Billeder på siden

or the other might be present to meet the indications as they


I saw Mrs. Haller for the first time early in the afternoon of the 12th, the flow was copious, the pulse small and compressible, with a tendency to drowsiness, and the pains weak and irregular. On examination I found the soft parts in a favorable condition for an immediate delivery. The os uteri wide open, so that the fingers of the hand used in manipulating could have been pushed into the cavity of the womb, had they not been obstructed by the placenta, which occupied and closed the passage. To the left the placenta was slightly detached from the uterus, and an opening wide enough to admit two or three fingers to pass between the placenta and the wall of the womb; which opening was enlarged by the fingers separating the placenta still more, till the fingers passed beyond and came in contact with the head of the child, which was engaged in the superior strait, the vertex presenting.

The nature of the trouble was now apparent, and the cause of the hemorrhage too plain to be misunderstood. An early and prompt delivery by some means was imperatively demanded to bring to a close this unpromising and perplexing case. Forceps might have been used and the delivery accomplished at once, I have no doubt; yet, I felt like resorting to other measures, and should they fail the forceps were ready, at hand, and could be applied.

The essential element, the contraction of the womb upon its contents, was wanting, and how to bring on the pains, and by what means, were the questions to be decided. Ergot promised as much if not more than any other agent. The fluid extract was selected, as a preparation readily taken and most generally retained. In drachm doses it was administered every half hour for several hours in succession, in sweetened water alone, afterwards with brandy, but to no effect. Two or three times our patient vomited and rejected everything she had taken. A mustard draft was applied over the stomach, and reapplied several times, in connection with warm applications to the feet, as they had become quite

[ocr errors]

cold, and were continued till the close of the labor. Thus far our remedies had been given in vain and our well directed efforts to bring about a favorable result had accomplished nothing. At this critical period Dr. Newton made another examination, ruptured the membranes and immediately commenced rubbing, briskly, the abdomen with the palm of the hand, and every now and then grasping the womb firmly with the hand. These manipulations were continued for some time before any material change took place in the force and frequency of the uterine pains. In the course of an hour or less, however, there was a marked improvement in the frequency as well as in the force of the pains; and the hemorrhage, which had continued to flow, now almost ceased, in consequence of the mechanical pressure of the contents of the womb against the bleeding vessels.

Between nine and ten of the evening of the 12th the mother gave birth to a still-born male child about seven or eight pounds in weight. The mother, though very much redaced in strength in consequence of the vast amount of blood lost, is in good spirits and doing remarkably well.

Cincinnati, O., Aug. 15.


Virchow's Views on Syphilis.

He divides the local syphilitic processes into three groups -the simply irritative (inflammatory, hyperplastic), the gummy, and the amyloid ; the first two belong actually to syphilis, the last to the syphilitic cachexia. Neither of the first two has added anything foreign to the natural elements of the body-anything in the sense of specific or heterologous, anything peculiar alone to syphilis. Every year, with all its abundance of new material for observation, confirms the author in the opinion that there is no more marked difference between the gummy tumor, with its mass of sypliilitic granulations, and a simple inflammatory granulation, than there is between roseola syphilitica and simple roseola. All admit that the same virus is within the body infectious,

without being contagious. The whole course of syphilis has much in common with that of malignant tumors. It begins, as a rule, with the indurated chancre; this induration corresponds to the mother nodule of the malignant tumor. It may extend in depth and superficially. Then the lymph-glands in the direction of the lymph-current are affected. Then the disease appears in remote points, at first in lighter, simply irritative forms, afterwards in the more severe, and at last in the gummy formations. In these last the induration of the mother nodule is repeated with the modifications imposed upon it by the nature of the local matrix. This is what in all other relations would be designated as metastasis. Whether this occurs through the blood and the lymph, or through the cells, is not yet clearly determined. This much is certain, that sooner or later there is an infection of the blood-a'dyscrasia is found to exist. Nor is this a permanent state. The idea of latency is to be explained by a metastasis already existing at the period when the original affection was healed, and which only after a certain period makes itself manifest. And so with regard to the tertiary products: if we give up the idea of a permanent dyscrasia, we must either admit a general diathesis of the whole body, a permanent syphilitic condition of all its elements, or else a still existing nidus, a deposit of virus in some given spot; and it is this view that the author does not hesitate to adopt. Thus, after the healing of a chancre and of the symptomatic buboes, a syphilitic hepatitis may continue to exist, without at first developing any symptoms; but upon some casual provocation it may be again excited, may attain increased development, and may become in turn infectious. By infection and the development of a new local nidus the process is made manifest. These views find their application in the history of congenital syphilis.- American Journal of Medical Sciences.

