being established, from those of the 'subsequent cases, or of many others whicn have eventually proved fatal. ciently The last three^however, were, 1 venture to think, of a suffibold and character,aud required a sufficiently grave of I the which am thorough application principles advocating, furnish serious their of value* test to a really I have treated three others of equal if not greater gravity on tunately result ; but I unforthe same principles,and with the same have them in
not

diarrhoea

such like
a

notes

of

them

as

to be

able

to

present

anything
all three

complete form.
after
of
severe

They
by
most

occurred

first labors
was,

terminated

the

severe

that The

think, the most with of the six,there was extfemely acute peritonitis distention of the belly,and, when distressing tympanitic and almost made subsided, pericarditis came me on despair. other two which I those referred to are as instancing the
one

forceps.

In

them,

which

formation other
much

of

abscesses, which
into
as

did

not, however,
to

occur

until

the

symptoms were fresh danger

and
recover. seen

beginning
the
cases.

abate, and did not import In all, most purging was

in every
case

continuous have

severe, it

it has

been

which

These themselves

results ; but

are,

seems

to

me,

sufficiently striking in
them
up

if I wished

to throw

into still bolder

518

Quarterly Report

on

Obstetrics

dark relief, a sufficiently of my

it does rhcea
were or

background could easily be got ont as remaining experience of puerperal fever, comprisino;
four of cases, none treated I should as which
now were

characterized

by

aiar-

treat

them, and
these
cases

all of which

fatal.
I do
not

wish, however,
conscious

to

strain this

to

any

euch

purpose, much as

being
one

that
a
case

would

of

them

was

of

that

hardly be malignant excessively

inas* fair,

unaccountable type where tlie vital powers being

poison ; form of peritonitis and that exhausting labors,

have
been

the blood

sinking sets in from the very first, by the force of probably overwhelmed others presented such while two acate an
set

in

so

ouickly

after

such

extremely

saved That

even

it is very doubtful whether they could such I should now under treatment as
not
am

employ.

they
in any The
made

were
case

they did with opium, I

could
not

good a chance, treated as certainlypersuaded, and the result

have
so worse. seems me

have

been

last of the

four, however,
Tlie

to

me

so

such

deep impression u}x"n

it.

at the

and instructive, time, that I must

a patient was healthy young woman, her third child,and her labor was in all respects favorable. On the third day febrile symptoms and peritonitis I did that and time set in, by entertaining,as (July,1871)the I do now, views firmlj so same as though I did not hold them

recount briefly lying-inwith

or

I began clearly, 1

the

treatment

as

I should

do
"

now.

tunately, Unfortion, modera-

however, something

about

the
"

case

^the very

the somehow think, of the febrile symptoms gave me the fever in which was really a case impression that here was only secondary to the local inflammation, and this error being called into clinched by the opinion of a gentleman who was

consultation
on

with

me,

the

eliminative

treatment

was

given

the

the established,

finning ad
of lived found
poor the
to have

day, before diarrhcea had istered and opium adminbeing very obstinate, This gave instead. and I was besome apparent relief, the correct distinctionwe to congratulate myself on tion made, when, on the seventh day, a large brawny infiltra-

evening

of

the

fourth

np been

bowels

tissues

about

the

left

hip, which
a

had must, if she abscess,was pain,and my

long enough,

have

softened without
to sink
a

into much and

tremendous attendant

lormed

commenced patient

died

on

the

example of the febrile symptoms thing occurring after labor as due to anybut Beptic poisoning,or of the jealousywith which we of opium ? The case gi^es ongnt to regard the administration
better
me

Could

there,I ask, be

day. following of garding redanger

occasion

also to

express

my

conviction

that

the

peritonitis

520

Quarterly Report

on

Oh8tetric8

articles of faith are not necessarily although in medicine the of because to test true they answer quod semper, quod such tins does ab in omnibus," ajs ubique, quod yet a catholicity and conscious reality depend upon a wide, though informal perhaps unfrom and induction can facts, only be encountered of less be induction, which by a corresponding process may such in but wide in proportion as it is more must a precise, yet And
"

case

as

this be may
"

very
not

wide

indeed.
the

Its width
"

daunt

daring heretics
it may which

who

inaugurate
them draw
;

sacred

wars

but againstold beliefs, any will

source

yet weary

and
an

if there array of

be

from

theyare

likelyto
I do
not

facts sufficient for their

be

any

contingent

furnished

from

campaign, the

believe

records

of

caemia. septi-

On

Immediate Journal
Dr.

Sctcre Great

in

Rii^ured
and

of

Britain

{Ohsfef, Ireland^ September, 1873.)

PEBiN^xTa:.

Boeckel and

writes

Gazette^
even

this subject in the upon concludes that it is best at

severest
cases. same

Stra^urg
once

cal Meditures su-

to

insert

in the would be

Dr.

Joulin, of
if the

Paris
the
a

Joulhi)^
the

of the
suture

immediate

and

opinion subsequent paring of

latter the
ne

alternative

{fe (6rtf5. tween belay edges of remarks bruised

ruptured parts, which when operation,especially

that and the

regardsas
is

dangerous

bowel
a

parts immediately

after

laborious

injured. He delivery are

indisposed to heal by first intention, and that the organism has a singular disposition to purulence after labor, which with lapse of time. He diminishes Moreover, for a week says,
"

woman

who
to

has

puerperal them While required to light accepting up. I believe it is advantagethe principleof primitiveinterference, ous I prefer to wait it immediately. to till the not to resort has till the passed, tissues, dangerous phase disgorged as it have their vitality.By attentively resumed watching the were, of the wound, it may be possible to choose the opportune state without be understood, till cicatrization moment, waiting,it must
often but little is has

the

undergone a general accidents

laborious

remains delivery,

cessible ac-

of

the

state, and

occurred."
"

good ; nevertheless, where there is reason that when the perinseum has sustained to believe of opinion that immediate but little bruising, will suture are we of much the results. The insertion best sutures yield shortly [Note.
precepts
are

M.

Joulin's

after the accident

is

less painfulthan considerably

at

any

other

time, and

may

be

done

without

the

use

of

ansesthetics

should

and

'Disedsea
be

of

Women
The

arid
most

GMldren.
convenient
curve

521

such
for

agents
to the

contraindicated.

needle

perinealoperationsis that made

shaft ; and twisted

with

the is

silver wire

gles rightanto the preferable

at

wire.] single
Physiolooical
lier Medical

Results
and

of

Double Journal

OvABioTOivn!'.

(MontpeVand
ire-

Obstet

of

Great

Britain

land^ September, 1873.)

on are

that his patients writes to M. Puech KoEBEBLE, of Strasbourg, whom he has performed the operationof double ovariotomy less The not lovingto their friends, parents, or husbands. remain excitable. The

genital organs
sweeter

Their
breasts

character

has

become

and is
no

less irascible.

have
it has

not
not

diminished.
isted already ex-

There
;

tendency
Perfect
menses.

to

obesitywhere
increase has been of the

no

alteration

in the

hair,
not

nor

modification in of spite
tion cessa-

of

the voice.
of the characters. Cysts

health The

rule

patientsdo

lose their distinctive

of

the

Parovarium.

{Gaz. Med,
Britain
and
at tlie

de

Strasbourg and
ciety So-

Obstet, Journal M. KoEBERLE

two
cases

of Great

Ireland^ Sept.,1873.) Strasbourg Medical

he had

exhibited lately of of

parovarian tumors
which
one was

which

successfully
before

removed,
the

and

diagnosed by puncture

formed operation. These by an extraordinary cysts are development of the organs of Eosenmtiller,and are situate at end
of the

the external
the broad from

Fallopiantube, in

the

part posterior
separates
volume

of

ovary ovarian

ligamentat the top of the space which the pavilion. They may acquire the tumor, but differ not only in origin but
and
contents.

the
an

of

in

their

tomical ana-

structure

They develop in
cellular where tissue, from enucleable
some

the thickness
numerous

their with

connections
are

ligament amongst abound, and are easdy have peritoneal covering. They may the uie Fallopianfringesor ovary, but
vessels w^alls are The difficulty. layer covered by a single layer of without sometimes very
are

of the broad

usually these
formed which

isolable

by

fine fibrous

with cylinderepithelium,
on

short

and cylinder,
The

fluid is
a more

vibratile cUim occasionally limpid,does not extremely

or

found.

contained
and has

less saltish taste. the

These

albumen, parovarian tumors

less than those

contain

to

influence

general health

much

appear of the

Their presents two ovary. course, also different, first in which the disease very slowly develops, and which, on the contrary, is very rapid*

periods,the the second,

522

Quartej'lyReport
Syphilis
of the

on

Obstetrics

On

Placenta.

By

Db.

Ebnst

Frankel,

Breslau.
The author in

vol. {Ibid,^ calls

1873 ) v., p. 1-54. the attention to formerly difficulty

sufficient

Elacental ealthy,and the foetus

able
to

obtaining a syphilis,the
any

quantity
far gone
to

of

cases

rienced expeof undoubted

parents

frequently appearing
in maceration the

quite
to

being
and

too
as

be

of

syphilitic degeneration sequence placenta; in conorgans, of which and the of difficulty, perhaps, exceedingly results of the examination of undoubtedly syphilitic variable placentae,the opinion had hitherto been prevalent, that no characteristic and general unfailingsigns or placental s^^hilis the matter could Thus be named. stood, Hennig stating in a of the prolate as 1872, that the similarity as special treatise, ducts of syphilis, and those of simpleinflammatory processes of placental syphilis from prevented the existence being more than b ut when not a 8upjx)8ition, definitely Wegner, proven, first assistant to Virchow, published his investigations in Virchow's and furnished conclusive Archiv, vol. 1., a proofof the of hereditarysyphilis, existence by the discoveryor a peculiar and of characteristic abnormal of the bony structure condition the foetus, tlie of inflammation at the point of junction an viz.,
its internal

draw

conclusions

consequentlyof its

diaphysisand the boundary

short,an
may be

the

of cartilage
the

the
and

or epiphysis,

in

the

ribs
"

at

between

osteo-chondritis the foetus be

examined

bony portions cartilaginous syphilitica. Thus hereditary syphilis

every case,
no or

in

in diagnosticated
or

matter

how

much

the

soft parts

macerated,
of 100

how

healthy the parents

the year

m^

Frankel

appear.

upwards

placentae during
macerated

1871, including all those obtained

besides solution then of the
a

carriages, embryos, missyphilitic mothers, or those presentinffany changes, number of normal for the sake oi comparison. placentae,

from

Fresh of
colored

specimens
salt in

were were

examined

in

one-half

per

cent

Cuts carmine
witn

fii'stinspected without

coloring,

solution of

ammoniac^ glycerine,aqueous and carmine, picric acid,or solution oi haeinatoxyline

and

alum,
lens.

cleared Other

Beale's

fluid

chromic ab6ve.

acid,

or

specimens were and alcohol,cleared with glycerine,

put under creasote, and in Mtlller'B fluid, hardened

or

colored

as

F. found
nature
or

in all been

had

whose placentae(with one exception), syphilitic the of determined by the examination parents of osteo-chondritis which
he calls

the

evidence

pathological change, of the granulation-ceUa qf

the

peculiar proUferaticn Deforming deplacental triUosities. He

in
a

the

child,

and

Diseases
the

of
the

Women

and

Ohildren.

523

scribes

it

as

of filling cells

with body of the villosity

rous nume-

proceeding from the vessels, complicated of the the of villi, covering epithelial by proliferation which bloated in the therefrom assume a thick, er highappearance of the the cellular of of this contents proliferation degrees
the
villi ; obliteration of the vessels and themselves the villosities condition for This is mistaken other pathoto be not ensues. logical
what changes frequentlyoccurringin the placenta, and somethe normal fatty degeneration resemoling it, viz., 1,

mediam-sized

and

tal foeperipheralvillosities in the mature which, like the analogous changes in the maternal placenta, and retrogrademetamorphosis placenta,are only the signs of involution obliteration the
of

of

this organ

at term

2, the infiltration of

the

villi

with and

molecular

granular masses,
disturbance
"

caused
the

by impeded
of the

circulation

functional
the

in villi
are

vessels

villi,found
going underbetween

mostly
flie

in abortions

the

and slender,atrophic,

degeneration; 3, coagula changed into molecular fat; 4, all may ancient confusing denominations, such as scirrhus, encephaloid, mean etc., which anything or nothing. Syphilitic placentae are, besides,generallyvery large,heavy, and of firm texture.
process which villi, become

of fibrous

F. closes his valuable

1.

article with become

the following

conclusions
are

"

The

placenta

may

and syphilitic,

mere

teristic charac-

signstherefor.
2. Placental
or

syphilisis only found in connection congenitalsyphilisof the foetus.

site and

with
the

tary heredi-

3.

The
well

of

disease
the

varies

accordinglyas
was as

mother
to the
ovum

mains re-

the

virus syphilitic
or

imparted
motner

directly through
In of
the the

former

case, which foetus,

semen, if the placenta takes is not

the

is also infected.

any

part

in the the

disease

of its foetal

portion become
the

absolutely necessary, degenerated by means

consecutive

villosities

of

deforming,
and

with cellulo-granular proliferation,

'

obliteration

atrophy of
4. the

and

with rapid provessels, fre(juently complicated liferation covering of tne villi. thickening o" the epithelial case, when

In the second

the mother

is

we syphilitic,

have

infected

following three possibilities : {a) the act or generation togetherwith the foetus : in by the placenta diffused vSlous syphilis then develop itself, may endometritis or plaprimary disease of the maternal portion, centaris, may was ensue, already syphilitic ip) The mother then before became afterwards: infected soon conception, or
The
becomes

"mother

the

placenta may
case

remain the

normal form
of

or

become

diseased

; in the

latter

under

endometritis also
as

placentarisgummosa,
decidnalis

or

(accordingto Yirchow)

endometritis

524

Quarterly Heport
(c) The
of
was

on

Obstetrics
infected
until tlie latter the both

alone,

mother

does

not

become

portion
rather
the

pregnancy

(7th-10th month).
th6 time

healthy at
and the

of

provided immunity of generation,

while

Then,

foetus 6. The

placenta
of
been the but

exist. ftetus

infection has

passing
and

the then

maternal
not

genitalcanal certainty.
The

seldom

proven,

with

Pathogenesis Giessen.

of

the

EACHrnc

Pelvis.

By

Dr.
v.,

F.

A. p.

Kehrer,

(Archiv fur

GynaekoL^ vol.

pt. 1,

55-99.)
positiveand valuable results on of rachitic pelves, the researches of development should in two a genetic and an directions, experimental.
to arrive at

In order

the

mode

be'made The first

class

must

seek

to

obtain

continuous

series of

of

the
of

various
; these
same

forms
must

of be

deformity at
compared with each specimen
of the

different normal
must

stages
examined and

development
children
to

pelves of

tlie

age, and and direction

be

ascertain

the form

spinal column

lower of

strength, diameter, and resulting force and of the ligaments,the growth firmness direction, elasticity, and advanced decrease of the bones by comparison with more be compared with specimens, etc. ; and all these results must
tnose

extremities, the the muscles, the

of

normal

pelves.
"

The

second

class

calls for

series of

the

the nearer the higher organized and experiments on animals human of and their in manner walking species holding the

bodv, the better.

To the immber six
new

of

published
other
at

cases

of

congenital rachitis
aod age,
: same

Kehrer has

adds

instances, the
with
arrive normal the

study, measurement,

comparison of
enabled of number rachitic

which
to

pelvesof the
are

him

following
and foetus,
are,

conclusions

of form, peculiarities

which

characteristic also

of the

occur pelvis,

already
or

in

the

in children of the ion flex-

who
sacrum

cannot

yet stand

walk.

Such
transverse

enlargement
inward the of

in the of

and longitudinal

diametere,
descent
ossa

its lower

extremity, advance
of

and the

sacrum,

flexion (antero-posterior) sagittal

of flattening dilatation
pressure
account

renif orm the cristas ilii, of the pubic arch, etc.

ilii, gaping and rounded or triangularinlet, the question of Inasmuch as

exerted with
and the

by

the

trunk

and

thighs does
muscular the
a

not

enter

into

loetus, but
pressure

only
on

and

traction

muscular that muscular

joints,the
much
was

ligamentous 3raict monstrate is de-

action

has

greater influence

on

the

formation

of

rachitic

pelvis than

formerlysup-

and

Diseases

of

Wom"fi
of
of the

and
rachitic

Children,
deviations
on

525

posed. Farther, a does not depend on

the

portion
anomalies

of form

and infractions, to arrest growth by Engel partial Wiener Med. Wocheyischrift^ 1872, p. 40) only imperfectly ( rachitic of shape, namely, the relative explains on^ peculiarity

growth, but

of

particularlyalluded

shortness

of

the

true

conjugate

diameter.

The

Etiology

of

Knee-Presentations.

By
different

Dr.

P.

Wurzburg,

{Archivfiir Gynaekol,, vol. v., pt. 1,p. 1

are

MfiLLER, 26-132.)

Knee-presentations
one case

very
to

rare,

authors That

develop
was

among themselves

from

1,000
out

5,000 deliveries.

finding they may

of

tions breech-presentaprimary-footling or

and mechanism of the deviation cause known, have not been three satisfactorily explained. M. has witnessed the lower in which stretched cases portion of the foetal leg was the brim of the pelvis; twice in the diagonal directlyacross in the the and the heel resting on transverse once diameter,

but the

and posterior
in

the knee

on

the

anterior

margin

of the

both pelvis,

plane. In the first case the knee was subsequently tlie uterine down veritable kneeand contractions, a by pressed the proximity of developed ; in the two other cases presentation the the the head brim made it of to pelvis extremely probable
the
same

that this had had been

been

the

originally-presenting part, and

warcGoeside
the

that the head.

legs
The

subsequentlypresseddown
stretched

by M., as their transverse position presented obvious obstacle to the an completion of the labor (the length of the of to a well-developed,newly-born child from knee leg and heel is 13-14 the diameter of the transverse pelvis cm., of 11 this the the of cm. 13^, conjugate only ; impaction part minated terleg is consequentlyquite possible). All three cases were extraction. deductions The a by manual are, that knee-presentation may develop itself out of a transverse tion posiliable of the leg in the pelvic brim this that is position ; under certain where to occur a conditions, head-presentation is

legs were

changed
transveree

to

breech-

or

position may
may
to

and footling-presentation; not only temporarilyproduce be

that
a

this

kneea

but presentation,

also

of

some

duration, and

cause

mechanical
A

obstacle Cyst

delivery.
the

Compound

of

Vagina. fur

Freiburg, Baden.
138-144.)
These
50

{ArcMv quite rare

By Dr. GynaekoL,

K. voL

Kaltenbach,
v.,

part 1, p.

cysts

are

(Winckel

was

able to collect Kaltenbach

only
de^

and cases)^

their

is satiology

still obscure.

526

Report Quao'tei'ly
occurring in a woman and iKwterior colporaphv
a

on

Obstetrics
whom

scribes cervix uteri.

cyst

were

In

tne

posteriorwall oi the

ampntation of the performed for prolapsus found flnctna vagina was

on

foimd to contain a tblckishf atiug tumor, wnieh, on puncture, was almost brown and removed in tbe fl"p which entire fluid, was dissected from tlie posteriorwall of the vagina during eolporaOn be two cysts close examination there were found to phy. with small lined of which of the size of a cherry, both were tesselated epithelium, the upper layers being flattened like epidermis ; m one of the cysts only here and there cylinder-

epithelium was

to be

seen.

The
in
"

internal surface
similar papillae,

of
to

one

of the of
a

covered with wart-like cysts was cystoma proliferum papillare ;

those

the

other

the

were papillae

much lare.

smaller

and

less

developed

cystoma proliferum glandu-

The

walls

septum
consisted found
and

situated of the cysts, which in the rectovaginal were the knife, without and could not be enucleated tissue and

of

fibrous
minute

epithelium,and
filled with
The

in

them

were

several

cystic
and in the

cells

glutinousmasses, forming fissures

in the ovary, with If

thick, cageoiis spaces of several accumulations microscopic

fibrous
tissue.

diflFei-ent stages
that in
a

of this

cysticdegeneration, which
are:

closelyresembles
of
cells distinct

taking
fibrous

place
stroma,

accumulation
without

small

spaces cystic

larger walls, finally

of several
did
not

cystic spaces

large cysts.
existence

walls, and, by the majority of

us

confluence
anatomists

of these,

deny the

of follicles in the
to

cysts might lead

we

might

attribute

the

lining of tliese vagina,the epithelial seek for their originin such ; or glands the the of cretory expersistence epithelium to
bodies.
the This is

ducts

of the Woman
must to

merely

hyjx)the-

sis, however, and we in uncertainty as

An
IN

therefore,for
of aetiology

the these

main represent, still

cysts.

Endemic Hospital

of

Morbus
in

Bdllosus

Neonatorum
Dr.
Ahlfeld.

in

thk

Lnxfi-

Leipzig.

By

(Archivfuf

Gi/naekoL,
Coincident
a Leipzig,

vol. v., with

a

part i., p. 150-159.)

similar
cases

number

of
The

alx)nt epidemic in the villages also be of this disease, which may the
an

called

pemphigus Lying-m Hospital

average fifteen
very
on

neonatoinim

occurred in non-syphiliticus, eruption appeared unexpectedlyon lasted from

and
one

tne

fourth few

day after birth,and

the vesicles with
cases

to

days

and
a

longer ;

enlarged
were
rea

increased
increase of
sitive; sen-

rapidly, in

accompanying
bases neck and in

temperature

; their

and peripheries
nrst
ou

and not
the

they appeared

the

ingamal

528

Quarterly Report
to, there will be
of the
a

on

Obstetrics^etc.
proper As cicatrix ; but
aiiv

already referred
once

no

when union

the
be

formation

part is completed, then

to

will

accompanied by
occurs

cicatrix.

the
a

way

in wliidi the

secondary cicatrization
sometimes after

occurs,

birth.

be by it may The proximal

process such as lip edges of the hareway, and the two

being
raw

surfaces

in contact, the epithelium may cicatrization. unite with

give

Death
THE

of

Child

caused

by

Introduction

of

Chyme

dtto

Air-Passages.

{London

Lancet^ Sept, 1873.)

communicated
de and Biologic, The

This
at the

was very interestins:case the last sitting Societe of

by

Dr.

Parrutt

is the second
was

of the
one

kind
clock

that

lie has

observed. already
fed

child

aged

year, and, after

o

being
at

by

the

bottle,was
all the

put

to bed at

six

and At

died the lower

midnight, with
of the of

dyspn(i"a.
death)
the

post-mortem
lobes
a

examination

two

hmgs

were

signs of intense (ten hours after tened, found quitesofa

grayish, having
undergone
in
^

smell

butter, and,
Altered

in

word,
was

having
found

the

action and

of

juice. gastric
In

milk

the

trachea

bronchi. which
on

in the
was

stomach, and vomited, and,

into the

this case, the milk taken doubtless had been of

contained
in excess?, had

account

the

horizontal Parix"tt

posture,
drew

penetrated

the attention air-passages. Dr, fact from a of his colleagues to the importance of the lie that this occurrence thinks medico-legal point of view, be rather must two cases frequent, as he has already witnessed in his own sphere of observation.

Properties
OF

of

Pancreatic

Juice

and

of

Parotedean

Saliva

Infants.

(fientroMatt fur

Med.

Wissensck,^IKo. 17,

1873.)
to the Children's CUnique assistant-physician series of St. Petersburg,has conducted of a experiments with the liquids taken the pancreas from and parotidean glandsof several children who died intestinal from had or puhnonaiy

Dr.

Korowin,

maladies, and
has stated life does sugar
;

tried the

their

fermentative
of

action the

on

starch.

He of

that
not

pancreatic juice during

tlie

first months
the

possess

property

transforming
only after
of

starch into

this and

property
attains its

becomes

manifest other
the

third
the
verts con-

month,

highest degree
On the

towards intensity
saliva

.end of the

fii-styear. starch into sugar ascertain is

hand, parotidean

during
this
as

is

possibleto
more

eSect

and \X very first days of life, of the liquidfrom birth. The

more

action

powerful

the child is

developed.

THE

AMEEICA.N

JOUENAL

OF
AITD.

OBSTETRICS

DISEASES

OF

WOMEN

AND

CHILDREN.

VOL.

VL]

FEBRUARY,

1874.

[No.

4.

ORIGINAL

COMMUNICATIONS

CASE

OF

RETROFLEXION CAUSING

OF
STERILriT

THE
;

UTERUS

TN
;

THE

THHID
;

DEGREE, VAGINISMUS

TREATMENT CONFINEMENT.

PREGNANCY

PERSISTING

AFTER

Bt

8AHUBL
New New York

B.

WARD,
; Prof, of

M.D.,
Anatomy
etc.

Suigeon

to

the

Presbyterian

Hoepltol,

in the

Woman^i

Medical

lege Col-

of the

York

Inflrmazy,

Mrs.

X
,

married,
account

age

25, consulted
was a

me

May

5th,

1870,

on

of

sterility. She

remarkably
the

healthy, robust, fine-looking woman,

taking plenty
bowels
the of
"

in

habit

of

out-door in

exercise,appetite excellent,
did
not

regular

short,
disease
had been I

know

that Her

she

was

subject .of
was,

any

whatever.
married

only
years

plaint com-

that

she
never

been

three

and

half, and
Her
a

had

pregnant.
knew

husband,

whom

also, was
man,

to

all

ance appear-

perfectly healthy, vigorous

wife,
34

and

had, by his

former

two

children, who

are

still

living.

530

Ward
X.'8 menstruation and

Cme

of
at

Mrs.

was

established
come
on

the

age of
or

fourteen,

had
with

always

every had
never

nineteen gone
to

twenty days
a

regularity ;
flow had

she

over

single epoch marriage

it had

without
the

menstruating. Up
been excessive and
was,

the time

of her time
she

; since that
at

diminished

very

much,
more

the time

sought advice, somewhat

two
or

scanty than
She
out

normal,
no

lasting only
at these

three

days.
went

suffered
as

pain

epochs, and

always
or

usuaL

After

seeing hfer two

came

three
"

times, and
^and
so

considering
informed for her
her
ility, ster-

her case, I
"

to the

conclusion

^that there
the

must

be

some

mechanical
could

cause

nature

of

which

only
At
the could

be
same

ascertaioed
time
a

by

an

examination

of the uterus.

it was

difficult to understand

how

there

be
no

mecbaaical

impediment
whatever.

to

impregnation,and
idea of
a

yet

dysmenorrhcea
was

The
to

physical examination
I

very

repugnant
go
to

her

and feelings,
so,

suggested that
this she

we

should

Dr.

Peaslee, and

perhaps, avoid
To

imnecessary

of repetition
on

the examination.

agreed, finally
do

being
We

told

that

it

was

absolutelyimpossible to
was

anything
saw

for her unless Dr.

she
on

willing to
11th,
to

submit

to it

Peaslee
the

May

1870.

examination Digital

showed
thiixl Dr.

uterus

be

retroflexed
any other

in the

but apparently free degree,

a

from
"

trouble.
rected beingdi-

P. introduced backwards

uterine

sound

^itscurve
"

instead

of forwards before

found

the oi^an
ment the instru-

to

be the

normal

length,and
to

removing shape.
the A

restored
gave

the uterus

its normal

This procedure

rise to considerable for

a

pain at

time, which,

however, only lasted

few

minutes.

ringpesr

jRetroJkxionof
sary
use a

the

Uterus^etc.
Mrs. X.
was

531

was

then

introduced, and

advised

to

of vaginalinjection
next

flaxseed -tea

every
to my

evening.
office, saying

The

morning
pessary vulva.
a

the
was

patient came
so

that
out

the the

small

that

it had

slipped
June sizes

of

From of

this

date, May

12th, to
various
was
no-

15th,
and

I tried

number

of ring-pessaries Thef
e

different

degrees of shape
and

stiffness. would

great
in
a

in fitting one difficulty

that

retain the uterus

but the

nearly
from much be
worn

normal

position ; spread
few
the

pressure,

above
as

downwards,
set up
more a

ring laterallyso
of
a

to

and vaginitis, than

a

none

them

^ould

for
so

days

at

time
to

without

causing
its

much On

pain
June

and

annoyance I removed

as

necessitate
last

removal

15th

the

ringten

pessai^, the vagina being acutelyinflamed,and

a

ing dischargnext
a

considerable
were

amount to
use

of

muco-pus.

The
to

days

devoted

restoringthe vagina
of

healthy

condition

by

the

astringentand

soothing injections.

On pessary,

June

25th

I introduced the uterus of

an

ordinary double-buckle
its normal
not

which

held

nearly in
On
return
me

shape,
upon
went 1st.
worn

and, in
or

consequence

its

did rigidity,

press X.

irritate the

the

vaginal walls.
and

July
until

1st

Mrs.

to

country,
latter

did not
she her any

September
she had

At the

this

date

informed entire
abnormal

that

pessary known

during
from

absence, and
sensation with
as

would
that she
wore

not

have
there.

it

was

The
pessary

degree of
was

comfort

which

the

rigid

noteworthy, by
that
the

compared
ones. was

with

this
ination exam-

discomfort

caused

the flexible

Vaginal

showed

instrument

in its proper

582

Wabd:

Case

of

positionand
was

the

parts all healthy. Her

could be

general health
she continued the
ment instru-

everything that
wear

desired,and

to

the

pessary

until

April Ist, 1871,

for
a

being only removed

menstrual

few

days

soon

after each nant. preg-

epoch, in hope
I

that she

might by

become

During September
after
was,

ascertained
become

strict

inquiry,
Mrs. X

my in

suspicionshad
addition
She
to

excited, that troubles,the

her

other
had

subjectof
her band husher

vaginismus.
more
"

never once

connection

with

than

in the month

; it then

caused she
nausea

perfect agony," frequently

severe

syncope,

and

always
and

had

pain
for
to

in

the

back, headache,
as

vomiting compelled
next

hours

afterwards,so
in bed very
a

to

be

frequently
of the would
she

remain seemed
so

part
this

or

the

whole

day.

It

improbable
as

that

become

pregnant
when

long
was

condition
to

of
to

things
the

lasted ; but

it

proposed
she

her

have

sphinctervaginae muscle
time
to

niptured, she
had
not

put it off from

to

time, saying

that

the leisure

stay

in bed.

She and

menstruated after that.

on

Dec

1st, and
uterus at

again on
this

Dec.

20th,

not

The

time

seemed
with uteri

somewhat the
on
on

gorged
of Dr.

with

blood, and, in
I leeched

accordance the

advice Dec. Dec

Peaslee,
had
not

cervix
her

24th.

She
and

connection

with
Jan.

husband

11th,

again

until

21st, 1871, in
the

consequence
menses were

of Mr. due she

and
on

X.'s

absence

from

city. Sept
2d

The
On

Jan.

9th, but did

the

not

appear.

April
labor

25th

felt
on

life, on
the

evening
of

of

30th
was

began,

morning

Oct.

she

Hetroflexionof
delivered of
a

the

Uterus^ etc.

533

and fine, healthy girl, weighing nine lbs.,

evidentlyat
Here there
can are

full term.
a

series of
no

facts
and

of

the accuracy
enable
us

of which mine to deter-

be

doubt,

which

the duration
if
we

of pregnancy, the

in this about

particular case, days.

which
30th I suppose caused

admit that

that

period is
20th,
that
"

280

the

ovum,
on

thieripening of which
was

the
was

menstruation fecundated of
the

Dec. from year

the
to
on

one

; and

date

the

of

Sept.
menced com-

succeeding
"

the
But

day

which

labor

was

285

days.
6n Dec.

if this that

is so, then
must

the have

spermatozoon
entered for nine

which

fecundated

ovum

the uterus

11th,and
than the

retained
is

its vitality
posed sup-

days

"

longer period
If
the
we

conmionly

possible.
allowable matured
we
are

make

only other supposition

the
on ovum

under
on

that circumstances,
was

which

Dec.

1st two

fecundated

the

11th, then
the standing notwith-

met

by
ovum

grave

that : first, objections

in

fecundated
a

remained

the
;

uterus

subsequent
who

menstruation
294

and, second, that

Cases
are

the
met

period of gestationwas
of
women

days. they

often

say and

that

have

menstruated

during
months

pregnancy,
;

especially during inquiry

the is made
is almost

the
into

early
the ered, discov-

but

when

careful

something unusual particulars, either in the quality of

or

always

its amount, discharge,

the

period

at

which

it

occurs.

Denman,
declared
is
one

and their

the

late
"

Hamilton, of Edinburgh,
that

have

ion opinneverbers num-

suppression of
of
"

the

menses

of the
are

failingconsequences
of
cases on

conception.'^ There
and

record

they

are

so

common

that

534

Ward:

"a%e

of
with them
from
so
"

every
some

mast practitioner

have

met

^inwhicli
the

kind the

of

discharge
months

takes

place
pregnancy,
as

vagina
for it
panying accom-

during
In

early

of
flow of

sembling closelyre-

the
most

catamenial
cases

to

be
we
"

mistaken find
more
or

recorded remark

this kind

the

that that

the
it
"

discharge
"

was

profuse
"

than

usual," or

was

more

scanty,"
come

of

lightercolor,"or
time." this The

that

it did

not
cases

at

the

right
on

histories of

other

are

of

no

value

particularpoint,because
said that first two

they simply^ state

she menstruated of her pregnancy.
cases

that

trustworthy patient
the
are,
or

during
There in

three
a

months few
to

however,
"

very

fln

record

whicli
time tation. ges-

menstruation of
appearance

regular as
"

quantity,quality,and
occurred

seems

to

have

during
words

We
seems

are

not

disposed
these

to
to

quibble about
be

; but it

question,still

whether settled,

charge the disfrom the

under

circumstances
or

reallycomes
rather,in
most

body
at

of the

uterus,
from

does

not

instances

come least,

the upper

portion of
all
to

the

vagina and
it

from may any

the
be

cervix. considered
flow

Still,f o^
proper

practical purposes
as

designate
which
the

memtrmA
is not the

periodic
of

fi'om
In when

the

vagina

result
on

disease. very

this

case

discharge
was

occurred

the

day
blood

menstruation

expected^ apparently
in every that
a

lasted the usual

number
as

of

days, contained
"

just

as

much

usual

^in

short, was

respect normal.

It

seems

almost should

impossible
whose
.

newly-impregnated ovum
to the

retain

its attachment

internal

surface

of

uterus

blood-vessels

536

Ward: of the female

ovum

Ca%e

of days, and
at

apparatus
the

for

few

then fecundated

which
not

matured
at

the

strual mensucceeding one

epoch, and supposed

in these
duration
cases

the

preceding

Thus

tie

of

gestationmight
or

have
even

been

reduced and

by

six

eight days, or
no one

more,

brought
William observed either
any

Avithin limits which

would

discredit

Hunter,
that

and

many

others

since his
more

day,have
to
occur

impregnation
or

is much after

apt

just

before
A

just

menstruation
proves very
a

than at

other

time.

mass

of

evidence

pregnati that imrare

though
thirteen
or

not

impossible, is
after cessation
can

at

fifteen How

days

of

strual givenmena

flow.

else,then,
two
or

impregnationfrom
before
a

coitus
flow

occurring
be
so

three

days
as

menstrual

explained rationally
somewhere there
we

by supposingthat
those
two
or

the

fecundating spermatozoon days

in the its
to
"

remains

three

genitalapparatus
? vitality be
most

of the
ditions con-

female, and

retains
know

Two

of the

which

necessary

to its

living are
and

certainlyfulfilled
And if
two
a

^the presence

of warmth
can,
as a

of moisture.

spermatozoon
or

rule,
it

retain
not

its

potency for
so

three
or

days, why
more

may

do occasionally

for
some

week

We

are

aware

that For

observers

deny
Farre,
says than

the possibility

of

this.
to

instance,Arthur
"

in the supplement that

Todd's

* Cyclopsedia,"

they

never

retain the furthest be

some

their

for vitality
seem

more

hours thirty ever, must, how-

at

It would mistake

that

there

about

this statement

Alien ; for
in the

Thompson
"

f
v.,

has
p.

observed

living speimatozoa
t Op, dt,
Vol.

Vol

668.

II.,p. 465.

Het/roflexion of
uterus

the

Uterus
j

etc.

537

of the bitch observers

five

or

six

days

after

and connection, in other From of

other the

have

noticed

their presence
a

higher vertebrates
we

after conclude

even

longer period. they

least
*

analogy
their female

might
Seuckart

that
at

would
in the

retain
human

vitalityfor
; and

some

days
and

Wagner
case

state, from
"

actual

observation, that

such
not

is the

for many.

several

days,"
X., it
ovum,
a

though they
Of
seems

do

specifyhow
much

the
to

two
our

in possibilities mind
more

the

case

of Mrs.
that the

probable

escaping

on

December

20th, became
the
uterus

impregnated by
on

spermatozoon,

entering days
to

the that
on

11th, and
an ovum

required 285 escaping on

and in the every
course

reach
1st

maturity,than
was

December

impregnated
what

the

11th

required 294
meantime, respect, a
the of

days
to

to reach

maturity,being obliged, appeared

to

survive

be, in
Of came beit

perfectly normal
remains
of
on

menstruation.

question
the
ovum

to

be

answered, what
1st, and

December
11th ?

why

was

not

impregnated
waf

the

We

can

only reply that

first ten others

it

probably blighted
so

within millions

the

days

of

its

existence,as
similar

many

of

have

been

under

circumstances.

Montgomery
seems

(op, cit,
absent from

p.
to

83)
this

relates
"

case

which

entirelyanalogous
had been and secretly, consequence

one.

A
some

gentleman
months,
with
as

who

his
one

family
she

for

returned

spent
of

night at

home

his the
cata-

wife,
event

in

which the

conceived,
of her

proved, although
a

regular return
usual

menia,

week

in their aftersvai^ds,
"

quantity,had

Op. cit, Vol.

IV.,

p.

505.

538

Wabd:

Case

of impunity." help thintthe week the

led On

her

to

expect that she had

short

escaped with
could
not

reading this
in all

we history,

ing that
remained which
next

probabilitythe fecundating spermatozoon

this

in

woman's
between and

uterus

during
the

intervened

the

husband's

visit
ovum,

and

menstruation,
matured. On

fecundated
up the this

which
case, in

then Dewees
at the

looking
months

original lady
be
was

(p. 1 68J, it appears

end of

that and

delivered from the

as one

nine

thirteen

days

day
of

of coitus

; and

this
"

case

might
to

quoted
But this the the

prolonged gestation
at
a

286
we

288

days.
and

it appears
seven

glance that
have

if

deduct the coitus

from

days interveningbetween
menstruation,
280
we

succeeding

the actual

period of gestation,
It is no
more

days

"

what ^just

is

usually accepted.
cases

than

fair to presume

that many
be
one

of

supposedprotracted
the
"

gestationmay
On

explained in
must

this way.
that tables from

reflection, every
the

admit

showing
a

as period of utero-gestation,

deduced

single coitus,"are
follows which
the

only
the has

accurate

when otherwise

immediately
show the intercourse thereof. We
two
must

act;

impregnation they merely

a

time and

elapsed
of
a

between
as

fruitful

birth

child

the consequence

not

lose

sight
in

of

the

fact

that

there

are

questions of
First, the

interest

connection

with

ject. this subWhat is

purely

scientific

question,
*

the When for

period
a

of

human

utero-gestation? And
us, how
can we

second,
determine

patient appliesto
the

her

date
on

of

her

delivery?
to

There
to

seem

to be to tlie

enough

facts

record

enable

us

answer,

Hetroflexionof
that the period is first, in the ascertaining
must

tlie

Uterus^etc. days.
cautious
of
.numerous

539

about

280

The

difficulty
of

date

of the commencement
a answer

tion gestato

always
the

necessitate We
all know

the

second in

question.
on

mistakes

reckoning
in it behooves This
case

part of accomplished accoucheurs,

instances
to two
or

amounting
and

some

three

months

us

always

to be

guarded.
in and

is

instinctive, mus. again, as regardsthe vaginissuffered

more

Mrs. other have

X.

this
as

way much

than
as

any any I

patient I
ever

have
of.

ever

seen,

read

Nothing
to

but

her indomitable
a

will,

and her

her
to

fii'm determination endure the

become her

mother, enabled
standing Notwith-

approach
became

of

husband.
;

this she

pregnant
it
a was

during gestationit
that In the

and disappeared entirely, of the child

we were

hoped
cure.

birth

would

prove

radical

ever, this,how-

disappointed;
and ocular

for the

returned difficulty
as

after
ever.

the

confinement

proved
of

troublesome

as

By
to

"examination

the

parts, I
or

was

unable
cause

discover

hypei^trophied papilte
Dr. Peaslee and

any the that

other
case

for
on

the

vaginismus.

saw

again
of the of

February 15th, 1872,

the left labium
to

thought
the did
so

few
face sur-

were papillae

slightly enlarged on
minus
; but to
cause

inner

not

suppose

the

hypertrophy
he Still, of and made further
no

be

sufficient surface

much of the

trouble.

brushed the

the

with

solution

nitrate
ounce,

of silver,

strength of twenty
that the
same

grains to

recommended
once or

applicationshould Strangely enough,

and Mrs. X. has

be
no

twice

week. necessary,

applicationwas
of the
trouble

had

return

during

the twenty-one

months

540

Engelmann

Prolapse of the
On

that have
was

since

elapsed.
of her kind
we

February 2l8t, 1873, she

child, having needed
from may
no

delivered
of

second

treatment

any that

since last date.

may

It

seems

learn

this

case

that a be the

ifetroflexion in
cause

the third

degree

exist,and

of

without sterility,
or

manifesting its
any other

presence

by

any

dysmenorrhoea,
that
a

rational

ever; sign whatcommonlv

degree
of
be

of

vaginismus, which
not

proves may
our

source

is sterility,

so'and necessarily
;

sometimes

very

readilyrelieved
case

and
we

if lastly, learn that

interpretationof
spermatozoon
in the
a

the

is correct, in the
of

may

remain
organs

or Fallopian tubes,

elsewhere
its

female

and generation,

retain

for vitality,

period

of at least nine

days.

ON

PROLAPSE

OP

THE

UMBILICAL TREATMENT.

CORD,

ITS

CAUSE

AND

Bt
Master

GEO.
of the Member

J.

ENGELM

ANN,
of London

A.M.,

M.D.,
Fellow of

St.
the

Lonifl, Mo.,
London
etc.

in

Otwtetrica

University
of the

Vienna;

ObatetzicalSodetj.

Pathologioal

Society,

{ConUnued

from

page

443,

Vol.

vi.)

VL

RBLATIVB

FBBQUENCT

OP

THE

FBOLAPSB PARS.

IK

FBIMIPAILfi

AND

MtJLTI-

As

to the

relative

frequency

of

the

prolapse among
has
as

and multiparsB,no primipar89 made accepted,the statements

so differing

average

yetbeen

by

various my

investigators
results may I"e
conpoint also,

very

much in the

; that

at least

I must, precise,

discussion

of this

Umhilical
fine

Cord.

