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her any relief from the ordinary means of medical treatment, which have been properly and perseveringly tried, has consulted with me as to the propriety of attempting a cure by a surgical operation. I saw the patient to-day, and finding no sign of disease external to the brain, to which the convulsions could be referred, agreed with Dr P. as to the propriety of attempting to relieve her by applying a ligature to the common carotid artery of one side. It was decided not to use choloroform, as generally hazardous in operations of importance about the head, and for such a one as this, and in such a case, as particularly imprudent.
5th. Operated to-day, assisted by my brother and Dr Alfred Brush, Dr Pitcher and some other medical gentlemen being present. The vessel upon the right side was selected, and tied above the omohyoideus, a slight enlargement of the thyroid gland interfering with the artery below. No chloroform was used. Pulsation immediately ceased in the temporal and facial arteries of the side, upon tightening the ligature, but no perceptible change in the feelings of the patient was experienced.”
The above is an extract from my note-book, kept at the time. The relief afforded by the operation was immediate. The ligature came away on the twentieth day, long before which time pulsation was re-established in the right temporal. Constant service upon a remote frontier has until recently prevented me from hearing the subsequent history of the case. Dr Pitcher reports (July, 1853) that “the aura has never returned, neither have the grave and convulsive forms of the disease; but within the past year, when exercise is omitted, and any unpleasant mental disturbance takes place at the same time, very slight returns of the petit mal occur, but never to occasion loss of consciousness. The health of the patient is now perfect. Her temper, which had been rendered irritable by the disease of her nervous centre, is very much improved, and her appreciation of existence greatly enhanced.”
For more than three years she was exempt from seizure of any kind.
The history and statistics of ligation of the carotid have been made the subject of a valuable essay by Dr Norris, of Philadelphia.' His tables show that this operation, though several times performed for cases of epilepsy, has never been successful for the cure, but all have recovered from the effects of the operation. He says that “the idea of curing epilepsy by tying the carotid seems to have been founded on false principles.” It is certainly difficult to reason upon this matter, when the pathology of epilepsy, the species designated as centric epilepsy especially, is so imperfectly understood. Should it depend upon a functional derangement of the relation between the arterial and venous circulation within the head (as probably in the above case), a measure which would so materially diminish the force and volume of the blood sent to the brain as ligation of the carotid, would seem, if not expressly indicated, at least to demand a trial. It is true, the difficulty of diagnosing cases in which this derangement operates must ever exist; but the above case certainly shows that the most aggravated forms of the disease may arise from some such cause, and that mechanically checking the volume and force of the arterial blood poured into the brain may restore the balance and effect a cure. The operation has never proved fatal, though uniformly, till the present case, unsuccessful as a cure; but with the experience of this one, productive of so much benefit, restoring the patient from a state of existence too horrible to endure, to the comfort of health, it seems to me that, in proper cases, we should not be justified to abandon it entirely.--American Journ. of Med. Sciences.
[The great difficulty in all such cases is to determine whether the operation acts locally on the brain, or only like many other things in epilepsy, simply on the imagination of the patient.]
I Am. Journ. Med. Sciences, July 1847.
OBSTETRICAL SOCIETY OF EDINBURGH.
Session XII.-Professor Simpson, President, in the Chair. ON RECURRENT ABORTION AND PREMATURE LABOUR. BY DR KEILLER. Dr Keiller directed the attention of the Society to the frequent recurrence of abortion and premature labour in the same individual, and made some observations on the various predisposing and exciting causes which are supposed to operate in such cases. Dr K. mentioned several illustrative cases, and stated that he had recently attended a patient who had aborted, or given birth to still-born or putrid children, in seven out of her ten pregnancies. The fol. lowing are the particulars of the case referred to.
Mrs F., æt. 32, married ten years, has had ten pregnancies, of which three terminated in miscarriages, four in premature births, and three in the delivery of full grown children, now alive, their ages being respectively nine, seven, and five years. Knows of nothing of any consequence in regard to her previous health that could account for her losing so many children. Has had, however, several attacks of jaundice, both before and after marriage. The results of the ten pregnancies were :
Ist. Male, now alive. 2d. Miscarriage at about third month. 3d. Miscarriage at fifth month. 4th. Female, now alive. 5th. Miscarriage at six weeks. 6th. Female, now alive. 7th. Female, premature about seventh month, dead about ten days. 8th. Male, about full time, dead about ten days. 9th. Male, premature, about eighth month, dead about eight days. 10th. Male, premature, about seventh month, dead about seven days. There was nothing peculiar in the deliveries except in the two last, the one being an arm presentation, the other requiring the placenta to be detached from the uterus, and removed piecemeal, there being considerable hemorrhage during its removal. In the former case the placenta was hypertrophied, and presented the usual characters of fatty degeneration. In the latter case, the cord, although unusually thick, was easily lacerated, the coats of its vessels being evidently diseased. The placental structure was also found to be fatty.
The causes assumed for the abortions were extra fatigue, etc.