Diseases of the Urinary Organs.

We take the following abstract of Sir Henry Thompson's Lectures on Urinary Diseases from Braithwaite's Retrospect for July. Sir Henry Thompson is universally acknowledged to be the highest authority on affections of the urinary organs, and we feel assured that these extracts from his valuable Lectures cannot fail to prove acceptable to the readers of the Review:

ENLARGED Prostate.—One man in every three who dies above the age of fifty-five has some enlargement of the prostate, but only one in seven has any symptoms of it, and probably only one in ten requires treatment for St. The size of the prostate does not influence the degree of obstruction to the urethra ; it is the amount of enlargement of the middle lobe which is the matter of import. For ordinary use in prostatic cases the English gum-elastic catheter is by far the best. The point is generally not curved as it should be. The instrument should be well curved to the very point: with this object it may be kept on an over-bent stylet for a month; it will thus pass easily without a stylet, for the tendency to over-curve which the instrument possesses will ride it over the obstrucion into the bladder. The general treatment of prostate enlargement consists mainly in preventing local congestion, the most frequent cause of which is the undertaking long journeys, and exposure to cold.

It is a peculiarity in the frequency of micturition which exists in hypertrophy of the prostate, in common with all serious urinary diseases, that it is more urgent at night than during the day. This is an aid in diagnosis, and should be made a point of inquiry in investigating urinary diseases.

Diagnosis between Prostatitis and Calculus.--Pain in micturition from prostatitis is toward the end of the act of micturition, when the bladder begins to contract on the tender prostate; but when the pain is from an inflamed bladder, it is at the commencement of the act of micturition. Pain from calculus in the bladder also occurs towards the end of micturition, when the rough surface of the stone comes in contact with the mucous membrane. Pain from this cause, however, is very characteristic, it is increased by movement and is felt very acutely about the base of the glans penis. Pain froma prostatitis also sometimes occurs in the penis, but is less severe, and is not much increased by riding in a roughgoing vehicle, as is that from stone.

There is one point of great service in the diagnosis between prostatitis and calculus, especially if we wish to avoid the passage

of a cound. Tell the patient to pass a little urine so as to wash out the urethra, set that aside in a vessel, and then let him empty the bladder into a second vessel: If tho first only is thick from pus or mucus, whilst the second is clear, it is prostatitis; if the second is turbid, the cause of the turbidity is in the bladder, and may be stone.

FREQUENCY OF MICTURITION.- Whenever the natural characters of the urine are altered before it reaches the bladder,

the secretion produces irritation. Diluted or watery urine is often regarded as unirritating; on the contrary, it is not generally well retained by the bladder. In pyelitis, and in almost all organic Manges of the kidney, in Bright's disease, and in diabetes, there is frequency of making water. The bladder is always irritated by the pale urine passed by hysterical patients.

Précaution in Examining the Urine. Always first flush the urethra and take the urine in a separate vessel, say a wine-glass, and let the rest of the urine be passed into another vessel. If this is not done we get any matter from prostatitis or urethritis mixed up with the whole quantity of urine. A case came under Sir H. Thompson's observation which had been treated by a physician for months as pyelitis, whereas when the urethra had been flushed the rest of the urine was quite healthy, proving that the pus came from some part of the urethra.

STRICTURE OF THE URETHRADiagnosis.- When a case of stricture, or supposed stricture, is first examined, a fair sized instrument must be first taken, say No. 8 or 9. If there is a stricture you ascertain its position but do not expect the instrument to pass, whereas if there is no stricture it passes at once. When the instrument is passed through the first few inches of the urethra, it must be kept well on the floor of the canal in order to avoid the lacuna magna. The second place in which a mistake may be made is at the commencement of the membranous portion of the urethra, or rather, in the bulb, where the canal is wider and more distensible than in the membranous portion. It is the lower part of the bulb whiclì bags out and is so distensible, and consequently it is here that the point of the instrument is liable to catch, and, if force is used, a false passage to be made; consequently the rule in this part is to use an instrument with the point pretty well turned up and to keep it on the roof instead of on the floor of the passage. The last place at which there inay be difficulty in passing an instrument is at the neck of the bladder. We used to hear a good deal about “stricture of the neck of the bladder;" there is no such thing. It is simply because there is sometimes difficulty in passing the neck of the bladder that it came to be regarded as a locality of stricture. In this case also a well curved instrument is the best thing to get in.

There is no such thing as "impermeable” stricture. It is a contradiction in terms. Stricture is a narrowing of the canal; it is not an obliteration of it. A stricture always

[ocr errors]
« ForrigeFortsæt »