541

myself

to

the

deliveries

observed

in the

Lying-in

Housa
Table V.

"

Relative

Fbequency
AND

of

the

Prolapse

among

Primifabje

MULTIFAILfi.

Lying-in Hooae.

Ont^oor

85 27 62

camfi
"

of
"

prolspaeto 2,9T7 mnltipane

" "

= =

1 1

: :

85 108 94

248 67

prolapaes
**

among
**

2,988 primipane

mnltipane .prlmlparBB

4.26:1

r"
it It

t"

"

5,900 deUveries

800
BelaHo*

freqnencT
and

of

prolapee
4 26
=

among
:

mnl1.4
:

Prolapse tipane

1.S7
than

timea among

more

frequent primiparas.

among

mTil-

tipane

prlmipcunB

-^

Among
upon
was we

the
have

5,900
2,923

parturient women
in primipai-ge,

there
of

waited

27

whom

labor

complicated by prolapse
these
we

of

the

cord ;
number

compared
of of multi-

with
parsB,

find

an

almost
cases

equal
14

2,977, with
in
see

85

of

prolapse (21
in

which

occurred
So
we

secundiparsBand
that the

pluriparae).
1 prolapse

to

108

Lying-inHouse cases give us whereas parturientprimiparae, among

ratio is
as

the

multiparsBthe
of the
parsB

85, making

the

occurrence

prolapse somewhat
than
among I have
to be

more

frequent only
the

among

multi-

primiparae (1.27 : 1).

said
that above

Though
was

tion compilarefrain

thoroughly relied
result
are,

upon,

I cannot from

from

giving the
cases,

of my
to

calculations
the

the outdoor

which

say

and least, interesting,

claim

certain with

importance
the
numbers

fi'om

their remarkable
in

cidence coin-

obtained

the

Lying-in
have this

House,

Among

the out-door the

cases

of labor

in which

we

prolapse of

cord^multiparsewere

afflicted with

542

Engelmann

Prolapse of
whilst

the

complication
times As

in

243

cases,

it occurred
a

but
:

57
1.

among
I have of

this being primiparae,

no

ratio

of 4.26
me

statistics which

would

give

the distributio
cases

primiparaeand
in

multiparae among
same

of
must
an

normal take the

labor

Berlin

during the

time, I
that
are

generally accepted
3 of

statement

upon

average that
cases

every labor

parturientwomen
are

multipara?;
found
occur

of
than
our

times

more

frequent among
We have the
4.26

multipane prolapse
times make
more

among

primiparae.
cases

in

out-door

actually to
of its

frequently among
relative and

multiparae,which
occurrence

would among
1.4

the

frequence
as

multipam
ratio very
House Our
a

primipara
to that

1,

or

as

1,a

similar

obtained

from

the

Lying-in

records.
cases

show

that

the prolapse relatively almost

as

occurs

as

complication
as

of labor

often

among

parae primithat

among

multiparae ;
become

I must

acknowledge
as a

when

the

contracted

pelvis
less

is excluded

cause,

the

prolapse will

frequent,but
causes

especially
we

among traced

as primiparae, more

those

of the

which
then

Lave

to multiparae particularly

become

prominent.
This is
a

point which

I must

discuss
in

more

at

length,
the

it

being Among

of

great importance

the

of aetiology

prolapse.
the
i5rst to that the combat

the

assertion
the cord
was

made

by

most
more

authors,

prolapse of multiparae
at

by far

frequent
was

among

than had

among

parae, primi-

Martin, then

Jena, who

observed its

544

Engelmann

Prolapse of
21

the is no ratio

36

occur

in

and primiparaB,
in the
:

in

which multiparsB,

great
here

increase
1

the proportion of multiparse,

being
is
much

1.4.

It is
the
at
a OS

true certainly
more or

that in

multiparaBthe
dilatation than in in labor

occlusion
takes

of

less

imperfect ;
of

place pelvic

earlier

period
head

primiparse,
the of

whilst

the

presenting

is still

high

canal, thus

greatlyfavoring
space
more

the

occurrence

the prolapse
may

by giving readilyglide,if
lead
more

through
potent
causes

which
are

the

cord

acting which multiparaswe

tions, presentaof
peated re-

to

this

mishap.
the
"

Moreover,
transverse

among and

frequently have
and also labors

shoulder

venter

propendens^
which

the

result

circumstances of the
In

indeed
but

greatly rarely pelvisis

we

favor
occur

the
in

occurrence

prolapse, and
the contracted

primiparae.
cause

these

the this

main
to

of this
case

dangerous accident; and

p.
c.

find

be

the

in 60

of

all the

served primiparaeobwas

in the

Lying-in House

whose

labor

cated complithat
the

with
As

prolapse of
due

the cord.
to

another

argument

prove

his

theory
a

prolapse is
action of the
woman

mainly
womb,

and

primarily to
cites

pathological
cases

the

Hildebrandt
been

those

in

which
same

prolapse has
; he

repeatedly observed
a

in the

admits

that
cases,

contracted

quently pelvis frehis

soning rea-

complicatesthese
it is not action

but

according to prolapse of
the

this,but
which

the
causes

always equally insufficient

the the cord.
the
nection con-

of the uterus
not

I will
cord

deny

the

that possibility
cases

prolapse of
may be in

in several

successive

of labor
a

with,or dependent

upon,

condition pathological

Umbilical
of the I could In I know of

Cord. instance single

been the

545

uterus

yet

no

in which
case.

assert confidently

this to have observed

cases,
we

all such
or

labors,whether
the out-door

in the find
cause a

Lying-in

House

among this is

contracted of the prolapse from this

state

and pelvis,
; how

the primary certainly may have way

far the uterus and pelvis, the

suffered

condition
may One have
case

of the

in what

its diseased

affected

cannot prolapse,I,at least,

say.
an

only (No.
the
child ; several

11

of

the

out-door

cases) is

exception :
sixteenth
cases,

pelvisis moderately enlarged ; it was

of the last had the cord in
one. come as

the

footling
we

with
admit

prolapseof
that

Here

must

indeed
and
were

the laxness with

of the tissues of the womb

abdominal
causes

walls,

malposition of

the

foetus,
case

of the
was

repeated accident.
have

Another

in of

which
the

prolapse
the

repeatedly observed placed

19
cm.

(No.
the

17 normal

out-door

cases),I
ant.

among

pelves,as
transv.

measurements

given
cm.,

show

nothing
v.

cidedly de-

abnormal,
sup.

post.

inf. trans

27.5,
in-

28.5, oblique 21
of the

The
more

somewhat

sufiicient

length

but latter, lead

me

particularlya
look upon it
as

consideration
a

of the

whole,

to

somewhat
Michaelis

contracted and others

pelvis.
have also observed the
same

the

repeated always
very

occurrence

of the with

prolapse in
contraction
eminent
own

woman,

in combination

of the

pelvis. This
mind
one

fact, observed
established

by
our

and authorities,
cases,

thoroughly
a

by

is to

my

most

strikingpr6of
main
causes

that

the

contracted

pelvisis
various

of

the

of the

'primary and prolapse,

the

pre-eminent.
circumstances

It is

to study interesting
35

546
to
^

Engelmann

Prolapseof the
for somesearching of the conl: prolapse

which the different authors, each

have
accuses

thing new,
thus

attributed the
all such

Hohl

conditions

which

serve,

or temporarily of regular position

to changethe normal permanently,

and

the foetus in

vtero

; he

the lays others do

main stress upon the position of the upon the condition of the uterus.
This between
as

as foetus,

is but

an

idle

war

of words.
an

The

difference

these various

is not opinions
same

essentialone,
cause.

all may
APPEARANCE

be traced to the
AND CONDmON

fundamental
OF THE PROLAPSED

C.

CORD.

The the

circumstances which

which the picture complete

of prolapse

under

which
are it,

the cord presentsto us, the conditions it appears, the complications which surround
more importance, so for especially

all of

the

treatment,and

hence claim

our

attention-

It is

necessary that I should define the terms

as

they have

heretofore been
a

used

employed. indiscriminately,
here

whereas

I make

well-marked

distinction between

and presentation, and trust that it will be prolapse more universally adopted. Prolapseof tlieCoi'd. So far I have alwaysspoken of the prolapse the appearance of of tJiecord^that is, the cord in the os, or its descent through the os, after the ruptureof the membranes,as this really is the point of clinical importance, the condition which threatens
"

the

life of the child and

calls forth

our

most

active

efforts for its relief.

Presentation from

servation of (lieCord. If the labor is under obin its the very beginning, we may often,
"

Umhilical

Cord,

547

early stages,
this term
the still intact

detect

presentaiion ^of the cord.

its appearance
so

By
,

I understand

in the it may

os, within

memhraneSj

that

be

reached

by

the
In

examining finger. Lying-in House

funis
was we

the the

have

cases

recorded of the 50
cases

in

which observed

found from that been

7 presenting,

throughout
thus
the

the among

very

commencement

of of prolapse
one.

labor

showing
had

every

cases

funis
cases,

presenting in
of the

but the

In

all such of
the

prolapse inevitablyfollows
and
are

rupture

membranes
measures

the

escape and

waters, unless
prove very

active

taken

circumstances

favoidable

for treatment. the out-door

cases

Among
cord
cases was

the

presentation of instances,but
with

the

discovered
useless
to
us

in for

several any
as

these

are

comparison
it
was

regard
very the

to

fi'equencyof
of the

occurrence,

mostly
which

the

fact

cords midwife

having prolapsed
to
summon

caused

attending
were
see

medical

aid ; very of labor.

few We

observed
that
a

from
are

the
rare

commencement

the

cases

in which

the

cord

presents,
lies

where
in the

loop
os,

of

the

soft,slippery, pulsatingfunis
within the
foetal in membranes.

still enclosed the

The
when

life of the head the

foetus

is threatened the

this

situation,
may

presents,as
cord

descending

cranium

compress
sence

notwithstanding the shieldingpre-*

that
the that

of the waters. sometimes

It

happens

funis
we

is not

to

be

reached
it of

by digitalexamination,
yet
of
the the

do not
ceases

suspect
to

presenting,and
with the
escape

foetal heart
waters
a

beat,

and

pulselessfunis

548

Engelmann

ProlapBe of tJie
a

prolapses, indicating that slippeddown, though

had been
not

small
to

loop

which

had

far

enough

present plainly,
head. is not

compressed by
the
waters

the

descending
with
cord Of

Ordinarily
until forced the down. of

threatening danger
escape, and the does

suspected
cord is

these

the

Rarely
the

the prolapse after

cases we

rupture
but
4
on

membranes.

such

have

record

among

our

entire number

of

; prolapses

they
waters

occur

under
at
an

peculiar circumstances,
and small the fcetal

when

the the
o^

escape

early period of labor, while

the but

is still

imperfectly dilated
across

membrane?

stretched tightly
in the
OS.

opening

; the

rupture
the

membranes such until have

being
the been

and slight, it is

high

above

Under

conditions
os

impossible for fully dilated loop

and

the cord and the

to

prolapse
Extent

is

more

membranes

forced
"

aside.

of

the

Prolapse.
much in
a

Usually

one

lies in the the cord

OS

or

descends

through
a

it into the

vagina, yet
contracted several

may from in

prolapse to
the foot and

greater extent,
very much

protrude
or pelvis,

genitals ;
cross

presentations ;
lie in the
of

loops of
without

the

funis

sometimes

vagina ; yet
and

all these

varying
tance impor-

circumstances either

are

little interest

for the

prognosisor
the

treatment

.Table

VI."

Location

of

Pbolapsed PHEBBNTATION.

Loop

36

Cases

op

Tertei

PodtioiUw

Left

sacro-iliac
sacro-iliac acetabular

fossa fossa

Right
Left

regfion Right acetabular region. Behind the symphysis pubis.

. . .

Umhilical

Cord.
the

549

Location
the

of

the

Prolapse.
"

define

of locality
either

prolapse as
an

that

part
the

of

the

pelvisin which,
the the

by

in irregularity
or

of configuration

maternal

parts,

by
an

an

abnormal

positionof
The
upon

tal presenting foethe two,

part,

nnoccTipied space
the

is left between

through
this

which

cord

escapes.

determination it the

of
to
a

point
extent

is of the

importance, as
pressure the
to

depends
funis

great

which

will

be

subjected during
In
to

progress of this

of labor.

the

discussion

subject I
I

shall

confine

self myin the

vertex
or

presentations.
shoulder
difiicult for the

merely mention,
and

that

foot, cross,

the locality of pj'esentations

to

prolapse
less
cases

is

more

determine
the

is of

far

importance usually
the

prognosis;
that the of

prolapse in
the

these

takes

place in
directed

part of the

pelvisto
abdominal the
one

which
front
sacrum,
or

foetal insertion is foetus, cord

funis,

of

the the

; this

mostly being
the

is thus

thrown

into

shelter of

the In

other
vertex

of the

sacro-iliac

fossae.
well

presentationsas
lead
ns

purely

theoretical fossae

considerations
as

to

suspect the
funis
most

sacroiliac

the

space
to

in which

the

frequently finds
:

room

the following reasons descend, and i.^g

The
as

nerve

of the
one

pelvis in
recesses

the sacro-iliac fossae is such

to leave

of these may
assume

unoccupied
those the

in any
vertex

tion posichild

the

head

; moreover,

sentation pre-

predominate
looks

in which the of

face of

the

towards
the the

one

of

sacro-iliac the cord

we

synchondroses,
in the also

placing
part
of

foetal insertion

posterior
find its of

uterine
in

cavity, where by
far

placental

insertion

the

greater number

550

Engelmann

Prola/pBe of
of the

the

cases

; this

throws

the

mass

funis

into
to

the

terior posa

part of the cavity,everything tending

guide

descending loop
In the

into the

sacro-iliac fossa. which

the

first vertex

presentation in
of the

right
the
near

oblique

diameter

pelvis

is

occupied by occiput right path

longitudinal axis
the

of

the the

foetal head, the forehead

in seek the the

left acetabulum,

iliac sacro-

fossa, we

would
at
one

naturally
of

of
pied unoccu-

the

prolapsed
of the
In
a

cord

the extremities
the

of the

diameter,

in the

region of

right acetabulum,
should

or

left sacro-iliac second

vertex

synchondrosis. presentationwe
the

expect the
fossa
or

prolapse to
the

take the the

place in

right sacro-iliac
deductions
and
to

in

region of
are

left acetabulum.
theoretical upon
me,

Such forced
say, I
our

which
I
am

have
to

themselves

which,

proud
review

have

been

amply
that

able

verify by
of

of

c^ses.

Notwithstanding
vertex

the often

prolapse
occurs

the

cord the

in

presentations so
is still

while

fcetal
verse trans-

head

high
or

in that

the
a

pelvis,occupying
defoimed

the

diameter,
the the
to case,

pelvis complicates
normal
course

somewhat of the the

changing
various
a

fhe

and

relation
those of

diameters
certain

of the

foetal head

to pelvis,

extent

the liberating

diameters
that

theoretically occupied,we
the

still find in the

(Tab. VL)
first vertex the
ace-

when

prolapse
cord

takes

place
most

the presentation,

descends in the
right and

frequentlyin
the

left
*

sacro-

iliac fossa and

named

region of
left

right
to

I have

the

diameters

obliqne, aooording

their

j!Wf-

terioT

terminal

point.

552

Engelmann:

Prolapse of by
the

the descent
and

preserved

from
the
our

pressure

rapid
a

deliveryof
As
am

head
cases

after

assuming
the

first my

position.
; and

far

as

go, facts prove

theory
the
one

warranted

in

that stating
a

prolapse of place in
of
"

cord, in
of
the

vertex

as presentations,

rule,takes

terminal which

points of
is not

that

diagonal diameter
the foetal is most of the head

the ^the

pelvis
iliac sacro-

occupied by
the
one

fossa
seat

being

which
account

frequently
formation

the of

of

the

accident,on
of the

that

section

pelvis;
and

less often
most

is it the

acetabular

region. Very
occurrence

rare,

in

instances

fatal,is

the the

of the

prolapsein
but

any

region occupied by
to

occiput,as
of the
and and

its roimded

shape, adapted
little space

the the

formation cord scend, to de-

leaves pelvis,

for

subjects it, once

fatal pressure. is the

prolapsed, to
the cord
are no

an

able unavoidand
not

Equally dangerous,
there

often

met

with,

prolapse of

hind directlybesoft

the
to

symphysis pubis,where
must

parts

protect the funis,which

between

inevitablybe crushed,
the

forced the

cranium

and

symphysis in
^The

descent

of

head.

Pressure
cord been

upon

tlie

Cord.
the

"

prolapse
as

of

the often

imperils the supposed, by

to

life of
the

child,not,
of the

has

exposure

the

prolapsed
to

loop
it is of

the

atmosphere, but
and

by
kind

pressure

which

subjected;
maternal

this

depends
the

upon of

the

condition

the

parts,

pains,
cord

the

foBtal
a

part which
hard

presents.

In

head-presentationswhere
the

unyielding part endangers

the

for

longer
to

time, the location of

the

prolapsed loop,with
the foetal

regard

pelvic

diameter

occupied by

head, is

Umhilical

Cord.

553

the
the In

most

important
to which

of

all those the cord

points which
is

determine

pressure

subjected.
threatens
until for
so

all other
as

less danger presentations

not

the the any

cord,
very

it is often

subjected to
the

pressure then
not

last

stage

of

and parturition,
cases

length
scarce

of time

; in many

pressure

is

slight,
vessels,

the affecting the powers

circulation

in the

umbilical

that

of nature

suffice to

develop a livingchild,
Several
such
some

unaided
cases were

by

the hand observed

of the
in

obstetrician.
out-door

the

department,
latter
was

few
a case

in the

Lying-inHouse
found and

; one

of these first

even

of vertex cord
was

a presentation,

in position, the

which

the in

presentingwhile
the
os

head
1.5
cm.

was

still
in di-

the

brim,
The

not

more

than upon her

ameter.

patient was
the condition

placed
of the

left side,the
the descent
course

side the

occupied by
head. labor The
were

occiput,to

hasten
cord and

of
of

the
the

the

continuallywatched,
to

and

patient by
all

directed
means

how
in her the

assist
;

its

favorable
there
was

progress
no

power hand of

yet

as

dbect
may

ference interstill bidden forthus

by
call it
a case

of

the

obstetrician, we
The

natural

labor.

patient was
muscles,
the
os

to

press

with
were

her

abdominal
until

and

the

membranes With

preserved
escape of the

was

fully
came

dilated. down

the

waters

the

cord

in the

right acetabular
the

region,the healthy
a

anterior The

nal termi-

point of
and

unoccupied pelvic diameter.

a

head
of

being rapidly developed by

uterus
was

action

the

abdominal

muscles,

strong, living child

the

born.

The

two

other

cases

in which

cord

escaped

any

554

Engelmann

Prolapse of

the

serious
no

compression
assistance
manual

were

in foot-presentations,

which
such

further
"

was

rendered

than

is usual

in

cases

delivery of
are

the head.
but

Unfortunately,these
the

exceptional instances, as
a

prolapsed
is of the cord

funis
or

is less

inevitably subject to according

to
; thus

pressure tion condi-

which

greater

the relative
the

antagonistic powers
may be but

compression
or

of the
and

slightyet continued,
a

sudden
a

severe,

causing either
the

slow

diminution,
the child

or

rapid
its
ceives re-

cessation
source

of

interchangebetween
placenta.
of The
amount

foetus
no

and

of the

life,the
full for

longer
of

oxygenized blood, purified,

The
to

necessary acid

its existence. the foetus

accumulation
seek its oxygen the and As

bonic car-

causes

from

other
but amnii

sources

; intra-uterine

are inspirations

result

it is not

oxygen, fill the

not

air,it

is meconium

liquor
as

which

expanding lung.
of
a

long

the

medulla

oblongata
the the

is still stimulated
mass

to increased
a

action

by

the

accumulating
and

COj,

morbidly
weak

increased

activityof
follow,
"

heart,
foetus
an

few

rapid,
to

inspirations
CO2
cation intoxi-

succumbs

the

perishesin superior or
the
to be

asphycticstate.
"

Prolapse of
of the

Extremities.

Presentation, or

prolapse
is

inferior extremities, not

unfrequently by
no

complicates
means

prolapse
as

of
one

the

cord, yet it
causes,
as

considered
The of the and

of the the
are

Scanzoni
is

takes

it to
to

be.

prolapse of
cord those
to ; both
cases

extremities

alent equivby
in

that

brought
the

about
rare

the

same

causes,
we
are

are

exceedingly
one as

which
of the

forced

look

upon

the

cause

other.

Umbilical
In of the
was

Cord.
from other the is the

555

our

63

prolapse
of
one or

cases,

the

Lying-in
ities extrem-

House

descent
noticed

the of

of

the

by

the

side

presenting head, prolapse of

the cord the

and

in

head-presentationsalone
in combination

extremities
interest

with

prolapse of
cases

of is

Among
much
are more

the

out-door

this combination the

noticed
occurrence

frequently,as
far
more

conditions
in
302

for its

by
cord,
had

favorable
50

the
cases

greater
of prolapse
course

number of

of

multiparsB.
one

In

of

the

the
arm,

of

the

extremities, of
the

mostly
of the

an

prolapsed with
the

funis
its

on

account

of irregularity

pelviccanal, or
in the

incomplete
of

obstruction

by

an

abnormity

descent

the

vancing ad-

head.

Saxtorph, in
he of
cases

his

obtains compilation,
an

similar

result

finds the

prolapse of
cord in

extremity complicating prolapse

times
out

41 head-pi:esentations

of

253

of

prolapsus funiculi.
POST-MORTEM
APPEARANCE

D.

OF

THE

CIULI).

We

have

seen

in what life of

way

the

prolapse of
we

the
next

cord

endangers
What
are

the the

the

foetus,and

must
a

ask,
sents pre-

anatomical
has

changes
been caused cord ?

which

child

whose

death the that

to
are

inter-partum by
Is the

compression of
condition
such

prolapsed
the

post-mortem
can

pathologicalanatomist
the cord the
as

vnth of

certaintypoint
death? These

prolapse of
I can,

the

cause

questions of

utmost

practical
in
a

importance, which
very indefinite
to

answer unfortunately,

but

way.

Hoping

obtain

some

definite

and

positive results,

556

Engelmann

Prolapse of

the examinations
of

made

veiy whose

thorough post-mortem
death the had been
; at

ehildi-en

caused, during labor,

same

by prolapse of
upon the fi'om my bodies other of

funis

the

time,
with

as

check
care,

I examined, investigation, those who The had result

equal

perished iyvter-partuia
was a

causes.

negative
an

one,

so

that I desisted which looked

from
so

farther

pursuit of

investigation
to particularly

unpromising.
in my
statements 13
more

I shall the

refer

post-mortems
death cord.
; the

of

thoroughly
caused of

examined

cases

in which

had

been

by compression
cases are

of the from with

prolapsed
the

Some

the

taken made
us

books

autopsies not
to

having
now

been

special reference points here

necessary
an

the

question
have the
not

before

; the

of

importance
;

always

received

the

consideration
of the

yet

notes

suffice to

giveus

understanding
The

subject.
found
in

pathologicalconditions considerably; we
venous

the
a

different
more or

subjects vary
less marked of especially of the liver

mostly
the

find

of liyperaBmia

internal the

organs,

the
was

lungs,liver,and frequently found margin,

In
two

kidneys ;
to be

surface
gested con-

very

dark,

along
in the
centre.

the

and

pale,sometimes
the organs
most
were

marbled found
quisitely ex-

cases

anaemic.
are numerous

Among

the

constant

findings
of the 13 ces instan-

small
none

ecchymoses
were

; in

only
small

post-mortems

discovered

; in several

they
found
most

were

quite scarce,
heart and in

only
the

few

ones

being

in

the

kidneys.
and

Ecchymoses
the
as

frequently occur
and

in the the

lung

pleura,in gland
as

heart

pericardium, in

thymus

well

Ufnbilical

Cord.

557
in

upon

the and

liver; they

are

more

rarely
mucous

found
membrane

the
of

spleen
the

kidneys,
In occurred in the
a

and

in of the

the
our

stomach. had

few
in

cases

small

tions extravasa-

galea, beneath
of
the

the

periosof the

tenm,
The

and

brain.

serous

membranes

large cavities

body
all

principallyare
the

threatened

with

ecchymoses, above inspiration,

a sponding corre-

pleura, for
is
an

with

every of the

intra-uterine thorax
on

which

expansion
external

without of

expansion
of air ; the

of the pressure

lung
upon

account

the

lack

the

congested vessels,
from

w^hich

counteracts

the

force of the blood

walls of

within, is

diminished,
no

the

delicate

the

can capillaries

longer resist, they burst,

the

blood

extravasates, and
which and
has
most

we

have

ecchymosis.
one

The

oedema,

been
stant con-

considered

of the in but

most

characteristic
caused
our

appearances

death
6 of

by prolapse of
and the

the

cord,

we

find

in

cases,

affecting very
scrotum,
the that

different umbilical
5
was
cases

most localities,

frequently

the
; in

the porta hepatis^ and vessels, the fact is

lungs
no

mentioned especially

oedema

found. Small

extravasations,of blood, ecchymoses, occur,

seen,
more

as

we

have

frequently than
in most

the

oedema

; and

this is to be

expected, as
upon the

instances

where

sure pres-

is exercised which

the

prolapsed cord, the

of

stances circumare

favor
the

production

ecchymoses
the
case

given, whatever
be it
a

individualities continuous
the
a or a

of

may

be,

slight and
which

sudden
The

and

severe
on

pressure

constricts

cord.

oedema,

the

contrary, is dependent

upon

but long-continued slight

558

Engelmakn

Prolapse of

the

compression

of the

umbilical

vessels, the increased

Sudden
and the

sure prespression com-

in the arterial

system.

thorough
too

prevents its appearance

of life. The

by
in

rapid
of

structi de-

lungs only

are

mostly
few

found

state
a

complete
air, and

atelectasis

; very

rarely they
of the

contain

little

then

in but

alveolL
were,

Meconium in the

and

liquoramnii
not

in two

cases,

found
the air-

bronchi, probably
were

oftener

because

passages

not
a

in all

cases

carefully opened.
twice

Twice

they
were

contained found

and fluid, sero-hemorrhagic normal.

case,

they

quite empty,
in
one

The amniotic The

tonsBum serous,

stomach,
fluid. ca\aties
are

contained

meconium

and

of

the
cases

pleura, pericardium,
more or

and

periwith
a

in most

less

filled

slightly hemorrhagic
see

fluid.
cases

We

that

these

various in common,

have, yet
not

to

certain
we

extent,
find

some

changes

one

which

throughout, not
; and

one

which

we

might
there

call

monic pathognowhich
is the cord?

yet
for ? the

we

must

ask, Is
caused ?

nothing

characteristic the
as

death

by prolapse of My
own

oedema

ecchymoses
of

investigations,
ords rec-

well of

as

the records

of the Berlin

Lying-inHouse,
prove in children

large number changes

other the
are

post-mortems,

that the

very

same

also found

who

have

perished from
I have the

causes

during parturition.
oedema,
even

found

same

the

oedema

of

in head-presentations genitals, ; it

in

tions breech-presentaecchymoses
with

is, of

course,

usual

occurrence;

are

quite frequent,even

in connection

complete

560

Engelmann

Prolapse of

the

us

to

refer them

to

any

of the

above-mentioned

cations. complivesseb,
than
as

I cannot

concede

that
more

one

of

the

umbilical
pressure

veins
other been
same

or

is arteries,
account

subject to
anatomical
;

the has the the

on

of

their

conditions,

asserted

by
the
can

many

they
of

are

enveloped by gelatine, and

walls
is
so

protecting tissue,Wharton's
in
structure

difference that the

no

their

slight,
;

theories
cannot

be

based

upon

these

circumstances
than the the other.

one

resist

compression more
the

It is the between

position of
which it is

cord, the
and

shape
the
causes

of

parts

crowded,

part of the cord

the flow
to

which
blood

is most

compressed, which
veins
or

of be

through
This of

arteries, or
an

through both,
the

checked. appearances

gives us

explnation for
and

var}'ing

hyperaemia
must

anaemia.
that the

To

conclude, I

again
children
has

state

post-mortem
was

examinations

of the

whose

death
us

caused

by prolapse of
as

the cord
more

given
a

but

sult, negative re-

it is the

nothing

than from is

death many

from
other

asphyxia,
causes;

which
the

foetus

suffers

so

circulation

of the blood is
no

hindered, checked,
the

the allfoetus

important perishesin

oxygen
a

longer supplied,and

COg

intoxication.

E.

DIAGNOSIS.

The
a

prolapse of loop

the

cord the

is

diagnosed, so easily
it is
a

also

simple presentationof
we are

cord, provided
and
not

sating pulin

dealing with, eai'ly stage

tenseness

too

high

the

at pelvis,

very

of

labor, or protected

from

touch

by great

of the foetal membranes.

Umbilical
A the

Cord.

561

of possibility

mistake
has

in the

diagnosis may
to

arise if the
os

presenting cord

ceased this will

of the
os.

pulsate and

is but littledilated ; but

more

be easily

rectified upon

perfectdilatation
F.

PROONOSIS,

The

risk to the life of the would

seem

child

from

the
our

prolapse of
results from

the cord the

great,accordingto
and itself out-door
on cases

Lying-in House large in

not

; the

mortality
is forced
to

is indeed

account

of

the unfavorable

circumstances

under

which
the

the

obstetrician

act, but

large,on
the results

contrary favorable,as

pared com-

with

of others.

Table

VIL"

Mobtality.

Lying-in
Saved.

House.
%
"

Ont-door
/"

Caws.
Saved.
\
r-

Total

ll
u

Saved.

PreeentationB.

i
a
s

"

S
p

Vertex

presentaUon.
** '* ** 4i 44

11
1 2

81.4 100. 100. 81. 0. 80. 60.

Face
Breech Foot Transverse Shonlder

24 0 0
8 4

68.6 0. 0. 19. 100. 20. 60.

66 8 86 11 140
'

89. 25. 68. 54. 42.

102 2
6

61.

76
4 4 49

88.7126

62

40.
76. 82. 46. 68. 68.6

44. 60. 29. 60. 50. 62.3

13 0 4 81

17 20 16

28 16 171

1 82

46.61162

Of
the the
over

the

total number

of 365

cases

of

prolapse 171 (Tab. VII.) ;

of
in

children,47.7

per cent., were the number

saved saved

Lying-inHouse
50 cent

is

a little greater,

per cent;

in the outdoor

department only
the result
very

46.6

per

This
one

looks

unfavorable, but

is

very

fair
com-

for

and hospitalpractice,
36

fair when

563

"

Engelmann

Prolapse of
of most

the

pared

with of

the the

average 743
cases

results of

obstetricians
the cord
piled com-

thus, out
from

prolapse of

various
were

authorities

by Scanzoni, only
cent. ;
even

335

of

the children
than per
our

saved, 45
cases.

per

less fortunate
not
save over

out-door

Michaelis
his

did

26

cent.

Churchill, in
cases

work, has
the funis per
cent,

gathered
from of all the

large

number
sources,
were

of

of finds To that cited

prolapse of
that
account

possible
children

and saved.

47.9

for

this

favorable
the

result, I

need
custom

but

state

Churchill
the
are cases

has of

followed Mesdames

good

old and I it of

and

Boivin successful deem

roll

Lachapelle, which
for time my

so

wonderfully
faith

part
that

can

place myths
least
202

no

in them, and
from
our

these

be

stricken

facts.
Our results
are

fortunate

in

cases

of

vertex

pnwas

mentation; out
saved
not

of

such, the
per
cent.

life of This

the

child

in

only 76,
the cord

36.7

is accounted

for,

only by
and

the fact that

at
an

the

foetal

part, which
of

already

threatens

early stage
also
cases

labor, is large,
serious
troubles

hard,
which
and
a

unyielding,but
these
of the

by
"

the the Then

complicated
the
cases

22

craniotomies,
we

placenta prsBvia.
out-door had
cases

have

quite
was

number

of

in which
to

assistance

asked all

after the cord have

with

ceased
cases

pulsate. Deducting
vertex

these, we

left 111

of
the

presentation
were

complicated
amenable
the these saved
"

prolapse
for
65
as

of

cord, which
were

to

treatment, and
and
not cases,

which

treated Out

for of
were

prolapse
111
a

any per
we

complication.
cent,

simple
result

of the children
soon see

which,

will

(Tab. IX.),

Umbilical achieved
in

Cord.

563

was

the

out-door

department

as

well

as

in the The

Lying-in House. mortalityamong

to

^e
among

is smaller, face-presentations
vertex

strange
the the
6

say,

than

presentations;of
our

observed face-presentations
were

among

cases,

4 of

children
number

saved. of
cases

The

being

so

limited, I
any
not

should

not

deem

in making myself justified

so particularly as

general
seem

deduc-

more tioiis,

it does

rational

that

the

dreaded face-presentation,

under

ordinary
child

cumstance cir-

should, when
the

complicated with
to

prolapse of
than this
cases

cord, be lesa dangerous

vertex

the

life of the
for

the

presentation. sought
is

The

reason

strange
cal medi-

result

is to be

in the fact that in these

as soon as

assistance

procured long
under
a case

the

face is found

presenting,often
The
case

before

the

prolapse takes
in
a

place.
earlier

thus

comes

observation
of

much
an

stage of labor
vertex
'to

than

thus presentation, the efforts of the

ordinary cess giving greater promise of sucobstetrician child.

prolapse in

in behalf

of

the

threatened But few

existence

of the

are hreechypresentations

recorded,
the
10

and

these

remarkably
saved
came

unfortunate,
4

the

life of the
cases

child
cases

being
which in the

in

but

(40

per

cent.) of
The
2

under

observation.

treated

Lying-in House,
both

twin-children

in

each

instance, were

successful.
our

are Foot-presentations

most

successful

cases,

and in

fortunate
number
365
cases

it
next

is, as
to

they
vertex

are

veiy

frequent, ranking
69

presentations. Among
have

our

of

prolapse,we

foot-presentations,

564

Engelmakn

Prolapse of
per per

ths in
"

with
the per the

49

of the

children, 71
68

cent., saved
cent,
were

even

out-door
cent,

department
cases

saved

68

of all

those observed, including

the

in which

obstetrician

found

prolapsed

coi'd

cold

and

pulseless upon
Of which
were

his arrival.

the
were

complicated with foot-presentations

observed
fact in the
100

prolapse,
per
cent

Lying-inHouse,
cent., for among
have
6 2

81

saved, in
in those
not

per
we

the

3 stiU-

bom

16

cases,

premature
and

deliveries
one

(foetus of
these
cases

much

over

months),
process In
;
so

child,
:

already in probably syphilitic,

we
can

of maceration

certainlyexclude.
were-

the that

remaining
in the lost

13

the children
not
one

all saved

Lyingin the

in House
cases

of the

viable

children

was

of cord.

foot-presentation complicatedwith

prolapse of
and

the

The

prognosis

offered much

by

t/ranaverse

sliouUer
fortunate
transverse
we

is very presentatioiis than

as we

the same,
In

and the

more

might expect
as

it to be.

47

well

in
our

the 31
total
were

shoulder number

^vhich. presentations
of

find among of the

prolapses,50
fortunate
cases

per

cent

children

saved. fact
that

This
in these

result I cord is

account

for

by

the

the

less
is

endangered by
betimes. then that

pressure,

and

that

medical

assistance

sought
We
see

in the

prolapse of
with with

the cord

the prognosis
the

is most
*

favorable
the

to the

life of the child when the feet

latter Next the

enters
to

pelvic canal
and
vertex

presenting.
more

but foot-presentations,
transverse
are

by

far

risk

to

child,come

shoulder

presentations;

the most

dangerous

presentations.

Umbilical

Cord.

565

The is

number
so

of

carefully observed
that
I
cannot

tions breech-presentaresult

limited
a

accept the

they

give
by

us

as

standard.

The

prognosis

in

breech-prethat

sentations

is at least and

equally favorable

with

offered

transverse

shoulder

presentations.
as

So

much

for the risk to life

child

affected

by

the* condition

of for the
in the To
a

the

itself.

The
are

points
those

most

important
we

the
side

however, prognosis,
of the mother. A

which

find

on

prolapse which
which in

takes

place
to

primipara gives a prognosis much

life of the child than
one occurs

less favorable
a

multipara.
lapse proably favor-

only

34

per. cent, cord in

of deliveries

complicated with
terminated
of the

of the for the

which primiparse, have

50

we child,

per

cent,

children

of

multiparse saved.
That
a

first labor in
cases

should

be

so

much

more

dangerous
which
I here

to

the

child

of

accounted prolapse,is partially

for

by
1.

circumstances

already mentioned, pelvis, which frequent

cent,

: recapitulate

The

contracted

prolongs primipara primiparsB

per
cent,

and than

dangers en-

labor, is

more

in

in

multiparse:
a

68

per

of

the
56

showed of the

deformed

pelvis, while
so

only

multiparsB were
3.
more

affected.
render

Vertex

which presentations,
occur more

the

prognosis

unfavorable,
in

frequently in primiparsB

than
3.

multiparsB.
of rigidity
labor
os

The

the

parts in primiparsB causes

prolongationof
to

which
but

greatly increases
tedious

the

risk

the child ; the renders rigid,

and, being firm slowly dilates,

and

and

any

operationmore

diffi-

566

Engelmann

Prolapse of

the

cult.

It is
uterus

the greater especially and the

laxness
of

in the tissues

of the
makes

circular
the cord
a

fibres
a

the
less

os

which

the

prolapse of

much

dangerous
goes
on

accident
more

when

occurring in
cord,
if

multipara ; compressed,
os,

labor is

rapidly, the
a

endangered yielding,
sion, compresthe hand

for
not

shorter

space
more

of time ; the

being more
causes

only

dilates
above

but readily,

less
to

and,

all,gives ready
at
a

entrance

of the obstetrician
labor.

of comparatively early period

The
of the

contracted child any

pelviscauses
the

increased
labor
more

risk tedious

to the life

by making

and

dering ren-

operation undertaken
more

for
extreme

the

preservation
cases

of the
course

child the

difficult

In

it is of
not

deformity
of the

of the

and pelvisin itself,

the

prolapse mostly

cord, which

necessitates

an

operation

difficult and into

account

dangerous.
the

Taking
must

various
the

we points considered,

say

that the
"

prolapse of

cord, with
the

all its com-

plications^
consequent

the

contracted

pelvis and
of the

operations
centae pla-

thereupon,the premature prognosisfor

over

deliveries and

the tardy arrival pi-a^viaB, make the

one,

obstetrician, etc,"
an

the life of the child

ceiit.

able unfavor-

50

per

of

the

children

having

the prolapse of the cord as consider perished. If we if we take in which the those cases such, theoretically,

prolapse is
and when

the

only danger
aid

which

threatens
we

the

child,

obstetrical

is at

hand,
cases

may of this

call the
as kind,

In prognosisa passably fair one. in the Lying-in House, observed

72

per

cent

of the

children

were

saved.

In

the safety foot-presentations

568

Taylor:

CongenitalSyphilis
not

pelves
was

and

is placentaepraevisB,
in every

surprising;

but it

caused

instance

by

Dhe

and complication,

never

by

the

prolapse itself.

CONGENrrAL

SYPHILIS

IN

SIX

SUCCESSIVE

INFANTS

Bt

WM.
the

T.

TAYLOR,

M.D.,

Phila.

Pa.

(Read

before

Philadelphia

Obetetrical

Society, Jolj 3, 1873.)

Mrs.
18
to

Julia and

M.
soon

was

married

in

1866,

at

the gave

age of

years,
a

after

becoming pregnant,
a

bii'tL

premature

child at five and

had
a

half

months

of uteroher

gestation,having
labor. She week she became before

chill

days previous to
time ; had
chill

pregnant
the
a

second of

one

sixth

month

when utero-gestation,

again

had

still-born

child.
in

Her
a

third

pregnancy end

occurred seventh

1868, when
month of

she had her nancy, preg-

cliillat the

of the
in
10

followed
dead Her month Her babe
was

days by labor,
skin
was

when

another

born, whose
pregnancy
a

exfoliating.
at

fourth she had had

occurred, and
in and

the

eighth
labor.

followed chill, been very

2 weeks

by
child

health

good,
life.
veiy

the

quite
of her

vigorous during
former had
met

its uterine
was

In

consequence of

misfortunes, she
with
child
no

careful

and herself,

injury.
very for repulsive, the

This

was

skin

was

ing peel-

from

its whole

body.

In Six Successive After which of ext its birth she had

Infants.

569

secretion of milk, copious under the local application rapidly disappeared

a

belladonnsB.

Again she became pregnant for the fifth time,and cessfully. sucpassedthroughthe whole periodof utero-gestation Her child was bom apparently healthyand but when 3 weeks old an eruption appeared on strong, the body. the feet,which extended gradually over had the appearance of bullaB filledwith a This eruption which burst, sores. liquid, leaving sero-purulent
When
8

weeks
in

old the child

a

was

attacked its death.

to

with

which diarrhoea,

few

days caused
she
came

During
attendance

her sixth pregnancy

; and

engage

my

beingin the seventh

a

month
a

of utero-

I gave gestation,

3 teaspoonful

times

day

of the

mixture : following Hydrarg. bichlorid., 5. gr. ij. Potas. iodid., 3 ij. f j. Aqu8B font.,

Syi\sarsap.
If I had have used the

co., I iij. sooner,

been

aware

of her pregnancy

I should
ing remov-

the medicine

with the hope of earlier,

taint from her babe. syphilitic On April 13th,1871, she gave birth to a very large, after an easy labor, and in a fat, healthy-looking girl, few days had a profuse secretion of mUk, which the took. child eagerly On April 19th the mother had a chill, followed by a and two or three discharges from copious perspiration the bowels, which prostrated her very much. She had in breathing, pain in the stomach,and was difficulty

570

Taylor

Congenital Syphilis.
that she
was

very

nervous, not
was

assuringme
see

dying,
The

and

that

I should

her

alive

in two
the

hours.
were

secretion

of milk
An

but arrested,

lochia

quit" profuse.
the
use

antispasmodic relieved
and the

her, and
soon

under

of

cinchona When
excoriation

valerian child
of the the
to
was

she
two
on

recovered.

weeks the
on

old, there neck, with

the and soles
nates.

was

some

skin hands

pustuleson
of
the There

the which
also I

palms

of

and

feet,
was

extended
an

the
the

thighs
same

eruption of
it
a

character times
c. a

about of the

the mouth.
: following

gave

teaspoonfulthree
9.

day

Hydrarg.
"

cretA, gr. xij.

3 ss.

Syr. rhei aromat,,

sarsap.
co.,

|j.
hands
the and

May diy
nates

1st.

