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extension and counter-extension in fractures of the lower limbs, the application of adhesive plaster is by far the best. He refers to several cases in proof of this, which he has published in prior volumes of the American Journal,' and in the present number gives the particulars of three additional cases.
Dr. Shrady, speaking of the practice of the New York Hospital, gives the following account of the mode of treating fracture of the thigh there :"When a patient is admitted, there being generally a good deal of swelling present, the limb is placed upon the double inclined plane, until this has subsided. Then he is prepared for the application of the straight apparatus. The first step consists in the preparation of a double band of adhesive plaster, about three inches in breadth, which is cut long enough to extend from below the point of fracture on either side of the limb, forming a loop underneath the foot, a sufficient distance from the sole to allow of the introduction of a square block. This block is a little broader than the foot, and serves to prevent the pressure of the adhesive bands over the ankles, and also affords a firm point to which is attached a short cord for extension. The adhesive strap is applied smoothly to the sides of the limb, and a bandage over it, leaving the loop free, extension being in the meantime kept up by an assistant. The body belt and perineal strap are next adjusted, after which the coaptation splints are applied in the usual manner around the seat of fracture. Then the upper end of the long splint is placed in a pocket of the body-belt, the limb drawn down as far as possible, and kept extended by means of a stout cord over the foot-piece; this cord is attached to a ring in a large wooden screw, which plays through the block standing out from the internal surface of the splint. Next, the inside splint, extending from the groin to the malleolus, is applied; pads of blanket being stuffed in on either side, to adapt the splints to the inequalities of the limb. The last step consists in binding the splints together. Three strips of bandage are passed at equal distances from each other behind the limb; and their ends are brought forward between the limb and the splints, carried over the anterior edges backward over the outside of the apparatus, crossed behind, and finally brought forward around the whole again, and tied in front. By this arrangement a sling apparatus is made for the whole limb, at the same time that the splints are nicely secured to each other. The extending force is regulated by means of the screw in the block. This block, I should say, slides in a fenestrum, being secured at any part by a screw arrangement, by which means the proper distance between it and the foot can be regulated, in order to have the full advantage of extension."
The results obtained by this treatment may be judged of from the following statement of 74 cases, which involved the shaft of the femur, exclusive of either extremity. These cases were taken in the order of their occurrence. In 19 of the 74 there was no shortening, and in 55 it averaged less than threequarters of an inch. The ages ranged from three to sixty-four. There were 57 patients more than, and 17 less, than twelve. Of the 57 there was no shortening in 13 cases; but in the remaining 44, it was a fraction over threequarters of an inch. Of the 17 under twelve, there was no shortening in 6, and in the remaining 11 it averaged less than half an inch."
VIII. On the Secale Cornutum in Disturbance of the Accommodation-power of the Eyes. By Professor WILLEBRAND. (Graefe's Arch. für Ophthalmologie,. B. 4, Ath. 1, s. 341.)