The three living children were nursed, 11, 14, and 20 months, during which time she did not menstruate except one month, before weaning the last child.
She usually fell in the family way immediately after weaning her children, only “altering once afterwards.” And with all the abortions and dead children, did not menstruate oftener than twice or thrice between each.
She felt occasional “ stitches and pains in the side” when pregnant with the still-born children.
TURNING IN CHEST COMPLICATION. BY DR MOIR. Dr Moir communicated the particulars of a case of severe chest complication, in which he succeeded in safely expediting delivery by the operation of
NEW SERIES.-NO. II. FEBRUARY 1855.
turning. He stated that during one of his visits to the Maternity Hospital, in which the case occurred, he found the woman sitting up in bed, the breathing so laboured as to lead to the fear of immediate suffocation; the lips livid, and the utmost distress depicted on the countenance. As a chance of possibly alleviating the patient's sufferings, he at first resolved to induce premature labour. With that view, and as a means of inducing it as early as possible, a sponge tent was introduced into the os uteri, and warm water was also injected into the vagina. He, however, did not think it advisable to allow the woman to pass through the various steps of labour, believing that she would have died under the pains, if at all severe, accordingly, so soon as the os uteri was enlarged to the size of a crown piece he proceeded to turn, and delivered the patient without much difficulty. She was at first a good deal exhausted, but ultimately did well so long as she remained under Dr Moir's care.
NOVEL VAGINAL PLUG. Dr Keiller exhibited a vaginal plug, which had been used in a case of concealed delivery and suspected infanticide, with the view of obviating the discovery of any lochial indication of the recent delivery. The plug consisted of & considerable sized oblong or somewhat conical shaped bag (hurriedly constructed out of a piece of old striped petticoat, or corset cloth), and stuffed, so as, from its form and saturated appearance, to have thoroughly answered its intended purpose—that of a well-fitting and sufficiently absorbing plug. On making a section of this rude tampon of undoubted home manufacture, it was found to be ingeniously stuffed with bran!
Dr K. stated that it was found along with the dead body of a child, which he had examined medico-legally, at the instance of the authorities.
INCISION OF CERVIX UTERI IN CASES OF RIGIDITY OF THE OS IN LABOUR.
Dr Simpson communicated some observations on the propriety of incising the cervix uteri, in certain cases of rigidity, and referred to the lacerations which frequently take place in the os in natural labour ; from the occurrence of such natural wounds, Dr S. deduced the propriety of having recourse to artificial wounds or lacerations in some cases. A conversation followed on the various modes of artificially dilating the os uteri.
Extra-UTERINE CONCEPTIONS.—Dr Simpson exhibited three specimens of extra-uterine conceptions, and made some remarks on the cases.
PREMATURE LABOUR INDUCED BY WARM WATER INJECTIONS. Dr Thomson mentioned the particulars of a case in which he had adopted this method with success. The patient had, in her previous labours, required interference in consequence of defective brim. The child presented by the feet, and considerable extractive force was required to complete its delivery. A conversation took place on the various modes of operating with the douche, and several cases were referred to by the members present.
OVARIAN TUMOURS. Dr Simpson stated that he had recently seen a very large ovarian tumour discharging its contents by the urinary bladder, and made some remarks on the modes of performing " paracentesis," and the rules in regard to the first operation. He had now discontinued the use of the abdominal bandage while operating, the position of the patient lying well over on her side he considered, from his experience, sufficient.
VaginAL MELANotic TUMOUR.-Dr Simpson exhibited a melanotic tumour found in the vagina, and made some remarks as to the rarity of such a case.
CASE OF SPINA BIFIDA. Dr Keiller stated that he had visited, along with Dr M‘Gregor, an infant presenting an aggravated form of spina bifida. The arrest of development was situated in the lumbar region, and from the large size and appearance of the tumour at birth, the vertebral deficiency seemed unusually great. When seen by Dr Keiller, the tumour exhibited the character of a large vascular fungus containing fluid, its surface was very livid, its walls thin, and as if altogether devoid of cutaneous covering, the skin apparently terminating in an atrophied and irregular form, at some distance from the circumference of the tumour. The child was in every other respect healthy and well formed. The tumour became more and more discoloured, and burst about the 8th day, when, by the escape of its fluid contents, it became quite collapsed. This was not followed by any immediate bad effects on the child, it continuing, although somewhat restless, to suckle as greedily as before the rupture of the spinal cyst. The now collapsed and undefended mass, however, took on an inflammatory action, which soon gave rise to considerable constitutional irritation, under which the child sank.
No minute post-mortem examination of the parts involved in the congenital deficiency was obtained.
TWO HEPATA SUCCENTURIATA IN A FETUS. BY PROFESSOR SIMPSON. Cases of malformation in which there exist small additional spleens, or spleen-lobes, are sometimes met with. Instances of analogous malformations of the liver are much more rare. Dr Simpson showed a recent specimen of this last malformation in a fætus which he saw and dissected along with Dr M'Cowan. The child was born with a large umbilical hernia or abdominal extraversion. The umbilical cord was provided with only one artery.