The

pustules on
of the neck
; in

the and

feet

are

; the'excoriation
are

eruption on
be

the

better

fact,the
the

disease babe

is fast
to

ing. disappearnourished of the with

a

About

this

time

had

wholly
mother diarrhoea

on

cow^s

milk, for
; when

the

lacteal

secretion

had and

ceased

it became
in
a

affected

vomiting,which
she has

few

days terminated
but I have
to
me

in death. Since advised

then
not

been

pregnant,
so, to

her
that
"

that
I
can

if she

becomes
on

report

early,so
medicines

put her
such

the

use

of

antisyphilitic
her

hoping by

means

to

prevent
the

off-

spiing poison.
Her

from

becoming
denies
and

affected

with

venereal

husband
"

having
"

ever

had I

the

yet disease,
reason

being
doubt

gay

festive

youth,
is

have

to

his

veracity;

his wife

perfectlyhealthy.

Habsis

Early Pregnancy.

571

EARLY

PREGNANCY.

Bt

BOBEBT the

p.

HABBIS,

M.D.,

Pha,

Pa.

(Bead

before

Philadelphia

Obstetrical

Society, May

1, 1873.)

In the in

review

of the last volume Obstetrical

number

of the

"

Transactions I

of

Edinburgh
the the
case

vsrhich Society," of
The American

presented
Journal

April, 1873,
Medical
of

of
a

Sciences^there
pregnancy
was a

appeared
Dr.

the

report

of

early

by
7

James

Young,
commenced birth
13

the
to to
a

subject
menstruate

of which
at 13

white
and

who gii'l

years
at
a

months,
10

gave

large
was

male

child of

14

years, when

months,

days, and
old.

delivered upon

second

just 16
eye have

years

My
of
markable re-

remarks M.

this case,

meeting the
of two
now

of Dr.
the of
a

Charles

Ellis,of Elkton, Maryland,

to

been
cases

means

bringing
1.

lightthe reports
I born girl,
11

more

character,which
A white

present :
to 5 months

September 22d, 1859; began

and
4
or

menstruate

when
a

years

old;
June years

gave

birth

to

male the The

child,rather
care

on over-size,

21st,
and
9

1872,
months

under old.

of Dr.
was

Ellis,when
stout

12

mother time

and

well-developed,
100

weighing
She
vertex

at the
a

of her labor

delivery about

pounds.
the the

had

natural

lasting eighteen hours,

and position,
had
an

presenting in escaping
and A nursed mulatto her

the second
She

neum periof

laceration.
child.

abundance

milk,
2.

girl, bom
in
summer

October
of

Ist, 1860,
to
a

1848

menced com-

to menstruate 1 1 years

at the

age

of

and

9 months

; gave

birth

well-developed

572

Harris

Edrly Pregnancy.
20th, 1861,
was
a

female under the

14

child, September
13

when time

10

days
when first

years

old ; and
a

second

delivered,

child being
years
was

full-sized
old. of 17.
case

male. May
The

2d, 1863,
of
the

and
a

7 white

months

father

child
A Dr.

boy
similar

somewhat

was

reported in
the A

1849, by

George

A.

Ketchum,
....

before

Medical

Society of
13

Mobile, Alabama.

negress,

just

years
at

old, gave
the age and
16
menses

birth

to

female
and

child at full term,

which

of 10
12

years

9 months

began
Before second
and in

to

menstruate,
mother
was

at

became

pregnant.
bii'th to
at
a a

the

years

old she gave

first

daughter, whose
If the
as

appeared
became

7 years mother
negress and
9

6 months.

first

daughter
the

due

time,
have

pated, anticia

first-mentioned
at 25

must

become

grandmother
A the but
case

years

months.

Sexual

cocity pre-

is in many negress mother I do

not

instances
15 at
as

inherited. age
not

under
of

(exact

given)
York,
as

became
;

twins,

Nassau, New
so

in 1822

regard
Dr.
14

this

remarkable
two

the

second

given by
the age

where Ellis,
years and

births single We States

case

occurred have
; but
a

at

of
to

7 months.

not

known

this

be exceeded D.
at

in the United

the

late Prof.

Chas.

Meigs reported the

Maracaibo,
who and
"

of birth

girlof
to
was one

Spanish blood,
child
In
at

gave

13

years

of

age, upon

twins

before

she
read

14.

my

researches

Early Puberty,"
to

before

this
cases

Society,* I
of

refeiTed

three

well-autJimiticatd
than the
1871.

white

American One of

all girls, these

younger in

those

just

related.
"

occurred

State

of

Published

in T?ie Amer.

Jour,

Feb., of Obstet.,

Harris:

Early* Pregnancy
in

573
.

Kentucky,
this years

second

Massachusetts,
mother

and

the

third
at

in
10 8

city.
and
and

The
13

Kentucky days,
the

became
at

such
10

Massachusetts
the
was

years,
11

months,
and

days,
The

and

at Philadelphia
a case

years

3 months.

first others

of
to

sexual infantile
a

precocity, and period,the

but
a

the

belonged

much

later

menstrual
months

function

having
and

been All

established had well-

few

prior to conception.
the
and bore is
a

large mammae, developed pelves,

of

general marks
in

womanhood,

livingchildren.
general
made
sexual

Although
children of

there

precocity
which

tropical countries,freaks of nature^ by

either
sex are

young
the
met

to

approximate
to

early development
\yith even
claimed
years
as

of the
north
as

lower
St.
a

animals, are

be

far
a

where Petersburg, who

a

it is
9

that of age.

girlbecame
Sir

mother
saw

was

under Scotland

Astley Cooper

girlin
and
5

with

pelvis at full-developed
his
at

7 years
no

months,
becopie

who,
a

from

could description,
age

doubt

have

mother

the

claimed
veiy
a

at

St.

Petersburg.
from their

Fortunately,

these

female precociously-developed

subjects differ,as
counterparts of the male
the
we

general rule,
who
more

sex,

ble closelyresem-

lower
more

animals

in their salacious

else propensities,

should We

frequently meet
several times
was

with
met

juvenile illegitimacy.
with
cases

have

where

the ages

menstrual
of
was

function
10

established

between

the

9 and

years,

in

whose girls with

physical development
sexual, and
was

in
was

correspondence
in

their

in

whom

it

highly probable
none

that
was

impregnation
there
any

possible;

but

of them

apparent

"?'

574

Kabris

Early Pregnancy.

the male with change as to their moral peJaiionship all from the higher walks of life, and sex. They were otherwise carefully trained, they might baYe l"eeii brought under the influence of temptation as in "e

examplesreported. The of mensti'uation in our large cities, iiicipieiicy marks as a general rule, only the gradual approach of cided and occurs the nubile period, before there are very dein evidences of womanly development, especially the maturityof the pelvic diameters ; so that the possibility of conception is still quite remote. Pelvic expansion, of which in cases appears to have been general of it the subjects earlypregnancy at any age, enabling children of full or nearlyfull size, to bringforth living in a large number is evidently only in its incipiency of young menstinious girls. The ji)?'"2^arato7'y which usually exists between periodj
the first appeai'ance of the
menses a

and few

the age
to

varies conception, years ; but there have

from

months

of sible posseveral

been instances in which

nation impreg-

took epoch,or even countries, place before it had appeared. In tropical pregnati imwhere young menstrual are givenin marriage, girls takes placeuntil some time has very rarely thus marking the duration of this periodof elapsed, sexual preparation.In cases where seinial maturityis followed the first menstrual attained
the
at the age

of 9, 10, 11, or

12

years,

we

have

conditions

immorallyor
The

which, being sometimes found in the lead to juvenile trained, carelessly timate illegi-

pregnancy.

precocious maternityin largemanufacturing

576 of her
married and
was

Cleemann: life two

at
a

Case

of
children,
at

still-bom
two

about which

full
events

term,

least

abortions;

with

there

history of profound albuminuria,

reached she the middle

and convulsions, On

mania.

January 27th, 1870, having

another
term

period of
to the

of pregnancy,

fell

suddenly
From the
to

floor while

approaching the
servant

tea-table.

testimony
have
was

of
due

in

attendance, this
seizure ; the

appears

been
unaware

to

convulsive
muscular

lady
or

herself loss of
to lose

of

any

contortion,

that she seemed consciousness, declaring

control
over

merely
a

her limbs.
was

saw

her

within
on

half-hour the

after side

her fall ; she

; when

then

hemiplegic
her
and

right

she
to

protruded
same

tongue, its point was

there
of
was

deviated
some

the

side;

obseiTed
sion expres-

distortion

of
on

the

face,the right.
all of

lack

normal
mental her

being
seemed
at

also

the

Her

faculties feature

first little if at
a

disturbed,

wearing merely
manifested
Her On

look

anxiety,but
and
98

before

longshe

confusion
hard

of ideas
and reached

of speecL difficulty beats

to

pulse was
she

in the minute. time had been in her been

cently re-

inquiry,I

learned

that

up

this

pregnancy in

had

felt

unusually well, and

that

excellent
found In
a

but spirits;
to be
or

her

urine Dr. E.

had

albuminous
her

by
been
in

Wilson.

day

two

mind
had

became

perfectlyclear, degree, general

there

which irritability, gastric

and

present, disappeared,
some

the

paralysis diminished
of asthenia
a

symptoms

remaining; subsequently
of power
over

slowly

returned muscles.

slightincrease

fected the af-

Puerperal Edamvp^ia.
After
convulsions several and

577 three

six weeks

had

gone

by

the
were

patienthad

(March 6th) ;
some

these

preceded,during
left lumbar
of

days, by
two

pain
a

in the

region,
oedema
" "

for

days by

slightappearance integument
on

without
some

pitting of
at

the

pressure sound

and

of respiration, difficulty a wheezing the close

of

being
the
"

heard

expiration.
with
albumen.

Meanwhile Coma
"

urine

had

become the the

a

loaded

^not

profound,
of

patient being easily roused

stomach, followed week,
amount
ovum

tability ^with irri-

the

convulsions,and

for persisted
the
same

the

urine
of
was

all the while At

containing
the the end

large
an

albumen.

of

this time after

a

entire

expelled from
duration. The
was

uterus,
had
; the

labor

of four
and
a

hours' half

foetus dead

advanced

to six

months,
to

and

placenta was
hours
evacuation several

small

and
the

beginning (9 p.m.),and

degenerate.
this

Four
an

subsequent to
of urine times
before

parturitionthe patienthad
was

repeated

the next

morning's visit.
the
on

Till the
an

third

with day following,

syncope

exception of evening
albumen On this of in

alarming,but evanescent,
urine

the
the

March the

14th, the patientdid well, while

diminished
the
to
scarce a

trace.

day
up

(March 16th)
to 100

pulse,not wanting
minute, while
the

in

ran fulness,

beats
to

in the

patienttalked
hard and

coherent in-

the herself,though answering rationally

to

questionsput
the

her.
was

The

breasts

were

len; swolin

oedema
had

scarcely to
the

be

perceived
There the had

the

face, and
where
a

disappeared from
been

paralyzed extremity
been

it had

observed. especially from the bowels

large evacuation
37

during

previous

578

Cleemank

Case

of by
another. after wards To11

afternoon,followed evening
P.M.

in

few

hours very

she

became
a

but restless,

(at

which
was

time

hypodermic
take

injection of
for
two

^th

gr.

morphia
She she and
more was

given), slept quietly

roused
to
some

hours.

then

milk-punch,
much she

Tvhich

received disturbed.

unwillingly,appearing
Quieted
about

frightened
was once

by
half

her
an

nurse,

tranquilfor
off the

hour, when

she

began
deal of

throwing
the
muscular froth

bed-clothes
her

and

attempting to
a

rise from

bed, manifesting in
power
;

exertions

good
I her

finally, shortly before

her mouth.
a

reached

her,
state

appeared pulse.

about

I found

in

of extreme

with prostration, From

a

fluttering, scarcelyperceptible
uttering a sharp pulse
An the tient pashe

this condition, after

cry

and

after

few

long
of

gasps,

rallied ; the in the minute.

but

becoming
attempt

fuller and external

100

beats
was

at

stimulation

made,

the suddenly died, respirationceasing first,

heart

stopping
In the fi'om the
from the

afterwards.
treatment

of this case, rest

in bed

was

enjoined
excretion
use

time

of the
was

paralyticseizure.
insured

Free

kidneys
of

by

the continuous the bowels

of

carbonate

potassa, and

from
the

by
the

senna

and
was

other

evacuants, while

strength of
Chloric

patient
of

fostered

by

iron

and

different

stimulants^ tonics,

and

nourishment. systematic

ether,hydrate
as

chloral,and
the soporifics,

opium,
last
was

were

prescribed
very

anodynes
For
the

and
ralysis, pa-

drug
In

cautiously.
nux

friction

first

used, then

vomica,
of March

and 6th

faradization. finally ether

was

the

convulsions

administered

by

inhalation.

Eclanvpda. Ptierperal
A

579
record is the

very

feature striking
of

of

the

above

occurrence

convulsions

followed

by persisting ralysis paIn

in the
to

earlyperiod of mid-pregnancy.
of the

regard
turbance dis-

the

nature

convulsive
is vague.

movements,
The such
as

nately unfortu-

the may

testimony
have

muscular

been

merely
of of

occasionally
fore, thereturbance dis-

accompanies ordinary symptomatic

; but

attacks

apoplexy, and,
intra-cranial

only
the

sudden the

the
and

historyof
fair the

previous pregnancies
condition that
of

of

the

patient
make
more

albuminous

her

urine

presumption
The

puerperal
true

eclampsia
vascular

had

supervened.
within
the involvement

complication of
cranium
of \he

extravasation

the

is,however,
of the

inferred, from tongue

the and

muscles

of the face in the of

from subsequent paralysis, in the

power of

lack
a

improvement lapse
and

motion,

after
the

considerable
had

of

time^-even, indeed, when

and the

uterus

discharged its contents

"

urine

was

free from after the the

albumen

from also

the character

of the

pulse
But

which accident, of the

supports this view. respect

to

condition

patient mth
was

vascular
as

tension,at
warrant

this

time,

not

considered

such

to

venesection
this
measure.

; and

subsequently asthenia
The

contra-

indicated the other

opportunity for employing

in
"

most

prominent therapeutical resource

"

puerperal eclampsia
itself with the

the

emptying
of

of the uterus of

sented ^preand

convulsions week left to

coma.

March
But

6th,

during
observed who

the

subsequent
this
was

it will be

that

the

initiative of

Nature,
fully success-

proved
without

herself aid.

capable of accomplishing it
After the delivery,

kidneys

were

580

BuLKLEY from

On

Herpes
ed, appearbe in
a

freed

and congestionby copious secretion,

absence of albumen
to

in the

from

the

urine,to
since ceased.
the

condition
But
was

favorable

returning health.
from
apnoea, heart In
nection con-

the

patient

died

still

beating

after

had respiration
of death
a

with that the

this mode

it is and
a

to interesting

note

patient,with
the
to

cry

few

long
of

gasps, her

rallied

fc*om

syncopal
her what in

attack

in which

I found

just previous

death.
occurs

This
in

succession
some

nomena pheof
we

resembles

instances when
panied accom-

laryngismus
recall

stridulus

young
spasm

infants ; and is sometimes

we

that

the

laryngeal

by general convulsions, eclampsisfexpressed

cause

may The

presume

complete in-

here.

detennining
damage
gata, oblonof
a

of these symptoms, annihilated

may

and

of the intra-cranial of the

which

the

function found

medulla shock

possiblybe
trouble

in the

mental

domestic
critical

which

became

aggravated

at

this

period.

ON
A RARE AFFECTION

HERPES
OF THE

GESTATIONIS

SKIN,
BULKLBY,

PECULIAR

TO

PRBGNANCT.

By

L.

DUNCAN

M.D.,

New

Yoik.

(Bead

befiore the

New

York

Academy

of

Medldne,

Febnuoy

6th, 1874.)

The differs

eruption,the history of materiallyfrom

known
and the

which
of

is here

presented,
disease character nine
cases

forms

vesicular is of
of
a

commonly
so

but described,

distinct and

yet

so

marked
it claims

in each

the

here

analyzed, that

recognition and

descrip-

Gestationis. tion with.

I will first my

581

among

the

cutaneous

lesions

liable

to

be

met

give
let

the clinical
other
cases

history which
and

furnishes
low. fol-

text, and

the

commentary
confined

Mrs. her her

J. H
^

aged 32^
1870.

years, Two
to

was

with

first child

in Nov.

months
appear,

previous to
first and

delivery,an
the
or

eruption began
and

chieflyon
to
a

hands
less

feet, subsequently involving

all the rest of the

greater
the

degree
in

body,
not

cept ex-

head.
as

This

eruption,which

I did

see, is

described

beginning
the

papules, which
were

rapidly
the
one

veloped de-

into

blebs while, later, vesicles,

formed, soles, inch,

were

especiallyon
of
or

feet about
and

the

toes

and

on

irregularshape
even

from size, the

one-half

to

more,

in

diameter;
also the
or

vesicles,which
in size

generally in
these

groups,
to

varied

from

very

nute mi-

elevations had

bullae
were

above

described.

After
up,

ruptured
a

punctured they
was

dried
no

leaving only
any

brownish

stain ; there

at

time the

exuding
of
never

surface the be

resembling eczema,
became

and

though

contents

vesicles called

turbid, the
The

eruption
of the it

could

pustular.
intense

affection

skin
had

was

attended extended

with
was

and itching,

after
much

become

accompanied
Fahr.
to

with
over

and prostration

considerable
104"
seem

fever, a pulse of
affected for

100,

and

temperature of
disease
treatment

The

did

not

be

by

the

most

varied
but

which

was

employed

her

relief,

towards
so as

the very
to

end of

gestationdisappeared gradually,
on

be

almost

entirelyabsent

the birth

582

BuLKLEY

On

Herpes
months.
One made
or

oi the child,after
two

having

lasted two vesicles

days days
much

after in and
a

deliveiy the
then

again

their for that

was a

appearance

pretty general crop, which

dried
up the about

lasted
at

few time

slowly,yielding eruption
the

discharge. During
with

she

troubled

nem*algic seizures disappearance of

was
no

chest, which
of disease.

ceased After
to

with
the

the cutaneous

manifestations
the
a

eruption,subsequent
recurrence

there delivery,

sign of

for

more

than

2\ years,

when

she

again became

enceinte. months
to

In

the

interval, however,
the and

conmiencing
child, she
was

several

after

birth

of

the

subject
wheals
to

occasional

quite
for

severe

attacks
a

of

which urticaria, would

tendency
appear about

lasted

about

year.

The

at chiefly

the wrists

when

exposed

cold, also
breakfast
swell

the

face, and

frequently,coming
remain but

to

feeling
with She
or an

well, the lips would perfectly

suddenly
half
an

erythema
nursed
the and

and

so

for

hour. three

had
four

child

for insufficiently

weeks,
When

the milk
first
seen

then

ceased. June

by

me,

2d, 1873, she

; in fair

was

for

the second

time

pregnant,
moderate

five months

general
of
the

health, pulse of
except
uterus.

strength, 70, appetite good

She
had retroflexion

in

the

morning.
weeks the

About

two

previously she b^an

of
the the

to

notice

an

irritation caused
her

of
to

skin

hands

and

feet, which
there would

scratch

parts, when
of

shortly appear
were

little groups

which vesico-papules, the ulnar the

ai'ms

observed and also

about principally

aspect of the
;
on

hand

running up

on

the

feet

584

BuLKLEY

On

Herpes
ext. tarax. ext. fl.,

acetat.

iv. ;

spts.etheris nitrosi, | i. ;
aa

rumicis in \
if

rad. IL

iss. M.
5

Teaspoonful hydrat scratching.

still attends

between gi\
x.

meals
at

glass water
to

; and

Chloral
not

night
the

necessary veiy

insure

Puncture

vesicles

carefullyby insertinga
She is up, and

needle
to

laterally
household

at their base.

duties.
June
16.
"

Patient
very

has

been

more

comfortable,
been
no new

the mation forhas

a

urine

has of

been

free ; there
until very

has

vesicles
in
a

this
hot

afternoon, when

she

been

working
roof, and
and and

garret, directlybeneath
The
now

tin

is much the

prostratedtherefrom.
feet

ing burn-

in itching-

and

hands

is

ble, unbeara-

the disease

is

developing with
of vesicles
over

great rapidity,
the soles nails
to

there

being large crops

and
on

of and

the
at

feet
the

the

palms,

also around
64.

the

end

of the toes.
the

Pulse

Ordered

doul"le

the

strength of
alh
to

tar-wash, using sij.of

water, and
to
to
one

the

Zfiq, picU dry,

the

I iv. of

apply thereafter,when
on

mutton-tallow diuretic times

a

hand,
and
a

trial.
half

Increase

mixture

one

teaspoonful
use

four
if

day.
17. the

Remain

recumbent

and

chloral

necessary.

June
of

"

Is
hands

much feeling and

better; there is
many

less

ing swell-

feet, and
The
a

of

the

papules
was

and
very

vesicles have
and grateful, The
case

vanished.
she
was

stronger tar-wash

passed
seen

quiet night
my

without
Dr. the

chloral.
Wm.

to-day by

friend
as

H.

Draper,
character

in

consultation,who
the

agreed

to

neurotic
to

of

disease, and
the

suggested

in addition of

the present

treatment

administration

Gestationis.

585

two

drachms Fowler's

of cod-liver

oil, togetherwith
times
to
a

three
The

drops

of of
no

solution,three
were

day.

contents
was

the vesicles elevation June

and
19.
"

found

be

alkaline; there

of temperature.
Much
more

comfortable of

; there

ing is less itchPatient the

also still

less

development

vesicles.
to

keeps
treatment

the

bed, and
and
return

is ordered
to

continue

local
oil

the

pills, taking
of

the

and

arsenic,stopping
30.
or
"

the

acetate

potash

mixture.

June

Patient
in

is feeling very the

well ; very affection

ritatio little irappears

burning
but
are

skin ; the

checked,
the old

as

occasional

isolated

vesicles
T.

appear,

and

ones

rapidly drying, C.
was

July
month

7.

"

Patient the

up

and

aroimd
on

at about

one

from is
now

time
any in

of

entering
of the
or

treatment,
no

and
scars

there
are

hardly
She leaves

trace
a

eruption;
for the
reached

left.

day
no

two

country.
the

The and

vesicles and
extent

bullae

at

time

have

size

of distribution the

attained of
the

during the
onset

first pregnancy,

although
appearance attack.
an

rigor

and
a

the

early
severe

of None in

the

eruption
and

threatened been

more

of the

bullae have but few

more

than

J of
could portion protion erupwas

inch

diameter,
other
name
as

of the

elements

merit

any

than

while vesicles,

quite a
the

aborted
almost

papules. During
of the

the former

the whole

body, except
to chiefly
as

head,

involved, whereas
have

in the
been

present, the
far

cutaneous

festations maniand and

confined

the the

hands elbows

feet,with knees, and

some

development
very
16.
"

as

slightsprinklingon
Has
been

the trunk. since last

September

perfectly well

586

BuLKLEY

On

Herpes
of doors
in the

note,
There

spending
has been

much
no

time

out

country.

return

of the
no

eruption,save

occasional

scattered
treatment.

vesicles, giving

annoyance.

Still continues

October

21.

"

^Was
and
never

delivered child
had
was

five welL

days

since

of

thy healis

boy

; mother

did

(The

first child

li^nngand
internal Two

has

any

cutaneous

trouble until

The

treatment

continued

confinement
curred oc-

days
some

ago,

^.^.,

three

days

after

delivery, there
and there
are

burning of
vesicles, veiy

feet and

hands,
about

now

groups

of

minute,
the

the

soles of
; the

the

feet and
are a

dorsal

aspect of

ends

of the
matter

toes

feet
or

little swollen, but

and is

the whole

gives little
to

no

annoyance,

insignificant compared shortly after

to

the

tack at-

which She returned

followed
at
once

the

fii^st confinement the

the

pillsand

wash,

and

the

are papulo-vesicles

rapidly subsiding.
Child
one

Nbveynher
but in

17.

"

month

old, healthy,
No

nurs^

part.
Takes

Mother

doing

well.

sign

of the

tion. erup-

porter every
1.
"

day.
of
on

December the air.

ferri meals.

Slightdevelopment
the and

urticaria, as
exposure is

after

previous attack, about

She

wrists

to cold

is very

strong
x., and

well,
nux.

and
vom.

taking

Tinct

chloridi

gtt

Tinct

after gtt iij.

fTanua/ry 6,
well ; tinues
no

1874.

"

Patient

is

looking remarkably
kind.

cutaneous
use

trouble
the

of any and
at
nux

She

still and

con-

the

of

iron

vomica,

takes par-

yet of nourishment

night,as

before, beef -tea,

milk,

etc.

Gestationis.

587

After

very

considerable
at all
one

search, I find mention

these
that

of but

eight other
exactly with
all in f ection and
to
a

cases

and similar, above the

correspond so
I

the

detailed
to

give them
the af

brief,in
to

order

establish from

identityof
The

it distinguish
or

other

eruptionsresem
cases are

bling it
corded

greater

less

degree.

re

by Gibert, Chausit, Hardy,

Hebra,
1872
*

Wilson,

Milton

Klein, and
1868, and
Gibert's
"

in the

years

1840, 1852, 1863, 1867

respectively.
is very

mention

brief,and
Dr.

is Jos.

as

follows
has her

German
a

physician,quoted by
every attacked

Frank,
after

seen

patient who, during

of

pregnancy

first

confinement, was

with

pemphigus, during
between

the last months

gestation."
notice any
but

Chausitf does
disease
and

not

connection
case answers

the

pregnancy,
ours :

the

in many

respects to
is
as

he calls it

pemphigus prurighwsiLSj it
delivered
te"m.

follows

J
a

Anna, aged 23, was

six weeks before of
no

of her first child,

was

boy,

full

She
at

of

robust

and constitution,

good health, but

known
cause,
an

the fifth month

of

from gestation,

she

began

to be

tor*

mented and

with
of

intense
numerous

itchingand
minute

eruption on papules ;

the

body
On

limbs

solid
pregnancy

ing the itch-

increased

in

severityas

advanced.

the fifth day after

accouchement^ she experiencedgreater

The fever
rose,

itching and generalburning.

delirium covered ensued. with
a

and

some

In

the

morning

the whole
of

body

was

very

confluent

eruption
la peau,

large

salient

Traits Annales

piatiqae des maladieg

des maladies

Bp^ciales de
et de

Paris, 1840,

p.

102.

de la peaa

la syphilis, March,

1852,

p. 142.

588

BuLKLEY

On

Herpes
ma respects those of erythethe
same

red

papules,resemblingin papulatum.
for two The

some

eruption preserved
on

pearance apseen

days, and
scattered
a

the

third

there

were

on

the

arms

some

varying transparent bullsB,

to
a

in

size from

that of

haricot-bean

hazel-nut
to

The

ber num-

of these
on

bullae increased

from

day

day, until

now,

the eleventh

day, the
the
ten

whole
and
new

body, includingthe
bullae form

face,

is covered, and ceased.

From
or

burning
to

itchinghave completely
out daily withor

twenty
if

pain
small

burning, and, by
not

large, soon
and

rupture,

if

subside

the

absorption of
them.

their contenta
the bullaB bullae few

The
ing formceased

originalpapules daily are

to

have

disappeared

preceded by eruption had

The
a

appear

on

the seventeenth

day, and
A

days

later

all traces

of the

vanished, except brownish

month
was

stainingwhere

the

bullae existed.

later, i.e^
a

six weeks, about, after

confinement, there

slight
groups
soon

generalitchingover
of

the

body, followed

by

few

papules,on
no

different

parts of the body, which

formed.

faded,

bullae

being
a

Hardy*
with
name

describes

similar
a

eruption of
woman,

blebs attended also under

the
35
was

great itchingin

pregnant

penvphigus pruriginostiS.
of age, had

The

patient

was

years
now

already had
in her tenth

nine

children,and
Since similar
some

far

advanced

gestation.
from
a

her

second

child,she
each

had

suffered it

eruption
after

with

pregnancy,
one

commencing being

weeks

conception,the

described

the

eighth.

The

Le^on

BUT

les

maladies

de

la

peau,

2d

part, p. 136.

2d

ed., Pazist

1863.

Gestationis. whole itched The

589

body

so excessively, were

that

sleep was
and

almost

impossible.
of
of
a

bullsB
the

small,not exceeding the size

became darker

and hazel-nut,

skin

the seat

viscid secretion. in

These

phenomena
each

in each instance

continued

until delivery, when severity increasing

return
at

they

gradually disappeared,to
greater

conceptionwith
were

intensity.
outbreaks month

After
the

delivery there
disease, but
birth she

several

slight
well
one

of

was

entirely
terval In the inwere

after the

of the child. and

she

was

perfectly well,
the title of
a

the

children

healthy. Wilson,*
mentions with

under
cases

eircinnatus Tierpes

hulloaus^
"

two

bullous

eruption,

associated

pregnancy,
the
:

beginning with conception and

of

ending

with
account

completion
"

parturition." I quote
were

his short

Both

cases

remarkable

for

perpetual
The bullae filled with

irritation
were

and
the

intense
flat and and

pruritic suffering.
foliaceous with
moist In
one a

of

kind,

some

limpid serum,
were

others with

and muco-purulent fluid,

associated

excoriations,thin

crusts,
ease disdisease four
hausted ex-

and pruritus. papulae,

was

patientthe
of pregnancy

cutaneous ; the

the fii'stintimation

continued
or

during
her

the

whole

period,accompanied
In other and
us

five

pregnancies
health intervals
other the The

in
and

succession, and

completely
handsome
the age

strength.
was a

respects

and
woman.

in

she

strong
before

patient came
; the

at

of

36 ; she

had

nine

children
fourth

eruption
and

made
has

its appearance
panied accom-

with
every
*

the

pregnancy, since. When

pregnancy
Diseases of the

was parturition

On

Skin, London, 1867,

p.

294.

590

BuLKLEY

On

Herpes
on

over

the

eruption ceased
ago,

; but

the
now

last

occasion,
a

nine
manent perthe In pathetic sym-

months

it

remained,
She
may be

and

has

assumed
that

character. present both time she the

thinks, moreover,
in the
was

at

family-way againaccompanied
with
a

cases

eruption
skin."
*

Tvith

gastric disturbance,and
cachexia
of the

duskiness

and

J. L. Milton

recorded, shortlyafter,a parallel case,

giving
his
we

Wilson's
was

designation,herpes
afterwards,
to

drdnnatus
case

bulto

losuSj which

in

the transcribing

book, f changed
have

which herpes gestationiSj

case
was

name

adopted.
of

Milton's

in brief in be

as

follows
fourth

A month

healthy-looking woman,
her

aged 45, began

to

the

eighth
and

pregnancy,

distressed

by

most

intense
arms

smarting, and itching,

forearms,
upon

heat

of
a

the cular vesifirst

skin of the
and seen,

which

parts
When

bullous

soon eruj)tion

developed.
of
the inner less but and

nearly
and

the whole

surface
a

part

of

the

rightarm
covered

forearm, and
extent

somewhat left
arm

still very
were

consiflerable with

of

the

forearm,

vivid

red, very
that of
a

elevated slightly
bean
to

patches,
the base cles vesi-

vaiying in
of
a

size from

that of

splitwalnut.
about

On
a

most

of these pea;
two

patches were
four.

the size of

small of

very
to

rarely solitary, They

some
were

and

generally in
with

groups

mostly prominent oblong, They

*

and

pointed

in

shape, but

were

the

ends

apparently communicating. quite tense

8, p.
of 311. the

were

in all

stages,some
Vol. of

from

accumu-

Joum.

of Qatan.

Medicine,
and Treatment

I.,No.

t The
205.

Pathology

DiseaBes

Skin, London.

1873, pw

592

BuLKLEY
of
on

On

Herjpea
each
arm,

able the

crop

large vesicles
the

on

while

many

of

spots

legs and
cmsts.

trunk These almost

became
soon

speedily covered
abated

with
two

dry, yellow
weeks later
no

again,and
from
them

she

was

free entirely

and

had

relapse.
had

This

woman

had

similar attacks

twice

previously,
attacks
coui^se,

with

her first and

at

fifth
same

pregnancies ; period,ran
after
much than

all three
same

gan beand

about

the

the

disappeared spontaneously having

attack
worse

parturition^without
The
the second and first, occurred age
"

been
was

influenced
more

by

treatment.

severe

the

third
first in

than

the

second.
was

The

disease
of

1853, when
lived ; the attended
above

she

thirty-one years eruption

still-bom
at

^the child

second
a

her

fifth well

gestation was
as

with

child,as
intervals
two

the years

one

detailed. each of

There the

were

of

seven

tween be-

and eruptions,

living

children
any

bom

between

each, without
theuL

the

mother

having

eruption with
"

From

the very

outset," says he,

to

"

I had any

expressed a
treatment

decided

opinion
and

as

the

of inefficacy observed least real

whatever,

I certainly

never

that control

cines the mediover

prescribed exerted
progress The of the
next

the

the

complaint."
case

similar

which

I find

is

given by
of age, noticed

Dr.

Klein,* of Jicin.

The

patient,32
of
the

years

in the
on

beginning
the upper the
*

of the

7th month and

pregnancy,
a

extremities size of
Med.
p.

thorax

number of which

of vesicles
were

the millet-seeds,
Zeituiig,Vienna, Aug.
203.

contents
6, 1867

AUgemein.

; quoted

in Joor.

Gatan.

Med., Jnly, 1868,

Gcstationis. She
took few

593

transparent.
under their and

baths,

but

grew with that covered

worse

and influence, in such

the vesicles formed

such

rapidity
every

increased
was

numbers,
very in
soon

almost with that

part of the body

and

them,

they they
hen's

also

so

increased

magnitude
that of
a

by
to

this time

varied
egg, At

in

size from
the
same

walnut

that
became

of

and the

soon contents, clear at first,

turbid.

time, she given, with

surfaces
and

suffered

very

severelyfrom
A

pains,and
treatment

her
was

strength declined
dusted

visibly. lycopation consti-

supporting
and

iron,quinine,
with

wine

beer, the

affected

podium, starch,and
relieved
This she
at

morphine,
months,

the obstinate

by clysters.
imtil

state
once

lasted two

confinement, when
the in

began
the the

to mend

rapidly ;
and had

which vesicles,

still appeared, grew

the skin
on

fewer

fewer
been up.
a

number, while
became

parts which
bed-sores
her

invaded

healthy and
she

closed
and

In fourteen

days
had

could

leave

bed,
The

within

few

weeks

recovered. entirely cared for

which child, The

by

another
two

person.

was healthy, patient had previously was

borne

strong, healthy children,and

had

joyed en-

good
Hebra*

health

during
account

her

pregnancies.
case

gives an

of another He

of the
:

same

nature, which
Several
from

he calls
ago,
a

pemphigus.
young
woman

says
came

years

to

Vienna

during the first occasion, it three successive pregnancies. On appeared during the fifth month, and disappeared after
and delivery,
*

Russia, having suffered

from

pemphigus

on

th6
Medioin.

second, it continued
"

one

month
^

Wiener

Wocheoflchrift,No.

48,

1872.

38

594

BuLKLEY

On

Herpes
not

after
but it the

delivery.
into that

On
a

the

third,it did
of chronic
to

thus

disappear,
and
use

passed
was

state

pemphigus,
Under
she the

this of

brought During
buUaB
as

her and the

Vienna.
means,

the

baths

of Voslau

other

completely
next

recovered.
nancy, and
to
some

first month
on

of

pr^-

appeared
in the of

the

lower

extremities,

afterwards,
the
arras.

former

extended pregnancies,

Loss
same

appetite and
she
was

sleepreduced
she first lost her became

her
came

to

much

the

condition

in when
soon

to Vienna.

After

deliveryshe
occasions both

pemphigus.
the

On

two

subsequent

she

pregnant,

pemphigus reappearing in
time after

and

lasting for

some

delivery.
of

The

peculiarfeatures

this remarkable

disease,as

gathered from the preceding clinical histories of nine servers almost precisely similar cases, recorded by eight obduring
summed
1.
a

period

of

twenty

yeara,

may

be

thus

up

There
the

is

an

affection of the skin

state

directly dependent
may make
to

upon

gravid
month,
of

of

the

uterus, which
of

its appearance

at

any

period

gestation up

the

seventh
is

and

generally continues
has in
a

until the organ

measure
ed resum-

emptied
its former

its
state

contents, and
;

this

eruption is

very

apt, moreover,
Table

to

recur

at

each

successive

conception. (See

of

Cases.)
2.

The

cutaneous

manifestations

are

chiefly an
of

intense

of irritation, consisting
and sometimes

burning, itching, or
the

stinging,
erythema,
a

pains,with

development
to

and papules, vesicles,

bullae up

the

size of

hen's

Gestationis.

595

^ggj

the

majority
in size
a

of

the

blebs, however,
of do

seldom

passing sur-

large bulla
but

herpes.
not

These
any

vesicles definite

are

commonly

in groups,

follow the

nerve-tracks, appearing first generally on

and

extremities the

afterwards
may

involvingthe larger part

ensue

of

body.

Exhaustion
but
3.

from

the

cutaneous

irritation,

the The

disease

is non-febrile. disease does

not

eruptive

terminate
the

at

once

after

delivery,but
of fewer and

slowly retrogrades,by
fewer
vesicles
ceases

ment developintervals,
An
burst out-

at

increased

until

the of

dispositionthereto
greater
or

entirely.

less

severityis most
rare

likelyto happen
manifestations of

on

the

third
to

day

; it is
a

for

any

the
4.

disease This

remain

month

after

parturition.
or

affection neurotic

is sometimes

accompanied
as

ed followcaria, urti-

by

other
and

manifestations,
may

erythema,
in the

which neuralgia,
in many

continue

interval
periences ex-

of

conception, while

instances
interim.

the

patient

perfect health
5.

in the

This that

eruption

has

occasionallybeen
has
cases

cation the first indi-

impregnation
of the

taken

place.
been
on

6.

The

majority

have

uninfluenced

by treatment,
the uterus. 7. The

relief

occurring only
"

the

emptying
by
was

of

children in the

are

not,

as

rule, affected
one case

the
companied ac-

eruption

mother, although in
instances

it

in two the
a

by

still-birth ;

ever, here, how-

first

eruption was
the any

followed
second maternal

by

the

delivery of
gave
a

living child, whereas

child

conception eruption.

still-born

without

596

Bui^KLET

On

Herpes

'I

i.

Si

1st
"a

lit
OS
o o O O
m

CQ

o
"-"

00

19

4f

i3-

as

"-a

"."11 "IE

Gestationis.

597

:i -a 3-; o. "Sse
"

psIIi
53 'rf s

CQ

ig^

"3 S

"

a 1^ 0 "

9^

3
a

"I

.t3

"'S

S --S

"-3

"-a

1-4 "-4

w
"

"

ki

598

BuLKLEY

On

Het'pes
is the
nature

The

questions now
treatment? I

arise,what

of
its

this

disease, its nosological relations,and

can

what
very
or

priate approin the

find

but

little in the of

works gynaecological

at

my

command,
to

ical periodthe sldn

literature with
and and the

reference
than

the

relations

uterus, other

brief mention
the

of the

pniritus
also very the

chloasma

attending
of the

pregnant
organs.
the

state, and
That* skin
a

certain

disorders
connection

female

intimate

exists from many

between

and

genitalsis
Thus,
the

evident

circimistances. which take

all

recognize the changes envelope pubic

color and and of of
as

place

in the

cutaneous

puberty approaches,
in both the

growth
the
abundant the
aware

of the

axillaryhairs adipose tissue

in
man.

sexes,
more

changes

expression,with
in We
or

development
of
arrest

females^
are

and

appearance

the of

beard sexual

equally
an

of

an

development
functions darkened and

of

proper im-

performance by
the faces
eyes, of the chlorotic the and

of

the

connected skin

with, therebeneath

pallor or
these

clammy phenomena

hands

acne-sprinkled
Not the

those the

misusing
the

functions. observed of the

in

less lower
in the

strikingare
animal

kingdom,

development
animals

antlera

of plumage of birds, and stag,the increase in brilliancy

changes

in the fur of

during

seasons

of

sexual

excitement.*
we Pathologically,

observe of

acne

punctata
cases

and

simplex

appearing in
about and girls,
*

large share
in

the

early in life,at
of the in the
menses

the time

of the first appearance

in of

puberty
Dr.

boys, and
Med.

again

decline

J. M.

Hyde, Chicago

Jour., Maroh, 1873.

600

Bulkley:

On

Herpes
surface,and
the
tlie margins skin.

not

at

all elevated

above

the

fade
Dr. of

sometimes H. G.

insensiblyinto
*

surrounding
the
a

Hand of

reports
whole

case

of very
to

deep bronzing
color half of dark months

the

skin

the

body
three

coffee, which
before

commenced
at

and

delivery

full

terra, and

gradually
a

faded
in her
on

thereafter. first pregnancy the sides

Montgomeiy
observed forehead
on

tells of

lady
or

who

brownish
and

spots

patches
she
at

of the
for

temples,which they
after far

first manent per-

mistook

soils when made dark that

a

the

skin, but

remained
a

; and

she became
to

pregnant again
so

further nancies pregside her

markable re-

addition

was

them,

that
so

several each

the of hair the in

marks the
as

extended

down
to

face,
such

lady
to

was

obliged
them.
the

dress
most

way

cover

The

circumstance of the

in this almost the

case

case

was

permanence

marks, which
Lacet relates

always disappear
of
a woman

after

de-

liveiy.
in three

whose

face,

successive
among
are

became pregnancies, the effects

more

quite black.
pregnancy
on

Prominent economy the

nervous

of

the

those

referable
as

or

less

directly to

system,

facial

neuralgia, cephalalgia,
of

of the chorea, palpitation

heart, mania, etc.,J together

of

with

anomalous

affections

the organs

sense,

cially espe-

of

sight and

of hearing,altered sensibility spasms, the

various

parts, occasional
and which
*

slight attacks
The

of

singultus,"
affection,
and
eon-

pruritus of

integument.
us,

last

interests principally
NorthWestern and

is either local

Med.

and

Surg. Jour., Jan., 187S. Pregnancy,

Phila.
,

f Signs

Symptoms

of

1839,

p.

103.

\ Tyler Smith, Lancet,

March

1, 1856.
Medicine. Vol.

" Copland's

Diet,

of Pract.

III.,p. 50i.

Gestdtionis.