When local hyperæmia is dependent upon a laxity of the walls of the bloodvessels, advantage attends, Professor Willebrand of Helsingfors, states, the employment of secale cornutum. He was induced to use it in these cases by the expectation that a means which acts so specifically upon the unstriped
uterine muscular fibre must excite some power over the analogous structure of the arteries, and which its hæmostatic action proves, in fact, that it does. During his investigations he soon became struck with the fact that the heart of persons employing it soon underwent contraction in all its dimensions, and that even within the first twenty-four hours-a circumstance which he has frequently verified since. The first case that came under his care was an example of exophthalmos, accompanied with enlargement of the thyroid gland and hypertrophy of the heart. After a few weeks' use of the secale the hypertrophy of the heart and thyroid, as well as the projection of the eye, much diminished. The patient, however, left off the medicine, and the exophthalmos returned worse than ever. Since that period he has employed the secale in various cases in which increasing the contractility of the muscles of the bloodvessels or other tissues seemed to be indicated. It was found of especial advantage in a disturbed state of the accommodation-power of the eye, especially induced by over-taxing the organ on small objects with an insufficient amount of light. Children from some of the schools have furnished the author with many instances, and they have always been relieved by the secale. He relates a case in which impaired vision was always brought on by sewing or reading, and wherein the signs of some amount of chronic congestion were visible. Relief rapidly followed, and when the affection recurred some months after, it was as speedily relieved. He has also found the secale of great use in several cases of acute or chronic inflammation of the eye, and especially in blepharitis and the pustular conjunctivitis of children, the case proving much more rapid, and relapse being much less rare, than when local means alone are relied upon. No benefit has been derived from it in granular conjunctivitis and
Proceeding upon the theory of its stimulant action upon the vaso-motoric nerves, the author has extended the employment of the secale to other local disturbances of the economy; and, as already observed, he has had frequent occasions of observing its transitory influence in hypertrophy of the heart, without having any reason to believe that it is of any permanent utility in affections of this organ, the heart always returning to its former size soon after the use of the secale has ceased. In many cases of both chronic and acute hyperemia it has proved of great service, and especially in cases of galactorrhea, and in indurations, tumefactions, and catarrhal affections of the uterus. Also, it has been very useful in enlarged spleen from intermittent fever, and when large doses of quinine have failed. It is especially indicated in the cases of relapsing intermittent depending upon enlarged spleen. In erysipelatous affections, it has often done good service applied externally as a cataplasm. The author formerly gave ten grains ter die, but now gives but five, combining it with magnesia, or, when chlorosis is present, with iron.
QUARTERLY REPORT ON MIDWIFERY.
BY ROBERT BARNES, M.D. LOND.
Physician to the Royal Maternity Charity, Assistant Obstetric Physician to the London Hospital, &c.
I. THE NON-PREGNANT STATE.
1. Case of Vesico-Vaginal Fistula. By HENRY THORP, M.D. Quarterly Journal of Medical Science, February, 1859.)
(Dublin By M.
2. Death through an Injection of Carbonic Acid into the Uterus. SCANZONI. (Beiträge zur Geburtsk. tome iii., 1858; and Arch. Gén. de Méd., March, 1859.)
3. A Case of Chancre of the Uterus. By C. KOLLOCK, M.D. (Charleston: Med. Journ, and Review, March, 1859.)
1. DR. THORP Contributes a practical paper on Vesico-Vaginal Fistula. He believes that the shield recommended by Bozeman has no advantage over the quilled suture when properly constructed and applied, and that the latter has the advantage of simplicity. The case he relates is that of a woman delivered of her second child, in March, 1856, after a tedious labour. A month afterwards a slough came away from just behind the neck of the bladder, leaving an opening of an oval form, through which a catheter passed from the urethra into the vagina; it measured an inch from before backwards, and three-quarters of an inch from side to side. The first operation was performed on the 30th of May, 1856. It was unsuccessful, but the opening was narrowed one-half. In August the actual cautery was applied, but the opening remained. In December, 1857, she was again delivered. A second operation was performed in July, 1858. The opening now was as large as at first. The operation was that of Dr. Hayward, of Boston, the object being to obtain extensive raw surfaces for immediate union, by separating the vagina from the base of the bladder to the extent of half an inch around the fistulous perforation-that is, splitting the vesico-vaginal septum into two laminæ, and so adjusting the fresh-cut surfaces of the respective flaps, that when turned upon themselves and retained in contact by quilled suture, they shall adhere and unite by the first intention. Dr. Thorp thinks it essential that the needle should penetrate the vesico-vaginal septum, so as to enter about two lines in front, and crossing the area of the fistulous perforation, emerge at the same distance behind the line of division of the membrane into two flaps, and should in its course precisely hit off this angle anteriorly and posteriorly, so that the ligatures when tied shall cause the quills to press together the cut surfaces at their furthest point from the abnormal opening-that is to say, at the divisional line already spoken of.