The mass of the liver was of the ordinary size, but two additional lobules were projected froin its anterior edge, and affixed to the inner surface of the abdominal walls. These two additional lobules were flat and button-shaped, being each about the size of a sixpence. They were connected to the anterior border of the liver by prolongations or thin bands of tissue, the thickness of whip-cord, and about an inch long.
The supernumerary lobules seemed, in fact, like two small portions of the liver which had become morbidly adherent during development to the opposite peritoneum, and then become gradually drawn out and pediculated, during the further growth of the parts. The intestines were also in several parts morbidly and firmly adherent to the abdominal peritoneum. · The case was probably an illustration of the origin or commencement of some malformations, in the results or effects of inflammation or inflammatory adhesions in the foetus.
Dr Simpson showed the uterus of a cow-the inner surface of which was studded over with a crystaline substance which he had not previously observed, and the nature of which he had not as yet examined.
THE PELVIC ARTICULATIONS IN PARTURITION, BY DR MATTHEWS DUNCAN, Dr Duncan first showed to the Society the dissected pelvis of a cow which had died on the day of delivery. This specimen had been exhibited by Mr Barlow to the Physiological Society, and he had pointed out the great mobility of the sacrum, the increased thickness and elongation of the sacrosciatic ligaments, the relaxation of the sacroiliac ligaments, and the formation of a large synovial cavity in the sacroiliac joint. Mr Barlow had shown that the change in the sacrosciatic ligaments consisted in the development of new longitudinal fibres of large size comparatively, and somewhat like the ribband-like uterine fibres described by Kölliker in the anatomy of the human uterus.
He then called the attention of the Society to the researches of the late Mr Zaglas, in regard to the natural motions existing in man in the sacroiliac joints, whereby the sacrum described a rotatory motion upon the centre of the sacroiliac articulation
Dr Duncan then stated, that in woman about the period of parturition there had been shown to occur a softening and relaxation of the softer tissues forming the pelvic articulations. Under such circumstances, the motions of the sacrum would be much more easy and extensive than at other times. Cases occasionally occurred where this relaxation proceeded to a morbid extent, but to these he would not refer at present. He stated also that obstetricians had hitherto erred in studying this relaxation chiefly in regard to the symphisis pubis. The most important point was the relaxation of the sacroiliac joints in connection with the rotatory motion of the sacrum, the nodding forwards of the promontory involving diminution of the inlet of the pelvis, and enlargement of the outlet; the nodding backwards, involving enlargement of the inlet, and diminution of the outlet; and even though this were only to a small extent, it was of the greatest importance, as a slight diminution in pelvic diameters was the cause of very serious consequences. This movement was slight at the promontory from its proximity to the centre of motion, and of course greater at the point of the coccyx, because of its greater distance from the centre of motion. This motion was strikingly analogous to that exhibited in the cow's pelvis. It would amount in the human pelvis to at least a line at the promontory, and twice or thrice that amount at the coccyx.
Dr Duncan then showed by a brief analysis of the circumstances of a female in the first and second stages of labour, how they were consentaneous with the best position of the sacrum in these two stages of labour. In the first stage, erect position, or straight recumbent position and absence of bearing down, coincided with the nodding backwards of the sacral promontory ; in the second stage, limbs drawn up, body bent forwards, muscular bearing down efforts, coincided with the nodding backwards of the coccyx, and enlargement of the outlet. To this also would contribute the separation of the thighs, and the contraction of the internal femoral muscles by their influence upon the pubic articulation.
Dr Duncan concluded with some reflections upon symphyscotomy,--an operation which, he believed, had been much misconceived. The first great error in regard to it was its proposal as a substitute for Cæsarean section. In pelves requiring this operation, symphyscotomy could be of little or no value. It was in cases of slight contraction that Dr Duncan thought symphyscotomy might some day come to be of service, although now its applicability would be more limited than formerly by the introduction of artificial premature labour. He would also suggest that the operation might now be done by subcutaneous incision, and be by improvements rendered of moderate consideration in itself. Obstetricians had also entertained erronevus notions in regard to the possible amount of separation of the symphisis without laceration of the sacroiliac ligaments. Dr D. had the previous day performed with Dr Struthers an experiment upon a pelvis taken at random in the dissecting room, and found that on cutting through the symphisis, the pubic bones separated without the smallest amount of force to the extent of an inch and a half; and in parturition, the relaxation of the sacroiliac ligaments undoubtedly permitted much more extensive separation without any injury to pelvic structure. He believed also that a certain amount of separation might take place spontaneously in natural labour when the child's head was with much force propelled through the pelvic ring.
Some conversation followed, in which the President Dr Simpson, and Dr Keiller, took part.
Dr Thomson stated the particulars of an interesting case of morbid alteration of the pelvic joints in pregnancy. Other members had seen similar cases.