601

fined
so

to

the the
we

region of
whole shall say

the

or genitals,

it may
Of

be

general,
local

that

body
but its

is distressed.
as little,

the

variety
and of very the

it is well
treatment

recognized
in most
It

described

with

appropriate
and
on

'yyorks on

obstetrics

diseases
causes

of

women.

fi*e(5[uently depends
with
pregnancy,

local

connecte entirelydis-

as

vulvar ascarides, pediculi, of

folliculitis, an
vascular

acrid
tumors

condition
of the

the

sebaceous

tions, secre-

urethra, etc.,* although

cent,

Meigsf
instances

states

that he
met

judges that ninety per

with
were

of the neral Gea

he had

in but

women

encemte.
or

pruritus is
disease
inasmuch
as

less common,
on

is

more

less

tinct dis-

dependent
relates
"a

the

gravid state
once

of the uterus,
upon

it disappearscompletely at
a case

rition. partu-

Cazeaux

published by
in

Maslieuratnancies pregto

Lagemart,
was

of

lady,
labors.

who

eight

successive
as

afflicted with

itchingsso
On
at

violent

duce pro-

premature
in and the sixth

four

occasions
months

they began
and
a

month, twice
in

eight
month.

half,

twice

the

seventh the

They

appeared
; the

almost

instantlyover

entire

cutaneous

surface

legs, thighs,genital parts, the

were face,scalp,

whole

trunk, the
but
at
a

neck,
the later

all affected and

even

nothing escaped
invaded

palms

of the So

hands,
severe

they wrere
excoriated

period.
she

was

the irritation that the violent rubbings the

of the
was

poor

sufferer when

delivered
had
seen

they
cases

vanished

Hardly entirely." He
(B Potass,

skin.

himself

three

of

general itchingwhich
bath
car-

yieldedquite promptly
"

to

alkaline

GraUy
Woman

Hewitt, Dia. of Women,

and her Diseases. 8d

Phil.,1868,
Edit.

p.

665.
p.

Phil.,1854,

93.

602

Bulkley:
the

On

Herpes
records
of
a

bonat.
of
a

"v.

to

bath).

Hebra*

the five

case
cessive suc-

lady

who

during
her
rest

the first five months from

so

pregnancies suffered
cutaneus

violent been her

pruritus
her paired, im-

that

at

night had presented

disturbed^
nutrition

mind

kept

in constant

irritation,and
a

while

her

skin
on

scratched

ance appear-

usually seen
have of
very

those under

suffering from
my
care a

epizoa
case

recentlyhad
connected

distressing
where of the

pruritus
the

with

pregnancy,
lower

the trunk seemed

ment, treat-

shoulders,
were

arms,

thighs,and
intense

part

seat

of such

itchingthat
of

rest

impossible;upon
which

the

subsidence

this
not

under due
to

persistenthoarseness gives no
above
nervous,
a

ensued,
save

cold,

annoyance The

the

inabilityof speaking
voice

whisper.

loss

of

it when

having
it lasted

occmTcd
to

with

the

evidently preceding pregnancy,

taneously sponto

is

delivery and disappeared

result she

which thereafter,

expects
a

happen
or

again
two

Avith

the

expirationof gestationyet phenomena, by

that
also be
to

month

distant. Such then

being the
in here

nervous

with

many

others,excited
uterus

certain
let

instances
me

the
the

ed impregnatpigmentary
to

(and

say may

anomalies

described

above

referred

verted percase

innervation, as
in leucoderma
or

appears

be
us

certainlythe
see

let vitiligo), result

how

farther
as

nerve-irritation
in the
cases

may

in true form

cutaneous

lesions
of

of

herpes

which

the

basis

our

article.
The
nerve

of origin
*

many

diseases of the skin

has

now

Wiener

Med.

Wohcenfiohrift,No. 48, 1872.

Gestationis.

603

passed beyond
wouhl
be of results
out

the
of

and although it region of conjecture,

place here
lesions,we
and their

to

study

the

mode
some

of production

the

may relation

mention
to

of

the
Dr.

observed
*

each

other. where

Woaks
or

has
was

collected associated

numerous

instances

injury
and

shock

with

neuralgic symptoms
the skin

alterations,to varying degrees,in

the
nerves

supplied by herpes,and
and
to

implicated. Erythema,
were

eczema,

ulceration
zoster

observed

thus

connected,
with

herpes
shock arrived

studied being especially the

reference
was

from
at

impression of cold, the

to

conclusion
the

"that, owing
exercised
a

the

suspension of
the of These and

regulating
nerves

power
over

mainly by
effusion

sympathetic being

given artery,
the
on

fluid takes

place
of the
caused

from
to
sory sen-

its ultimate
the skin
nerves on

ramifications.
one

distributed

hand,

to the

texture
so

the

other, the
rash in

effusion former

duces profrom

the

herpetic
pressure

the

and

pain
of

mechanical

in the latter."
nerve-paresis and
as

Handfield
a cause

Jones many

recognizesvaso-motor
affections of the skin

instances

of zona,

pemphigus,
with
nerve-

and urticaria, hyperidrosis, and

hyperaemia
weakened
some

connected relaxed skin

evidentlydependent
This

on

and

power.

neuro-pathology of by
very human upon many, the

diseases and

is

recognized also
Now
any
nerve

in text-books
can

where. else-

system

hardly undergo
and those of

greater strain
elements which
latter

its powers,

its

than especially, is evidenced

is afforded

by

nancy, preg-

by
Vol

the

manifestations

Journal

of Cataneoos

Medicine^
6.

L,

No.

3.

Ibid.,Vol.

n.,

No.

^^^

BuLKLEY disorders inferred from

On

Herpes
alluded
that

9f

nervous

we

have the fact

to, and
nerves
as

which of
to

might
uterus

be
are

the
*

the
meet

enlarged during
cutaneous

pregnancy,
are

if

this
to to

requirement. Consequently we
find

not

surprised
that
mon com-

disorders

especially attributaT"le simplest

the
and

nei've-paresisoccurring repeatedly during

As before

state.

stated,the
observed
nerves nerve

most
or

derangement
of

is
of

simple pruritus,
skin.

tation irrinow,

the sensory

When,
of

there

is still

greater
in

irritation, paresis causing hyperaemia, and

rise

the fluid caria, urtiits the

fined con-

vaso-motor

nerves

ensues,

is

poured
and

out

varying quantity,giving
the idiosyncrasy, and

to to

eczema, extent

herpes,and
individual

pemphigus, according
first

being

least

expressed form,
and limited

the

last the

greatest, of

exudation. of skin-disease
are

These with

forms
and

occasionally
pregnant
Hebra McCall Its
occurrence

met

during
the

dependent
cases are

on

the few.
and
:
"

state,

although

recorded
them thus

mentions'

having
not

seen

connected,
of
eczema

Anderis
case

son,f quoting Hebra,

unf the the

says

requently favored
and feet,

by

pregnancy,

in

which the

the

hands,
are

the

neighborhood of
the

genital
So formly uni-

organs

parts
occui*

most
on

affected. frequently hands

of
some

does when

this

females
tell
more

they

become

pregnant, that

they

can

with child by the appearance that they are certainly the eczematous eruptions than by the cessation of menstrual

of the

discharge."
Strieker, Manual
A Practical of

find,on

inquiringalso

among

Histology, p. 616.
upon

Treatise

Eczema, London, 1867, p. 42.

Geatationis.

605

some

of the obstetric
of
eczema

in practitioners

this
each

that city, pregnancy

the

observance
not

accompanying
those

is

at all uncommon.

Other

eruptions besides
have
not

mentioned
to

above,
on

and

which

been

demonstrated

depend

nerve

are influence,

frequentlyseen
at

attending each patient under developed

also
my about

pregnancy

thus, I
whom and
an

have
acne

present
rosacea

charge
the

in

has

mouth
had is

chin

with

each

pregnancy,

one

who

has

since early childhbod, in whom psoriasis during gestation. McCall always worse

the disease Anderson*

gives a
while in children

case

of

woman

in

whom male
while

psoriasisappeared
it being children,
sent ab-

nursing
the
; it

each

of three
and about

interval

nursing
sixth

two

female
of
cases

appeared
soon

the

month

ling, suckof M.

and

vanished

after
are

weaning.
also

Three

during psoriasis
H.

lactation
are

recorded
to

by
the

Dr.

Henry. t
but

These

all

evidentlydue
cannot

debility
in
our

caused

by lactation, and
are

be

included

argument,
To
return

inserted
the

here

for

completeness.*
which
we ced, commen-

to

affection

with

herpes geatationia. The

above nine

analogies and
the

illustrations

cited,together with
cases,

clinical histories of the

we

in

seven

of

which

have

the

histoiy of
on

recurrence

with

each

gestationand

disappearance

rule, are to us sufficient proof that the as a parturition, and with connected dependent eruption is essentially
on

the

gravid state

of

the

uterus, and

is,moreover,

neurosis.
*

Fsoiiaais Am. Jour.

and

Lepra, London, Derm.,

1865,

p. 14. p.

Syph. and

Jan., 1871,

49.

606

BuLKLEY
to establish
we are

On

Herpes
of

In order

more

clearlythe individuality
must

the

affection

studying,we
have but been differ

briefly

notie^^
rt-

geveral eruptionswhich
semble this in
a

described, which

measure,

essentiallyin
*

many ami five

a points.And, first, peculiarone

pregnant affecting
had
seen

parturientwomen,
but instances,
one

of which
of the five

Hebra
cases

only
The

surviving.

tion, erupacterized char-

which

he

terms

impetigo herpetiformisj'was
with
pus
at

by pustules,filled
which
and

their of

first appearance,

affected

peculiar
In
on

mode

grouping
case

peripheric extension. appeared

small first

almost

every

the of the cessive Suc-

efilorescences

the

inner

surface isolated.

thighs,partly in
crops the few

groups,

partly
iris

immediately followed, extending

a

towards in
a

periphery in days
the the

circular

or

form,

so

that

whole
centre

body
of

was

involved.
group
ones

While

the

pustules in
with
were

each
new

became filled

covere*! with pu?

dark-brown flat,

crusts,

being constantly produced

iris
course

at

the circumference,
The affection intense three continued
; while

resembling herpes throughout

these

cvrcinnatus.
was

its whole
and

attended

with
In

fever, dry tongue,

cases

great prostration.
of the

of

this
or

reproduction rapidityuntil
after
scabs several

pustules

with
in

more

less

patient died
and

the

other up, the

two,
thick

weeks'

duration, they
ing leav-

dried

finally fallingoff
of

the skin
Some of the

beneath

healthy,but strongly pigmented.

at drying,especially

pustules,instead
were joints,

the bends

of the

converted
a

into
and

grayish,

stinking mass,
*

which, resting on
Wiener Med.

red

moistened

Woohenschxift,

l^o.

48, 1872.

608

BuLKLEY
Nor do

On

Herpes
to

our

cases

correspond
in his
cases

those
on

detailed
Acute

bv

Henry

Contagne*

monograph
were

general
spectively re-

febrile herpes. His

all years;

in the

males, aged
course

17, 18, 20,

disease
was

and

39

of

the

short,lasting from
in but
one

eleven there
a

to

twenty-one
of

days
the

; and

instance

was

recun-ence

eruption,and
Neumannf

that

only

once. a disease A^7;p^",

under describes, but still very of small

somewhat

resembling ours
but five
cases

different ; he
males and
one

had

observed
It creased in-

it, four

female.
a

began

mth

papules, which
apex
soon

after

few

days

the peripherally,
These
were
new

becoming
patches
vesicle

vesicular.
on

seated

upon

infiltrated

whose
while

margin
in it.

papulo-vesicles continually formed,

dried up, with occasionally
a

the centre

produced body
fluence con-

By
was

this
covered of

means

in

two

cases

almost

the

whole

with

gyrate forms
of these

produced
bore

by
the

the

the

margins
and

vesicle-bearing patches.
greatest parts of
and

On

the

palms
to

soles the
on

vesicles
some

resemblance
crusts

eczema;
were

the

body
The

the ease dis-

formed lasted many

very

thick

adherent* instance
An
two

months, and
with
severe

in

one

years: cisely pre-

it

was

attended similar
case

itching. by
is Ad.

almost

is described

Lafaurie^Jand
It occurred
in and

an

excellent

plate of

the

same

given.
many

girltwenty-four years
*

old, lasted

months,

De

THerpes
der

G^^ralis6

Febrile, Paris,
3d

1871.
p.

f Lehrbuch
\ Ueber
die 68.

Hautkrankheiten,

edition,1873,

188.

Unzulanglichkeit der bishderigen Femphigos-diagnoaey WQzstniig,

1866,

p.

Geatationis.

609

\vas

accompanied
it
many

with

intense

and itching buiiiing ;

But
our

he

called

herpes pemphigodes.
features

eruption
from

sents pre-

widely

different

this affection.

Acute some*

febrile pemphigus
and
as

has in
us

been adult
to

described
but life,

by
the
to

denied

f by others,
to

symptoms

depicted appear
the

belong
as

rather

herpes
That
eczema

than the

disease
we

generally known
have described
women,
no

pemphigus. simply an

affection
in

is not

appearing
histories

pregnant
there
were

is certain from

the

given;

moist, scaling,or

cracking surfaces, but

and vesicles, in

simply

the

development
when of
a

of

pulae, pa-

bullae,as

described, which

peared disappricked

part without
subsided
on

and exfoliation,

the vesicles remained

rapidly.

No

trace

the

tion erup-

the parts

affected,save

ingslightstain-

As

seen

from

the

this eruption histories, of the

cases

has

been

called
Wilson I first

pemphigus
and
saw

in most

I have

quoted,
When the
taneous cu-

Milton the
case

alone
I

designatingit herpes.
the
name

gave

herpes
have been

to

manifestations
in the
on

present, and
the

ened strengthstudies which

an

propriety of
At
no

diagnosissince
than

mj^

the

subject
were

period during
bullae
very
more

the attack half

I witnessed in

there that the

inch

diameter, and
of

whereas rarely, of

by

far the
and

larger part
vesicles

eniption consisted
eczema,

papules

resembling
de

but,

as

before

stated,the
No.

Aimales

Deimatologie Thtoiqne

et de et

Sypbiligraphie,4th
GUnique
de

yeax

6,

p.

401.

f Gintrao.
712.

Gouxb

Pathologie interne,

yoL

4, p.

39

610

BuLKLEY
was

On

Herpes

and we forced to were wanting, the diagnosis of herpes. Then again, the efflorescence? in groups, mostly of circular form, which Xeu were mann* asserts is "the only constant signpathc^omonic of herpes." The term herpes must, therefore, receive
a

catarrhal element

wider

than is accorded signification he made

to include
a

it m

some

and text-books,

vesicular

eruption
nerTou?

the whole involving

body,and from

its proven

cannot rightly be restrictedto the herpes zoster, origin or shingles f has recently zona^ as McCall Anderson to do. We claim a species of general attempted herpes, but slightly if at all febrile, commencingon the hands and feet, attended with very considerable burning and stinging, which while acute is prolonged itching, of several months,it may be,by the fresh development tie its elements, and which persists, until as a rule, of is removed,and that cause is the gravid state cause cided the uterus. This eruption, has a verydemoreover, to recur with each successivegestation. tendency The name, herpes from Mr. have adopted we gestationis^ of Milton's work, as embodyingthe clinical characters the eruption, and signifying time thesex at the same and state of body in which it appears.

Treatment tion which the end

"

In

most

of the instances of the erup

we

have

to the disease progressed collated,

of pregnancy

withotit

inthe being influenced

an Our case proved degreeby treatment. slightest atthe in being relieved almost completely exception of one month's treatment, that the expiration so
"

Loa

dt,

p.

191.
of DiseaseB of the

t On

the Treatment

Skin,London, 1872.

-^

Gestationis.

611

three
moreover,

months there

of

gestation
was

were
no

passed
vesicles

in

comfort;
ment, confine-

almost

relapse after

only
w^hich The
gave

very

few

scattered

appearing,
for soothing

no

annoyance.

indications

for treatment

seemed

to be

local applications, and powerful tonics, antipruritic

especially those
local

directed
was

to

the
the

nervous
"

system.
the

The alka-

remedy

employed
we

Liquor picis
to

linusj^ which

have

before

presented

fession.* pro-

Picis

liquidsB
causticed font
one

3 3

ij.
i.

Potass,

AqusB
M.

3 v.

Use

diluted

teaspoonful
inunctions
of
was

to four mutton

ounces

of

water,
The
and

followed

by
the
in

tallow.

strengthof
may very be used

diluted

wash

doubled This

later,
ed affordwere

far greater

strength.
other

and, although great relief,

returned
to
as

remedies

tried, was
all

the

best, indeed,

ing answer-

requirements.
disease
the
cui-e

The
lasted

recumbent
two

posture

taken

after

the

had and

weeks

undoubtedly
The
ternal in-

assisted

saved of

much

suffering.
the

medication

consisted
the

of iron, quinine,and pills

to

strychninefrom only on
diuretic the

beginning
of
one or

end, interrupted
a

occasion

two

exacerbations, when
of

mixture, composed of
and rumex, caused and

acetate

potash, nitre,
amelioration
at
a

taraxacum,
of

immediate

feelings. Arsenic
Archiyes of Scientific and

cod-liver oil,added

later

"

Practical

Medicine

(Brown-S4qnard), Febroazy,

1873.

612

Btjlkley:

On

Herpes
of Dr.

GestcUionis.

period
their We
.

on

the
to

suggestion
the result.

Draper,

contributed

quota

lay

considerable which
was

stress

upon

dietary
after

element
the ap till
siderable con-

of

treatment

begun
and

shortly
was

pearance

of
after

the

disease,

which
the

continued

long

confinement,

namely, just
bread
can

taking

of

portion night
this
;

of

oatmeal

before
and

retiring
milk,
in

even-

this of

was

replaced
nourishment

by
we

later.
the

Of

plan

speak
whenever

highest
is
;
a

terms,
state

using
of

it

very and

frequently impairment
in
a

there nutrition
fonn and results.

low ditional adthis

health nutiiment

of

the
at

digestible given
as

time
cereals little

of

day
answer

has

with very

us

excellent cracked

Other

well,
may and be

wheat,
I find

etc.,
this very

and

wine
to

or

milk

added.
that it

ceptable ac-

patient^,
breakfast the
for

rather

increases

the

appetite
None
treatment
so

for
of

than
we

otherwise. have in

writers the disease

quoted
and
case

mention
our

any results
a

question,
that
case,

were

thoroughly affection, general hoped

or

satisfactory
in another of
treatment.

in
we

of

retnni

of
the

the
same

should

follow

plan

It

is

that

other

observations
are

wUl

follow

on

this

affection, by

those

who

largely occupied

^vith

obstetric

practice.

McClueb

Ca%e

of

Ovarian

Hernia.

613

CASE

OF

OVARIAN

HERNIA.

By

ben

J.

HcCLXTER,

M.D.,

Dubuqitx,

Iowa.

(Bead before

the

Iowa

State

Medical

Society

at

Den

Moinea, January, 1874.)

May

13th, 1873,
for

called

to

treat

Mrs. her

L. A.

Butler

aged 38,
of
action

uterine

disease.

Found

complaining
disturbed
at

pain through hips and

of
the

pelvicregion,with
nervous

heart, headache, and,

erosions
on

depression
the
tincae.

time

of menses, and
second
to
was a

examination, quite extensive

of and week around
os

ulceration
At my my

visit, one
"

the patient called later,

attention
This

miserable

thing

"

she had
to
a

in her left sition. po-

groin.
I felt inches

after she had

my

risen the
one
a

standing
and

Placing
a

hand

upon about

indicated, locality

soft,oval tumor,
in

by

one

half

diameter, occupying
the

position just by
as

below her

Poupart'sligament, i^
to
assume
a

left

groin. Requesting
free

prone

I position,
was

examined

handling

and

with

the eye, but

uncertain
at my

to its character.

I re-examined
on

the tumor

and subsequent visits,

June
was

1st, having learned

of
about
seven

the

that following history, that it

came

it
on

years'existence;
severe

suddenly, after
not

rather
to

exertion
and gave
was

; that
no

usually

it was but

tender

the

touch,

annoyance,
sation pulling sen-

at the

time

of

the
as

menses

there

in the

tumor,
if she

if connected upon her

with feet

some

internal

organ

; that

was

for continuously

several hours

it became

and when sensitive,

pressed upon,

614

McClueb:

Case

of
a

as

by leaningagainst a table,it
that

caused

peculiar pain
minutes
a

and

it varied

not unfrequently considerablyin size,

a

increasingand
size and
came

decreasing within
to

few

; and

noticing that handling seemed

hardness
the of

produce

change
hernia

in I

the

body,
the

whatever
tumor
was

it

might be,
a

to

conclusion

that

of

the
out

left ovary, from On

the below 20th

through
of June,

the femoral

openiug,it coming
"

Poupaii's ligament.
near

the close of with

menstrual abdominal

period,"the patientwas pain,with great

concentrated

attacked

severe

tenderness

extending over
several hours

the

dominal entire abbecame the

region.
size of tender

After

the

pain

in this tumor,
now

which

usually was
swollen
and

about

walnut, but inches,and

This

became

extremely
three
ral cru-

to the

touch, and

having

diameters

of about
over

by
but

four

apparently rollingup
condition
use

the

ligament. by
the until the it assumed

existed
it

for

some

days,
At
what some-

external

of iodine

gradually subsided,
character.
and

its
"

ordinary
"

size and

subsequent

periods
above

it

was

quite tender
A
tumor

enlarged,as
could with
out tumor.
now

described.
when

distinct
was
as

pedicle

be

felt
and
an

the

grasped
raise it
the

the
of

hand,

attempt
the

made

if to

its

position by

fingerspressing under
that

The
to

opinion
annoy
; and

was

given
it could made
the

it would
as

probably
efforts the

tinue con-

the
as

patient as long
not

her menstrual

life hav-

continued

be that

reduced, end, and

of

been ing ineffectually

to

patient

being
she

satisfied

as

to

correctness

the
so

diagnosis,
I

requested its

removal.

Before

doing

requested

616

McClueb:

Case

of
makes

Holmes^ System of Surgery, 2d edition, 1871,

no

reference.

Graily Ilewett^in
of Diseases has
a

his

Diagnosis,Pathology,
1st American

and

ment Treat-

of Women,

edition,186S,
mentioiy intere^?!the

short
case

paragraph
of double
Dr.

upon

the

subject,
and
an

Potts's

inguinal hernia,
in

ing
ovary from

case

by
an

Meadows,
In

which
case

he the

removed
ovary

by
the

operation.

this

escaped
hernia.

pelvis in

connection
on

with Diseases

an

intestinal
of
to

West^
in
a

in his Lectures
to
"

Women,
hernia my

1857,
of the tion." observa-

foot-note
but says,

page

354, refers
has
come

ovary,

No

case

under

Scanzoni^

4th

American
the

edition, edited
the editor

by

Dr.

Gairdner, mentions
to
a

while subject,

refer?
oyan"n

case,

under

his

observation, of inguinal

hernia.
From

the

above

it will

be

seen

how
I

poor

was

the

literature The
CAN

upon

this

subject to

which
I

had

accesa

day
Journal
a

after
of

the

operation
Dr.

received

The

Amkei-

Obstetrics,

for

August, 1873,
of
an

whici
on

contained

lecture

by
and

Meadows,

London,

ovarian his
and
case,

physiology
and
was a

pathology, also
his method

account of

descriptionof
the
come

ion; of operaf
an

this

first

information hand.

from

actual

observer

that had then

the the

to my

Since

Biennial Nexo
to

Retrospect of Medicine Society^for

w/

Surgery of
1873,
has

Sydenham

1872 and

come

under hand, containing,

a

of the title

"Hernia the

of the It

Ovary,"
appears

very

r^sum^ interesting
"

np^^
cases

subject.

that

exclusive

of the

Ovaricm
in Avith of
one
"

Hernia.

617

which
the

the uterus
ovary,

has
are

been
on

found
record

displaced along
cases thirty-eight

there
"

ovarian

hernia

nine femoral, ^twenty-seven inguinal,

obturator.
cases

and sciatic, In one-third

one

of the
was on

of

inguinal ovarian
In
seventeen

hernia,
cases

the
the and
....

displacement
hernia
all the
was

both

sides.

congenital;
of
cases

in all these

it

was

inguinal, inguinal.
came on

cases

double of

hernia

were

also which for

Those
at
a

ovarian be

hernia

later

period of
as

life must

accounted

by

some

such

condition

excessive

length

of

the

ovarian

ment, ligaan

bending
forward

forward of
with the
a

of the utenis, too

or pelvis,

great

clinati in-

the
....

drawing
alone.

down

of

the

ovary hernia

hernial contains
in

sac

Acquired
. . .

ovarian
The

usually
was

the

ovary
cases

displaced ovary
;

fifteen it had

normal

; in

seventeen, inflamed
and
in
one

in five

undergone cystic,
Of
the

cancerous,

degeneration
thirteen
were

fifteen while could Of of

congenital hernia,
fifteen
cases

irreducible;
three

of
be

acquired hernia, in
into the

only
. . .

the ovary
cases

not

returned

abdomen.
a

the

in
was

which

extirpationof
its results."
it will be

healthy
of

ducible irre-

ovary

died performed, one-luilf

and

itoneal subper-

inflammation
In the
1st.
case

above

given

noticed

"

It It

was

acquired.
femoral
"

2d.

was

reducing
with

it to

class

of

only

nine of the
3d It
was

thirty-eight
not

connected

any

other

displaced
from the

organ.
And

finally,the

patient

has

recovered

618

McClueb is relieved caused

Cme

of frequent,
abnormal if
not
con

and operation,

of the

staut, annoyance,
the ovary.

by

the

position

of

I will ^warded Journal

only
to
of

add B.

that the tumor,

F.

after removal,
of The that

was

for-

Dr.

Dawson,

editor
a

American it be
amined ex-

Obstetrics, with
competent
to be
an

request
and
me

by
on

microscopist ;
ovary,
to

if determined of the fact ; New

examination
from

inform

and

him

received

the

following, dated

York, Oct
Db. Benj.

8th, 1873:
McClueb.

Dear

Sib:
to

The
an

specimen The

you
case

sent

me

for

examination

proves

be

ovary.

is

an

one interesting

of

nia her-

of the ovary I am,

very

truly, yours,
B. F. Dawson.

Db.

B. F.

Dawson,
:

Edftob

"

Am. you

Joub.
sent
me.

Obstetbics."
me

Deab
been is that and

Db.

The

specimen
ovoid At its

for examination appearance

has

thoroughly investigatedby
of
a

Its external
inches

flattened thick.

body If
lower the

long, 1 inch
it shows
an

broad,
incised divided
a

i inch

border
at

edge, this being evidently

from small
its attachments.

spot

which

it and

was

The

surface
tissue

is smooth
to

shiny, and
in of

portion of adipose
On

adheres

its side

several

spots.
a

cutting into
section for

the the

body
took

for the purpose found

procuring
it
tained con-

transverse
a

microscope, I
up

that

large cavity which

the

the whole

of the
in
to

specimen,
thickness.
consist

leaving
Under fibrous

walls

of

this

cavity barely \ inch

were

the

microscope these walls

found
in

of

stroma,

occasionallyarranged apparently
without the

regular bundles,
direction.
to

bnt In

usually interlaced
various

distinct

near spots, particularly

margin,

were

be

seen

Ovarian

Hetmia.
few

619

round
the of

or cells,

of follicles,

which fine

contained
matter.

nucleus,
walls
no

majority,however, only
these

granular
follicles less

The

follicles

were

perfectlydistinct,but
These

I could

detect

epithelium
Oraafian

lining them.
the

were

tered sparsely scat-

throughout larger
there
than the

stroma, much
ovary,

numerously
as a

than

the

follicles in the normal latter before section streak of

and,

rule,somewhat
Here and

they begin developing.

of
a

the transverse
A

blood-vessel

could

plainlybe
the

distinguished.
stroma,
I ovary
am near

fat-cells

occasionally traversed

the

margin.
without doubt
to

inchned

consider

this

specimen

an

degenerated hy cystic disease^the

gradual development
obliterated for the altered of the

of the

which

compressed
of the walls of the

the stroma

and

atrophied and
the scattered

which, pressed from follicles,

of the

within, would

account

thinness appearance

cyst and
follicle.

and

tlie Graafian case,

Knowing
an

nothing

history
view

of

this

is,of

course,

entirelyimpartial

of the matter.

Yours, respectfully,
Paul F. Munde.

Dubuque, B.

Iowa,

Sept, 10, 1878.

McCluek,
Deab
Sm
:

M.D., Dubuque

City,Iowa.
your

Agreeable
"tumor,"
left

to

request, I give you

you have
me so

here

the

historyof
from

the
my

which

moved successfullyre-

groin.
have

Permit
been

to

state

that

I "am

thirty-eight years
years ;

old;
no

married

nearly eighteen
never

have

borne

children, and
to

have of

been

nant, pregat

owing,
mouth of the

presume,

the
was

existence

polypus
seven

the ago

womb,

which

removed

about

years

by C. C. Green, M.D., of Virginia City, Nevada.

time

I him from

was

at the
ing concern-

residing at Dayton, Nevada,

the very

and

consulted

labored

and

painful
He

menstruation

which

was

at suffering

the time.

considered

my

caused difficulty

620

McGluer:

Case

of
with
a

by

some

obstruction,and
and
soon

upon
a

examination

speculum

covered dis-

removed this

polypus

the size of

butter-bean.

Two furniture

days

after

operation, while
I strained left

engaged
in
a manner

changing the
to
cause a

in my appear
was

room, in
not

myself

lump
nut.

to

my

groin, about
at

the

size in

of

hickoryat until,

This

tender
two

but all, it
was

increased
as

size
a

the
egg, As

expiration of
when it ceased
me

months,

large as
it very

small

hen's

growing.
no

it caused

inconvenience, I
it to the

gave

little attention,
ining exam-

though
it

I mentioned
it
a

doctor, who

without

pronounced
use an

gland, and
of
some

thought
I

it would

disappear

if I would eflFect; and years

ointment it
no more

which kind-,
came

I did without
to

gave it

thought until
annoy
me

Iowa, tro
menstmal ing wait-

ago, when

began
times

to

during
been

the

"

period," and
much. At such

also at

when

I had

standingor
hard

times
a

it became kind

more

prominent, was
in
at it,

and

sitive, sen-

having
me

of

pulling sensation
my

it,which
same

inclined

to

rub

it

by passing
it,till

hand

over

the

time pressing
on

gently upon
as

it would
was

leave
; but

the
a

surface

that side it would the

same

smooth

as

the

right side
was as

in

few

minutes

rise

slowly till it

large and
did

hard

as

before, with

pulling sensation
When annoyance. Thus for in June
severe

in it.

I felt

well, and

not

exercise

much,

it gave

me

no

nearly

seven

years
At

it

remained,

and

until the third with the

The

week
most

of this year.

about

midnight
lower

I awoke

pains in,
till
so

as

thought, the
when

bowels.
about

pains continued
leaving
hand the

morning,
sore

they
not

had

siibsideo,

parts
my

that I could

bear

the

of wy weight
to

upon

bowels

anywhere.

Upon
my

trying

arisem

dress, and

bearing my
eflFort caused. leave

weight
In

upon the the

feet,I fainted with the

the tenderness

pain began
until

the
to

afternoon, as
tumor

the abdomen,
a

commenced
and
was
so

swelling.
tender

it

was

tlie size of

large goose-egg,

Ovaria/n

Hernia.

621

could

only
which size.
tumor

touch

it

lightly.
the time

Tou

gave

me

iodine
many

ointment

to

apply,
former
in

reduced
All
or

swelling,
I
was never

after free
on

days, pain,

to

its

this
in
tumor

from

either I
tre cen-

the

the

pelvic cavity pain

; to

that follow

side.
a

When
and

pressed
in

upon the

the

the

seemed
and

to

cord,

(abdominal
the
the side

?) cavity
seemed Observe

if I

pressed just
same

above

the
and

pehac
centre

bones in

pain

follow
! the

the

cord
never

back,
felt

tumor.

pain

was

upon

the
to

right
the

of the of
the

abdomen,
centre

but
never

always
sent

in the

left,and
to

pressing
tumor.

right

the
to

pain

the

noticed the

this

always.
of
the

(After
the

referring
she
came

peculiar
Since for I
am

pains
the
ten

felt

during
is

removal

tumor,
that
not

says and

:)

woimd

nearly
the

healed,

pains
have

went

days

after nine
time

operation
of

been

felt, and by
its that

well, after
From the
to

weeks of
its and

suffering
in

caused until

tumor.

swelling, rapid
to

June,
in
me

removal,

it

was

subject
cause,

sudden it
never

changes
remind
it

size, without
of
its existence
me

apparent
at

and

failed The
in
some

each

menstrual
nection, con-

period.

pain

caused vrith

convinced the the

of
witliin

its intimate

manner,

parts
first

the
"

pelvis, and
since
as

as

have

just passed

through
any

"

period
felt
I
as

its
at

moval, re-

without other the did

suffering
confirmed

pain, having
in my

well
not

any

time, I feel
symptoms
not

belief.
menstruation
on

did

even

feel
and dences evi-

usually
that
my it

felt had

when
come

approaches, discovering
not

know
upon

until could

the

clothing.
of
me

This

have

happened
tion sensa-

before

the

removal gave

the

tumor,
of
its

because

that

pulling

always

warning
Yours,

approach.

respectfully,
Mrs. L. a. Butler.

622

Makn

Case

of Cystic

CASE

OF

CYSTIC

TUMOR

OF

THE

UTERUS;

Bt

IC. D.

HANN,

M.D.,

Nrtr

Tokk.

(Presented

to

the

New

York

Obstetrical

Society,

Dea

Otii, 1878.)

Gentlemen
my

The

followingcase,
acting
as so

which

came

under
at

notice

while

house-physician
many

the of terest in-

Hospital, possesses Strangers's

that notice. I feel

points
it to

in presenting quitejustified

your

The

patient,Ellen
into Dr. she that been A

R
^

aet.

28, married,

was

mitted adShe had been

Thomas's had
been

wards

Sept 24th,
two

1871. but

stated
never

majfried

years,

pregnant.
year

Menstruation
had

had

always
some

regular.
in the

before, she
the

noticed

swelling
the but

lower

part of
At

towards abdomen, inclining had been very Within

left side. it latterly time she

first its increase

slow,
a

had
had

developed
suffered and had

very

rapidly.
from

short

greatly
been

dyspnoea, great
by
Had also lost her On P. mission, ad105.

pain

in the

back,
of the

greatly distressed
debilitated.

the tension

abdominal
very but
to

walls.

appetite and
Examination her abdomen walls
not
on

become

much in
be
a

patient

weak
her

good
very

spirits.
The

shows

much
tumor.

emaciated,

and

distended
very
tense

by
and Over

large
hard. the

minal abdopression deness dullamined ex-

The
tumor

umbilical

effaced.

absolute
Not

and percussion,
per

distinct fluctuation. the

vaginum

at

hospital, having

been

seen

624

Mann

Case of Oystw
further Ordered
the mouth. up

and
P.M.

adhesive

plaster,to prevent
well.

bleeding.
to

Doing
and

Pulse,

108.

be

kej^t
to

quiet,with
milk whole

morphine given by
beef -tea, which
was

Diet

\k

kept

througliout
monocular,

thr

convalescence. of the cyst showed

were

Examination
and

it to be

the
a

walls

found,
of

under

the

microscope,
of
on

to

contain fluid
was

few

bundles
one

unstriped muscle-fibres.
in

Tht
a

about

gallon

quantity, and
sediment consist

dark

chocolate

thick color, depositing a sediment

blood
were
was

ing. standof

This broken-down
threads

found

to

largely
flakes

corpuscles.
also

Many
the

and

of fibrine
26.
"

in floating

fluid up.
1

Sqjt.
was

^Doing well, morphine kept

and

The

tent

removed,

replaced by
allow of

No.

hard-rubber tube

vaginal syringe,to passed

down
"

drainage, the

being
aod

as

deeply as possiblebehind doing very

the

the

uterus.

Sept. 27.

Patient

well, comfortable

quiet.
28. Se2yt.
out
"

^At
warm

noon

peritonealcavity was
of

washed
soda in

with

solution of
a

hyposulphite syiinge. slough

a warm

of

water,

by
29.

means

Davidson's

The

perature tem-

fell

trifle after it. Smell

out

Sept. cavity
salt and
1.

"

from

the

very

offensive;
solution
of

washed
water.
"

carefullywith
100.5^.

Oct

^Temperature

Syringed Doing

every very

day.
well ;

Some

discharge from
Sutures and

the

wound.

prognosisgood.
Oct. 3.
The
"

clamp

removed.

Union

finiL

hard-rubber

tube

still retained.

Tumor Oct

of

the Uterus.
this

625

4.

"

^Temperature 100"
very

a.m.

Patient
1 J to 2 grs.

ates toler-

morphine
with
vrashed very
out

well

; takes

from

daily

little

apparent
been

effect.

Abdominal

cavitystill only
one

twice
has

daily. For
drawn

the last 24
off

hours

pint of
has fluid been

urine
a

by

the catheter. of
a

There

large and
abdominal
Flow
a

continuous wound.
the

flow

nearly clear
and

from
"

Oct. 5.

from

abdomen

increased smell

very
some

profuse ; has
pus,
as seen

ammoniacal slightly the

a

; contains

under gr.

microscope. Morphine
the

much

duced, re-

only \
Oct.
6.
"

day.
wound I
a

^The

fluid

to-day large
either remains
Oct.

examined
of the

discharged from and found chemically,

urea.

it to contain
to

amount

A
or

fistula

supposed
General

exist,

from
about 7.
"

ureter
same.

bladder.

condition

the

To-day

Dr.

Thomas with

injected the cochineal,part

thus of

bladder which

with

fluid

colored

passed out through opening cavity.

order
was
a

the

wound,
the be

proving a
and

fistulous

to

exist

between
to

bladder
to
some

peritoneal

Is

supposed
follows

due

to allow

of the fistulous tract

:

sloughing. In filling up, the patient

of the bed
was

treated

as

The

head
the

raised
more

foot from

the
a

and floor,

back patient's

still
a

elevated retentive allow of

by

largepad placed under

was

it.

Also
the
a

Sims's

catheter
constant

introduced
and

into

bladder,to tendency
of

drainage upwards.

prevent

the urine to pass her back

;
"

Patient

to lie constantly on

morphine
No

continued. urine

Oct. 8.

of discharge
was

through the
Considerable

fistula since

the treatment
40

commenced.

improve-

626

Mjlks
in

Oase

of Cystic Temperature,
9 A.M., l(Nj\

ment

general

condition.
on

axilla ; small of the urine.

14.
"

excoriations

the

back

from

irritation

Oct time. abdomen the

No

elevation condition

of

temperature

today,

for

first in
at

General

greatlyimproved.
is still
one

Wound

healingslowly ;
a

inch

in diameter the

surface, tapering to
;

point as
and

it

approaches
a narro^v

toneum peri-

beyond

that is traceable downwards

as

fistulous for

tract

extending

backwards

several

inches. Oct.
29.
"

^Patient

has

gained strength -wonderfully,

she passes her
water

wound

has

closed,and
cured.
seem

naturally
in this

Discharged
The
are
"

points which
The

worthy

of notice

case

Ist.

of making difficulty of their

several diagnosis,

tlemen, gen-

masters
as

art, having been

In

ceived entirely deas

to

its nature. have

fact,it
been of

seems

if

an

lute absothe
a

would diagnosis

impossible,though
examination and of the

latelyintroduced
careful
the
sac

method

rectal

microscopic examination
would
The

fluid

contents

of

undoubtedly
size reached of
a

have

helped.
a

2d. 3d.

great
blood had

by

simple
of the

uterine

cy^t
the

The
of

contents

the

cyst, showing from

dences evi-

that been

large part
due
to

rapid growth
into the cavity

of the

tumor

hemorrhage
enucleation

of cyst.
4th. The the

of possibility

the

of

such

mor, tu-

and
to cut
or

advantages by

of this

plan

over

any

attempt

break

the adhesiona the

use

5th.

The

treatment

of the

drainage-tabe,

Tumor

of

tlie

Uterus.

627

and

the

frequent impunity
first
case

washing
with
in

out

of this

the

peritoneal
be

cavity,
This

and

the

which
the

may

done.

was

the

which of

tube

was

used.

6th. the

The

occurrence

the

fistulous

opening allowing
the
means

between

bladder

and

abdominal
the

cavity,
wound,
from

of

the
taken

urine

discharging
determine

through
whether

and the
both

to

it

was

ureter

or

bladder,

question
treatment.

of

utmost

importance

as

to

prognosis

and

TtL
heal

The serious
The

very

simple
and

treatment

which

sufficed

to

so

unpleasant
also
illustrates

complication.
pretty
well the after-

8th.

case

treatment

generally Strangers's
the

adopted by
not
so

in

cases

of doses

ovariotomy
of
in

at

the

Hospital,
doses
were

large large
axilla

morphia,
other

though
cases.

as

many

The

temperature
and
was

in

the

never

rose

more

than

102.8",

most

of

the

time

below

101.5".

West

45th

Stbebt.

628

Traiudctions

of

the

TRANSACTIONS OBSTETRICAL
Reported
by

OF

THE

NEW

YORK

SOCIETY.
F.

PAUL

MUNDE,

M.D.,

Secbetary.

Stated

MEBTmo,

Jxtke

3,

1873.
m

Db.
the

J. H. Chaib.

Poolet,

Jr.,

ViCB-pRsaiDEsrT.

the was subjectof Bepticsemia, which read signed dea special order for thq evening, Dr. Munde paper of the qnestion, to represent the existing state larly particuthe opniions now held in Germany. In

continuation

of

the

Stated

Meetiho,

Oct.

21,

1873.

Db. Ghaib.

B.

F.

Dawson,

Pbesii"kkt"

ts

the

CASE

OF

RUPTURE

OF

THE

UTERUS.

Dr.

W.

T.
rent

Lusk

labor, the
about had
two

which presented a uterus ruptured the anterior extending transverselyacross above the
os

during
surface,
woman

inches six

externum

uteriand

The

had

labors, the
was

pelvis was

breech

and presented, had been became had

pains, which
woman

large roomy, when well, descending suddenly regular, ceased, and strong and
and it
was

the the tlie the

was

collapsed,and
into the

found

that The

part

of

escaped immediately extracted,and

Dr. Jacobi

child

peritoneal cavity.
the
uterus
woman

child after.

died

15

hours
been

asked
answered asked
was

if the

presented

had

examined

for microscopically

fatty degeneration or former

in the

lesion, which
ease

question was
Dr. Pooley the better

negative.
with in this have not case, it would which would allow of easj the peritoneal cavity of all of the

the apparent if,notwitlistanding delivered

which
been

child
to

perfonn gastrotomy,
of
and
a

extraction, a thorough emptying

foreign matters,
Dr. Noeogerath
one.

complete control
said

he

considered of the

Dr.

bleeding pointei Pooley^ plan a

such
as

good
Dr.
did

Lusk

said

the
one

condition would

patient was

that he she
was

tliink any and her collapsed

not

undertake

gastrotomy,
to

Dr.

Noeogerath
cases

pulse hardly perceptible. said that it is very important

shock
or

decide the

in

such

whether

hemorrhage

is

producing

symp-

Neto
of

York
if it be
an

Obstetrical

Society.
then
an or

629

toms

collapse ;
there

hemorrhage,
is not the

operation

is

called
even

; for if

shock,

operation
fluids in
the

demanded

justifiable,

though
be

be

peritoneal cavity,for these

The hypothetical.
would

could

evacuated

through
is

wound.

Dr.

Jacobi

thought me

principal symptom

reasoning too shock, and nobody

operate.