2. The observation of M. Scanzoni shows the hazard of gaseous injections into the uterus. In this case it had been determined to amputate the neck of the uterus in a woman who was pregnant, the pregnancy being masked by attendant circumstances. The father of the patient, himself a physician, wished to practise for a few days injections of carbonic acid into the cavity of the neck, hoping by this means to produce a contraction of the vessels and to obviate the hemorrhages which so often complicate amputations of the uterine neck. He tried a first injection with the aid of an elastic reservoir; but scarcely had two or three cubic inches of gas penetrated the gaping mouth of the neck, when the patient cried out that she felt air entering the abdomen, head, and neck. Immediately afterwards she was seized with general tetanic convulsions; respiration became laborious and stertorous; the pulse rapid, small; the extremities grew cold, and death followed at the end of an hour and three-quarters. The autopsy revealed nothing but considerable pulmonary oedema. The uterus, much thinned, contained a four months' fœtus; it seemed that the hypertrophy, of which the body of the uterus is the seat in normal pregnancies, had been entirely expended on the neck. The mode in which death was caused is not clear; but the case suggests that extreme reserve should be used in resorting to injections of carbonic acid, whether for the purpose of producing anæsthesia or premature labour. [For the latter purpose it is altogether superfluous, surer and safe means existing.-R. B.]
3. Dr. Kollock's case adds an instance to the rare observations of uterine chancre. It occurred in a woman, aged thirty-two. Two well-defined ulcers were observed-one on the parietes of the vagina, about an inch from the vulva; the other occupying the anterior lip of the uterus. They had every characteristic of the Hunterian chancre-greyish colour, excavated, with margins irregular and elevated; the vaginal discharge was puriform. In order to test this character, Dr. Kollock took pus from the chancre on the uterus, and
inoculated both thighs. Genuine Hunterian chancres were the result. All were cured by the internal use of bichloride of mercury and the topical use of caustic nitrate of mercury.
By J. MATTHEWS DUNCAN, M.D.
1. On the Cervix Uteri in Pregnancy.
2. On the Normal Hypertrophy of the Heart during Pregnancy, and on its Pathogenic Importance. By Dr. LARCHER. Memoir addressed to the
Academy of Medicine, 6th April, 1857. (Arch. Génerales de Médecine, March, 1859.)
1. Dr. Matthews Duncan discusses the prevalent notion as to the progressive shortening of the cervix uteri during pregnancy. With Stoltz and Caseaux, he shows the error of this doctrine. He says the length of the cavity of the cervix uteri undergoes little or no change during pregnancy; the evidence of this is based on the inspection of gravid uteri, and on vaginal examinations. He gives outline sectional views of four cervices of different stages of gestation, one taken from Coste, one from William Hunter, and three from dissection, which establish his proposition. With regard to the evidence from vaginal examination, Dr. Duncan cautions against being misled by the frequent obliteration of the vaginal portion of the cervix, this being only a fictitious, not a real shortening; he advises to measure the length of the cavity by gently intruding the finger through the external os uteri, as can generally be done in advanced pregnancy, in multipare, and frequently in primiparæ.
Dr. Duncan further affirms that, 2, the capacity of the cervical cavity becomes gradually greater as pregnancy advances; and this is effected by an increase of its diameter, or breadth, advancing from below upwards-that is, from the external to the internal os of the cervix. 3. The length of the vaginal portion of the cervix, or the amount of its projection into the vaginal cavity, generally diminishes as the uterus rises into the cavity of the abdomen. 4. The softening of the cervix uteri, already commenced superficially during the menstruation preceding conception, continues, and extends more deeply into the substance of the cervix, as pregnancy advances; and the process is generally completed two or three months before the end of utero-gestation. This softening is attended by a considerable increase of bulk. 5. In vaginal examinations during life, after the middle of pregnancy, the finger of the obstetrician feels the uterine cervix as if it were gradually shortened according as pregnancy still further advanced.
[Similar views to the above are advanced by Dr. Arthur Farre, in the article Uterus, Cyclopædia of Anatomy and Physiology; and in the April number of the Edinburgh Medical Journal' is another sketch of the cervix of a gravid uterus, taken from a dissection forwarded to Dr. Duncan by Dr. Barnes. -REPORTER.]
