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MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH.
December 20th.—Dr Seller, President, in the Chair.
The President made a few introductory remarks and thanked the Society for the honour they had conferred upon him.
ON THE STATICS OF PKEQNANCY. BY DR MATTHEWS DUNCAN, M.D.
Dr Duncan made observations on the three following subjects :—1st, on the position of the uterus; 2d, on the position of the child in utero; and 3d, on the position of the pregnant female. With regard to the first, he pointed out that the uterus was developed into the abdomen in the direction of the axis of the brim of the pelvis, i.e., at about an angle of 30* to the horizon, the brim of the pelvis being inclined to the horizon at an angle of above 60°. From these circumstances he showed that the brim of the pelvis was in no sense the part supporting the uterus. The uterus was supported on every side by the parts surrounding it much in the same way as a body floating and immersed is supported. The anterior abdominal flap being beneath the centre of gravity of the organ, was the part bearing the chief weight of the uterus. These circumstances afforded an explanation of pendulous belly and of the pain produced in the sides by the dragging at the insertion of the oblique muscles of the abdomen. The long axis of the uterus was inclined to the horizon in the erect position of the female at an angle of 30°, in the supine position it was more nearly vertical, being inclined at an angle of about b'0°. 2. As to the position of the child Dr D. said that the child in utero neither stood on its head nor carried itself in any position, but floated reposing in the liquor amnii in the attitude of stablest equilibrium, viz., in an oblique direction with its head lowest. From experiments which he had made he found the fresh foetus at the full time to float freely in a solution of salt of about its own specific gravity, in about the same position that it assumed in the pregnant female. Hydrocephalic children with large and heavy heads had been supposed to illustrate, by the frequency of their mal-presentation, the theory that the gravitation of their heads was not the cause of the ordinary position of the foetus in utero. But their heads though heavier in air were much lighter when floating in liquor amnii from the low specific gravity of the contained fluid. Consequently their mal-presentations could be equally well accounted for on the common laws of physics. Dr D. showed that the statistics used by Dubois, and others, to prove the uterine positions of premature foetuses, afforded no reliable conclusions. They showed only the positions during abortion or miscarriage, but nothing in regard to the position in utero before abortion or miscarriage. The statistics used by the same individuals, and their reasonings in regard to dead foetuses were utterly illogical, seeing that the altered statical circumstances of such foetuses were not known. Their frequent inal-presentations were probably the result of their altered circumstances. The uterus at the time when the child was becoming fixed in its position, was an oval cavity, with rounded glabrous walls, filled with a dense fluid, in which the foetus floated easily, with its legs, its chief organs of locomotion, highest. In these circumstances, it was almost impossible to conceive of its assuming, much less of its maintaining, any position against the influence of gravity. 3. Dr D. then pointed out the condition of the erect position in the virgin; showed how they were altered in the pregnant female; and illustrated the new conditions of the erect positions in pregancy. The centre of gravity might be retained in its usual site above the hip-joints, by the upper part of the trunk being moved backwards to counterbalance the pregnant womb. Or the centre of gravity might be moved forwards; in which case the hip-joints were moved forwards also, by the diminution of the inclination of the brim of the pelvis, as occurred in many cases of disease with anterior curvature of the spine.