On

if we if asked would where general principles, operate in a case would a we answer foreign body is in the peritonealcavity, yes, but when to the practical come we question it is hard to decide ; of the intestine from for instance,in perforation ulcerative cess, prothe wash out theoretically we cavity of the might say,

abdomen,
Dr.
cases

yet hardly any

said be
to

one

would

undertake

to do

so.

Byrne

the
save
"

main the

should
In

purpose child. Dr.

own was

of
B.

gastrotomy
liad
seen

in

these

7
in

cases

of the

rupture

of the but

uterus
one

3 in his
cases were

and practice
ne

tion. consultato

of these

operation ;
Dr.

foetal movements would

an

consented, the relatives

Lusk also
the

not

tempted to but felt, although the allow the operation.

monster.

resort,

mother

presented
Jacobi

acardiac

committee,
to

consistingof Drs,
and

and

Lusk,

were

appointed

examine

specimen. had who presented the brain of a young girl, been confined 30 days previous to her admission to hospital, she applied on of uterine hemorrhage. After account to which
report
on

Dr.

Lusk

then

admission
to go

she became

very

oedematous.

to the

cold and

water-closet,where she was and, after restoration, was insensible,

on on

nightshe was noticed after, discovered,shortly

At found
to be
pletely com-

paralyzed
delirious,and spot
as was

the

left side.
18th

On

the 14th
On of

day
the

she

became
a

died found the

the

day.
The

post-mortem,
middle and branch

tened softhe

in the of

corpus

striatum

right side,
of

well

as

in

island

Reif.

middle
found

cerebral
on

artery contained
valves.

emboli,

vegetations were

the

aortic

oflScers for 1873-74 elected following gentlemen were : E. Dr. Dr. R. John Byrne, President, Peaslee; Vice-Presidents, The
F. Munde Dr. Paul Recording Secretary, Dr. Emil CorrespondingSecretary, Koeggerath ; Treasurer,

Dr. T. A. G. S.

Emmet

Dr.
F.

Winston. Dr. B.

Committee
F. Dawson. On

on

Publication:
:

Dr.
A.

Paul

Munde,

Admission

Drs.

Jacobi, E.

Noeggerath,
Stated

J. E. Jamison.
Nov.

Meetino,

4^

1873.

Dr.

E.

B.

Peaslee,

PRFsmsNT,

in

the

Ghaib.
REPORT OF COMMrrXEB ON CASE

OF

ACABDIAO

MONSTER.

The

acardiac

monster

presented at

the

preceding meeting,

630

Transdctions

of
one

the
radiment the

has
to

ouly
the

two

complete toes, and

muscles the

boneless
are

attadbei
extengf"r

foot, the

of

which

complete,

third that it is attached to the j"eculiarity kidneys, metatarsal bone t\ro are ; the thigh is complete ; there with their ureters, the right kidney being situated higher thaii vertebrsB the left ; the ribs and is, as usual, are complete ; there communis

showing

no

sternum;
a

surmounting
There is
a

the vertebral well

column

is the

rudiment

developed pretty ; the testicles are not distinctly supposed apparent, although they were at the autopsy. to be discernible of The occupied the cephalic extremity large pouch which filled witn when the monstrosity was gelatinous fluid, and
of
cranium. bladder extracted head. and The

unopened, was placenta showed

There
the
an

considerablylarger
two

than

an a

adult
mon com-

umbilical

cords, vrith
cases,
an

insertion. between this the

we

is,as
to

is usual arteries the

in these and veins

mosis anastoon

umbilical

have

obstruction

circulation

; consequent and thrombosis

gradually stops, and the nutrition of the latter is accomplished by the current of blood from the The heart other and having thus stopped and stronger child. which graduallydisappeared by atrophy, we find those organs with from the blood umbilicus ^the lower are supplied directly extremities generallywell developed; exceptions are the liver, spleen,and pancreas, which are wanting in Uiis specimen. of the committee, presented a numDr. Jacobi, a member ber
heart
" "

of the weaker

foetus

of the

monographs
and this

6n

acardiac

monsters,

and

remarked

that

first accurate of

reallyscientific description and

dates
a

tion explanaback,
a ccim-

malformation described hundred that

only
cases

fourteen
and

years

w^hen

Claudius

few

new

Silation ius's theory was,

one

of

and about

twelve the cords

so

published previous specimens.

time of when the
two

Clauappears dispendent inde-

the

allantois

the

two
are

umbilical inserted
current

perfectly

foetuses w^hen
"the

stronger
heart of

weaker,

the

the

together as to anastomose, closely and the finally suppresses latter becoming atrophied and disap
retards

pearing
some

entirely. This
there which existing, acormus, extremities This

theory must,
have
must

however,. be
several
cases

modified
in which

in
a

instances, for
was

been be

heart

otherwise
but

explained.
five times
the from

One

form,
the

called

has
are

been

observed
or

; in it

lower

usual, the

upper. is wanting, the upper extremities deficient ; but when the vessels
are

is

wanting owing to

incomplete,instead
fact that when

of, as
heart it
are

the

directlysupplied

supplying the
exists, these
a

lower

extremities
are

deficient, even

if the heart Since

extremities

imcases

"

perfectly developed.

Claudius

number

of

new

632

Transactions

of
THE

tJie

CA8E

OF

ABORTION

IN

THISD

MONTH.

Dr.

Jacobi

also
of

presented
of had
who

specimen
older

from children
last in

la43y
a

with

chronic

mother nephritis, age,

of

two

and the

baby
nci
'when of the

eight months
on

menstruated

eonntiy
had

the 11th
unwell lost
a

July, 1873
until

(perhaps a miscarriage?),an"l
October

been she

since
mass

shaped like,and
a

16th, three montnjB evidently by, the

of

later,

cavity
upper

uterus, of the
clots of

togetherwith
mass

quantity
nard,
and

blood.

The
a

portion

is flat and and

one a

presents
and

blood with

minute of the

which fcetns, third

cavity containing velopment corresponds in its de-

week,

accurately
Distinct
and lower the

resemble?
numerous

wax-cast

villi the

an embryo (placentaltissue)are Dr. specimen, whence

of

of that founa Jacobi of

period.
concludes and

only in the
the

that

portion of lady having

July, dyiiig- fn^m of the later,the development hemorrhage about three weeks that (teased almost in of the placenta completely portion oi^n the upper where the hemorrhage took the of place,i.e,^ portion still the and lower and until developed portion specimen, grew the whole thus med mass was at expelled. The placenta a ^later ^than the foetus. different period
foetus
" "

conceived

about

the

end

Dr.

Peaslkb

said

that

such and

cases

are

medico-legalpoint of view,
experience.
CASE OF

mentioned

interesting also one occurring

in

in his

RUPrrBE

OF

UTERUS.

Dr.
taken

Lusk
from

presented another
a woman

specimen of
Bellevue

ruptured

uterus,
on

who

entered

Hospital

the

the preceding on Saturday previous. The pains had commenced had ceased the when flie ruptine suddenly Sunday, day after, probably occurred, and on Friday last some hemorrhage peared, apwell the as which, as exceedingly prostrated condition her friends of the patient, induced to bring her to the hospital Stimulants without avail. nand The were freelyadministered the far introduced the cervix the feet was elbow, as through up as
were

found

in the The

uterine child
was

cavity,seized, and
far advanced The
uterus

the

child

turned

and

extracted.

in

weighed
blooa
was

11

or

12

pounds.
the

contracted
woman

decomposition, and well, and no

died
the
next

lost At

during
the

operation. The

autopsy a large rupture was completely separating the posterior portion of the cervix from the body of the utenis also a smaller was perforation in ; there

morning.

found,

almost

the anterior

cervical

wall.

New

York

ObstePrical
,

Society.
Pbesident,
in

633

Stated

Meeting,

Dec.

2, 1873.

Dr. Chair.

E.

B.

Peaslbe,

the

SPECIMEN

OF

FATAL

CAUTERIZATION

OF

LARYNX

AND

(ESOPHAGUS.

Dr.
months

Jacobi

exhibited

the had

digestiveorgans
been taken attendant

of

child, nine
was ported re-

of
to

age, which
croup. Tlie

ill with advised

what

be

medical

cauterization

attempted it with the solid stick of nitrate of the child swallowed and silver the ; the stick broke, however, detached portion. The child died, and the specimen removed at the autopsy was sent to Dr. Jacobi, with the above imperfect the vocal whole interior chords, history. The epiglottis, upper of the larynx, and the upper siderably conportion of the trachea appear reddened and nypersBinic,which, however, may be
of the

larynx, and

partly

due

to

imbibition the

; at

all events of
a

there

were

no

traces

of

simple laryngeal catarrh. the nitrate not was localized,but the whole membrane was equally injected and laryngeal mucous hypersemic. The oesophagus was injured by the caustic to the distinct eschar inch at its commencement, of one extent a being shows visible ; the stomach no injury in its cardiac portion,the of caustic having followed the dependent position of the piece and the pylorus,where solid piece of the a lodged near organ stick of the nitrate of silver is still to be seen, surrounded by a thick and embedded in the coats of the layer of albuminates
but croup, The action

only

indications of

of

silver

stomach

: an

there

is

no

secondarv

local the

inflammation

about action

this

spot,
lunar

observation

agreeing

with

acknowledged

of

caustic.
"

CASE

OF

MONOPUS.

Db.

Jacobi
an

presented
infant

second
at

specimen,
the lower is
no

that

of

so-called of uterine intra-

monopus,

born

about

sixth

month the

with gestation,

only one
There
in and and

extremity,
umbilical
from fonn

rightleg
bilical um-

being

entirelyabsent.
vessels
of

cord, the
a

the covering composed of a pouch of the size of an and to the lower apple, attached the and pelvis. The anus are genital organs right portion of

running peritoneum

proceeding amnion, which

membrane

wanting;
a

in
can on

their be the

stead

there
of

is

common

opening
into and
an

into

which

sound

introduced left side

and

passed
abdomen,
vem,
a

oblong
connected

organ,
with
uterus.

situated the The small

the

and intestine, liver

;
on

possessingappendages, evidently the

the
umbilical
was

contained the

its left lobe

an

was

very

right side

found

kidneywith
stomach

unusually
were
nor-

large supra-renal capsule.

The

spleen ana

634

Transactions
careful
a

of

the
be

mal.

A and

more

made,

at repoi-ted

investigation of the specimen will subsequent meeting.

OVAKIOTOMY.

KOBMAL

Dr.

T.

G.

Thomas

reported
as a

case

of of
to

normal
intense

ovariotomy
and
not
on

moval (re-

of
nervous

both

ovaries

cure

the

incessant
account

sufferingattributable
usual
was

only

them, and

of the which

performed by cysticdegeneration) doing

very

him

11

days

ago,

well.*

CASE

OF

OVARIOTOMY.

the operaovariotomy, in which tion presented no peculiarfeatures,with the exception that the fuUv threecut although the ligature was edge of the pedicle, of an inch fourths beyond the end, slipped through the ligature, retraction took place and when which hemorrhage occurred, This is the third was easily conti-olled by separate ligation.

Dr.

Peaslee

related

case

of

time called

this accident
to

has
as

happened
25

to

Dr.

Petislee
and

; attention

was til un-

it

as

long

the seized

fourth with

day,

when

years she

ago.
was

The

patient did

well

suddenly
mental

unaccountably
to

intense

muscular
no

and remedies

excitement, similar

mania, against which

from exhaustion

slight signs of
the

proved available, and died the following day. There had been on only the third but on day, no tympanites, peritonitis

the somewhat At febrile. temperature and the pulse were fluid in the abdomen, or no peritonitis, ble autopsy no any palpacause

for Thomas

the

mania
a

could
similar and

be

found. of mania
on

Dr.

related

after

ovariotomy,
INTBA-UTERINE

coming terminating fatally.

case USE OF NITRIO

denly sud-

ACTO.

Dr. from

Chamberlain
the intra-uterine

reported exceedingly

favorable

results

application (to both cervical and corporal he has used canal} of the chemically pure nitric acid, which the least unpleasant results. without in 4-5 patients, dispensary The with of a glassstylet, cotton application is made by means the end, which is dipped in the acid, and introduced wrapped around through a slightly-bent glass tube.
Dr.
uses

Thomas

has his
so

used

tne

nitric knows would

acid
no

very

in fact frequently,

it

daily in
he likes

and office, well. He

which

to the cervix application hardly like to carry it so far

detaUed

aooonnt

of

this

rare

and

interestingoperation

will

appear

in

subseqaent

number

of the

Journal.

Nexo

York

Ohstet/rical

Society.
is

635

as

the

bk

to

fundns, certainlynot in an remain quiet for some perfectly

GALVANIC CAUTERY IN UTERINE

who office-patient, little time

una-

afterwards.

HEMORRHAGE.

Dr.
after
a

Jaoobi

mentioned

case

of

uncontrollable
checked

hemorrhage
the

intra-uteby rine applicationof the galvanic cautery, introducing the burner cold to the fundus, heating it rapidlyand immediately cooling it again,leaving it in the uterine cavity in all perhaps half a

miscarriage,which

he

mpidly

minute.

Stated

Meetino,

Dec.

16,

1873.

Db.

Peasleb,

President,

in

the

Chair.
NEW stem-pessary.

Dr.
to

Peaslke
directions

his

presented by Ford
stem,
which

new

stem-pessary, made
this

of

city.

It
one

is

according composed of a
and Two with slender
a

slender, hard-nibber
button steel
at

blunt-pointedat
the cervix side
to either

end

the

other, on
introduced when that These

is iborest.

springsare
bemg
in

attached

of
a

the

stem, which, the

pessary

by

means

of
is

diverge
a

conductor

place. Eessary le by pressure

utero
a

springs are
to

tor, sound-shaped conducwithdrawn, and retain the being compressiverj^ soft, in

equal

two

ounces

weight, and
the

are

incacases,

of injuringthe 1)able for caving it in

and three with but chief

uterus. two

He

has without uterine

use

used

it in several least evil He

weeks of the

results,

incre"se slight
to be
some an

propositions for
is
never

of

offers discharge. A : 1. stem-pessaries

a

stem-pessary
rare even

used

except in
of version.

case

of

as flexion,

exception
then is

in

cases

2. A

stem-pessary
and is to be the

always
no

instrument, objectionable
instrument

used There and

only
in

Dr.

object. 3. certain in which be used, are cases a stem-pessary must which will other instrument no supply its place. and thinks the cases should Byrne be carefully selected,
when

other

will

serve

care particular

taken is abnormal

not

to

introduce

the

stem uterus

in

where

there be

sensitiveness shorter than

of

the

any ; also

case

that

the
CASE

stem

at

least

\ inch
PELVIO

the uterine
PRODUCED

cavity.
BY THE

OF

metritis PROTRACTED

AND

CELLULmS OF A

TOO

WEARING

STEM-PESSARY.

Dr.
the too been

Munde

related

case,

at

present under

his care, in which

had long continued wearing of an intra-uterine pessary attack followed and of metritis litis. by a severe pelvic celluThe for patient had an extreme degree of anteflexion,

636

Transactions

of
even

the
urell

which
other and

numerous

mechanical, and
had been who

operative,
by
the other introd

as

as

remedies

applied

in vain

physicians
action used
nication, commu-

by

Dr.

Munde,
The

finally proposed

of

Btem-pessary.

intra-uterine

Greenhalgh,
cuous,

in London

devised and pessary verbal its .(which inventor, by considers

hv

employs
leaving Dr.
case

very it in situ

frequentlyand
even

entirely
exercise,
weeks of
two

inno and in
a

during horseback
a

which

Munde

had

previous
connected
director

without
links of for
some

employed lor over of injury), consisting

was copper, without purpose,

series

movably
on

zinc the

and

introduced,
any the

the The

made felt

difficulty.
introducticwi
was

patient
the with
severe

pessary,
strict

which

pain immediately soon subsided, and

to

after the

of

patient
have
she

dismissed any

directions in
to

return

at

once

if she

experience
the instrument

pain
or

the
remove

uterine it Munde's

region, and

removea,

herself,which
that
on

proved
to

herself,
do. About the that

by
sary pesshe

experiment
a

in Dr. she it

able oflice, perfectly she the

week

later

returned, saying

had
rectum

removed
;

because

pressed

too

mucli she

but

wished cessation

it

reintroduced, as
of the It The
was

felt much

relief lumbar

and

well-known

harassing

complete pains while

ble considera-

allow it to be removed, ever, hownot patient would and the strict left with the oflice as wished, the instrument and to remove injunctionagain present herself if she experienced any at once severe pain. She did not return She week the in her hand. till over a later, bringing pessary for fcur days after it was the instrument had last introduced, worn in spiteof the intense painit caused her, thinking, with an obstinacy peculiarto her, that she would get used to it after
Dr.
Munde
a

wearing pain.

it.

and reapplied,

a^aincaused

some

while.

An

examination

showed
under

fi-esh exudation
and
on

all

about

the uterus, but She is organ.

behind principally
now

the but

right side

of the

in bed

treatment,
WOMEN.

doing

welL

CYSTITIS

IN

Db.

Skenb
to ask

said

that which

he

had had

had

of him

late
much

several

cases

of He

cystitisin females
wished of the the

given

trouble.

Societywhether it had been noticed that some of the cystitis. according to the cause symptoms Thus in simple cystitis is a frequent and painful micturition symptom, and there is but little relief experienced by leading In cystitis, the voiding of the urine. or frequent distressing
differed
micturition

dependent and pelvic cellulitis,

on

adhesions,displacement of
uterine and

the

utenis,

other

pelvic diseases, the

Philadelphia
emptying
patient.
difference
In

Obstetrical

Society.
with

637

of
In

the the

bladder
latter
cases

is attended the

great relief

to

the
a

; the

erect

of the body position the position generallyincreases

the

makes

distress. ever. what-

simple cystitis, positionof

the

body

exerts

no

influence Dr.

is

feature of the A very distressing In disturbance of the night's rest.

frequent micturition
one case

Skene

procured
of Sims's

great relief by the

introduction the whole

and

sigmoid
of

catheter

during
Dr.

leaving in place night.

thinks
cases

Dr.
many

Byrne
cases

coincided

with

Skene.
are

He

there

are

which supposed cystitis

only
He

of granular

inflammation
up
an a

of

the

urethra of the

far up
for been many

the

canal,
years

which the

keeps
case

constant

irritation had

bladder.

related

of

old

lady,who
which
no

suffered
had

with

cystitis,
the canal
so

against
this with

treatment

successful.

Discovering

of the urethra, he cauterized granular condition the galvanic burner, and afforded the patient

much

relief

that she she

has

since
to
some

requested
trouble
to

the

operation
of
the

to be

repeated,
system
unnarco-

although, owing
(atheroma),
tized.
was

vascular

obliged

undergo

the

operation

TRANSACTIONS OBSTETRICAL

OF

THE

PHIA PHILADEL-

SOCIETY.
Secretary.

Reported

by

J. V.

INGHAM,

M.D.,

Stated

MEETina,

May

1, 1873.

Dr. Chair.

W.'Goodell,

President,

in

the

Dr.
cases

R.
of

p. Harris

read

early menstruation
referred
a

giving an account paper and conception (seepage

two
cases

of

some

571).
tion. observaat term.
was

Dr.

Ludlow

to 12

under age,
was

his

own

One,
She had Dr. The
and
never

child

of of

years

of
Another

delivered
a

menstruated.
years age.

case,

negress,

livered de-

at

13 T.

W.

Taylor

reierred confined.
been

to

case

that

he had
13

Medical
in

Examiner^
had

in 1852

; the

girlwas
years

reported in in Februaiy,
3

August was
McCall

Dr.

called

to

girl13

and

months,

638
.

Transdctions
delivered her of four-months' the gave of house a
at 10

of

the

and

foetus.

She

made

^onI
:

recovery.

Dr. A

I)e

F. Willard
in

of history

case

as

f ollowii

child,brought up had connection 8 years, had of the neighborhood. At

and him when
2

prostitutionfrom
once a

the the

least
years

week

-with

age b":iv5 At
11

of

she

menstruated. and
\ra8

years

months
11

she 11

became

pregnant,
and 24 for
two

delivered The w^hen of lal"""r she

by
was

normal, and

months, years, the mother did well

limbs.
She

days

old.

weeks,
led
a

had

milk-legin both
since.

afterwards
and

life had

titution,was
miscarriages Dr. Betts 5 months.

then got married, syphilized,

mentioned

has

pr"i"several

case

of

menstruation

at

years

and

suggested that some were early menstruation merely those

The the
was

Dr.

Ludlow'

of
of

the

supposed cases, bloody discharges.

rules hot
Bummer

of

report of management
then read

the

committee

on

the

preparation of
the

for

of

infants

during

months

and

adopted.
5, 1873.
Dr.
Chair.

Stated

Mbeting,

Juxe

W.

Qogdeli.,

PBBsn"EST,

cr

the

Dr.
These The the the

J. V.

Ingham

two presented

specimens
from

of

hydrops

tnba?

Fallopii.
specimens
were
was

of

interest

their

dissimilaritv.
to

fii-stone

exhibited

Sosterior
Dr. Dr.
account

In by the bound the the down case, however, npon cystswere animation. extensive wall of the uterus by an perimetritic inof interest the The points noses diagsuggested were and Could the cysts be recognized treatment. except ? Should they be punctured ? through the rectum

uterus, except

attachments entirelyfree from natural .extremity of the tube.

other

Ingham
Jenks

also exhibited remarked that

retro-uterine

fibroid
were

tumor.

these

cases

of

interest

on

of

conditions

which
tumor

patliolt^cal pointsof diagnosis. There are many rectal exploration might be confoimded upon
of
the

with
others

a an

posteriorwall
a cancerous

of

the

uterus.

Among

enlarged ovary,
exudation

or effusion,

in which

growth, an inflammatory absorption is taking place,were

of
use

suggested.
Dr. results Goodell of their

asked

the

members in the

the

Society to give Ae
method
a

experience
tumors

of

Hildebrand's
use

o^ treating uterine
of

by the hypodermic
water.

of

solution

ergotinein glycerineor

640

Transactions
The
morbid

of

the

litems.
excrescence,

ffrowth

had

first appeared

as

canliflower

fix)m
was

the

inner

removed
no

and the vagina, nearly filling springing apparently Thi? surface oi the posteriorlip of the cervix. clean and entirelyby scraping, leaving the neck In
two

with

tendency to bleeding.
and but
on

months

the the

mass

had
was

turned, ream-

consultation

with

Dr.

Parry

cervix time.

Eutated, eing treated by

under the
care

the

growth
several of Dr.

returned

in three

weeks'

After
came was

the patient practitioners irregular the whom Barr, through specimen

obtained.

Dr.
"

Parry
was

remarked
the unusual Another

one

of peculiarity
to which
was

the

cancerous

mass,

that the

extent

it had the

involved

the
ureter

body
and

of

uterus.

feature
these
were

dilated
not

pelvisof
upon the

the

kidneys, yet
Sinkler the

apparently
a case

dependent congenital
the of

carcinoma.

Dr.

Wharton

exhibited This
was

child
was

with

of deficiency

left forearm.

Society by
interest

Dr.

Geo. Ludlow
did

Pepper,
with

and
case

in connection J. of

the from
vary

reported to as being again shown of fir.Beecher.

collection of
to

Dr.
infants

L.

presented
ages,
not

stomachs

of

various

nineteen in

days

five

monthsw with the

These ages Dr.

of
or

stomachs

size,in

accordance

of the children. Ludlow

the

remarked of the
for

that he

bring

attention

to presented these specimens Societyto the fact that tne qnantity

milk

necessary size, for in many and

a

t!ie infant
cases
a a

does

not

depend

npon

large
one.

stomach,
was a

small

child

lar^e
of

cliild may have a He thought that

and the time of

its age small there

limit should

to

the
be

quantity
read

food,
account

feeding,

which

ascertained. carefully
an

Dr. lie desired

Wm.

T. from

Taylor

of the

case

of

successive

abortions

remarked

congenitalsyphilis. that the peculiarity of

advanced
a

case

was

that
age.

each He

succeeding
regard
mother
to

pregnancy
the

little farther

in

to know

opinion
of

of

the

gentlemen

of the
treatment

Society in
of the

the value

constitutional persistent that

in these

cases.

Db. before
value lie

Ludlow
the

remarked

this

question
many
cases

had

already

been

Society several
treatment

times, and
had the
been

the illustrating

of such
had

given.
of iodide the of

earlynoticed
by
Other
some

intolerance

potassium
tration. adminisor

manifested
mucous

patients,the
and other take

effects
it for

upon
a

Schneiderian

membrane,

symptoms

followingits
long time,

patientscan
without

for

an

indefinite

time,

unpleasanteffects.

PhiladelpliiaObstetrical Society.
Dr.

641

Parry
the
was

remarked fact
the of

that there
six abortions

were

two

facts

in

tliiscase

in favor firet was second

of Dr.

theory of Taylor's
presence Taylor did with

constitutional

syphilis. The the having taken place;

one was

of
not

in plantar-pemphigns mention
a

of

the any

children. coryza unless

or

Dr.
not.

whether child

there does

Pemphigus

in

syphilitic
Tne
two

not

occur

associated

together.
and
two to
was

Observations

coryza. in thirty cases

to

symptoms
that the

always go
of

(twenty-eightFrench
power In this

of

Dr.

went Parry's^

show

the
the

father

transmit

father
be could

doubtful
cause

case questionable. was syphilis should he also healthy was healthy. If the mother conditions of syphilis. Other of the existence Dr. results similar to those in Dr. Taylor'scase.

Parry

then

referred

to

case

of

woman

who

had

had

six

owing abortions, placenta.

Dr. The After
maternal several

in every

instance

the to fattydegenerationof
not

Taylor

remarked
of

that he had
upon

noticed

any

coryza.

report
was

the committee then

read. the

the

subjectof

congenital

deficiencies the

reading of
who
four

the effect of report the subjectof the fcetus in utero detailed

instances
was

impressions upon

discussed

by
the

gentlemen,
on

supporting
cases.

popular views
JDr. Ludlow the mother
for white

the

subject.
well-authenticated
a

had

In
were

one

case

daily passed

child
was

whose bom

limbs with
a

bandaged

swelling.
Another
was

Her

child
was a

mother with

frightened by
In
on

located. limb disevery face ; hideous

her

child

bom

hare-lip.
her fece fire-mark

another
the

instance
of
a

the

mother the

placed her hand

was

child Dr.

bom

with
seen

upon a red
a

the occasion upon

fire ;

face.
was

Taylor

had
mother

fingers. The
her

child whose for it accounted

asked her

righthand

without

gestation a thrustingout a
Dr.
asked hands.
Keuel

beggar
mutilated

by the fact that early in time for alms, at the same

in which

hand. the mother

about the well fonned finger. The mother her

immediately
Each hand
been

recalled a case Stewart the child was whether

had
a

supernumerary
man

had

impressed by seeing a fingera.

had
a a

pass

house

with

these

supernumerary
Another had been child

blue
child

mark

upon

its face.

The

mother

affected

by

Dr.

J. V.

Ingham

recommended He

by Dr.
had
to 41

and cuttingits face. falling exhibited a specimen of soft soap, as tions. examinaAtthill,for making vaginal
soap with
a

used

this

much

preferred it

etc., as lard,oil,

lubricating

He satisfaction. agent, because

642

Quarterly Report
effectually prevented
any

on

Obstetrics
from
upon tti

it

smell

remaining
case

finger.
Dr.
J, L. Ludlow
motlier of

referred
had been

to

curious her

of irrita:!
.:

nipples. The
strong
cliild it
tanned skin washes
was

preparing
etc.

nipplesby us:
the birth of
u

alum, borax,
to

Axter
as

unable

draw

the

milk,

the

by the applications.Poultices were was removed, and then the difficulty

Albert

nipple had l-eti and a thi: applied,

of

over.

Dr.
the

H. of
use

Smith the

was

in

the had

habit
never

recomnieDdir^'
seen

hardening

nipples,but

any

Xt^A

from arising

tlie

of

washes. astringent

QUARTERLY
AND CHILDREN.

REPORT DISEASES

ON OF

OBSTETRICS
WOMEN
AND

The

Formation

of

Ketro-uterine

and

Ante-uteedje

toi-

TocELE.

By Oyndkologie^

Karl
v.

Sghroeder,
1873.)

Erlangen"

Jif {Archiv

2.

cul-deeac capacity,and, indeed, existence of Douglas's tiness is physiologically dependent on the relative distention or empThe of the
the filled, closed

bladder

and
to the

rectum.

When

both

are these organs

entrance

recto-uterine the

small
loose likewise and

thev are empty, ; when intestine into it. glide

fluids in

oreDtirelt pouch is partly oi pouch is open, and folds

tlie law
as

the
to

abdominal
the bottom

Following sucn cavity,

of with the air and

of
or

gra^^j
rte

serum

descend

cul-de-sac

blood, of Dous:l"8j

the

intestines, being filled

float on lighter,

which is itself displaceable motion of the body. at every fluid, ^^ the v^m^ This be felt from fluid cannot loose,movable
tense

fluctuating tumor,
tumor

otherwise

we

should

find
or

sucn

uterine retro-

in
as

almost

But

as

soon

the

of ascites case every be it blood fluid fluid, or

to

ovarian d^op^T.

pelveo-peritoiut
becomes

ana shape,size, "^ on The is then displaced, sistence. uterus not materially it "^ remains in the same position in which pretty much when the fluid coagulated. If?however, formerly movable

exudation, commences ble vaginam, per

the coagulate,
a

tumor

pP*"

and

assumes

definite

and

Diseases
the

of

Women
become

and

CJiildren.
closed

643

the

entrance

to

cul-de-sac the
intestinal

by peritonitic
the surface
of the
entrance

adhesions of the

between

folds

floatingon
in

of the peritonitis fluid,or by adhesive still fluid accumulation a pouch, then, even the vagina, and a fresh 18 palpable from

the

cul-de-sac of that
tion) exuda-

increase
or

fluid

(from
will

some

new

rupture of

vessel
the

fresh
A

cause

the

displacement

of

uterus

anteriorly,
hsemait is

commonly found in retro-uterine tocele generally, therefore, exists for some is hardly possibleper which diagnosticated,
so

hsematocele.
time

before

vaginam until the becomes the bloody effusion is closed at the top and cul-de-sac of distinct hematocele, In most cases distinct encysted mass. a the point below situated from a spot the blood,therefore, oomes almost always from one its origin is, therefore, of occlusion,and peritoneum of the of the generativeorgans, the tubes, ovaries, themselves. blood-vessels of the pseudo-membranes or cul-de-sac, accumulate may Blood from a source higher up in the abdomen hsemaof retro-uterine tumor but the characteristic in the pelvis, in this formed pushes the uterus forward, is never tocele,which The inflammatory closure of the recto-uterine pouch is manner. however, that of the ante-uterine cavity, comparativelyfrequent, that region; and, indeed, is also hemorrhage from rare, as
very there
are

only
on

two

such
one

cases

of

ante-uterine intra-peritoneal

hsematocele

conjunction with a retro-uterine the other hemorrhage related by Martin-Magron and Soulie,and which relates a third case lately Schroeder now by Gr. Braun.
record"in
came

to his

notice, and
a

which
not

invalidates

what
as

has such of

been until the who

a

said

above

about become

hsematocele

being palpable
of the of

after

it has died

encysted by
For
at

closure

aperture
this woman,

toneal perihad

pouch.
from blood
the

the

autopsy
the
sac m

rupture of

tubal

pregnancy,

large,
coagulated the as

ante-uterine intra-peritoneal,
was

accumulation
extended
was

of fluid and
as

found, which
external
been
os,

far down
in

neighborhood adhesions, and

of the

not

retained

positionby

during life as an distinctly palpable Tne ante-uterine tumor. posterior cul-de-sac, unmistakable hesions, closed by adcontained which coagulated blood, was some the uterus whereby a 6j)ecies and retroverted, slightly
had
of vicarious

fossa of

Douglas

was

formed
blood sac,

anterior

to the

uterus.

The

flrethemorrhage caused
of the anterior
to the

the

which peritonitis

resulted

in the

closure

Douglas's fossa, the

level

into gravitated
it till it descended

cul-de

subsequentlydischarged distended and gi*adually

os.

of the external
and

The the

time

tween bewas
'

the
26

first

hemorrhage

the death

of

patient

days.

644

Quarterly Report
HiEMATOOELE. mann'B Klinische indefinite

on

Obstetrics

EETBouTERmE

By Db. Fkitsch, Halle. Vortrdge^No. 56. 1873.)

allusions
to
no

(Volk-

While

some

this affection

are

quot^
first
"

from

Hippocrates by Voisin, there is

and named and the

doubt
now

^at

Nelaton
as

defined clinically
and

disease

known

tro-uterine re-

that his descriptionswere hsematocele," his pupils Vigues, Gaillet, Bonchet by ; others, completed Denon villiers, Huffuier,Trousseau, Puech, Gallard, Richet, Delto Nelatou's valz,Eayer, Depain, Onlmoiit, supported and added views from them another. dissented in or one or Among way the Germans, Ferber, Fflhrer, Crede, Braun, Hegar, Krieger, edge Betschler, Schroeder, and Olshausen soughtto increase our knowltlie the subject, whilst Virchow demonstrated on pathologithe As of co-anatomical points are portion question. setiological of a Graafian ing mentioned follicle (Xelaton) ; coition dur: rupture varicosities menstruation (Puech) ; internal (Richet, Delin the ovaries vaTz) Delvalz) ; tubal h^n(Laugier, ; changes from the blood uterus orrhage, regurgitationof menstrual (Bemutz, Goupil) ; obstinate constipation (Rayer,Depaul, Oul-

echoed

mont);
sac

temperament,
exanthemata from

exertion, cAtching cold, rupture

pregnancy

of

the

in extra-uterine

(Vigues); hemorrhagic

diatliesis

in acute

Barlow, Trousseau);
of blood nitis the

(Laboulbene, Uelie, Simpson, Scanzoni, heematocele tion cachectic (Voisin) ; exhalaperitonaeum (Huguier) ; a pelveo-perito-

hemorrhagica menstrualis recurring from pelveo-peritonitis

"

(Bernutz);
time has
in is
to time

more
"

or

less recent
that be

orrhagica hem^peritonitis
to

(Virchow) ; only
the when

Sciiroeder
of the
a

attempted
the small into
a

prove

the

objective presence

tumor

pelviscan
closed

cavity, inflammatoiy adhesive of Douglas's cul-de-sac. closure Olshausen, however, considers the coagulated blood excite to inflammation, and the of the haemato be not the cause, but the result, pelveo-peritonitis consequently primary
occurrence

ascertained

blood

poured
must

be

the

tocele.

ered considby some hemorrhagic exudation was "ofDouglas (Nelaton, to be only the cul-de-sac Denonvilliers, lateral and anterior admitted a Fenerly, Oulmont). Puech and hemhsematocele. Nonat speaks of extraintra-peritoneal held the opinion that its seat was oiThage, and Vigues once controverti only. Schroeder, however, proved that an inextra-peritoneal
seat

The

of

the

only
of

in

one

case

had extra-peritoneal hsematocele and of (that Ott, in Tubingen),

case
was

been
even

found then the

of the setiology

obscure.

Real

traumatic in the

extravasations

tlooa, traumatic

hsematocele, may

occur

pelvisas

else-

and
where in the

Diseases

of

Women

and

CMld/ren.

645

traumatic and
are

; hsematomata

body

according to Winckel,
occur

such

extra-peritonea
not

about

once

in

1,400 conhnements,
with hse-

to be

classed

with does

thrombus

vaginseand
to decide

matocele Whilst
to

proper. the author

and

not

pretend
greater

the

questionas
the
ception ex-

the the

cause
sources

originof

the
a

nemorrhage, he
or

attributes to each
the
siders con-

of

enumerated
that

less

share, with

of
Graafian
too

first advocated

follicle
minute "The
a

during
to account

by Ndlaton, the rupture of menstruation, which injury he

for
so

great

dischargeof bl(X)d.
by
K^laton from nishing furis

He

says: caused by the

clinical condition
small is

first descdbed

sudden generally of the blood

and generallyimpossible, always without affection practicalimportance, but the diagnosisof the whole
IS

organs the

intra-peritoneal hemorrhage The diagnosis of the organ pelvis.

in many The symptoms easy. admit of no other explanation. who tells you that that she

cases

are

so are

characteristic called
to
a woman

as

to

If

you

in
on

struation, suddenly fainted,perhaps during mencontinual violent chill, experienced a pain the pelviswhich occasionallyshoots into the thigh,ana if, feel the posterior laquear vaginae digitalexploration, you

she

somewhat fiat,

with certainty projecting downwards, you can The the advent ing duraffection in sudden question. diagnosticate pelveo-periperfect good health,or also after long-recognized the distressingsymptoms of acute tonitis, ansemia, the cyano the small without crease intic lips, the increased thirst, rapid pulse accelerated and interrupted of temperature, the respiration all doubt to the as by fear and pain, will permit you to banish
nature

of
of

the

affection.

If the

disease

came

on

after

ance disturb-

struation, menstruation, perhaps during an unusually strong menthe more certain,"etc. your diagnosiswill be so much aid differential in the from As diagnosis,particularly an if authors stated nave struation that, menexudation, English peritonitic has it if it is have haeinatocele, ceased, only been usual absence The of typicalexirregular,pelvicexudation.

aceroations

of

fever, and

of increase

of

pulse and
is valuable

temperatui*e

39" Celsius)in hoematocele a diagnostic (seldom over the has the shown difference between Schroder sign. ance appearand collection in an hsematocele of blood a presented by atretic horn
women or

of

uterus

septus;

the latter
and the

occurs

in is

nulliparous

at

the age
; the in

of

puberty,
is
not

tumor

usuallylateral
merely thick,
in
a

anterior

blood

coagulated
a

but

tarrv.

Hsematocele
woman
a

nulliparais

set

of

symptoms

parturient ordinarilypointing to haeinatocele

great rarity ;

646

Quarterly R^ort
indicate
a

on

Obstetrics
for
this and intra-

would

free

extra-peritoneal hsBmatoma,
has
never

an

Jeritoneal [fiematocele
occurs

hematocele the

been the

seen

at

peric"'i
47, and
to

mostly

between

ages

of

21

principally among
work other stated
or

poorer
to

and

expose

themselves influences.

those who classes, are cold, over-exertion,

obliged
and diflFerentk

various

external

Its

frequency

is

very

by different observers, perhaps according to their greater less skepticism or desire to see the disease. Seiffert saw,
1,272 gynaicological cases, 34; Weber, in 1,145, Baw
66

among among

htematocelcs

; Olshausen,
met
saw

St.

Petersburg,
hand, Scanzoni
no case

it

in f oiilv

On the other per cent, of his ci^s. in 20 yeai*s ; Spiegelberg saw 2 cases

among

363, anii
The

Hugenberger
treatment

none

among

3,801 gynaecological patients.

is the

recommended

expectant
useful

operative
to

ence interfer-

being
the abdomen

absolutelyforbidden.
are

Tepid-water
simple
well
or

veiy

agreeableand

for superfluous, externally is generally

arrest hemorrhage sandbag in peritonitis and a poultice is moi-e secondary hemorrhage will call for

on compress^ the ioe patient ; with a pressure

will

the

as

better

(1 Rev.),

the

usual

dietetic
rest

measures

Absolute

during

the

next
as

agreeable. Only a fresli ice. Best, narcotics, and complete the therapeutic rnle^ menstrual fear of " period, tor
and

is relapse,

recommended,

also tonics

baths

for

the

usually

existingansBmia.
On

the

Complication
of the

of

Pregnancy

and-

PARTUxmoN Berlin.

wrra

Cancer

Uterus.
2.

By

Dr.

Cohnstein,

{Ardiif:

fur
With

Gyndkologie^ v.
the view of

1873.)

and systematizing
on

the

conflictingopinions therapeutics of
from the literature
as

the the
age

defining the numerous history,pathology,and espeeiallv

has

this
on

complication, Cohnstein

collected
he has
finements, con-

subject 134
and of the

cases,

which
the

analyzed
termination and

regards
nature

the

number
the
cancer,

of

previous
course

the of

and draws

seat

aiiJ
child,

the he

labor,and
the

result

for mother

and and

from
:
"

which

followingconclusions
of
cancer

tions deducthe

1. There called

are

two

varieties

of

the

womb,

socrescence), ex-

papillaryhypertrophy (cauliflower infiltration of the lipsof the os epithelial uteri, or of the cervix, without papillary proliferation. The in fii'st superficial of time, passes the into the course variety,
and the second aeep

epithelioma, with

form,

or

true

carcinoma,

2. The

of diagnosis

the

first stage of

cancer

of the womb

is

648

Qvxx^terly Report on

Obstetrics

vix and lower portion inTolved, of the corpus uteri has become of the pregnancy in the cases. great majoritj goes to term influence the whole,exerts a favorable 6. Pregnancy, on the -where the progress of tlie cancer. In those cases on less disease began to developduring pregnancy, its more or it had however, in which rapid progress was noted ; in those,

^indeed, appreciable progress rather an arrest of development observed. The disturbance was is also and inconvenience accompanying of the ^romb cancer SieE. diminished v. usually during gestation. temporarily
existed before
no conception,
"

bold
nancy

even

asserts

that carcinoma

uteri has been

cured

bj
been

pr^taken mis-

! and delivery
cancerous

7. The
for

of the degeneration

cervix has
in

excrescence a papillary placenta pi'sevia,

epithelionjj

of a foetus. Pregnancy in may be overlooked carcinoma ; but the least signof it, if an operation particularly should be careiully be intended, attended to,knowing,as we do, of the cervix favors conception.It does not follow, that cancer that pregnancy would necessarily forbid the proposed however, excision of the carcinoma. unfavorable 8. The prognosis more is, numerically, decidedly for than the for the children mothers. Of 126 mothers 54, = 42.9 per cent, recovered, and 72,= died duringlabor or the puerperal 57.1 per cent., state. Oi 116 children 42, = and 36.2 per cent., bom were alive, bom dead. 63.8 were 74, = per ";;ent., Of these 74 still-born tlie death of 29 was children, owing to them duringlabor,to the uncalled-for operations on performed

for the hand

and to the undue death of the mothers undelivered, tion prolongawould be of the labors. The true figui*e, then, oiiiy 38 per
cent, of

Of
or

in

mortality. and 53 after delivery 19 died undelivered, motheiis, ately puerpeiio ; 31 times death ensued duringlabor or immedithus showingtliatlalxjr itself is more afterwards, ous dangerthe
state. puerperal

of death-were pent(H of ansemia, fever, nitis, puerperal rupture the uterus,cancerous who metastasis. Those mothers survived longer livered had been dethan those who had been confined prematurely. at term
than the

The

causes

As

the regards

diminution

or

prolongation by

the

puerperal
allottc^i to labor,and

condition of the average time of 1 to 1^ years carcinoma, it must be confessed that pregnancy,
furtlier the rapid progress together puerperium

of the disease ; of tlian comthe favorable influence pensated pregnancy alone is more and the puerperal for by delivery state. 9. The

of dystocia dependson degree

the extent

of the de-

.vS!

and

Diseases

of

Women
"

a/nd Child/fen.