2. The memoir of Dr. Larcher points out a most important physiological consequence of pregnancy. He affirms that, in the human species, the heart is normally hypertrophied during the course of gestation. The proposition is so interesting that it is desirable to cite in detail the evidence upon which it is based. M. Larcher was interne to the Maternité at Paris in 1826 and 1827. His observation bore mostly upon women aged from eighteen to thirty-five, and their number was so great as to present in turn every imaginable variety of temperament and organization. Some had been ill a long time before delivery, some for a short time; but the greater number had preserved perfect health to that event, and had almost all succumbed to puerperal fever. This is
to say, that no internal disorder, no lesion, had preceded or excited in them hypertrophy of the heart. Hence the conclusion is rigorous that we were witnessing a physiological condition, spontaneous, necessary-a condition which could derive its explanation only from the new conditions produced by pregnancy. One hundred and thirty observations were made. Taking for standard the relative proportions of the ventricles of the heart laid down by Laennec, it is assumed that the walls of the left ventricle have naturally a little more than double the thickness of those of the right. In pregnancy this is no longer so; the aortic ventricle is manifestly hypertrophied, the thickness of its walls is increased by a fourth at least, by a third at most; the right ventricle and the auricles preserve their normal thickness; the left ventricle only becomes thicker, firmer, and of a deeper red.
In the physiological condition, the heart thus temporarily hypertrophied in pregnant women imparts to the circulating movement a greater energy, which is revealed to auscultation by the bruit de soufflet, as is the case in every other hypertrophy of the same order; and it is this greater muscularity of the redblooded heart that enables it to provide at the same time for two beings.
On the other hand, in the diseased condition this normal hypertrophy becomes a danger, and may determine or augment various functional disturbances.
The observations of M. Larcher were cited by Dr. Ménière, in the 'Archives Générales de Médecine,' in 1828; who, discussing the subject of cerebral hæmorrhage during pregnancy, referred to this normal hypertrophy of the heart as perhaps the cause of the cerebral effusions.
In 1837, Dr. Jacquemier, then interne at the Maternité, established the bellows-sound in the precordial region during pregnancy; and M. Larcher declares that he has observed the constant relation between this sound and the hypertrophic condition of the left ventricle, always verified by dissection.
In 1843, Dr. Beau, having regard to his own researches on the sound of the arteries, seeking to verify Dr. Larcher's fact, requested M. Ducrest, then interne at the Maison d'Accouchements, to take the measurements of the walls of the heart in a certain number of women who might die after labour. M. Ducrest drew up a statistical return based upon the examination of 100 women, mostly aged from twenty to thirty, who had died in childbed; in all the measure of the walls of the heart was taken at the thickest part of the left ventricle. The maximum of this thickness is 0.018 millimetres in 5 cases; it rises even in one case to 0.022 millimetres; the lowest figure is 0·011 millimetres in 8 cases; in the greater number the thickness is 0.016 millimetres; the mean is 0·016 millimetres. If this mean be compared with that of 0010 millimetres, given by M. Bizot as representing the normal thickness of the left ventricle in women, we find an excess of 0.005 millimetres. Hence it follows, says M. Beau in 1846, that the observations of M. Larcher are correct.
M. Larcher next insists upon the markworthy law of coincidence between the hypertrophy of the heart and of the uterus during pregnancy; and that the plethora of pregnant women is not an accident, but a constant physiological necessity. M. Larcher objects to the view of Andral, which assigns the relative diminution of the red globules as the cause of the bellows-sound in pregnant women. He observes that Andral's researches are based upon examinations of venous blood only.
The Pathogenic Importance of the Normal Hypertrophy of the Heart during Pregnancy-This condition quite coincident with health, when existing within its natural limits, contains a necessary predisposition to sanguineous congestions and hemorrhages. It may happen that this hypertrophy may gradually disappear after labour, or it may be otherwise. If pregnancies rapidly succeed upon each other, this condition of hypertrophy may be so kept up as to obtain permanence. It is quite conceivable that bronchitis, so common during preg