Dr Simpson said that when he Drought before the Society, some years ago, the subject of the influence of excito-motory action as the kind of vital mechanism, by which the foetus assumed and maintained its position, he felt himself at a loss to explain some of the residuary phenomena, he believed that gravitation might so far explain them, but as yet he was not convinced that the gravitation theory was the only key to the solution of the whole question. We ( had the third position of Naegele occurring 28 or 29 times in every 100 cases of head presentation and the position thus assumed, viz., the back and occiput of the child lying to the back of the uterus was the very opposite to what we would expect on the gravitation theory. It was not suddenly assumed. We had the evidence of auscultation that this position had been present for weeks before. He did not believe that the death of the child had no influence in determining its position. With living children the proportion of breech presentations was about 1 in 60, but when the child had been dead for some days before birth, the proportion rose to 1 in 6. It was difficult to avoid the concln-' sion that the position assumed by the child was not a physical act, but one connected with life, it was lost with the loss of life, and was hence a vital act to that extent. Dr D. attempted to account for this frequency of breech presentations by stating that the statics of the child had been altered by decomposition which had taken place after death. But the first change observed was an enlargement of the abdomen, which ought rather to keep the head downwards than force the pelvic extremity upwards. In fact, after death the body of the child was subject to statical laws alone, and hence its new position. As to the argument from hydrocephalic foetuses, Dr D. forgot that there was a marked increase in the weight of the cranial bones, and yet in such cases the breech was found presenting in the enormously increased proportion of 1 in 6. To his mind, cases where there were twins or a recurrence of mal-presentations in single births with the uterus of a more or less irregular form, virtually decided the question, for were the position of the child solely dependant on gravitation, this irregularity of form should not interfere with the physical action of gravitation, and yet preternatural position frequently recurred in such cases. The subject was one of great extent, and would require much more time than could be given to it at such a meeting.
Dr Slorar maintained that if the position of the foetus was purely physical, and the result of gravitation and buoyancy combined as Dr D. held, then, when a woman turned round, the child ought always to turn more or less round on its longitudinal axis; and yet it did not make such rotation.
Dr Matthews Duncan, in reply, stated that his researches referred exclusively to the position of the child before labour; and all he wished to show was, that the position of equilibrium of the floating foetus was an oblique one, as in the human female. His investigations did not enable him to say whether in this oblique position, the child should float with back lowest, or one of the sides. Peculiar attitudes of the uterus or foetus, or the position of the liver, might explain the positions to which DrS. had referred. These questions had to be decided, before any argument against their production by gravity could be admitted. He held that we are in entire ignorance as to the altered statical relations of dead children, and therefore, no decision could be come to whether the mal-presentations in the instance cited by Dr S., depended on loss of life, and of power of motion, or on the possibly altered statics. He could furnish one fact, however, which might serve to elucidate this subject. In floating a six-month foetus, born dead, and with /the skin separating, in a saline solution of similar density to itself, he had found that the head remained the highest. This foetus in labour had presented the breech. The fact was a striking one, and was worth a cart-load of arguments. As to what Dr S. had stated with regard to hydrocephalic fectusus, he (Dr D.) was of opinion, that until experiments were instituted to ascertain the position of equilibrium of floating hydrocephalic children, we had no right to argue from what might possibly be the result of such experiments. He (Dr D.) believed that if the skull'was really found to be increased in weight, it would probably be counterbalanced by the increased density of the other parts of the child's body, the result of atrophy. Dr Simpson had alluded to cases in which mal-presentations were found to occur. Dr Duncan held that no argument could be drawn from such cases, till their whole circumstances had been investigated, and he showed that where the uterus was irregular in form, gravitation afforded a more satisfactory explanation of the position than the motions of the child. The object of his paper was not to discuss the position of the foetus in utero, but merely its statical relations, which, in his opinion, afforded an easy solution of many questions which Dr S. had referred to reflex actions in the foetus.
Dr Strachan had listened with great interest to the discussion, but he personally was of opinion that both gravitation and reflex action had to do with the position of the child, and that neither of these agencies could be defended as the sole producing cause.
_^ January 3, 1855.—Dr Seller, President, in the Chair.
ON A NEW METHOD OF INTRODUCING MEDICINES INTO TOE ST8TEM, MORE ESPECIALLY APPLICABLE TO PAINFUL LOCAL NERVOUS AFFECTIONS. BT ALEXANDER WOOD, M.D.
Dr Wood had been led to introduce solutions of morphia and Batley's sedative solution into the cellular tissue, as near as possible to the affected nerve, by means of the small perforating syringe, constructed by Mr Ferguson of Giltspnr Street, for injecting aneurisms with perchloride of iron. Dr Wood narrated nine cases in which he had employed this method of treatment, in all with perfect safety, in some with complete, in others with partial, success. As to the modus operandi of this method of treatment, he endeavoured to show, from the experiments of Muller and others, that the effect of the local application of opium to a nerve was to destroy its sensibility at the part, and that from this action of the drug the immediate cessation of the pain arose, fie then pointed out the rapidity with which absorption appeared to take place from the cellular tissue, which seemed to account for the rapidity of the narcotic effect which a small dose of opium so introduced was found to produce. He also pointed out, that other medicines might be introduced in the same way.