649

feneration
even

the mechanical obstacle it presents to delivery. )isea8e of one of the lips of the cervix only will generally mit perextensive the easy and safe expulsion of the child ; more
tion lacerauterus

and

and entails tedious labor, degeneration usually bruising the and perhaps of the cervix, oi complete rupture if the the be spontaneous, delivery membitines

rupture

and the tedious labor thus also endangers the life very early, of the child. At a stillmore advanced stageof the disease the firm infiltratedcervix presents an insurmountable obstacle to
aid becomes artificial spontaneousdelivery,

latter be
or,
rare

the neglected,

from undelivered, the pains cease, cases

necessary, or if the woman rupture of the uterus, anaemia. In or exhaustion, peritonitis,

dies from and the pregnancy

oversteps the

natural limits. The

state met

various dangers of labor and the puei^peral with in normal deliveriesare, of course, intensifiedby

this

complication.
some

10. The

of

no

the

the should be relied upon to terminate of the labor. For cancer the anterior lip, is favorable the result of expectanttreatment for the children in 83.3 per for the mother in 75.5 per cent., If the disease, to the whole os and cent. however,has spread the results are less than one-half the cervix, and 33.3 per cent., and even less. 37.5,
as

ter adoptionof the correct planof treatment is a matsuch as venesection, dimculty. Various old remedies, for the purand other agents and applications mercurials, pose and arresting of softening the cancerous are degeneration, As that relied as we a rule, longas longer may say upon. is of confined t he not exhausted, to one woman cancer lip alone membranes nature and the OS are uteri, unbroken,

viz. : favorable,

dilatation of the lower orificeof the uterus in Spontaneous either does not take place at all, advanced cases or onlyby less extensive laceration and rupture or the of more means or cervix. If incisions of the cervix are made, theyare extremely liable to be torn,even to the extent of opening the peritoneal made in nine cases, and aelivery accomplished cavity ; theywere orable and cephalotripsis tne favversion, extraction, by the forceps, 50 for the result was for the mothers, children, cent., per 62.5 per cent. Manual dilatation has been twice tried in vain. Incisions of the os and cervix are to be recommended pally princiwhen the labor painsare insufiicient to expel the child. Their dangers have been hinted at and are obvious. result : mothThe forceps ers, five times (favorable was applied version and 50 per cent.) tion extrac75 per cent., children, ; result: mothers,18.1 per cent., eleven times (favorable
"

650

Quarterly Report
per
cent

on

Ohstei/ricB

12.5 childi-en,
to

; the latter

mortality was

greatlj'owing

of extraction). difficulty child Craniotomy and embryotomy destroy the life of the whom six Of without profiting the mother." women, upon of the these operations were performed, two died of rupture in undelivered and one during the operation, uterus, one puerperio. The induction labor of abortion and might be premature three times as many than women justified by the fact that more
the
"
"

"

die

at

term

than

after

abortion,
as

the

ratio

of
at

abortion, premature
13
soon :

delivery,and
most

delivery
the

mortalitj term being

die the

for
8;
or

30

; but

inasmuch

of

mothers

during
child
as

after of

the

becomes

puerperal state, and the life of primary importance, this fact loses
the
cancer was

thus
a

its value

therapeuticindication.
Excision the mothers
; four of

performed

in

six
on

cases

survived

the
were

day

children
a

bom

operation,one alive, one

as

dying
was

the

all of ; seventh Of and

macerated. its size

course,

only such
on

tumor

would
organs

be
to

likely by
be

pressure pregnancy
undertaken

the and
at

neighboring
labor
would

troublesome
which
"

during
is for best

call

for
or

removal,

the during labor, time better than during labor." bears uterus at no great injuries ways (Michaelis.) A vertex presentationshould, if possible, albe produced by external manipulation, for the forceps

the end

of

pregnancy

"

offer much
excision of

better
an

chances

than

version

and

extraction.

If

the

epithelioma has been neglected before, it seems advisable it during the puerperal state (Jacobi and to peilorm Cormack). Cases reported by Langenbeck, Lisfranc, Put^net, of a cancerous and cervix Simpson prove that the removal does not prevent a new and even speedy conception. section The Cesarean was performed only foiu* times in the cases died, not reported bv Cohnstein ; only one of the mothers
from the operation, but
this

Stein, the
favor chances Scanzoni
to

previous rupture of the uterus. and Baudelocque, Oldham, Spiegelbeig youn^r, latter it offers all the that operation ; and the says
a

from

for
to

the the

preservationof
mother than allows
it when

the

child,and
is
even

is

hardly
calls

more

dangerous
allow

the the

condition
cancer

which
so
a

for it.
as

only

extensive

not

of the exti*action alternative

view

j9^

pdvem
and

of

mutilated
section

chili does
not

The

of the

craniotomy

Cesarean results

in exist,

of

exceedingly

poor

of

the

former

operation. Enumerating

the

operative procedures

which

offer

more

and

Diaeases

of

Women

and

Cldldren.
and

651

or

less favorable Incisions

and

prognosisboth
os

for mother
:

child,we

have,

beginning with the least favorable

1. 2.

of the

and

cervix

;
cancer

Forceps,applicable and
OS a

very

beneficial only in really small portion of the cervix ;

of the

3.

Excision
cases

of the
;

tumor,

applicableonly
or

in

certain

specified
for the
statistics

4.

Induction

of

abortion

mother,
6.

hopeless for

premature labor, doubtful the child, considering the

as

mortality after the latter operation ; Cesarean which for section, certainlyoffers the best chances both mother and than tlie child ; for the former, no worce disease for which the operation is performed ; for the latter, as good as Cesarean section at any time, if it be performed at a sufliciently early period of labor. Version and and extraction craniotomy deserve no mention lowing advisable results foloperations,owing to the unfavorable
their

of infantile

employment.

The

Pelvis

in

Congenital

Double

Luxation

of

the

Hip-

Joint.

By ndklogie^v.
S. describes

Ernst
2.

Sassmann,

Erlangen.

{Arohiv fur

Qy-

1873.)
case

of this

somewhat
draws

rare

affection
a

(only28
to

pelves of
facts and

this

class have

been

with described),

view

its

setiologyand

and pathogenesis,
:"

therefrom

the

following

conclusions

The in

pelvis by
constant

the
in

deformity
an

changes graduallyproduced in the question are various in degree,but

increased inclination

the

: an followingparticulai'S

absolute,but always relative increase open, of the transverse, and diminution of the conjugate diameter ; the of the of increase decrease and anteconstant a transverse,
of the

pelvis;

ro-posteriordiameters
flexion
oi

towards

the

pelvicoutlet
the cristjB
whole

ceedingly usually ex-

perpendicularpositionof
the coccyx
more

forward. than
the
one

The

and a ilii, sharp pelvis is generally

a

lighter and
appearance

slender

usual, and
are hip-joint or

presents
now some

flattened

from

above

downwards.

Congenital luxations of originate in two ways ; in

reason, normal

understood
as

to
known un-

which, for

yet
in

the

acetabulum

is other

primarilynot

formed

its

situation,but
occurs

therefore,a
dislocation

at some spot of the ileum, which fault of development, and in the other of which

is,
the

either of

in

utero

or

during early extra-uteidne

of certain

in consequence life,

some

disease

portions of

the

652

Report Qua/rterly
or system, paralysis

on

Obstetrics
of of muscles
and
mal nor-

nervous
or

weakness head the of

one

group
a

other, whereby their antagonists acquire

the dislocation of the
tne

supremacy
trom

produce
At
are

femur

its

socket. birth the

pelvis presents
steeper than
at

usual

appearance;

its walls ameter dijugate con-

higher and
is
or

the adult

a^e, the
snorter

transverse

much absolutely and relatively diagonal diameters, the sacrum

very
acute.

than

the

is

perpendicular,
normal

and

the

pubic anSe
as

form

the shape and child grows, the which natural influences The same to the adult age. duce prothis change also cause the peculiarshape of the deformed
the

Gradually under pelvis changes to

tions, condi-

pelvisunder
the

discussion, and

are

the

following:

the

weight

of

and still more while tension erect ; the erted exbody in sitting, of their ileo-sacral the tachment, on ligaments by posterior points atthe posterior superior spinous processes or the ilium ;

the
the

pressure
lateral

or

the

head

of the

femur

on

the

acetabulum is

and in

pelvicwall

of each

during standing pelvisby the of and the various action the of musor cles walking), groups influences the pelvis to the thighs. These going from the double to cause deformity peculiar congenital luxation of the hip-joint in different ways, according as the luxation is to be considered due actual to faulty development to or
the normal dislocation In
on

side rthis pressure pressure of the trunk

equalized

of

the

head

of

the
the

remur,

as

mentioned the trunk

above. presses fancy, inAs

the the

former
still soft
no

case,

before

weight

of

that pelvis,

in the recumbent is,

of position the the

soon

as

change is produced in the shape of the sitting erect or posture is assumed

above there
exert

pelvis.

influences

mentioned where the

is

their full power. In the latter case, however, real dislocation of the femur, of the head and distorted

pelvisbecomes
before
the

deformed

by
had

the

action
to

of

the

muscles its

weight
slender active
to

of the
the

body
can

has

occasion sit
or

exert

influence, thus,before
and less
to to

child
of of

either these

walk. is

The

lightweight

shape
use

pelves
walk

doubtless

owing
attacned

the

the

muscles
to

and

ligaments
the the the

them, owing
tension
cause an

the

inability
pelvis,and
the

greater
same

transverse

of the
which

properly, to probably also to

formation the
in of

unknown in

to

imperfect

acetabula

abnormal

positionis to be
that in

attributed. and
than

S. finds Practically,
state

pregnancy

puerperal
with

the

prognosis is
In

hardly less favorable

women

normal of the

if the increase labor,however, particularly and diameter be excessive, the conjugate contransverse sequently there is gener^y some corespondingly diminished,

pelves.

amd
for
are

Diseases

of

Women
for

and
mother

Children.

653

reason

apprehension
apt
to

both

and

child, and

liveries de-

be

either very
becomes

and and

operativeinterference

tedious,or again very rapid, tiianusuallynecessary more

frequent.
Rapid Dr.
In

The

Instrumenxal

Dilatation

of

the

Os 2.

Uteri.

By
"

Leopold

Ellinger, Stuttgart. {Ihid.^ v.

to

1873.)
not

contradistinction

the

tedious,uncertain, and

unfre-

quently dangerous dilatation of the os and cervix uteri by spongeand tne' use Dr. E. stronglyadvocates larainaria, tents, bougies, devised and employed by himself, with which of the instrument he a nd and internal rapidly, easily, safelydilates the external
orifice of the uterine

canal, and
in
numerous

which
cases

he

has

found

of great
mental instru-

and

service Burprisinff

requiringsuch
resembles
a

interference.

The

instrument

polypusfrom the

forceps,bent
the

at

an

obtuse

angle at
a

centimetres the

distance

blunt

point. By
open the

compressing
widUi
of
amount

handles, the
15 millimetres is measured of

parallel
at

branches blunt

to laterally

of

points,and
transverse

dilatation
to
one

by

graduated the instrument used

as

rod

attached in
a

the handles.
which

E. he
on

number

of The

cases,*of

reports ten, generallyin

foot

who office-patients,

left his office introduction

seldom
was

immediately
into

after the

operation.
use

of the attended

dilatorium
with

the

cavity of the
the of

uterus

was

and any difficulty, with. The pain

never

the

sound

pensed thereby disand

the

attendingthe

introduction

dilatation

was

greater
results

than

the

ordinary uterine

of that experienced during passage in three did and instances sound, only any
the

only one of which (in application, E. yielded to the solicitations which of the patient and dilated the stronglyretroflected and adherent uterus) could in reality be attributed The rapid,often instantaneous, to the dilatation. impleasant
relief
attended in which

follow

afforded
OS

by
the
cases

the

brisk

dilatation

of

the

external

and

ternal in-

in

cases

of

with
such

dysmenorrhcea, with or without flexion, of the system mon comso general disturbance freedom from pain with ; the comparative
appeared; the diminution
of the
secretion
occurrence

the
in

next

menstruation

of

the

flow after

menorrhagia, and repeated

the

in

chronic

tritis endome-

after
the

dilatation

; the
cases

of of

conception,
in
junction con-

dilatation,in several
with the

of

have, sterility,

attending
*

of, and facility operation,induced

to

absence

pain

and

danger
of

E.
me,

to

discard
sammer
"

sponge-tents,
1872, in

over

According to verbal commnnication twenty-five oases, with invariable

dnring the satisfactory results.

F.

F.

M.

654

Quarterly Report
and

on

Obstetrics
restrict the
same

laminaria,
wholly
as

bilateral
dilates

incision He
and

and entirely, it in

himself
manner

to

his dilatorium.

introduces

the
to

sound,
the the The of the

slowly
of
15

gradually, genoraUj
by
the

at

tint

not

maximum instrument indication cervical

as

millimetres, and
its
use are or

tiimii^
in 1.

the

points of

distends laterally, for

canal

all directions rowness Nar-

the

follo'wring:
Constriction nteri.

canal, with
married
women.

without
2.

dyBinenorrhcEa,
of
3. the the

in

virgins as
canal

well caused

uterine

by

deviation
causes

of

the

corpus chance

trorrhagi Me-

from from
4. the uterine

various

; the

free

discharge of
a

hVxA

cavity gives the organ

secretion. uterine the of

to

contract

Retention
the and

of catarrhal

5. The

necessity
the purpose

of
of

ducing introof the

brane, mem-

fingerinto
removal

cavity for

diagnosis

foreign substances
tumors.

(shreos
6-

coagula,placental fraffments)or
introduction
uterus.

The

cult diffi-

of

the

sound.

7. The
constriction
none:

elevation

of

tiie flexed canal

not

8.

caused Sterility there

by
are

of the
dilatorium

cervical may occasion

Counter-indications

the

ways alpent re-

all expectations, but satisfy used it* having

E.

never

had

to

The

Shape

op

the

CAVTrr

of

MANNj

Hannover.

By v. {Ihid,^ 2, 1873.)
the

Uterus.

Dk.

Hage-

In order
exact

to obtain

more

accurate

information

as

regards

the

of the uterine shape and configuration cavity, than k the various authors on subject, H. injected a given by the of uteri,of different ages, with paraffineand number metallic a studied compound (bismuth, lead, zinc, and cadmium), and he describes follows : the casts thus formed, which as
instrument the Being pereonallj weU acquainted with Dr. EUinger, I saw the laMt to this oonntzy. possession, and brought one with me During I have used it repeatedly in five cases sod of flexion of the eammer utema^ relief after evil results, but almost have its applicaseen no always a marked tion, oi diminution entire cessation consisting particularly in a temporary or and abdominal and the lumbar, discomfort commonly sacral, pain, ao genend In two in flexions. met of retenwith of metrorrhagia, in consequence tion cases of portions of the placenta after miscarriage in the third month, I eaisi^ and with the dHatorium sufficiently to en"bte dilated the external internal os the index finger,and on the latter a polypus forceps or curette, to introduce me I succeeded in removing the with which azzestix^ placental shreds and thus the hemorrhage. whatever the dilatation. No evil results foUowed in his In the October number
*

of the

I^ew N.

York

Medical
on

Journal,
and in

we

find

an

artide

by
of

Dr.
the

William Cervix
a

Ball, Brooklyn, Uteri, for the Cure

of
treatment
a

of

T.,
to

''Forcible

Bapid
which

Dilatation the
the

of

Dysmenorrhcea,^*
that of The Dr.

antlior tional addi-

describes
use

mode of

similar after
^F. F.

stem-pessary
"

dilatation.
ac

Ellinger, with priority of the

treatmeo^

may

be

difficult to decide.

656

Quarterly Report
of
an

on

Obstetrics
borders
is and

shape
rounded

isolateral The than here

trianffle

with of The
that

concave

angles.
narrower

right

half

the

cavity
surface
much

somewbt

longer and
uterine in

the left

of

the cast of
more

cavity,which

deserves

name

than

previous examples, is covered with numerous caused by the protruding small uterine pressioiis,
the Uterus
internal

small d^ follicles.

of

an

oM

virgtn

External

and orifice,

especialljthe
are

os, very

narrow

; the

cervical

canal

enlarged towards
still

its centre,

anteriorly hardly any

the lower uterine

folds,posteriorly toey

preserved in
of the whole

portion; length of the cervical canal fth? cavity. The cavity of the body enlai^

gradually,is almost

and entirely cylindrical,

are

suddenly

dilatesin

Sie
that

upper
ox a

third, the walls long triangle.

also

convex

inwards, the shape is

of an olS mvittipara: External orifice and cervical eter diamcanal in the transverse very wide, the latter particularly constricted at the internal os ; folds ; becoming slightly but indistinct; the uterine as long as the cavity is three times
Uter\ts
cervical

canal.
the than

ridge on
out
more

portion there anterior wall, the right side of the enlargement below the left,
and

In

the

lower

is

transveree

the
the

cavity bulges
tubal
thus

orifices

is
the

quite sudden,
uterus
an

the fundus
similar

is

convex

inwards,
of
a

giving
that

appearance
have

to that

uterus

bieomis.

The
their

entered injection

into slightly

the

tubes,

thus

showing

of the other patulous. In none casts did this happen. The enlargement of the cavity was quite tion and in all considerable, directions, equal owing to senile involuor a slight degree of hydi'ometraaccompanying it. of that Puerp"i'al Uterus : The physiologicalantenexion nal the interperiod,the point of flexion at or immediately above The OS. posteriorlip is imperceptible, the anterior well orifices must been

preserved, but
the
traction

the the

former

condition anteflected

may

have

been uteri.

caused bj

of

heavy

broad, distinct plicae on walls, most prominent anteriorly on posterior

on

canal

flat and

corpus both

Cervical

the the

anterior aiid
the

posterioriy left,
the lateftJ dus, the funthe left

the

right side, the

constricted extend in
a

cessation

of

which

plicaeindicates
point
up
to

hardly
borders the

internal

the latter os; from curved line inwards slightly shows

a

left border

distinct

excavation, and

portion of the uterus is much larger, owing to the insertionof is still fissnred and the placenta on that side, the site of which surface; occupies almost the whole superior half of tlie posterior

owing
the situated

to

the

retarded of the

involution

of

the

insertion
more

placenta there,the the right more anteriorly, posteriorly. The

left side, caused by is left tubal orifice

an-

and

Diseases

of

Women
is

and

Children.

657

tenor
a

surface

of the litems

tolerablysmooth, presentingonly
mucous

few
The

caused irregularities ilhistrations

by the regenerationof the

casts, of
theories
are

membrane.

of the
of the

the will

comprehension
be noticed

tlie several

course, conditions advanced

facilitate greatly

described

; still it

that of

to the

development
of the of

the uterus

substantiated

; the investigations

central longitudinal fundus indicate

by embryology as by the a!"ove ridge,and the impression

line of
connection uterus

in the middle the

two

the

of
and

ducts

Mliller,which
senile uteri.

together form
was no

the

vagina.
the
more

This

foetal reminiscence The

The
to be

longer visible in
size
on

the

multiparous and
uterus

large

of the

cavity of
cal cervi-

in old age
on

seems

dependent

senile involution
of the of

than canal

labors. preceding

greatest

width

is

generally found
of the orifices of

at about

the middle

that

cavity.
nal exteron

The

width

the

the uterus, particularly

to be OS, seems senile involution.

dependent only on

preceding labors,not

The

Conversion

of

Facial

into ONLY.

Vertex

Presentation

by

EXTERNAL

tock.
Formerly

By {Archivfur Gyndkologie^ v.
MaNLPULATION face and
to

FrIEDRICH 2.

ScHAl^,

RoS-

1873.)

and pathological, consequence and the children. with the

were supposed to be presentations call for active operative interterence,in

breech

of which

much the

Since
a

injurywas done have profession

be

both become

to the

mothers

rule,a child can the least interference without with the face or presenting, has the part of the accoucheur, the mortality in these cases on the find that, Still we diminished. much present notwithstanding and face of the mortality expectant and rational treatment, breech tions presentapresentations is at least double that of vertex mothers and the of three cent, breech presentations (in per six twenty-two per cent, of the children,in face presentations
fact

that,as
breech

acquainted normally expelled

per

cent,

of

the

mothei's

and

thirteen,

per

cent,

of the

children

in face die),and the after-effects for both mothers (particularly in breech and children presentations) (particularly presentations) serious of often import. are very that it is right and justifiable, the proon principle Acting with normal a comparato convert a presentation tively phylactically, it this better witn into a one prognosis, prognosis poor inconvenience without (a plan already be done can any serious of external lation manipuby means adopted in breech presentations in abandoned but Kicks' combined method, or Braxton
42

658

Quarterly Report
on presentations

on

Obstetrics
of difficulty

face
want

account

of

the

execution an]

operation after labor has commence]. method c: has, a ingenuity, devised changinga face into a vertex presentation,by external manija latioii alone, during the first stage of labor, or even the k while the membranes still intact an! period of pregnancy, are the uteri undilated. The modus OS a? operandi is,briefly, follows: 1. Between the pains the shoulder and thorax of tk fcetus are and uterine parietv* grasped through the abdominal tlie side where the kct and pushed first upwards and towards of the foetus is situated, the shoulder and thorax as and, as soon have into the been brought long foetal axis, no longer upwaru' towards the but dorsum of the child (i.^., the lateralwall only of the uterus). 2. In order not to push the whole body of the
success

of

of

the

Schatz

witli his

usual

foetus other

or

the

whole

uterus

in the hold the

direction fundus

last mentioned,

tk

hand of the

must

seize

and

uteri,and
even

with itthe it pusli

breech
towards

the

child,in

its former

position, and

where, hitherto, the foetal thorax was situatei This last action must be antagonistic to tlie firstnpwani not with the second be parallel impulsetowards jnotion, but should of the uterus, only in the opposite directioiL the lateral wall
side As
out
soon as

the

shoulders the

and

thorax

have

thus

been

fairlvlifttd

of the

and pelvis, the

breech

has then

been

pushed towani?

the

side to which

?ushed 'he second

and thorax points,and the shoulders 3. simultaneouslytowards the opposite or dorsal side, thorax hand
'

pushes the breech to the thoracic sideand brini the occiput against the opposite downwards, thus thrusting tie and face to approach of the pelvis and causing the head the pete chest. ShonJd the head be inclined to glide over
brim

during
will
be
on

this

last

midwife
will

head
S.

and no difficult; resistance, supply the rotation of the described found m accomplishing, and producing a vertex its transverse axis presentation
had

manoeuvi'e, the necessary

the

hand

of

an

assistant-r

has

occasion
in
one

to

practise this
was

devitci theoretically

operation only
and rapidity, succeeaed. To

instance, and
which
wish

safety with
those
:

the
to

^ho
in

surprisedat the "^, change of presentation tke employ it,he offers

of

following
1.

remarks

Be

well

schooled
skilful in A

the

diagnosis

pregnancy

and the

various

foetal

positions, by

external

and ";areful, uterine how

your

examination, and be gende, manipulations, so as not to excite

the

contraction.

kno"'a' obstetrical diagnostician practical

the easily be

different

parts of
thus often

foetus in utero
at
or

can

erally gen-

felt

by

external
can

examination

near

term, a^"

how

accuratelywe

feel, the breech, distinguish

and

Diseases

of

Women

and

Cliildren.

659

back, the forehead, and the thorax and anterior in a face shoulder in diagnosis, of presentation. A mistake frustrates the attempt to rectify the presentation. course, 2. The operation should at first be attempted only in supstill intact,the the membranes are easy cases, where lead high and the uterine and walls soft, abdominal movable, and The first of be labor should thin, chosen, impressible. stage and the patient may be ansesthetized to facilitate the operation.
"

direction

of the

!)osedly
3.

If the

uterine

walls
to

should

not

grasp
return

and

retain

the head

with

sufficient firmness

prevent the
os

of the
case, tbe

face

which, however, will usuallybe

be may desirable
on

the

tation, presenmembranes if it be

ruptured,if
to preserve

the

be

dilated,or, sufficiently

the

side

towards
she should the

be placed the membranes, the woman may of the child is directed. which the thorax

Ordinarily
4. Do
not

lie

on

her

back.

will
face

be

for it operation in a frontal presentation, strive the frontal into to convert unsuccessful, out a into the the mouth and presentation,by inserting finger

try

pulling down
5. Some

the chin. face

cannot presentations
reason

be reconverted

into vertex caused and

for the presentations, are preserved by the

inserted about around into the

that
of

they
the

have

been

shortness

umbilical side
has

the

placenta on
third

the thoracic

of

is cord, which the foetus, at

middle

of the
head

uterus, and
into the
child. this and

become the

wound latter
the

the neck

of the child

before

labor,pullingon
and pelvis, In other

during the descent of the the back occiput towards

to derive
as

drawing

of the

conclusion, in
external

order

the

full benefit from

as

lations, manipuall

well

pregnancy, if present, of him the position of the child,and the necessity, labor sets in. Many difficult operations and alteringit before
tedious

pregnant women, during the last portion

good to consult especiallv primigravidse,

oi

for their

Schatz generally,
a

advises

physician
from

tneir

and

ascertain

confinements

would

thus

be

avoided.

On

Meadows, M.D., Lond., By Alfred F.R.C.P., Physician-Accoucheur to St. Mary's Hospital, Lecturer on Midwifery at St. Mary's Hospital Medical {London School, Physician to the Hospital for Women.
Pelvic

Hematocele.*

Lancet^ 1873.)
As it is not the whole

for possible

me

in the time

at my

disposalto

cuss dis-

subject of pelvichssmatocele, I propose

*

to direct

Paper

zead

before

the

Harveian

Bodety.

660

Qua/rterlyReport
chieflyto
of these I shall its

on

Ohstet^^s

attention to both

symptoms
in

and
as own

treatment,

1 shall

keep myself
my

closelyas

rqrard possibleto the

m

and

facts
reason

which I

have

observed

consider into the of

the

blood
under

is effused
to

experience. that only variety or the disease the peritoneal cavity ; indeed
tiamiatocde
to

For

thii

wher? I think and

tu

it is better class

limit head

term

these

cases,

the

thrombus
tissue

those

in which the

the

blocxi i" Sceh

effused
a

into

the cellular

beneath

peritoneum.
that

classification
in

surgeons sound have

never
"

with in accordance is,I believe, and the case it is,I of the testicle, and convenient
a case

adopted l"j
a

think,
may

cally practithat I

arrangement.
of tlie latter I
was

I
"

say
to

yet

seen

kind

viz., pelvic thn'Oidiajit

bus,
nose

at least

none

in

which

able

satisf actorilv with

seen

that

From
me

my that such be

I ever have met condition,nor own experience, then, I have

a

poet-morteia
to

nothing
I very well

satisfy
how

condition

ever

nor exists,

do of

see

acute ordinary cases pelvic celkd do that believe not csfccs a certainly considerable this subperitoneal variety ever give rise to any fused that blood efquestion the statement swelling. I very much in this way into the pelvic cellular tissue may strip up abdominal and the peritoneum, give nse to a large pelvic or the that all cases On where the swelling. contrary, I believe of true intra-peritoneal liamais considerable tumor cases are toceles : it is important to bear this in mind, because obviously

it is to

diagnosed from
kind.

litis of

limited

it has its

bearing

upon

the

question
I knew

of

treatment,
the blood

in especiallv in tapping

surgical aspect
a

; at least 1 should

have that

less hesitation
was

licematpcele
in the thrombus

where

effused

and

encysted
a

cavity than peritoneal

the
blood extravasated

I should into

in the

punctorcellular

ing

with
than

tissue.

The

risk of mischief
case

is,I resulting

believe,

far

greater

in tlie latter

in tlie former.
to

in experience

Now,
enable
us

as

to the to

typicallyseen
recorded
Mrs. S the
:
"

regard which will in general trustworthysymptoms of true pelvichematoceles, thev are diagnose cases I have elsewhere in the following case, which
,

Such, tapping pelvicswellings.

at all events, is my

children,
on

married aged thirty, youngest being three

for
to
a an

ten

years,

and age,

has

liad two
me

years of
was

of
the

consulted

November
had been

she

14th, 1870, told,was due

I found that

leucorrhoeal
ulcer

wliicli, discharge,
cervix

uteri,

(^n

examination,
inches in

the uterus

measuring large,
was

tliree

and
in
a

length ; the mucous liningof the cervix is called being what deeply injected, by some All culs-de-sac the state of granularerosion.

everted, authorities

were

entirely

and

Diseases

of

Women

and

Children.

661

free
went

from
out to

any

determined
was

the day following she On deposit whatever. it was dinner, and, although wet, she very cold and walk her the house in dress she to to lightevening which visit, due
at
was

going
was

to

only
time,
sure was

few
was

doors

off.
She
severe

tion Menstrua-

about

the

but

frequentlyirregular,
date. with

so

that she
down

could

hardly be
when

of the seized

had

sat

to dinner

she

scarcely pain in the

the ill.
room

hypogastric
ana

region, which
carried

she

was

compelled home, feelingvery

her

to

leave and

faint

Some

fomentations brandy-and-water was taken at once, and warm but with were applied. The pain, however, continued slight I and called in. On the next was day abatement, examining the uterus, stretching a swelling behind per vaginam, I found side to side,and from wards foracross pushing that viscus slightly There the vagina. was treme ex; it also bulged a little into pain and tenderness in the lump, and also on deep pressure into tlie pelvis from The swellingwas above. somewhat but more elastic, boggy. On the following day the swelling had increased was more pain ; pulse 120, tongue furred, ; there could anxious. be felt externally. Next expression Kothing still greater increase and day there was bulging of the swelling
hot

vaginam, which pushing the uterus

per

now

invaded the

the

left siae
it

of
of

the

pelvis,
The

against
but

right obturator
was

foramen.
a

pain
and

was

not

so

bearing-down
I had
no

severe, character. doubt

differed in that The

forcing,

lump

was

that

it contained

Douglas's pouch so low down as to be either outlet,and might have been tapped with great facility, On fourth tne day there was vaginam or rectum. slight per aggravation of all the symptoms, with a relative increase in the size of the swelling,wnich, however, could nally only be felt exteron

elastic, distinctly It had fluid. pushed the quite near vaginal

more

pressing
the

into

the

pelvis. It

did

not

rise

above

the

level of
the and
course

obstruction either of There was no pelvicbrim. with bladder acted or difliculty rectum, though the bowels and after medicine. the only pain, During aperient great of the next ten days the symptoms greatlyabated, the

that on so pain diminished, and the swelling grew less and less, December month after of the the commencement 14th, just a that of the lump there is hardly a trace noted attack,it was left ; but a kind of ridge may the uterus, formbe felt behind ing, it were, cast of the as a peritonealfold in that direction." that I examined Even her ultimately disappeared, and when abnormal discoverable. in was early Februarynothing the 15th or On that month, it being a menstrual period, she again exposed herself to cold,and was seized in almost precisely
"

662

Quarterly Report
same manner.

on

Obstetrics

the

I the the

saw

her
was

I found

that and
to

uterus

left side

day after,and on examinatitm wards fordepressed, pushed somewhat which by a boggy, putty-like mass,
the

right lateral cul-de gac posteriorand part of me and Defecation was difficult, was extremely painfuL There veir violent bearing-down slight sanguineous dischargefrom the vagina, and Force if from her. The would pain, as everything a good-sized swelling at no time appeared to be larger than and A few days subsequent to this, after a good da! orange. tion, of forcing pain, she expelled which, on examinaa small mass, occupied
the

proved to be notliingmore clot, entanglinga good deal of

she
more

that
uterine

decolorized

fibrinou?

felt great

relief ; the

catamenial

epithelium. discharge came

to

After
on

thit

much

freely ;
she her
a

the
a

lump began post-uterine rapid

and

diminish
so

in size; when I

and
saw no

made

complete
the

recovery,
uterus
was

that

few

months

afterwards

quite movable;

deposit could
was

be felt in either
falls
case,

and cul-de-sac,

nothing

mal abnor-

discoverable. it seldom in this

to
our

]N"ow
was

lot to be

able
of

to

demonstrate,
a

as

done

the

rapid
the

formation
that of

of

post-nterine
of
acute

with swelling coincidently

occurrence

symptoms
hours

pelvicinflammation.
attack and
was came on

It

so

happened

few

before the
this ladn similar
amination, ex-

I had

the
no

opportimity
after the

examining
A
set

satisfied that made

a

pelvicswellingexisted.
hours attack

few

behind soft,elastic tumor the forwards and uterus pushing Douglas's pouch, that there is no swelling tumor or pubis. Kow
existence of
a

in,showed the the uterus, filling up

the against I know
can

of in
be

connection
formed
so

with

the

female

generative organs

which

This rapidly as this, except pelvic hasmatocele. and it sufficient the to warrant alone,therefore,was diagnosis, AVe corroborated entirelyby the accompanying symptoms. was such opportunities as were ed affordcannot, however, reckon upon
me

iui

in this

case

; and

will be diagnosis and

As
come

founded
the

partlyupon
my of uterine under

knowledge, our historyof the case, partly upon of the pelvic swelling. character
m

the

absence

of

that

the

I find regards history,

care or

that in all the

been
a more or

cases

which

hare

there

has

tory less distinct his-

ovarian in the

trouble,which
attack which

has, as
now

to

and
is

culminated
more

led up it w^re, claims attention.

cases

This

hsematocele menstruation.
and

is not In

observed in those particularly and directly immediately the

where

the

connected

with

majority
the
uterus

of

cases

there
the

is this

connection,

the h"eraatocele fluid from

results

either

from

menstrual

along

the

of the regurgitation FaUopiau tube into

664

Quarterly H^ort
symptoms
first
as severe as

on

Obstetrics
seldom
is is
not

the
at

of cellulitis and
; the

haematocele
of

are peritonitis pain of cellulitis

eo

severe
=":"

nearly
even

sharp
most

tliat of the

other

two, and

hsematocele

generally

the cx"V

all.

Faintness, great prostration,and

the lapse to an alarming extent, frequentlyaccompany ^th of cdconnection in neither these or occurs haematocele; lulitis or peritonitis.On the whole, it may be said that, takii2 these three haematocele of :^ cases affections, pelvic average aid characterized which are more sadden, by symptoms severe, its tirsit,in fact, shows alarming than either of the other two matic character and pain, prostration or collape, ; very distinctly
"

aceessiuj

with Tlie liar

sj'mptoms

of internal
course

hemorrhage, are
local and

its

leading
it has -which

feature.
a

pain

is of

very

limited,

and

rorcing, bearing-down character, a feeling if everjthing were scribed sometimes as being forced
With the
occurrence

pecais d^

away.

vaginal examination will in general suffice to make tlie diagnosis clear. If circumstances enabled monstrate nave already detailed, to deus, as in the case of the sudden formation a pelvic swelling, situate that the in be taken sive concluchiefly post-uterine region, as may of hsematocele evidence the swelling in ; for not only does much it cellulitis form differs also in situation more slowly, but
symptoms,
a

of such

and

character.
on or

It is at first neither
one

in f ix)nt of
as

nor

behind the

the

uterus, but
tissue

side,originating
broad still side
"

it does

in

cellakr

of

one

other
even one

ligament.
more more

In
is

pelvic peritonitisthe

swelling
uterus
"

forms
on

slowly,

generally
in extent

behind than

the either

not

and

limited

of the other

two.
are

swelhng. elastic, fluid,and fluctuating; doughy, non-fluctuating; tLeu hard, and with this change it contracts considerably, gettingsmaller and smaller, till it finallj and the contrary, is small first, at on disappears. Cellulitis, elastic tf gradually increases in size,becoming softer and more It its for one sometimes It increases. changes brawny character fluctuation made In all these be distinctly in which out. can far both and differ so pelvic peritonitis, respects it resembles their in haBmatocele but differ from frcjin pelvic turn one they ;

Again,

there

differences

in the

character

of

the

it is at first tense, time as boggy, goes on, it becomes firmer and finner,till it is almost

In haematocele

anotlier

in

this in

respect, that
it peritonitis

in

cellulitis

the

swelling

is

sided, one-

while

is situate

either

anteriorly or posteriorly.

is usually displaced laterally, Lastly,in cellulitis the uterus in the broad being pushed to one side by the swelling formed while in side the haematocele and in pelof ligament opposite ;

and

Diseases

of
is

Women

and

CMldren.

665

vie but

the peritonitis
most

uterus

displacedforwards
much
.

or so

backwards,

commonly
are

forwards, and

more

in haematocele

than

in

peritonitis.
the

Such three marked

characteristics Their
us

of the
are

conditions.
to

differences

pelvicswelling in these in general sufficiently

with tolerable the

enable

to

diagnose
Neither

them

when especially

taken

in connection

past

and

present.

certainty, history and symptoms the history nor the physical

with

signs
the careful the

taken

separately are
is of

in themselves be taken
utmost

sufficieijtto establish
but
a

diagnosis. JBoth must

examination

together;
more

minute
not

and

the

importance,
in

only for
to ment, treat-

purpose
and
to

of

but diagnosis,

still
to

reference of treatment
1

especiallyin regard
be that
were

that mode successful.

and

which
a

I believe

the

best

and

most

liave

strong

impression
haematocele
we

if the
more

symptoms
cases

physical signs of
ana are more

generally understood
of
this affection

pelvic appreciated,
common

should
is

find that

than

generallysupposed, and that it is not such a medical of pelvic cellulitis, imagine. Cases curiosity as some pelvic have and pelvichaematocele doubt no peritonitis, justsumcient of make to an error common m diagnosis pardonable ; but I
venture to

would
common

hope
as

that

mistakes

of

this kind better

may

be

less

in the future

the disease

becomes

imderstood.

content to follow are regards treatment^ those who a who, as it were, wait upon purely expectant method, and Nature will not in her efforts to repair the disaster, be very fail with if the true to exactness tliey diagnose dition conuneasy

As

of
diseases

affairs.
there

They
that

is not

think may much to very therefore

that choose

between in
a

these

three

therapeutical

precision of diagnosis is a point of little value, interesting but matter only to the specialist, importance to the busy practitioner. possessing no practical such On account to be laxity is,in my opinion, much every from and of the which view at therapeutical point deprecated ; such is not only mischievous, carelessness I regard these cases, For the relief which be absolutely fatal. but may able we are
of
to afford

view, and

is

prompt

and

effectual.

But
it is

employed with success, If otherwise, then be it is not correct. strictly diagnosis but probable, that the remedy which is intended only possible, life will have the contrary effect; for although the to save
the three diseases and I have
some

safetyand

it may be absolutelyessential that

in order

that

mentioned

bear

certain

external

blance, resemtially essen-

have

symptoms

in common,

they are
may
ensue

yet

and different,

irreparablemischief

if what

666

Qua/rterlyMq"ort
is the

on

OhstetricSj etc.
for kind I the
one

believe

right mode
omers.

of treatment

is

wronglj
cc*

appliedto the

Suppose, then,
rest, and
mind
cases

that

case

pf

the

have

described

enrs, the first thing to be done

to

undoubtedly

is to doses in

enjoin
;

absolute
in

administer
we

that

have

opium in moderate two objects in view

encystment
in the

bearinof
of

the

treatment

of the it

of this kind.

ThQjirst is to obtain
its

the space

coagulation
within

effused

blood, and

which matory inflam-

is effused ; the latter action in the

process is accomplished

partly by
entire
or

shape
be

of limited
done

and peritonitis,

partly by
mass moved re-

coagulation. Our
; and
or cases

second
may
own

object is to
either

get the

this

by absorption
records of of

by tapping,
takes aW

both.
me

My
to

experience and tne

that the
"

nnmeraus

lead

oelieve

place
round the

circumferentiallythat
the

process is to say, the and

on

coagulation
fibriii
either collects side

effused mass,

above, below,
some
or

; while matter,
on

serum, is, as it were,

together
on

with

blood-cells
within.
cases

and

coloring

enclosed

encysted

My
which
a was as

belief
I

this

r"int have sometimes

and
even

is founded

the fact that in

had
to thrust

have

tapped
of
one

in the trocar that there

distance

two

inches,showing
the
same

coagulation

at

bottom, suggested, upper by observingthat after a gooa deal of fluid has been withbeen a considerable swelling has sometimes felt, though, rawn,

while

fact is

regards the

Sart,

much of course, less than before. This point is of great importance,I

think,in reference
I
am now

to the

question of
Kest the
be and of

interference surgical

which

advocating.
the be

suflicient to opium are, I believe, the escaped blood ; possiblyit may

ice

secure

favored
may

coagulation by also

application of
useful in

within

and

without

the limiting or controlling hemorrhage. It would connected i*emedy in a case probably not be a fitting with menstruation. this It is uncertain how of long process is being effected ; and circumferential it varies, no coagulation

; and internal

this

doubt, with

the extent

of the effusion.

For

obvious

reasons

itis
ed resort-

that any surgical interference very has taken to until coagulation place.

undesirable

should

be

On

the

Dangers of the
to

of

DENirnoN.
Gairdner's

By

James

Fellow Assistant

Faculty of Physicians and

Prof. Medical

and

Ilouse-Surgeon to the Manchester for Children, Journal {Obstetrical JDispensary

and Ireland.

Finlayson",MJ)., Surgeons,Glasgow; merly Clinique; and forClinical Hospital

of Great

Britain I.

October, 1873.)

Introductory : Various Estimates of the Dangers of DenThe tition. the process of question as to the relation which
"

a/ad Diseases

tyf Women
disease there
or

mid
is of

Children.

667
well

teething
scientific
not must meet

bears
with

to

infantile If
case
"

practicalas

.as

importance.
in
one

is

other

scarcely any affection we do * of difficult dentition," it

the diseases
never

lie at the the other

very

root
"

of the

study of

of children.

If, on
the very

world much

is and hand, there never f the began, any such disease," in the

has view

been,
must

since stand

other

way

of
"

all true

diagnosis. Nor

is it

merely

that diagnosis

find
as
"

"

also vary ; and so we treatment must that the operationof lancing the is regarded by one gums to us an all-importantremedy," and that he recommends the

is involved

"

the greater part of freely and deeply over their twice a day ; " % while another, extent, daily or even has from convinced avoided experience of its futility," of revenue." statements " Such making it a source represent all and intermediate the two nearly extremes, degrees of

lance

gums

"

may opinion
time.

be

found

to exist

among

ourselves

at

the

present

It has

as

branch

gerated exagappeared to me, from personalobservation,tliat ideas and the of tion dentisuperstitious potency regarding of disease, are the study of this to a cause injurious of medicine, and less pernicious in their practical no

operation in the opinions prevailin

it
was

treatment

of

children.
well
as

As, however, such

amongst
doctrine the of

the
an

profession as
in different If
to

thought

that

of the investigation
it other

public, teething
some

at different

times

and ideas.

countries,might throw
no

lighton current least help the

statements

serve

reader

feel
to

that his

amidst
own

at purpose such contradictory

it may

it is safer to trust
to follow

than
may
to

blindlyany
It may
our

vation experience and obsertraditions, even although they

as a

be

the

latest.

act

also

wholesome
and

corrective

the

estimate

of

present controversies

of

our

latest

and

most

favorite
with

hobbies
excite
not

compared
now serve

others
to

(whatever they are) to find them which, after lastingfor centuries, may
a

only
matter

smile.

Nor
an

should
have

it be

forgotten

that

the
or

does

concern

obscure

identification

of which

may

disease,the nition recogvaried from time to

time the

is one of dentition requiringno great skill for process of its observation external manifestations; the experience
:

the

"

JoBeph

Fox,

"

The

Natural
*^

History of the Human

Teeth."

London, 1803.

P. 77.

f Selby Norton, M.D.,

vol. xi., for 1869.

Transactions
on
**

of the Obstetrical

Society of London,"
of
the

Paper

^Marshall
Yous

Hall, M.D.,

*'0n

Teething," p. 183. the Diseases and

^*

Derangements
are

Ner-

"

Dr.

System." Hudson,
P. 141.

P. 188. London, 1841. Blake. quoted by Robert

(The italics
De dentium

in the

original.)

formatione."

Edinb.,

1798.

668

Quarterly Report
centuries The

on

Obstetrics
with

obtained
ent

ago

is and

comparable fairly

that

time.

ideas have

however, superstitions,

p^es r^ardixio: tIl^ As easier methods has

room

of

the

obvious

in a remarkable manner. process of diseases has been rendered recognition definite varied

tL. tit d

bv

advance

of science
realm

and

by

the introduction
a cause

of

new

research, the
to

of

teethingas

of disease
but universal the

tenuiri
ii

be

narrowed.
if

their studies

for the
we

Specialistshave operation of such

the
to

found
a

little
cause

of of

41:^

order, and,
nervous

except
gave

revival

which

doctrine affections

reti-i

irritation

the

subjectof teething, the

only
disease those their

tendencj
whiei

has
are

been
more

to relegate to its influence

than
amount

The
been the

usuallyobscure in of mortalityand
"

etiology.
due is
to

dentition

ha=
r

a variously estimated shown will be while present time, as bills of mortality.* Berdmoref estimates

variation

which

perjjetuated
oiuown

discussing
that
to

one-half
;

of

tht.

deaths estimate

under

two

years dentition

may

be

attributed

teething
that A of sixth

another wL
:

^ gives one-third.
difficult have

St oil
one-third

" thought
French the

those

had
this

perished.

children
cause.

been
that

supposed by
1

authors

J
at

to

part ^f die fn^n:

Arbuthnot
states

estimates the fatal

mortality
of
as

one-tenth.
m^ne

Harris**

among
a

diseases

children

give rise to so many Andry tt says that in

the

grave

symptoms
of

diflBcult
most

dentition.

great number

families

part of

children disease

die
more

Hurlock

""
and

can

duces thinks that it in:j::|: teething. Underwood in the healthy and robust especially ; while faint a as consolation, that a only announce,

of

painful
and
*

grievous

dentition

is not child.

to

be

expected

as

certain

infallible event
See Section

in every

f f "
seq.

Thomas
and
**

II. of this paper. ^^ A Treatise Bexdmore,

on

the 193.

Disorders and

and

Beformities

of tk

Teeth A P. 75.

Gums."
on

London,
the

1770. of

P.

Treatise

Diseases

Infants

Children.*' 1788. Tom.

Lcmdon,
i. p.

1771 346

Maxim.

StoU,

**Pr"leotiones."

Vindobon",

ei

*' Dentition Traits de la Premidre et dea Maladies Baumes, sonTest P. 1806. 101. M. Marat, d6pendent.** Paris, **De"en Art qui graves M^dicales." Tom. Tiii, p. 411 Paris, 1814. tition," " Diet, des Sciences ** of Ailments Nature and PraoUcal Arbuthnot, M.D., ^ John Bulcs of 2d P. 408. Edition. Diet." London, 1732.

I M.

tros

""

Gualterus M.

Harris,
Children."
'^

**

De

morbis
or

acutis the
Art

Infantum."
of

ff

Andry,
in

^^Orthopsedia,

Correcting
Fiench. of

Lond.^ 1689. P. %. and formities PreTenting' De-

Translated Treatise
^'

from the

the

London,

1743. Edited

Yd

ii p. 159. ^ M. Underwood, Merriman. P. 14.

on

Diseases

Children.*'

bjS.
17il

London,

1827. A

P, 280.
Practical Treatise
upon

"" Joseph Hurlock,

Dentitioix."

London.

and
With

Diseases

of

Women

and

Children.

669

melancholy anticipationsof death and disease, with and the on them, irritability, suffering, anxiety attendant it might well have passed into a proverb that parents had no pleasure in their children till the process of teething had passed its worst.* Proverbs, however, are usuallyone-sided, and so if not opposite,estimate has been find that a very different, we made of the perilsof teething. Marshall Hall, from his great
all these carefulness
energy death a been
"

in

watching
gum
; who

the

in

usingthe
by
"

and his promptitude and process takes credit he had tnat never lancet,

from made

dentition
one

an

exactly similar
that

claim, however,
the
to the

has

boasts and

he

leaves
resorts

of diagnosis tion scarifica-

dental of

fever the

to

mothers,

seldom

gums-t
while
an some

Indeed,
of and dentition the

writers

seem

to see

in the
to the

local

process

event

with fraught

danger

general health

of the child,others have economy rather and of. dentition peculiarities irregularities
whole

regarded
as

the

tions manifestalooked

of
upon
most

the of
as

general
the

condition

of

the

infant,and
to bad

have

disasters

overtaking infants
constitution
or

ing duiing the teeth-

period
some

dfue to
in their

faultymanagement,
own

nutrition, or
of their

to

defect

in that

when

they
and

were

The milk the

regarded the quality of the existing between relationship and earliness so presumably the facility of
not
" "

to be

in the

lightof

nurses, cidences. simple coin-

dentition passages, Bight of

has
and

been
so

referred

to

by
that

Aristotle it
was

in :}:

two

separate

it is

probable

never

lost altogether and striking, the

by subsequent writers." of dentition,however, are xhe phenomena the importance of the teeth for tlie future
so

so

life of

infant
was

obvious,
to

that

we

need

not

wonder

that

great weight
attached

tached at-

Some
"^ ^^

the local process. indication of the

importance
"

thus

to

it in

Donee editi dentes, de dicisolet ab ocnlis non In proverbio euim sunt : Onmibonus Feirraius sont arte medica gaudentes. : De g^nitores non alao Lib. 8, p. 121. D. Sennertos libri quatuor." infantliun Brixiss, 1598. canini iinde Adest dolor etiam mazimuB autem cum erampunt vulga: says de liberis donee hi dentes Parentibus turn est non esse punt.'* eramgaudendum Tom. ii.,lib. ii., i.^cap. xi. Oi)era. Lugdini, 1650. pars See its Derangements.** New and York, 1862. f A. Jacobi, ** Dentition filiis
^^
"

pages

170
^^

and

129.
De

Aristotelis dentixmt

Hist.
quorum
y.

Animalium/*
nutrices lac
**

matnrius

lib. yii. cap. x. habent calidia"**

autem
usus

^^Denique
^'De

omnes

Generatione

Animalium.**
quamquam

Lib.
lactis

cap.

yiii.
ut

Laqtis

ipse
Judicium

nihil est

confert,

quod et dentiunt. utuntur lacte, ocyus qui calidiores Calor enim vim obtinet agendi." in this g Aristotle is referred to by Meicurialis,Sennertns, and Primerosius
calor

faciat

dentes

ii oriantur.

ipsorum

lactentium

infantes

connection.

670
ancient

Quarterly Report
times of those
times
to the

on

Obstetrics

may

bodies

Christian attached
But
some

burning fe practiceof uot who died before the epoch of dentition,* and b. have been to seems some special significance future teeth as oeing the seeds of the tion resurrecbe
seen

in the

body.f
important
as

the local process

to
see

of dentition
was

no

doubt
a

wa?.

physiciansbegan in the history of the chili changes occurring simultaneously to t^ethii:;' morbid and that many phenomena popularlyascribed the with referred other be could to systenia greater propriety
one

that

it

but

of

multitui

of

more

directlyconcerned,
so common

dian*hoea the

in

attacks of the Billard" refers children during the teething* period, to

if

other part? of the and follicles, development He likewise of the digestive system occurring at this epoch. points out that important changes take place in the brain of the that and he maintains child during the first year of its existence, buted the frequency of cereoral affeotions at that age ought to be attrias that to these changes ; this period, however, is the same of the intestinal

of the

the

appearance much moutn are

of

l^e first few

piore

teeth,and
than

as

the

changes in
brain, the?

obvious

tiiose in

the

and other producing the convulsive cerebral disorders of infancy. Doubts, indeed, as to convnlsions and could other infantile diseases being due to teething, not fail

have

received

the

credit

of

to

arise

in

critical mind,
that many
errors

Guersent, 1 after narrating

must

case

in

admits point,
to dentition

have
to

been

made

in

referring
at first

convulsions

reallydue
instances up

cerebral

disease.
the
case

De

Haen
were

^ gives two
cleared
was

obscure,
case
a

convulsions, which, In by stripping the children.

the skin
; in

of

one
a

pin

found

in sticking

the

other

Tom-i Tianslatioii. "Pliny^s '*Nat Hist.," Hb. 7, cap. 16, HoUand's 164. 1634. Lond., p. This zH. (Clark^s translation), " De resmrectione," f See Tertullian cap. ^* is referred medical to be by several wiiteza Qpas passage e,g.y J. Bidanus, P. 475. com physica turn medioa." Franc, 1611. ' * n"a BeroL Dentitio tcto X J. E. Liebioh, ' De dentitione diffidlL" ,1819. b" Ex locali sed oniYersali 23. erolntione est habenda," p. pro processa pro demum morbifific evolutione uniyersali dentitlosis morbosa phssnomena qxuB deduci nomine Baithezet oomprehendi sclent; satis laoenter possnnt," p. 27. 2* ^ditios. des Enfants." BilUet, '' Traits Oliniqne et Pratique des Maladies ** C^est an d^yeloppement Paris, 1853. preponderant de Tappazeil foUicQlaixe gastro-intestinal. c^est " Paocroissement rapide da ^jst^me eno6phalo"radudien activite f onctionelle et " son qn^il faut attribner une partie des phdnomeoes de la dentition.'* Tom. 220. i. pathologiques p. des EnfanteNoaTeaa-n^setalaUflBg 0. M. BiUard, '^ Traits des Maladies meUe." 2" :^dition. Paris, 1883. Pp. 402 and 601-602. de Mededne'* I M. Guersent, Article ''Dentition,'^ '" Dictioxmaire (en 99 Tome Paris, 1835. tomes). z. p. 138. Boerfaaaye Institatioiies Fatbo* ^ Ant. De Haen, '^ Praalectiones in Hermanni 1780. Tom. i. p. 531 (" 234). logicas." Vienna,
"

'

^*

672

Quarterly Report
of dentition. of the
error

on

Obstetrics
find
writer

process
convinced

Accordingly
of

we

that sixth

one

ia

waiting
to

till the

month

beft"re

infantile attributing

diseases

teething;*another
cause a

autljoriry
the child arbitrari"

begins
has

to

suspect
date

teethingas
month
as

the
;f

of third

illness somewhat

after

reached

his fourth of
a

assigns
dentition
"

the

birth fourth

the
states

beginning
somewhat

of

the

troubles that

"f

almost iriti early age, and indeed b^ns that I writer have IS no X (so far as surprising has to disordej^, connect noticed) sought distinctly congenital with the of such the It fetal teeth club-foot, as development is evident Hall | that to date birth,as Marshall teething from

; X while is a disease

vaguely

tion denti-

of

life."

I^

rather

seems

to

do, is
as

surely
as

with

very much

and arbitrary,
reason

the

congenital
to

club-foot

mar

be referred

the irritation

of teeth
"

deformity which results from the so-called While cliildren. such an paralysis affecting young hair of the of the in growth lookingthing as thej^etfis been supposed potent enough to induce sickness in the
the similar
"

dental

innocentutero

has

pregnant
dentitioD

mother, | it
any
share
an

seems

hard abundant

to

oeny
of

to

the

process

of

fetal itself.

in the

disorders time

of the fetus

With

available
up

range
to

almost extending
on

from

the

beginning of life
that of the it must

the

completion of dentition, it
the the

is evident

depend
to

of

numerous physicianas he is refer entitled to to teething. Some, infancy have sought to substitute for this process other causes equally universal,and they have not found it diflScult

much very if which, any, of

preeoneeptions
aihnent^

indeed,

nearly
to

refer

to

them

multitude

of

diseases

usually
fonns

attributed of

to

dentition.

Dr.
*

Ballai'dT finds in the various

B. W.

fruitless

sucking a

On the Medical of Diaetsesctf Histoiy and Treatment P. 127. Lond., 1860. Adjacent Structures.'* of Children." Boeen Trandated Rosenstein, ^^ The Diseases von f Nicholas *^ artiyes at the a^ As soon into English. of fooi as a chUd London, 1776. and months becomes indisposed we generally suspect its indifposition is oon*

EichaidBon,
the

^^

the

Teeth

and

sioned

by its teeth.''
^^

P. 21. On
the

of Infants, and Affections eqpecul^ ^"^DeotSociety, May 17, 1847. (Beprint.) the term, begins at birth," p. 18. tition, as I understand London, " John Hunter, Works, edited 1835, toL ii. p^ 105. by Palmer. to birth in the passage Hunter quoted. probably referred

X Hall, London Laryngismus."

Marshall

Gonvulsiye

Medical

I
hold Child
about to be feel the

**

because
a

the
cause worse

Child's of
when this

haire

is bred

and

partly
themselyes
new

sickness. Child's
^*

Plinie
haire

grown writes

great
that
come

'vrhich
women

some

vith

their

bc^^ins to
of

and

chiedj
James

of

the
^^

Moone." 1612.
A P.

Happy

Deliverie

Women."

Bj

Guillemeau.

^
culiar

Thomas to

London, Ballard,
Lifants
has and
ever no

87.

New

Mothers." before doubt

but

if it

sucking had,

I have

Bational Explanation of the Diseases P^ not that London, 1860. ** I am aware less] [fruitbeen of infantfle regarded as a cause disease; that it would long ago have taken the place d

and

aind Diseases
of infantile

of

Women

and

Child/ren,
it takes
no room

65*3

potent

cause
so

derangement, and
he
can

the

place of
cess pro-

dentition

that efficiently Dr.

make
at

for mis

in the likewise
our

Norton, nosology. contended that teething ought

disorders, and
*'

the

Obstetrical
to

be

list of dentition

he regarded
stai'ch food."

the but
*

evils These

Society, expunged from usuallyascribed

two

to

as

due of

to the universal
on

unphysioloffical practice
ideas
nave

of
at
on

feeding infants
merit

least the
some

basing
the

their

pathology of infantile disease

or

departure from
if
some

normal

physiological process
impliea,some
be entertained.

of
of

nutrition, and

departurebe
that it is

thus

hope

averting
there is

the

dangersmay
to
rear

confidentlv

But
is

reason

from precisely
a

its fatalistic ten-

dencyt that the doctrine of teethingas If a child die popular on all hands. said, it is regarded as havingsuccumbed
necessary

cause

of disease
"

so

from
in
nor

its teeth,"as the

nurse
course can

is
a

of
be

parents process if the doctor blamed and have scarified the gums or ; any way is ioin the done in the selfwhatever time, he too can popular at
satisfied lament
But
even
as

for which

neither

in

if

over

an

inevitable

catastrophe.
to

among

those who

every
two

illness
of

during the

readilywish teethingperiod as due

not
seem
or

do

edge acknowlthose

to this process,
:

sets

symptoms
either
occur

deserve

specialconsideration

which and

from

their local nature

those which

related to the teeth, directly subside about the time of the

of a given tooth. appearance is There of general agreement a regarding the possibility due infiammations local but it is to dentition, obviously J being

seldom of

that these
to

can

themselves

regarded as so general constitutional

be

serious

as

to

give

rise

disturbance."

Even

and the I" P. 25. teething, that bugbear of anzioiifl mothers nurseiy and reflected very this subject, and oarefolly apon Again : ^* I hove observed able been to satisfy myself ^lat any illness depended, have seldom or never of the teeth/* evolatlon P. 24. the or development upon * of Obstetrical on Teething, ^* Transaction* Selby Norton, M.D., paper See also, in this connection, Dr. Sodety of London,** vol. zi. London, 1870. C. H. F. Bouth, '^Infant Feeding.** London, 1868. '' its Derangements.** New Dentition and York, 1862. f A. Jaoobi, M.D., *^ of a chUd, in whid^ of the death announcement read the newspaper I once friends and acquaintances to attend the parents, while inviting all their thefun^^, afi^nned that *the Lord hauled the dear chUd up to heaven by

the
pp.

teeth.* 6-7.
This

Now

in

this

case

neither who
^'

the

father
be

nor

mother

was

at faults**

%
p.

is admitted See

even
*'

l^ those
and

may

regarded,

as

views. 189

Jacob!,
Wm.

Dentition

; and II est
assez

Cadogan,
Fourth

M.D.,

New its Derangements^** and. the Essay upon Ntuning

holding extreme York, 1862,

Managements

of ChUdren.**

Edition.

London,

"

^^

taire soit

possible que l*inflammation prononc^e pour causer

membrane

1750, p. 35. gingiviUe prodkiit par l*6mption denla sdoheresse de la bouche, la rongeur
oette

gSnSrale

de

la

muqueuse

de

cavity,tous

les

oaractdres, en

un.

43

6?4

Qua/rterlyReport

on

Obstetrics
referred Billard
and
a

local

be inflammatory changes, however, must caution to the presence the protruding tooth. or
two

with
rates nar-

observations

in children

few

in
as

a a

child who

had

cut

the whole

of the first

days old, teeth,t which

third
serve

warning against
an

too

readilyattributing inflammation
process of dentition. of
an

in

the

of gums With

inrant
to

to the

regard
me

the

symptoms
must

iUness

actually

ring concur-

with
mere

visible protrusion of the teeth, the

coincidence be

of a possibility

accidental
so

with
some

many

teeth to account
numerous

for of
some

of the

ailments appearance

carefullyconsiderea, and be prepared to find must we infancy concurring in point

Rilof the twenty teeth. dentition difficult seen a

of time

with

the

of

liet and

Barthez

concurring so the illness were due whether at first at a loss to know they were double to a single or cause. us a against too They also warn lihiess during the teething readilv regarding the gravityof an even or concurring with the teething process, as being this several fact to to having seen or ue one They testify

% speak of having exactlywith the development of meningitis,that

Seriod,

teeth

the piercing without

gum and enteritis, any

to

during
favorable

the

course

of

typhoid fever, without

modification of
even

meningitis, pneumonia, and difficulty,

of the
course

equally
This

of

the illness. leads

us

the

consideration is
or

the

other
more

phenomenon
striking to the
toms sympIt must be

already referred popular mind

about remembered
"

to, which the more

time

perhaps
less

sudden

subsidence of
a

of

the

of

the appearance
tne

tooth.

that

although
in miich
not
a

quoted cases is this disease, grave

IS

refer to

distinguishedauthorities just in the midst of teethingwent on

occurrence

usual

; the its

common

event

cuttingof a tooth after an propriety be regarded as having

of
course

the

illness which arrested

may of

with

great

progress

may

lead

to

the

erroneous

notion

this ; and the illness

mot, de
oris

la

stomatite
mais

6ryth6maten8e
il faat

aocompagn^e
cela

de

fidvre, d^agitetiaiiy de

continnels

ment/* meUe.
Palmer.

: pas le plus oomnmn^ que noaveaa-n^ des Enfants et " la MamBOlaro, ^* Traits des Maladies J. Hunter, 2" Edition.'* P. 269. Works, edited Paris, 1888. bj

conTenir

n^arrive

London,
Obs.
de
XT. :

1885. M.

YoL
de

ii., p. 107,

"The

looal

inflammation de

ia

not

great.**
*
"

D., flg^e
les

ment

sang

dans

alveoles.
et

6 jours. Tum^faotion ztL A. Obs. : destruction des

6.,

la genciTe ^ncbede 20 %"e joma.

Muguet, congestion sanguine gastrite." 4 Billard, Op. dt., p. 269. et Billiet,'^ Traits ; Barthez
2* Mtion.

gencires, toux

suffocante,

Olinique

et

Pratique

des Maladies

des

Enfinfea.'*

Paris, 1868.

Tome

i., p. 219-220.

(md

Diseases
due
to

of

Women

amd
the

Child/ren.
tooth with reach

675
the

having
surface.* The

been

the

strugglesof
symptoms

to

cases

in which

certain

recur

the

cutting

of every tooth,without by cause, constitute any other obvious denfar the strongest argument in favor of their depending on and careis well marked fully tition,tand when such an occurrence the force of its perobserved, it is not easy to overcome Bua8ion4 Nor, indeed, is it the object of the present paper that Its purpose will to deny hy teething. any illness is caused be
served if the reader be

kept from attributing too

mis

much

to

dentition, remembering
infantile disorders

that the

dunng
causes,

omy teething period, and the

ulness

is not

the

source

of

searching
to
a

carefullyfor other physiological process.

A

before

is referred

Case Ilidical

of

H^smophilia
and

by

the

Umbilical Cheat Britain,

Cord. and

{Alger.
Ireland^

Obstet

Jour.

Sept.,1873.)
This
an case was

observed

infant

(a boy) seven
determined Marcailhou
the

in the person of by Dr. Marcailhou tlie separationof the days old, in whom
a

umbilicus case. Dr.

hemorrhage.
extensive the

When

called
of
arms

to

the

observed

ecchymoses
on

recent

date under

axiUcBybelow
a

and breasts,

the

and
a

shoulders, and
tumor

dia^osed hsemophilia.
with hazel-nut,
a
an

The

navel

formed

of the size of gave

arrested

opening
The

in the middle

which

exit

to

quantityof
by horn's
means

blood.

bleeding was
in
eau

only
The breast

after four

of lint soaked

de

Pagliari.
next
was

day
given

the

temperature

was

notably
the
as

lowered

; the

but to the child,

with

first movements
it

of

suction the

was impossible to hour In after. the the child died an it, night it had two stop and chocolate-colored vomited. mattei*s were bloody stools, On the articular surfaces, rough crejpitation was rubbing be the effusion which could attributed of blood to heard, only and thighs shortly into the articular capsules. The scrotum

recommenced, and, bleeding

after death
was a

presentedsubcutaneous sanguineoustumors. tint before icteric was shortly death, which general
Dentition
the

There
more

Jaoobi, **

and

conyaleaoenoe

tooth

its Denngements." Yon cuts. say the

. . .

New child des

York,
cat
a a

1862. tooth."

*'

Daring'
it
was

tooth

after

She (the motiier) aays it got well well enoagh. " Traits Ptatiqae dee lialadies Boachat. P. f k la mammelle
''

after it cat

P. 172.

Noaveaa-n^s P. 456.

des Enfants

et de la seoonde

Enfanoe."

Paris, 1867.

Trousseaa,

Paris, 1862. Oliniqae M^cale." boils appeared with X Dr. B. W. Biohardson gives an onasoal case, in which *' Medical of Diseases of the Teeth." each tooth. Treatment Histozy and P. 135. London, 1860.

676

Report Qiux/rterly
There
was

on

Obstetrics
evidence

pronounced afterwards. of hsemophilia. ness

Albijmintjbio Chloral. Eclampsia

no

of

hereditari-

and

TJBiEMiA

; Cure

by

Hydrate

of

By
the
him

M.

Bouchut.

{Gazette des H"pitatiXj June

19, 1873.)
DisoussiNo
emitted cerebral

by

and

theories,he sustains the opinion originally is there in encephalopathic albuminnria wnich causes eclampsia. He meningeal cedema
that
honor

objectsto
and may claims be

the

of

this

theory being
says

attributed

to

Traube,

it for France.

lie

that

caused

(1)by

serous

effusion

eclampsic albominuiia of the of the meninges

brain ; and (2)by uraemic or of insuflBcience the secretory Details the of the
case

aramonisemic

poisoning through
The

kidneys.
are :

of

child

given.

patient presented

of Anasarca, ascites,a"lema shown the lungs and of retina, as by ophthalmoscopic, or, s" calls it, cerebroscopic examination. Bouchut Presumably, the free from not nection therefore, oedema, the conmeninges were between be^ the optic nerve and the pia mater having shown The fore therediagnosis was by Axel Key, of Stockholm. This cerebral oedema. view was supported by the facts that the child had neither vomiting nor diarrhoea, that the remained moist mouth without smokmess, and that the temper-

following symptoms

ature

was

about

normaL then passes

in review

Dr.
writers Dr.

Bouchut
on

the

several

theories

of

the views to subject, and inclines to subscribe that who shown has of there is an Boumeville, distinctly ureemic eclampsia and a simple eclampsia ; that in the "st is always a marked there lowering of temperature, whilst in

the

the
As

second

there

is

an

equally

marked

elevation indication by the

means

of

perature. tem-

regards treatment, the fundamental and this might be carried out depletion, chose or sweating. M. Bouchut bleeding,
attackea diet
was

was

sraons

of

drastics,

it last, believing

at

once

both

the

anasarca was

and

albuminuria. But of

Milk for the

given,and gallicacid eclampsia itself Dr. Bouchut he has a high opinion as which
Convulsions
THE m an

administered.

ordered
a

hydrate chloral,of preventiveof attacks.

to

Infant,
M. Vebnay.
a

dub

Abuse

of

Aixx"hol

is

NuBSE. author

By
which

{Lyon MediocH^ 1873.)

case striking

The

relates

very

of
abuse

the mischievoos of

consequences

may

result

from

the

wine-drink-

and

Dieeaaes
A

of
child

Women
taken
means,

cmd
with

Ohild/ren.

677

ing

iu

nurse.

was

convulsions, and
of

durinff

five

days
M.

all sorts

of

like

calomel, bromide
told in

potassium,

the

hot

bath, musk, belladonna, etc., were

eventuallv French
the The
wme

uselessly
the
nurse

employed.
drank
some

six to
more

was Vemay eightglassesof

that
the

day, and

had

at

night.
be

It occurred due
nurse.

to him

that the

convulsions

in thus

the

child absorbed

might
by

to

quantity of alcoholic
wine
was

liquid
to

the

ordered after. Chlobal

be

stopped, and
NooTUKNAL
DBATE.

the convulsions Inoontinbncb

OP
^

ceased Ubine

immediately
Cubed
by

Hy-

{London
GntoLEMo
cases

Lancet

Sept.,1873.)
recorded
in which in

Db. chloral

Leonabdi of the

has

RaecoglitoreMedico
use

five other

above,
the

the
had

of

solution

of

was hydrate

successful. entirely
disease

The

were patients

all

aged
wnich
was

eight
had

to

ten, and

resisted In all the

various
cases

means

been
most

previously employed.

the dose
or

cure was

effected
seven

promptly,and
once

was

permanent.
an ounce

The
a

from
ounces

to fifteen

grainsin about
or

and

half
some

two
cases were

of water, taken at first dose the very was to effect the cure. necessary

in two

doses.

In

successful, in others
The

five doses

drug

was

administered Dr. Leonardi

as

in the

evening,
recommends

two

hours

at least after

food, and
drink

strongly
as

that the

patientshould

littlewater

sible. pos-

On

the

Pathological Db. Damaschino. 1872.

cases :

Anatomy

of

Infanhle Clmiche
"

Pabalysis. Gaz. Med*

By
In
was

{Oaa. delle

Lomb.,52.
three found
1.

Ibid.) following
of condition
of

the

the the

spinal cord
sinus

Small

atrophic spots
of the
the in white

softening in
comua

of

the

cellular elements
2. Sclen)Bis

anterior

of the of their the

spinalcord.
lateral

substance and

columns,

atrophy
spreads
3.

of

the

nerve-tubules
roots.

which axis-cylinders, of the

to the

anterior

degenerationof the walls and congestionof the vessels. capillaries in various found These changes were the whole of the spinalcord. extent
Granular Pleubitis
in

intermeduUary

intensitythroughout

Childhood

and

Thobagooentesis.
90.

(r Union
BoQEB

MSd,

85, 86, 88,

1872.

By Ibid.)

H.

Boqeb.

givesthe followingrules

for the treatment

of

purulent

678

Qua/rterly Hepori
and the

on

Obstetrics
centesis thoraco-

pleurisy(empyema),
:

following indications
profuse
be

for

1.

In

acute

cases,

with

very

effusion

and

persistent
with
as

bad

symptoms,

puncture

should

then with and trocar capillary be can ema diagnosticated.

the

performed, first aspiratoras soon

in
return

the

empj-

If

the effusion
may

returns

operation
tne

be nstula be

slowly, and repeated; it the

should
be

less

degree, the same is rapid, however,

and
a

external canula

immediately made, only

in

short

metal

introduced.

Drainage

is to be

employed

older

children,

and

by

experienced operators. The out pleural cavityshould be washed through the cannk ; if suitable, medicated solutions (tincture of of iodine, decoction bark, etc.)may be used. the purulent discharge has When about to diminished a the and tablespoonful m twenty-four hours, equally only an
small

quantity of
and
treatment

fluid

can

be
soon

the injected,

canula

should

be

removed
2. The

the fistula will

close.
empyema is similsuto

of chronic

that

just

mentioned.
have perforation into the bronchi curred, ocbut the general symptoms do not disappear, the discharge of the pus is impeaed or pyopneumothorax oomes on, in the same be made the nstula should manner by puncture, or if the pleural contents thick. incision are is Tubercular 4. pleurisy no contrarindication,especiallyas 3. If

spontaneous

its

diagnosis is

uncertain

; at

all events

the
a

patient
child
can

will
never

be

lieved re-

an

by the operation. Hydrothorax in for thoracocentesis. indication

In
case

be

of

fibro-serous
is to be

effusion

in

articular for
be
an

rhenmatisnu
vita-

thoracocentesis
lis ;

performed only
pericardium may

indieado
neee^aiT.

of the paracentesis termination

is

oftener

The hood
in

smaple,serous, pleurisy in chiligenerallyrecovery, absorption being more rapid than

of
acute
even

adults,and death more rare, thoracocentesis side ; consequently of absolute necessity. case
In

in is to

pleurisyof
be

the

left in

performed only
and

chronic

if pleurisy,

the effusion
will

is abundant

remains lent, puru-

constant

for 6 to 8

weeks, it

generally have
indicated.

become

and
The

thoracocentesis

will be

effusion might be changed thought that a simple pleuritic to a purulent one by puncture, will deter us from unneceffiarilj the pleuralcavity in such cases. opemng

680

Reviews

cmd

Notices

of

Books.

REVIEWS

AND
Disbases.

NOTICES

OF

BOOKS.

The

Puerpbbai^ of

Clinical

Lectures

i"kljv"K"d

at

Bellevue Professor Bellevue Bellevue 1874. These

IIospital.

By
Medical

Fordyce
the

Barker,
Diseases
of

M.D.,
Women

Clinical
in the

Midwifery

and

Hospital Hospital,etc. Pp.526.

"Clinical

Physician to College ; Obstetric D. Appleton New York: Ca "

Lectures" the
value

are

the which

result
any
one

of

over

twenty

years' experience, pleasure of personally knowing

author, or acquainted readily appreciate. While
the last
and
lew

of

their
name

with

the

enjoying the distinguished and genial of Fordyce Barker, will

Winckel
want
on

Hervieux
to

and

have

within

years

attempted
work

supply the
a

felt
the

in

French
of

German

medical

literature of

book

pathology
this
need eonmtion of

the has
been

puerperal state, no appeared in the English language, and the much felt that, about a so year ago, a
book
was

treatingsolely of

it has of
was

translation

Winckel's frustrated Barker's which

by
book

the accidental thus

prepared, the publication of which loss of the ^hole manuscript.* is the first and only English work in
the
on

Dr.
ence exist-

treats

solely of
it does
so

diseases

incident

to

the

Eeral asis need

one

state.

That

the

latest practical

and

puerscientific

hardly bo

mentioned
a

; the

boot

would

expect from
"

physicianwith
rule
more

is in every what way the reputation of its is made class of

author.
as a clinical," Being valuable reallypractically

mention

of

the

points
at

of

each and

affections,

than the
are

of latter made

the
are

minutiae

of hinted

historical
when

scientific

research;

only
favor
or

in

of various the

necessary. the nature affections,

Exceptions
of
as

which

is still uncertain

subject of

discussion, such

peral puer-

the

convulsions, and albuminuria, phlegmasia dolens, puerperal septiceemiaand pyaemia, and puerperal rever, peritonitis, much contain that is new, chapters on which interesting,

and
us

original.With
in doubt his
as

customary
his

candor
on

the author

does

not

leave

to

opinions

any

subject, but

presses frankly ex-

convictions, however
his
case.

much

they
at
a

may

clafih with condnbook

himself.

those

of

others, or
be
we

to arrive inability

definite

sion,if such Although

*

the

cannot
oommnnicated

expect
to
na

to do
in
a

full

justice to

the

in

This

fact

was

latter hj Prof.

Winckel

Hevi"ws
review
to

aiid Noticea
the space
outline

of

Boohs.

681

mere

such

as

at

our

allows,we disposal
differs from This
his

will

endeavor

those Lecture

give a points
I.

short

of the various author

chapters,specifying
temporaries. con-

in which

the

among of that account

Puerperal other things, a

conmion

Convalescence, very

"

chapter

tains, con-

good

occurrence,

eminently practical secondary hemorrnage.

"

and

Leo.

II. Diet
after the

practice of
few
to
"

of Puerperal Women the diet of the restricting

confinement

Hetnorrlioids,
the rule

"

The

days give
an

puerpera is condemned, and

as

during the first

adopted
as

puerperal woman
can

good

nutritious

food

she

has

appetitefor,and
and many sensible

easilydigestand
are

assimilate."
agree

Most with

nurses,

we physicians,

afraid,will not

with castor-oil is likewise dosing puerperal women agreeable disapproved of. Dr. B. very rarelygives oil,as it is disin liable to to take, and predisposed persons very laxative be If is which the not always a needed, produce piles. case, In
an enema

this very The habit of

and

rational

advice.

given by

of soap the mouth.

and

water

is better

than

any

medicine

opposition to the view generally entertained. Dr. B. and always uses, aloes,in combination strongly recommends,
with the the other

drugs,
even

such
cure

as

opium, hyoscyamus,
of
is

or

relief and of the

nemorrhoids,
"

on

the
muscmar

iron, for ground that

tility contrac-

special property
colon the
of very

of aloes

to excite
"

the

system reports
Leo.
"

the venous to stimulate rectum," and and the of abdomen, especially pelvis,"and

and

results satisfactory
the

from

this treatment.
"

III. Laceration

of the PeriruBum.
in order
to

^Dr. B. thinks
the
to

that hand
be

support of

perinsBum,"

is prevent laceration,

an

unfortunate

to the

expression,and that the applicationof perinsBum m the last stage of labor, in order
done intelligently

of

service, should be the mechanism with

by

person
"

conversant

sion extenlabor,and that then, by aiding in occipito-anterior and flexion of the nead in of the head " in and some cases positions," by directing occipito-posterior of the toward from the the vulva, the force utenis perinseum

of

and

in

others

in

counteractingtne
may be the

too

violent much in

effects of diminished those

the in

uterus,"lacerations
extent.
"

The

use some

of

prevented or forceps may,

is excessive than

occipito-posterior
in
cases

deliveries,in
and the
sacrum

and face-presentations,

of

where vertex-presentation has

to
a

there

flexion of the
is

head,
lutely absoDr.

less curvature the

normal,

be

necessary

prevent laceration."

The

method

of

managing

perinseum suggested by

682

Reviews

cmd

Notices

of

Boohs.

Goodell, of Philadelphia,and
Barker,
Vienna Dr. whenever
"

i%

almost

identical

in

quoted and approved used principlewith tnat

the
woman

by Dr.
in the

Lying-in Wards.
B.'s with

practice
there the of
is

to

"

deliver
to

lying
of

on

her

back
riance va-

danger

the

is perinaBum,'^

in

direct
in

advice

and

reasoning
93 of the and

Sehroeder ^The

his

Manual Leo.

Midwifery," page
Thrombus that this oj
accident

translation.

IV.

the Vvlva

Vdffina.
"

alent prev-

notion

is almost
erroneous

of

varicose

veins, is pronounced
at, that

always a ; and,

consequenee

opinion

varicosityof the vulvar The of the veins is a prophylactic against thrombus. nee to arrest vaginal tampon, after the birth of the child,in order the growth of the thrombus, is considered bad practice, external and much raticmal sufficient and, stypticsbeing more pressure
hinted
treatment.

indeed, the and vaginal

Leo.
means

V.
to
or a

Puerperal albuminuria be always dependent upon,

but ui*8emia, may be caused

is not
or

considered

by
which
as
"

anv

identical any the

with, Briorht's
duces inthe
vulsions, con-

disease

bv

condition

or kidneys, such congestion temporary venous cold, pressure of the gravid uterus, the effects of external

the

various

phlegmasisBincident
conditions
has the

to the

tion, puerperalcondiana

the

pysBmic diathesis,septic absorption,

of which albuminuria

puerperal
is in
cause

fever," the effect, and

in all

reah'ty
of tlie

not,

as

often

been

supposed,

the

the cause therefore we By removing pathological phenomena. find the albumen from the urine, and graduallytotally vanishing loss of sight,convulsions, etc., improving oedema, irritability, without further treatment. and disappearingalmost Dr. of Barker
caused The
or

does

not

mention

the observations

of

Olshansen,
is
sionally occa-

Halle, who

has

found

that
ana

puerperal

albuminuria the

by

catarrhal

interstitial

purulent nephritis.

indications therapeutical

are, ^'"To relieve

hyperaBmic

to prevent the impoverishment or the blood congestea kidneys, from disturbances albuminuria, to prevent the nervous resulting terminate in often in convulsions, which culminate or paralysis, if it must induce and finally, labor." to be, premature Camyuleions. Lbos. V I. and VIL ^Dr. B. reviews Puerperal the theories of Frerichs,Eosenstein-Traube, Hicks, Carl Braun,
"

Frankenhaeuser, which
a

he

considers

sufficient in which

explanation of
do
not

large

number

of

cases cases

of of
be

eclampsia,but
detected or
for those
is

account
no

for

t"ose frequent

puerperal convulsions
present,
no

in which
nor

lesion of the
in which

kidneys can
occurred,
nor

for thoee
still
do

albuminuria

existed

during pre^ancy,
in which

and

convulsions

albuminuria

JReviews
existed when convnlsionB

cmd

Notices

of

BooJes.

683

occurred, and the urine

these Have
and
we

was cases

then found
we

filled with find other

that
some

albumen.
the

For
"

three
not

classes of
some
reason are

must

explanations.
convulsions
cause,
"

for
the science

believing
effect
has

both
common

the albuminuria
nature

(S

the exact

of which
the

not

determined?

blood goes
nervous on

Leaving the nature of which produces the convulsions to state the predisposing causes

excitingagent

in the

of

undetermined, Dr. B. minuria, albueclampsia,viz.,

hydrsemia, ansemia, ursemia, primiparity, hereditary and influence. a tmospheric occasionally temperament,

The

excitingcauses
retention

are,

stipation, conduring ^station, indigestion,

'"

distention or the uterus, urine, excessive renex ;"during labor,in addition, everything head makes the of the which on pain severe, pressure cervix, all soft varieties of the the examination, digital rigidity parts, moral pains, shocks
of which labor has developed, distocia ; after labor," those causes the in blood accumulation of the urea as during labor,
or

of

cerebral

renal

the congestions,

sudden

changesin

the

tion circula-

of long-continued the on following the removal pressure and moral exhaustion of nerve-power vessels, great abdominal disturbances; in fact,"in highly nervous temperaments, and in the very impressiblenervous systems of those sufferingfrom rect ansemia, albuminuria, or irsemia, anything which produces dior

indirect
on

irritation

of any

part of the

nervous

system, may
most

bring
cases are

convulsions."
"

1/reatment.

Above

if possible." In all,prophylaxis,

where causes predisposing any discovered sufficiently early, they may

of the
will

that I have
be

mentioned

and

convulsions of

occur

only

in

small

successfully treated, percentage." The

ursemia, a nutritious
gestions con-

removal

renal

tne congestion,

cure

of

diet,moderate
"

exercise

in the

open

air,the relief of local

"

and cerebral uterine,renal, convulsions against puerperal ; of

are a

all

sures meaprophylactic

last

resource

is the induction

if premature labor. During the convulsions,venesection, cathartic and the inhalation of chloroform admissible, a hydragogue

(which

reme^

rather

diminishes

cerebral

congestion bv
the attack

removing

the

spasmodic

muscular

until contractions)

and in order to allaynervous and is overcome, the irritability " of the eclampsia, morphiahypodermically ; ursemia does return
not not

contraindicate
been
as

the

use

of

this

efficacious in Dr. done without

B.'s

has agent." Chloral-hydrate he had hoped. as experience of is,

course,

The

artificial termination
can

of the labor

if it

be

Ad great is if

remedy

in
"

Leo.

Vln.

Lactation.

injury. puerperal convulsions. ^Witib proper prophylacticalmea-

In Dr.

B.'s

advisable, form opinion, chloro-

684

Reviews
now

and
almost

Notices of Boohs.

sares, such as are the child as soon etc.\ the occurrence

as

universally adopted(by applying possible, emptyingthe distended breasts

of milk-fever
can

be, and
"

now

is, almost

entirely prevented.
ence Abscess, EpideniicinfluLeo. IX!. Mastitis and Ma/niTna/ry is mentioned as one of the occasional predisposing causes. is described, at the end of the lecture, Mammary Neuralgia in lactation. Dr. B. has met with a few eases as preventing disease which the painof nursing was so intense, no althongli doned. that it had to be abanof nipple or breast could be detected, doses in the trouble. full removed Quinine Leo. X. Puerperal Mania, ^Dr. B. estimates " the ratio of mania of labor in of cases to the whole number puerperal Bellevue Hospital to be 1 in 80." in hospitals The wonderful contrast to the number occurring 5 in other partsof the world (Scanzoni, oat of Wurzburg, cases he attributes to the greater moral that is 1 in 1,487) 7,438,
"

influence and the greater in to emotional causes susceptibility in this country, who are obliged the women to hide their shame and feel the disgrace than is the case in a hospital, much more the lower in Germany, for instance, where, among classy it is

considered
nurse, and
us give a

business perfectly legitimate

pregnant,to
earn some

themselves qualify
money.

for young girls come to beof wetfor the position

several years, while of the average

to the
we can

ing observation dur(From personal well calculated a to occupying position the intellectualand moral
as

into thorough insight

status

class in Germany, as house-physician laboring viz., assistant to Scanzoni,

in Wurzburg, and Hospital Lying-ui

"

endorse every word said by Dr. Barker on fully There kinds of insanity several this subject. are ciated assoRev) of with the various phases of child-bearing : the insanity the insanity of lactation, and pregnancy, the delirium of labor,

mania puerperal
^^

proper.

of puerperal Moral emotions are the great exciting cause t"irteen Since 1855 I nave mania." ..." of puerseen cases peral all mania in the wives of physicians but one were ; in their husbands' These ladies had read enough ooks to fill their minds with apprehension to the horrois as which mightbe in store for them,and thus developedcerebral As a hypnotic, in doees the chloral-hydrate etc. disturbances, is of of ten to fifteengrains, frequently repeated, great service
....