Dr W. T. Gairdner mentioned, that a patient in his wards in the hospital, had been injected the other day in the way recommended by Dr Wood. The result was not decisive, as the complaint for which the man was under treatment, viz., lumbago, had been undergoing rapid amendment, and, indeed, the day after the operation, was nearly gone. The experiment, however, was attended with little suffering, and it was noted that some degree of giddiness was almost immediately produced.
ACCOUNT OF THE CASES TREATED IN THE CHOLERA HOSPITAL, SURGEON SQUARE, DURING THE LATE EPIDEMIC. BY DR BEGBIE, JUN.
The hospital wus opened in September 1853; it was temporarily closed about the commencement of June 1854, to be again opened on the 24th of August; it was finally closed a little more than a fortnight ago. During the whole period there were admitted in all 243 patients, of which number only 45 were brought to the hospital during the earlier period, and 198 during the weeks which intervened between the end of August and commencement of December. Of the 198, no less than 168 were admitted during September and October, and 97 in September alone. Placing the numbers together, the experience of the hospital has been roughly as follows:—Total number admitted, 243; of these, males, 97; females, 145; total recoveries, 12(5; total deaths, 117; deaths among males, 43; deaths among females, 74 ; recoveries among males, 54; recoveries among females, 72. Among these cases, however, it must be remembered, that not a few are included which were not genuine cholera. Of 68 cases of genuine cholera, in which the condition of the patient on admission was accurately noted, 42 were in a state of profound collapse, and 26 were affected either with the characteristic discharges, or, these having been arrested, with some other combination of symptoms distinctive of the disease. Of the 42, 28 were females, and 14 males; of the 26, 12 were females, and 14 males. Of the 42, 36 died, and only 6 recovered; 26 of the 36 surviving their admission less than twenty-four hours. Of the 26 who had not passed into collapse, 4 died and 22 recovered. Three pregnant women were admitted affected with genuine cholera—all died ; two of the three miscarried. Two nursing mothers were admitted ; one died, the other recovered. Of 63 cases in which the occurrence or non-occurrence of premonitory symptoms was carefully inquired into and noted, there were 32 in which there was certain evidence of their occurrence, and 21 in which no such evidence existed. In almost all the cases of recovery from severe collapse, the patients became affected with febrile symptoms ; in but few cases, however, did these symptoms run so high as to deserve the name of consecutive fever. Of 13 cases in which a severe form of consecutive fever did supervene, 8 died and 5 recovered. Of these, 7 were males and 6 females. Of the 8 deaths, 4 were in complete coma; 27 deaths, 19 of females and 8 of males, took place in profound collapse.
Dr Priestley remarked on the great revulsion that had taken place in the minds of the profession as to the use of diluents, which in the first epidemic were nearly entirely proscribed. Dr Begbie had not mentioned whether he had employed them, and to what amount.
Dr Andrew Wood said, that the most striking fact in the paper, to his mind, was the fearful mortality among drunkards affected with cholera, and he should like to know from Dr Begbie if any teetotalers had come under his treatment, and with what results? Indulgence in the use of strong drinks, he was convinced, was one of the chief causes of the prevalence and mortality of cholera among our labouring population, and unless total abstinence was more widely practised than it was, he looked forward with dread to the return of the epidemic. As to the use of diluents, having been a sufferer from the disease himself, he could speak with some degree of confidence. The worst symptom to contend against he had found to be thirst, and this could only be relieved (and that most gratefully) by the sucking of ice. This his physician had only allowed in limited quantity, but finding it act so beneficially, he (Dr Wood) took it in pounds, and with the best results.