Erimiparse."
in mania. puerperal

Lkc. XI. to the view

to
occur

Relaxation

of the Pelvic

Symphyses, Contrary
"

Dr. B. believes this accident expressed by ocanzoni. be due

to principally

in capacious to mostly pelves,

ji

jReviewB
excess

and

Notices

of Boohs.
relaxation
to have
no

685
of the
sary neces-

an

of the

tissues of the of the similar Lbo.

infiltratioiiand physiological during pregnancy, and symphyses

tne

relation Mrith hernia

process

of labor.
be

After for

the

subsidence

possibly accompanying
to
a

inflammation, a pelvicbandage,
worn a

truss,should

lengthened period.

Phlegmasia Dolens, According to Dr. B., in and the swellingbegins at the lower part of the leg, some cases in others the is advances The true. reverse upwards ; exactly of does afiPected the not seem leg temperature greater than that The of the sound limb. and the various pathology of the affection, theories of Dewees, Davis, Eobert Lee, Hervieux, Simpson, and discussed at Mackenzie, Tilbury Fox, others,are and the conclusion arrived while at that, we length, finally that phlegmasia dolens occurs in the puerperalstate, and in know association with diseases which cause inopexia (tendencyto coagulation of fibrine. Vogel)^ and that its most uniform autopsical
"

XII.

"

lesion is
other
occur

venous

thrombosis,we
as we are

are

still

as

of ignorant
and

its real

nature pathological

of that of
crural

diseases."
with t"^ether

It is not
the

but latter,

many it although phlebitis, may either may alone. occur and

rheuipatism

Leo. Xin.
are

Puerperal
kinds
:

Thromioais and The

a

Embolism.
and

"

There

various

arterial
arteries

thrombosis,thrombosis
of the
two

embolism

of the
and

pulmonary
the

rightcavities
latter
are more

of the

heart, again

cerebral

embolism.
As

conmion

than of

former.

regard the
the

and hyperinosis number

predisposingcause to peculiar mopexia

of
cases

we

must

the later months after confinement,

gestation. A
cause

of sudden

death

of which
and

to
"

cardiac

be attributed formerly obscure, must and embolism. pulmonary thrombosis

was

The

causes

of thrombosis from
a

of the
a

pulmonary artery

are

(a.)

An

embolus

clot in

vein, peripheral

condition of the arisingfrom the same thrombosis in the veins, sion (c.)Such leinopexia)as causes of the parenchyma of the lungs as arrests the current of of the pulmonary arthe blood through the smaller branches tery. rare.^' is The which most Arteritis, exceedingly (rf.J is the difficultv in oreathing, characteristic symptom respiration the increased to or a forty nfty minute; suddenly pulse is bein^ and
smau

(i.) ous, Spontaneblood (hyperinosis

and

weak,

the

face

cold

and

livid,and
immediate

the

expression
sists con-

that

of
in

unutterable and opiates

an^ish.

The

treatment

alcoholic stimulants.
accurate

We lucid

mend comparticularly
manner

this

for the chapter

and

in which

those
and

find

described omitted rare or entirely frequentlyimperfectly accidents treated are interestingpuerperal ; as a rule we taxt-books. mentioned them only in the latest surgical

686

Heviews
XIV.

and

Notices

of

Boohs.
whfle
it and

Leo.
then

puerperal fever, portions of the body, may tion also occasionally as a occur primary uncomplicated affecmay under More the form of uterine frequently is phlebitis. uterine found a as phlebitis primary lesion complicated with differential metritis. The or diagnosis between peritonitis and peritonitisis not primary uncomplicated uterine phlebitis to the In uterine the pain is chieflyconfined phlebitis easy. lateral portions of the uterus, the repeated chills tended atnot are generallyoccurs
of also affect
the veins

Puerperal PAfoW^w." a m secondary lesion

of

This

disease,

other

rather pain, the sensibiliti^ whenever dull ; in peritonitisthe pain is severe become more attended there is inflamed by peritonsBum, the chilis are each less is there in local the more or a besides, disease, progress tion innervais in both diseases the sensorium tympanites ; overcast, with
a new

access

of

enfeebled. The
treatment

The
consists and

danger
in

septicinfection is very great vascular excitement, nervous allaying

of the most
liness cleanlent excelwith

tonics irritation, by means

scrupulous of frequent antiseptic injections. The

veratrum

and stimulants,

effects in this affection of

viride, combined

the pulse, are mentioned, the brandy brandy, in bringing down of the yeratrum. appearing to increase the eflScacy Leo.
ay.

Puerperal

Metritis,

"

This

is

very

common

plication com-

of
or

fever,and puerperal
as
.

accompanies peritonitis i^equently

occurs

uterine
commences

it phlebitis ; occasionally

idicff"athieaIlT,

and
to

then

the

parenchyma of long enough, the

spreacb endometritis, which gradually If the inflammation the organ. tinues conconnective

tissue becomes

suffused
less size

with
are

of greater or down, and abscesses pus, breaks The formed. always-accompanying endometritis such
into

dimensions
a

as

to

change

the

mucous i^terine

reach may membrane mass, which

discolored,P^lpTj putrid,excessivelyfoetid
to the

imparts its odor

traumatic

and lesions,

discharges. The Causes are : imprudence, puerperal toxaemia principally

is attributable to the latter cause prognosis of the cases generally unfavorable, that of the former better, although the " affection areolar hyperplasia,'' tedious chronic or metritis,"

The

"

is very

liable to be the

consequence.

lai^r pain in the hypogastrium, uterus than it should be at that time, lochia diminished or suppressed, return quick a or or pulse, positive increase of the discharge, and The sedatives fever. saline and treatment frigerants, re: laxatives, the to abdomen, opium, quinine, turpentine stupe septic but not least, ana stimulants,and last, vaginal and uterine antiThe

symptoms

are

injections.

688

Reviews

and

Notices

of

Boohs.
and
and

of the
the

leading obstetriciaDs
of the

and

of pathologists with subject

a

past
has

years

present time, discusses

in many umits

the

thoroTignness
he

abilityindicative
and
Our

essential will

deep thought which points materially

allow
us

given it,
from the

differs

accepted views. generally

not, of course,
to

specify

all these

various held Dr.

the views theories ; all we can attempt to do is to mention ing by Dr. Barker, leavingto our readers the task of discover-

wherein
Barker

they differ from entirelydissents

those

of other
the be

prominent

scientists^

Schroeder, that the mother air has been if the access^of

have
not

been

opinion expressed by by a dead fcetus, if tlie membranes prevented, that is, discharged ; and, in ruptured and the waters
from
cannot

infected

proof
point
lection

of from
:

tlie correctness his

own

of his statements, practice. " There are

quotes
two

two

cases

in inthe

sources

of
....

auto-infection or individual, without^ the other, poison coming from of recent a septic materials being absorbed by the surface "rom in the air. wound, either by direct contact or particles
one

within

tne

the hetero-infection,

I do

not

believe

that traumatism Whether

this be

is

necessary
case
'*

antecedent
for of

of

auto-infection.
is not will vary and
as

the
etc. ;

or

not

fection hetero-in-

yet determined,"

the

symptoms
poison
be
so

cemia septi-

accoiding to the amount

of the disease. intensity
a

of the

absorbed intense
a

the consequent to destroy life in

It may

few

days,or
a

so

mild

as

only to
then
the

excite

erate mod-

degree
of
the continue
or

of fever

for

few
In and

days, and
other then
cases

all disturbance

system
for

disappears.
or

symptoms
in

may
covery re-

days

weeks,
fever

terminate in

either

death.''

due

to the

tissues.
elevation

septicaemia is always present chemical changes produced by the poison, to an acceleration of the molecular metamorphosis ox the blood and The chill ushers in the disease. single occasionally
The
is

of Dr.

of temperature temperature is often

B. has
never

constant, 100"
towards
marked

to

107^

; a

rapid

faU

noticed

the

fatal termination.

witnessed

the

rise of
some or

temperature,
The
sibilities sen-

immediately
are

after

death, mentioned

by

writers.
less wild cases;

dull,there is usually more frequently diarrhoea,vomiting in severe

deUrimn,
skin is of

the

usuallydry

and

flabby in the

later

stages.

These

symptoms

witn often marked septicaemiaare in puerperal cases puerperal The etc. fever,phlebitis, a principally autopsical lesions are nuid and condition of the dark, a softened, congested blood, There state of the visceral organs. tatic no are thrombi, no metasin pysemia. The there is no phlebitis, ment treatas abscesses, consists in

thorough

disinfection

by vaginal injections.

jReviewa
and

and

Notices

of

Books.

689

great cleanlineBs
of iron

as

regards the
of

bed-

and

lants, body-linen ; stimutincture

tonics,quinine, chlorate
chloride
in convalescence.

the potash,

of the
to produce

Measures
are

calculated
not

elimination

of the
"

toxic

elements
its

recommended

by Dr. B., because

which has would debilitated
its be

the

disease
increase rob

alreadyproduced
only
For
serve

is the consequence of a eliminative and effects,"

poison
dies reme-

to

the weakness

of

an

already
to

system
a

and

it of the
reason

strength.
used.
"

similar

regain power necessary the veratrum viriae is not to

are

Pycemia, Chills always intervals,indicating a new

the
incohei-ent
a

occur, and invasion the

repeated at regular
pus
in

of

the

blood;

brain-p^er is exhausted,

patient

becomes

stupid,

leaden

present, the skin is of ; aiarrhoea is only occasionally yellow hue (in septicaemia tne cheeks are flushed).

after delivery ; septiPysemik rarelv begins in the first week tion csemia generallydoes, and when is of much shorter durafatal, tlian pyaemia. Pathologically, it is a purulent infection of

without antecedent also occur tism. traumablood, which may The traumatism, in fact, becomes dangerous only when condition antecedent morbid of the blood, due some to epidemic influence or special is toxsemia, present. abscesses Metastatic in all parts of the body, due to capillary embolism, are a characteristic of the later stages of pyaemia. Dr. B. does not regard i)uerperal fatal as such, a very pygemia, other writers, since he has seen several disease as some of cases that septicsemic pyaemia and pericarditis recovery ; but thinks with puerperal or endocarditis, pyaemia, are exceedmgly fatal. is : quinme and alcohol, The both in large doses ; treatment
the later the chlorate
iron ;

of

potash and
as

the tincture

of the
as

cQoride

of

measures surgical

regards the

abscesses

they become
Barker, with
describes
1. The the

necessary. Legs. XIX.

and

XX.
and

admirable
various

clearness

Puerperal Fever, enumerates lucidity,

at the

"

^Dr.
and time.

doctrines

advocated

present

trine doc-

of the Alonzo French of

wound

origin of by secondary fever

lowed folpuerperal inflammation^ general symptoms (Meigs, and fe^hier, other Clark, Cazeaux, Trousseau, Velpeau, authors,in England only Robert Lee) ; 2. #The doctrine and and

local

the

traumatism

septicaemia,septic infection

from

fresh

this and

Suerperal
which
44

who of (D'Espine,Spiegelbei^, supports a doctrine the localist theory,Schroeder); 3. The that fever is an essential fever,primarilya blood-disease, eveloped by epidemic, endemic, and contagious causes, in
combination

the local lesions

are

the result of the disease and

not

the

690

Meviewa

and

Notices

of

JSooks.

(Gnerard, Dubois, Depaul, Danyau, LoraiiiL, Fomia*, Monneret, Tilbury Fox, Evory Kennedy, McClintock^; 4. The
cause

doctrine the

which

includes

*^

under

the

term

puerperal

fever

all

such as zymotic diseases, typhus fever, scarlet fever, ervsipall oi the and elas,diphtheria, hospitalgangrene, septicsemia, when in a puerperal severe tney occur primaryinflammations woman'' (Tyler Smith, Barnes, Hicks, Davis, Hewitt, tlajthat the fair,Scanzoni); 6. The theory of Martin of Berlin, in tbe genitalsof lying-in women is the diphtlieritic process trine docof the puerperal fever;" 6. The only essential element is there of Hervieux, who believes tnat a pliualityof the local lesions, each of a as as numerous puerperal diseases, aistinct character,but developed by, and taking their special he what terms puerperal poison^ a nii"ni of lyingtype from, in hospitals, of like the which, like the miasm camps, and
" "

miasm
numerous

of

the and

surgical wards
very

of

hospital,
can

engender

different diseases."

All

these

doctrines

having
"nd

abl^exhaustive
main

review readers
used

subjectedto an able and tolei^ discussion by Dr. Barker, and the

been

denied propositions leave

the

and

refuted, with
book
to

what

succe^

we

must

the

of the and

judge
are

for
too

themselv^
numerous

since

arguments

and

lengthy to

f ession
measure,

permit our the closes with portion of the subject of faith seems by Dr. Barker, which
"

examples cited reproducing them

here, logical pathofollowing ocwito us to be, in a

"

the

combination is
a

of

doctrines
is

3 and

4 mentioned

above

1. There

fever of
any

which
this

peculiarto puerperal women,

are

and
the

named is,therefore, appropriately

2. The

symptoms
of

disease

puerperal iever. and essential,

are

not

consequence disease as
3.

and it is as much tinct disa lesions, fever. typhus fever,typhoidfever, or relapsing It belongs to the class of zymotic (Useases, and results

local

from

some

unknown
are as we as

4. We

changes
scarlet
6. The

blood-changes. of these bloodcause ignorantof the specific of those which are develop relapsing fever,
of the other of essential fevers. this fever

fever,or

any

be either epidetermining cause demic may noeoo("mal infection, influences, probably, contagion, or,

malaria.
6.

Any
woman

of the

local

inflammations

may
to

occur on

in

the

peral puer-

without
may

fever ; puerperal
oe
so

and,

the other

hand,

puerperal fever
sufficient local the
cause

severe

as

destroy life
or

without

disease

to account

for the symptoms

explain

of death.
causes specific

7. The

which

develop

the

exanthemata, sach

Reviews
scarlet fever and

and

Notices

of

Boohs.

691
disease

develop tlie specific may small-pox, but this does in the puerperalwoman; Tvith intense malignancy fever. the disease into a puerperal not transform puerperal woman, be developed in a 8. Septicsemia may infection,without either from autogenetic and heterogenetic also complicate puerperal this infection may puerperalfever,but
as

fever. These
of
are propositions and deep thought of many with thorough acquaintance

various

the

result of the

acute

vation obser-

While
them

here

and

doctrines

quoted

in various and

puerperal

and of active practice, flie literature of the subject. of the six chief there agreeing Mrith portions to differ from will again be found above, fliey of septicaemia non-identilr material points, as the of contagiousness fever, the imdoubted

years

the latter

zymotic bloodstated to be a specific Puerperal fever is thus is contagious state, which the puerperal disease, peculiar to of the the nature epidemically, liable to spread and infectious, is different from, is unknown, and which blood-changesin which
and
"

its disease,

essential

^nnoticnature,

etc.

not

identical
are
no

with, any

other

disease.

There

pathognomonic symptoms

the exception oi the with diseases, fever, typhoid fever, relapsing Puerperal fever,like typhus by a genersu is only known essential diseases, fever, and all the combination of of the

of any of exanthemata

the

tial essen-

phenomena
disease."

nor

is the

any

one

symptom

sufficient to determine
to

or presence the existence

absence
or

of

existence non-

"Epidemic
of which the
attend

influences

seem

determine
of

the

acter special charthe

and, secondary lesions,

these lesions."
consists in veratrum

course,

symptoms

viride,opium, quinine, stimulants,and other antipyretics, and mineral acids,sponging tives, treatment, by venesection, purgaeliminative The nutrition. been proved has,in Dr. B.'s opinion, emetics, and diuretics, of purgatives, but, as in the instance practical utility, to be of no
The
treatment

injurious. positively
tried
A

The

by Dr. K,
number

but

without

have been extensively sulphites evidence finding any satisfactory the

of their

fever. in puerperal efficacy of

cases
irom

and private practice, Hospital,

of

obstetric service in Bellevue scriptio and complete the deillustrate that

Dr.

each
are

disease. well conscious

we

have Barker's

not

been

able

to

While
more

we

than

and that we which

imperfectly review have been compelled to

deserved much
more

excellent many

work,
jects sub-

touch

on lightly

careful

mention,

we

hope

that

692

Reviews
have been

and
in

Notices

of

BooTcs^

pointing out the majority of the items of interest, in calling attention and particularly principal the the No views autnor. to peculiar to general practitioner, the and be should without book; it will certainlyno specialist, the subject it treats information he needs on supply whatever
we

Buccessf nl

of, and
are

besides,by the
him

terse

and

decided
and

manner

in which
p. f.

facts
ii.

save expressed,

both

time

trouble.

Manual

of

Mtowifkry: the of the With

"

Includingthe
State. Dr.
of

Pathology
Kasl the Schboe-

of

and Pregnancy, DEB, Institution

Professor from

in the

Puerperal By and Director Midwifery Universityof Erlangen.

Third B.
26

Iiying-in
into

Translated

English
Cabteb, London,
D.

Gferman
S.

B.A., M.D.,
etc

II. Edition, by Chahlrb M. R. U. Lond., Physicians,

engravings on
388.

wood.

New

York:

Appleton
members

Co., 1878, pp.

of the
and be

Those the German few

professionwho
the medical

are

acquainted
of
the rank

with

language
need
not

literature

past
it is
same

years, holds Manual

time

told
the

how
on

high

Schroeder's how
the the

among considered not justly

of scientific, all modem

the text-books

Obstetrics,and
compact
but

only

most

and It

at

comparatively most

comprehensive,
works
on

also

most

the
we

subject

is^therefore,
some

with

satisfaction unqualified

that until

greet this for

time book

expected

an translation,which, original English void medical in literatare a our worthilysupplantsit, supplies he be still a undoubtedly felt by every medical man, whether student, or alreadyin a busy generalor specialpractice. While the enumeration and of exploded not wasting time or space by is careful less unfounded Schroeder to menor more tion theories, all facts or suppositions likelyto inter^tprove useful or the and the and brief historical rereader, view thereby, by ing to the list and authors and of articles usually accompanying, appended to, each chapter,makes his book serviceable as a book

of

reference We
the

also
cannot

to

the

advanced

and specialist admiration

obstetrical

author. skill of many

waste

author
latest in

help expressing our much in bringing so

discoveries
a

for
and

the
so

information
a

of

the

into

so

small
is

arranging them
or

practicaland
space.

scientific book
;

manner

compass, without
one

and

words word modem

and of

This

therefore
as

of

those,every
treatise
on

which

is valuable

it is

yet the

only

still

so

little

of which there is obstetrics, physiological in aid known, and wnl, we hope, deliveringoar

Reviews
from specialty
rests
01

and
the
mere

Notices

of

Boohs.
which
not

693

noble aefinea

imputation

under

quently it still fre-

being

empiricism, and

guided by well
like
most

and physiological
ox

pathologicalrules

other

branches It
some

medical

science.

of is,

course, impossiblefor us to more various salient points of interest and

on

than

notice briefly In the

importance.

chapter

the
the

physiology of

brief mention

made

published in
the minute

find necessarily we pregnancy, of the very latest researches and discoveries medical journalsof the last few years, such as of
of the the the placenta, various
nature

structure
causes

of

placental
of the find
:

the respiration,

foetal

the presentations, condition

changes
cervix

in

the

maternal

the body generally,

etc.

uteri

In the
the
cause

during chapter on

pregnancy,
"

pregnancy

we Physiology of Parturition the setting-inof labor explained as follows or advances a fatty degenerationof the decidua

The

"

As

takes

place (which
month),
the
uterus

reaches the

its climax

at the

end

of

the

tenth
ovum

lunar
and
as a

whereby
and

organic connection
becomes the terminal when

between

the
ovum

gradually

solved, and

the

acts

foreignbody
of the
a

irritates

fibres of the motor-nerve

this imtation has reached

uterus, the sympathetic;

of is

certain

degree,a corresponding reflex action, in

the
uterine
as

the form

of

contraction contraction is

muscular
soon as

fibres,takes requisitesum

place, which
of irritation successive
ovum

repeated

the

again

obtainea

contraction the uterine

being
wall,

this rotation continues, each ; and intensified by the separationof the therefore
ovum

from

and

stronger

and

more

rapid,until
is admitted consider weaker it and that
a

the

expulsionof the
but possible,
; the

takes

place.
uterine is contraction
to

The
as

nature peristaltic

of

the

it practically

thoughtbest
being
much

simultaneous
less dense simultaneous

fibi'es or
of the of

the cervix

than

those

body
the

contraction

fundus, latter, whereby

or

it is evident

the

ovum

is

will gradually overthe womb, come opening pressed against the resistance of the circular fibres of the cervix, dilate the and latter,

the

of

expel the
the
"

ovum.

The
"

force of the
the

uterus

during parturition
to

varies

in different
tonus

individuals. of

According
and
amounts

Schatz, the
cles mus-

pressure

which

uterine

abdominal
to 5

exerts

of mercury.
the

upon This

the uterine pressure

rises

contents

centimetres intervals tween be-

remains

the

same

in the

pains,and

of the
has

uterus contracting

been

expelled from
Schatz has is divided

only in the intervals when the muscles begin to thicken after a part of the foetus the uterus, and particularly during the
it to amount
to 80-250

when pains,

found
into

milliiuetres.

Parturition

three stages :

I
Heviews Notices JBooTcs.
; 2.
"

694
I. The

and

of

stage of dilatation of the ob uteri expnlBion ; 3. The stage of the after-birth.

The classificationof the
(

The

stage

of

is exceedinglysimple : presentations
ft

{t. Face J1-Cephalicend on, 1 ". ^1 ThelongitudinaW -Breech

I2. Pelvic
end

Head

fPresentation

{J" J^^ [presentation

II. The transverse. is then divided into a firsts of of these presentations Each the more forehead, accordingas frequentoccurrence occiput, back, and shoulder respectively point to the lert side of the mother, and into a second^accoidingas the parts mentioned side. pointto the right Tlie two forces which effect the expulsion of the foetus are :
the ovum, produced by the contractions of the muscular fibres, the internal uterine pressure *' (Schatz), pressure
ovum on
"

1. A

uniform

and dilates the internal pressedagainst 2. The tendencyof the uterus,during its contractions, to OS ; and "the round the assume form, power" (Schatz), form-restoring is shortened, the diameter foetus whereby the transverse

by

which

the

is

breech forced towards the fundus and through the vertebral column, the head pushed into the pelvic inlet Both these forces exert their full influence only after rupture of the membranes, and through them are produced the various which makes fcBtal in order the head movements to regular the diameters the of pelvisand pass through adapt itself to This adaptation of the longest diameter that canal. of ^e the the diameter is the main of foetalhead to canal, pelvic longest mechanism of the of given by Schroeder, principle parturition the of which will not allow to enter. mto our us particulars space " In the chapter The Dietetics of Parturition," on as regards

the straightened,

posture
suitable
atter

during confinement, the dorsal positionis considered while the head is only in the brim and cavity of the
"

but irrational in the expulsive stageproper, because in the {"elvi8, be forced,opposed its the head gravity,
must to
own over

the

ascendinginclined

is then the position better still, lateral position such as the exaggerated side with the body bending forwards, If the abdominal walls are tense and face position (like Sims's). (ifnot, a binder will press the uterus towards the lumbar verteof the child against the head is thus forced by the gravity brse), and the perinseum is only the anterior wall of the pelvis, fact distended of for the preventionof note a wortliy slightly which in the dorsal position ui primiparse rupture of the latter, is by experience shown to be almost unavoidable, at least in a
"

plane preferred, or,

or

the

pelvicfloor ;

"

tlie

696

jReviewa
the
curved

cmd

Notices
instruments
novel

of
we

Books.
find of
among
"

Among
Brami's

craniotomy

enumerated

and trephine-perforator various

cranioclast, Barnes's

craniotomy
etc., with
ments

forceps,the
manner

kinds
Braun's

cepbalotribes,
the instmor decollator,"

the

of

their
226

application;
281
are

for of
"

embryotomy

is mentioned
to

Schlusaelhaken, Anomalies

Pages
of

devoted
as

to

the

tion descrip-

the

Bony Pelvis," such

the

the

generally
pelvis

uniformly

contracted
or

pelvis;
the

flat pelvis ; the rachitic

and

tracted generallycon-

pelvis, (comprising contracted

flat

generallyunequally
pelves of

contracted

non-rachitic

origin) ;

the

the kyphotic, the spondylolisthetic,

funnel-shaped

anchylosed obliquely contracted, the anchjloeed rowed narcontracted, the osteomalacic pelvis, the pelvis transversely the with their various suband varieties, by osseous tumora, attitude of the influence of the contraction the position and on and termination the mechanism, course, consequences, on fcetus, and of of labor, the treatment parturitionto be emploved in the
narrow

contracted,the

pelvis. Among the Passages,"we find mention

of the
a mucous

"

Lacerations

of the Soft
the

l^arturient

made

of the lacerations
between in

occasionally
caveraoos

occurring
urethra
tissue
nature

membrane

clitoris and the

; even at that of

very may

tear superficial

the vascular

spot
not

be

followed

by
not

great loss of blood.

(The

text-books, is

hemorrhages, they being spoken and known, they may therefore be generally for uterine flooding, mistaken and the proper local treatment by until be omitted a compression and styptics great amount of
blood
has been

these

of in the

lost, as

was

the

case

in several
our own a

cases

which

came

to

our

knowledge, although not

The immediate and

under

observation."^*??.)
lacerated
is perinsenm doubt that it be
no

recommended,
is the it is statea of

union, by in our opinion

sutures, of
there

can

As regards the etiologyof eclampea, proper treatment. that nothing definite is yet known, and the theories and

Frericlis, Ilalbertsma,Traube,
treatment

Bosenstein

are

related. roform, by chlo-

The
An
on
"

of

the convulsions

is absolute

narcosis

chloral, or, best, morphia.

not always found interestin^article,

in

text-books,is tiiat
turition," duringParthe

Premature

and Kespii-ation
treats

JJeath

of the Child
the

which
fcetal

of

the

effects of

compression of
premature

brain,of the umbilical

cord, and

admifision

of air to
with

the foetus in premature of by the investigations

cidated as eluprincipally respiration, B. S. Schultze, wno, tqgether and

Ilohl, Stolz, Cajeaux, Kiwisch, Huter, in the that the disturbance himself, observed
^ases
in the

Schroeder

of interchange

the foetal

increases placenta considerably pulse,and attributes this increase

the f reqnencv oi of to the paralyBis

Meviewa
the

amd

Notices

of

Books.

697

which paralysisis nerve, vaguB and of the vagus irritation a decrease foetal heart-sounds. The
is

always preceded by
in the

an

frequency or
is due
to

the
the

view

that

"

the

originof puerperal fever

the

absorption
the

surface of the wound," septicmaterial from the theoiy this is Schroeder one adopted by ; substantially in 1847, with that the modification advanced by Semmelweiss the poison need not be of cadaveric originonly,but may proceed from The any itself
"

of

organic substance
may
"

in

infectingmatter
external

be

derived
"

process of decomposition. either from the infected from

"

organism
"

auto-infection There is it

or

it is introduced

without

infection.

fever,'' neither
transferable."
"

in puerperal nothing specific but reallycontagious, only manually

is

The
cases

fever,and
of

show the pulse, especially

in

general peritonitis.Tne
C, or even that it only rises
with in
a

great variations times sometemperature, which

rises to above

41"

42"
to

low, so strikingly
remissions

C, is in other 39" C., and very

instances able considerFever

alternate

complete intermissions.
very
acute state

may

often
very

be

absent entirely exudation.

copious
It is

The

of

there is case, and where the pulse is more stant con-

frequent than would always small, and always more be expected from the degree of the temperature. Yet this^ also is not without etc. exception," " " If the accoucheur takes all these precautions (the prevention the of decomposed oreanic matter to being brought peral puerstruments cleanliness of sheets, scrupulous woman; sponges, in'^ and the clothes of hands, physicianand nurse^, he will not Tbeforced to give up his obstetric practicefor a time, if has attended who puerperal fever happensto occur." A nurse deceased puerperal to be a careful, being less likely woman, admitted be after. should not to a new soon case Against the of high temperature, the methodical long continuation cation appliof cold water, in the shape of the cold,or gradually cooled, vals bath, and the cold wet sheet (the latter to be repeated in interuntil the temperature falls), is strongly of a few moments is highly In mild cases recommended. the purgative treatment of for the neutralization spokenof, and the use of the sulpnites and veratrine tne septicmatter, and of digitalis Barker, (Elliot,
and
V.

Griinewaldt) for the reduction

food and
book
an

of the

fever,is mentioned.
be

Good
The

abundance
"

Sf wine should
not

given,even
Infection

when
"

tliefever

is considerable.

closes with

Diseases

Due
in the

to

the

last article

being
veins.

on

"

Sudden

Death

Puerperal State,"
of air into

by

embolism

of the

pulmonary

artery, and

entrance

the uterine

698

Heviews
have
we

and

Notices

of

JSooha.
exhaustive
in in
our

Although
of this
to show
are

we

not

attempted
we

to

give an

review endear"9

work,
to

trust

that

nave

succeeded

its merits

and
been

vahie, and
able
to

glad
Let
us

have

by aiding a deserving pay

its distribntion tribute

to its

talented

author.

not, however,
book.

German-speaking

to forgetthe translator, portionof the professionowe

whom
the
a

the

non-

pleasureof
detect
any

perusing tnis

He
and

has

done have

his work
not

in

generally reiy
to

we manner, satisfactory in the language material discrepancies

been

able the

of the

translation.
exterior
p.

The of the
f. il

print is good, tne few

book

illustrations fair, and of its contents.

generallyworthy
Notes J.

CuNiCAL

on

the

Electrio

Cautery

in

UxERmK

Suegeet.
St.
etc.

Byrne, M.D., M.RC.S.E., Surgeon-in-chief to Mary's Hospital for Diseases of Women, Brooklyn, " New Co. York William Wood : 1873, pp. m.

By

In order and learn take

minute various

to to
a

supply
enable
book and in

want

found

in all works well

as

on

Female suigeon

eases, Disto

the

as gynsecolo^st

the

from
much

time of

3iort penod what otherwise a trouble to acquire,viz.,the nature

used

it wonld of the and

cases

kinds
details such
an

apparatus

for

electric
in the

caatery

the in has

of the vnodus

operandi
now

numerous

which

operation

is deemed

enumerated

various

batteries

the necessary, in use, such

author
as

Bunsen's,

Grove's, MiddeldorpfiPs, Stohrer's, Grevet's,commenting on their fied relative merits,but expressinghimself not as completely satiswith their qualities, they being either too bulky and expensive, reliable or powerful in proportion touieir not sufficiently or then describes size. He new a battery,devised and used by
him

for the last two

twelve
as

vears,
*"'

which

"

consists

of

twelve
and

carbons
1

and
so

zincs,each
an
"

by

5
or

inches, combined
cells of three

arranged
By
in

to

represent four
of
to

sets

means
a

electro-tension

disc/^the
two
or

pairs each." maybemade battery

cells.
or

moment

represent either
of

four

This 12

batteir

heats No. has this

can

from
21. been

6 to 8 inches

No.

16

wire,

over

inches

of

This
used

battery is very by Dr. B. in

is
:

neat, compact,
numerous

and

and portable,

inglygratifying results.
apparatus
be

The
"

^eat
much of

operations with nnvaiyprinciple illustratedby

greater thermal

First
120

That

power
in
"

obtained of small
manner,

from

inches

suirace,

by a represented
indies

number

certain

connected and plates(3 x 5),combined than can possiblybe produced by 378

Reviews

and

Notices

of

Boohs.

699

'when

elements

four

times the
same

the size
in

are

employed^ the intensity

cases, and each

arrangements
of consisting
one

being
two

of

these

vessel.

Secondly. A
about

battery immersed in cells, compound open battery of two cells also in one fluid,
inches
amount

both

each

representing
elements 8
two

70
like

of
of

negative surface
zinc
or

in

the

aggregate,
the of
in carbons

opposed to a measuring
and
8 zincs

positive metal,
cell made up

5 inches of

by 1^,
same

and

each

the

size,alternately arran^a

purposes

results for most surgical rows, will give better thermal than either of the preceding." More efficient stul,if

but necessary, 18 zincs, each open A

also

more

li inch

expensive, would by 5 inches, divided

as

be

18

carbons

and
sets
or

into

three

instead cells,

of two,

in the

preceding.

power
m a

of explanation of the extraordinair increase satisfactory small tlius of number t he produced by miiltiplying plates is it is the to to not battery give ; perhaps owing easy portional proin surface of with contact amount brought greater fluid ? advance

the

The
in

fact

itself is

and incontestable,

most

tant impor-

Dr. hints

Byrne
he
as

has

electrology. employed the

of which

relates

electric cautery in 72 cases, 18 valuable at length, and gives besides many

the manoeuvres operations, often the pedicle of a to slip the wire-loop around necessary used the self fibroid speculum polypus, by him during -retaining is Ulustrnted the operation, etc.* The work excet by numerous lent illustrations of the batteries, cauterizers, loop-instruments, and We various

to the

details of the various

operations.
an

desire to correct
is

erroneous

statement at
a a

on

page
of the

62,
Kew

which York
in the uteri the

reportedto have
of
a

been

made

meeting
error

Obstetrical
case

that viz., Society, fibrous

in the

fatal

in

diagnosis
fundus within mistaken

poljpusspringing from
ctinic of
the
was

the

had

occurred of

Professor

Scanzoni

last two

years,

in which

thepedicle, the patient and Having repeatedlyexamined in March, 1867, and .assisted at the operation, occurred which in in of Vol. V. ScansonPa was Beitrdge zv/r 1869, published the that a ssert Gebv/rUhande^ we can positively diagnosisof
in consequence.

for the base

uteri, being and the patient died extirpated,

fundus

chronic

inversion

of the uterus

was

absolutely certain
was

when

the All

operation of amputation of the

tumor

decided

upon.

***

For

a
**

fall Notes

descriptionof
on

this speoolnm

see

this Journal
first

These Medicai nal and

Electric
and

Gauteiy^'

were

for Angnst, 1871* York printed in the New

Becord,
other

December

Janoaiy, 1872-3,

and

reprinted

in

this

Jonr-

leading periodicals.

700
doubts

Reviews
to the

and

Notices

of
had

Boohs.
removed
and

as

nature

of the tumor

been

by
of

ful, care-

repeated examination per va^nam, rectum, although they had previouslyexisted in the minds
saw

vesicam,
all who
sion inverdebflithe

the case, and

had been

two

vain

attempts

at rednction
was

of

made.

The

patient,who

very

mnch

tated
on

the inverted nterus, died by frequent hemorrhage from the sixth by slight day of pure exhaustion, accompanied

local

We this correction consider in pelvicperitonitis. proper, of Scanzoni's skilf al diagnostician. vindication as a I'eputation
p. F. M.

The

Handbook

fob

MrowivES.

By

Henky

Fly

Smfth, B.A.,

1K.B., Oxon., M.R.C.S. Co. " Boston, Mass.

This than
and

Green : Longmans, Engl.,etc, London 158. James : Campbell, 1873, pp. all the

book

contains

information, perhaps
who is entrusted is the is with
case

even

more

necessary, to a management of a normal the continent

conversant

midwife

the in
to

whole

confinement, as
and who the

England
ciently be suffi-

of with

Europe,

required

conditions signs of the pathological and to be able to recognize them occurring during parturition, call in

the

timely aid
no

of

physician.
to

In

this

ever, oountiy, how-

where with
the

female
of
an

able

bear

the

expense
even

will

dispense

an physician, ordinary confinement, a book like this seems hardly necessair, of the it is too elaborate for for understanding of the majority who the female have nurses only to carry out the directions of the attending physician,and do not need to be acquainted with and the anatomical, physiological, pathologicaldetails of parturition.

services

educated

during

however, that it would not be well if monthly nui'ses were acquainted with these details and as presented in this book, and they are clearly concisely in course of time they will be trained somewhat trust tnat u
do
not
mean

We

to

say,

"

"

the

midwives

are

in

Europe,

with

less

power

and

range

of
far

functions, however, than there ; for, in our opinion, and as there is an as our experience goes, the institution of midwives A discossion of this point a necessary one. evil,and not even Manual of course exceed would our space. Schroeder, in his " It is tne duty of that attendant of Midwifery," says : to assist the woman and carefullythe deed, and tQ| watch by word interferes of the labor,in order that course anything which with its normal that the actual course may be removed, and be of accident or occurrence immediately recogmay Ganger
"

nized

and

proper

means

at once

taken.

As

role,these

daties

JReviews

and

Notices

of

JBoohs.

701

be denied performed by trained midwiveB, but it cannot that for their task. It they are only very improperly qualified is of the lying-in woman just the prophylactic treatment but that skilled a obstetrician, physician requires not only a his science. of the branches with all thoroughly acquainted midwife A is only able to recognize pathological conditions fully developed,and after she has recognized them, is forced
are

to

summon

medical
it

certainly not
In

conducive
seems

man, to the
to
us

so

that Dr.

the

loss

of book

time

is

safetyof
that

the

woman." parturient
will be

America,

Smith's

of mind who turn chiefly of interest to ladies of an inquisitive and desire become indeed veiy correctly, to not a unnaturally, little better acquainted with the mysteries of child-birth, and with of infants. To these we the management can mend recomfitly it ; there is a great deal in it which need, any lady may that and should which momer know, and nothing may every do harm. woodcuts and The are quite numerous very good, and book very neatlygotten up. the whole p. f. m. Eepobt Columbia Hospftal Women Lying-in

of

the

fob

and

Asylum,

Thompson, A.M., Washington, D. C. By J. Hakey M.D., Surgeon-in-chief.With an Appendix. Washington : Government Printing-OflSce, 1873, pp. 430.
This

report, the discussion

of which

has been

unintentionally

of all the principal operations delajred,comprises a summary in the "Columbia per^rmed by the author Hospital for from March, 1866, to June, 1872, witli short reports Women," Diseases Diseases of of Children," and eases Dison Women,"
" " "

the

Eye Hospital.

of the

and

Ear," from
of

the

Dispensary connected
out-

with

The
was

total number

patientsadmitted, both
cured, and

and

in-door,
in

11,455 ; of these 9,457

In addition
to
a

number

were 1,081 relieved. of operations and related cases

detail, of which
of

the

operations for
and

the

uterus, rectocele
some

ruptured perinseum, prolapse and hsemorrhoids, cystocele,

contain

deserve

mention,
of the

of
Such

the

chapters
the

elaborate

counts ac-

and history, setiology, pathology,

are

treatment

of the

affection in

question.

chapterson

carcinoma, the

histology, pathology,and prognosisof which are discussed in a manner worthy ot a monograph on cancer, on foreignbodies in the female diseases of the vagina and blaidder, on cervix, on uterine The various and others. Dispensary report tumors, Diseases of Females consists almost on a or entirely long discussion by the author (Dr. F. A. Ashford, Assistant-Surgeon
" "

702
in

Reviews

and

Notices

of

Boohs.

condifioos of the variety and of symptoms charge of section) " metntis and endometritis,** and comprised under the heads the the larger portion of their and on treatment; report " Samuel Dr. of C. Diseases Children," by Busey, Physician-in" cholerais the Entero-colitis, chapterson charge, occupied by The Talue and and dentitio difficilis," on infantum, dysenteria, of bronchitis,"the latter being of certain drugs in the treatment
" " "

the enumeration

of

number

tion,and

the
"

discussion Diseases
of

in that aifeo of expectorants used of their therapeutical properties. The the

chapter on
cases

of
the

Eye and

Ear" of

gives
diseases

list of of
the

196
ear

of diseases
at the

treated and
and
"

eye and 38 cases by D. Webster Dispensary

two

Prentiss, A.M., MJ).,

consists

of mainly
do
not

articles

on

"^erpes

of the Cornea"

Trachoma,"
we

the deserves "Eeport" still Bcathingcriticism given it in a medical journal of this citj, cannot we help expressing our disappointment at finding so in the book, and our little original matter opinion that "e cases of voluminous the so port. a republication reportedhardly wantint " the bulk of the of is In fact, made quotations, Keport up

While

think

that

this

"

extracts, and

descriptions taken from well-known, especially in themselves, certainly valuable are Grerman, authors,which well read in A of fair be but can the number just as original.
woodcuts
illustrate

the book.

p.

f.

k.

Fistula, H-fiMORRHoms, PAmrmi

BUS,
AND
AND

TJloees, Stbtctijkb, PbolapTHE

OTHEB

DISEASES
Bv

OF

BeOTUM,
and
pp.

THEIB

DIAGNOSIS

Tkeatment.
etc.
:

William

At.t.inqham, F.R.C.S., England,

Second

Edition, *Eevised
"

Enlarged.
265.

delphia Phila-

Lindsay

Blakiston, 1873,
of

Tms

little volume
discussion
as

treats

the various
last 50
or

affections
less

of

the

tum rec-

mentioned
to

in the title, only the of

a

pages being devoted

common

the

few

other

more

rectal

such diseases,

rectum,
removal from

rodent

of the cancer pruritus ani,impaction of faeces, villous tumor, neuralgia recti, proctitis, ulcer,

of

struation gonorrhoea of rectum, and vicarious mencoccyx, the rectum. from material The is taken princi^lly cases

4,000

of rectal
in

diseases

met

with

in St. Mark's

Hos-

?ital, he book is written

of
cases are

in addition

to the extensive
an

privatepractice of

the author,
accounts

easy,

manner. pleasant

Short

and alto^ther it accomplishes frequentlyintermingled, ffie author if concisely, what in Ins very satisfactorily, for his claims to give the non-specialist preface object,viz., ticularly parclear and of a a applicableknowledge very preva"

704
there is no

Reviews
of necessity

and Notices
a

of Boohs.

series of stitchesto close the septum, of those used for the closure of the perinaeam. independent " be used for the quill That the interrupted suture. can (3^ " of is division That not to cure. (4) sphincter necessary " sutures That the superficial (5) mpy be dispensedwith." the head of Vesico-vaginal Fistula the author refers Under and gives a careful literature of the subject, to the modem and r^sum^ of the history, treatment. He causes, dia^osis, of Dr. Sims, Dr. McGuire, and his describes the operations Uis directions are simple and plain struments own. ; the necessary inwell described and illustrated. A largenumber are and carefully of cases are minutely reported. well merit this more These two monographs durable and convenient form in which theynow appear.

Ekbatum. In the foot-note at the bottom of page

"

459

of this

volume,the

second line should

read,

fluid of uterine

and not ovarian^ as printcystsinvariably coagulates,'' ed*

"

[Editor.]