Dr W. Begbie knew that a few patients who had come under his care in the hospital were total abstainers ; he could not, however, give the exact number of such. The impression left on his mind was, that excessive indulgence in spirituous drinks appeared to act as a predisposing cause to attacks of cholera, while the condition of the system, induced by habitual intemperance, was manifestly one which made recovery from the disease more unfrequent than any oilier. He had allowed diluents in all cases; ice he had generally found most grateful to the patient.
Dr Alexander Wood thought that more had been made of the liability of persons addicted to the use of spirits than was proper. They were certainly not more lialde to cholera than to other diseases; and he held, that where intemperance was indulged in, provided it was unattended with physical wretchedness and want, no such marked liability existed.
Dr Simpson could not agree with Dr Andrew Wood as to the preventive influence of total abstinence ; and begged to remind him, that the nations among which the disease had raged with the greatest virulence were practical abstainers. He referred to the Turks and the Hindoos ; and, indeed, the whole Mahoinmedan races might be included in the same category.
Dr W. T. Gairdner was of opinion that the advocates of the preventive efficacy of total abstinence had overlooked two striking facts—viz., 1, the greater predominance of cholera in females than in males; and 2, the immense number of children who were attacked. Such evidence he felt it difficult to explain away, on the principles laid down by Dr Andrew Wood. Dr Gairdner alluded to the very ingenious theory propounded by the registrar-general, as to the influence of locality on the disease ; Mr Farr asserting that in low localities there was greater prevalence and mortality. Now, Dr Gairdner doubted whether this was owing so much to the relative altitude of the localities as to the poor circumstances of the inhabitants, who usually crowded together on level ground, along the banks of rivers, and the lines of greatest intercourse. In his opinion, Edinburgh, from its peculiar construction, with our huge back-bone of houses running from east to west, with the diverging closes and their rapid declivities, should be the experimentum cruris in the question. He had made inquiries among the poor-law officers, as to the relative prevalence of cholera in high and low localities in the town ; and, as far as the data went, they did not entirely support Mr Farr's theory. Lastly, Dr Gairdner noticed the presence of bile in the stools, and the good indications that were usually drawn from its reappearance. He had always maintained, as the result of clinical and post-mortem observation, that in cholera there was no want of bile in the liver and intestines; and he believed that where, from the appearance of the stools, it had been supposed to be absent, it was really present, though, from its diffusion in the intestinal discharges, the peculiar colour was lost. Any theory of the disease, and any mode of treatment founded on this presumed absence of the bile, must, in his opinion, be erroneous.
SIR GEORGE BALLINGALL ON THE NECESSITY OF IMPROVING THE CONDITION OF ARMY SURGEONS.
Sin George Ballingall has written an excellent letter to the Secretary-ofwar, from which we give some abstracts :—
"An extensive reduction of the medical staff, as well as the other departments of the army, is a measure which the public would no doubt most willingly contemplate. The great and praiseworthy anxiety which at present prevails in the public mind for the relief of our wounded soldiers and seamen, and the natural desire that those brave men who have so freely shed their blood in the service of the country, should meet with the most efficient medical treatment, seems to render this an opportune moment for entering upon the whole question; and I would desire to consider it in the following points of view,—the description of young men whom it is desirable to attract to the service—the objections, real or imaginary, which some of the most considerate and eligible students make to it—aud the means of obviating these.
"It is certainly not a wise policy to encourage young men to enter the army who do not intend to make a profession of it, but only look to spending a few years in a red coat, in the society of gentlemen, and then retiring into private life, not only without loss of time, but claiming credit for experience in their profession. That views of this nature are occasionally entertained, both by young men themselves and by their parents, I have reason to know, and have taken every opportunity of discouraging them. It is not for such men that I ain going to plead. But there are others who have come forward on the present emergency in the most commendable spirit, prepared to devote themselves to the most perilous duties of the service, and ready to take their places in the field and in the trenches. These young men have made themselves the children of the country, and I am well convinced that the public
■will be well disposed to treat them liberally.
• » • •
"I come now, sir, to the object which I more particularly proposed to myself in this letter, and which falls more especially within your province as the finance minister of the army—the half-pay and retiring allowance to medical
NEW SERIES. NO. II. FEBRCABY 1855. 2 A