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along with it, some constitutional taint in both the mother and child; and he concludes his paper by remarking:

1st, That owing to some peculiar diathesis the process of ossification in the fœtus becomes retarded, and the power of resisting pressure during labour consequently diminished.

2d, During labour the maternal soft parts exercise a degree of pressure on the liver, proportionately greater as the ossification of the head is less complete. 3d, The diathesis alluded to, in conjunction with contusion of the liver, explains the fatal result in M. Charrier's cases.-Gazette des Hóp., 24th April and 5th May 1855.

INCISION OF THE VULVÆ FOR THE PREVENTION OF RUPTURE OF THE PERINEUM. BY M. CARPENTIER.

Two cases are described by this author, which, if they do not show the necessity of this proceeding, at least point out its efficacy as an operation. It was recommended by Michaëlis in 1810, since which time it has been practised by Weire, Eichelberg and other accoucheurs, and does not deserve the neglect into which it has fallen at the present day.

The first case related is that of a primipara where the labour had been protracted, the head of the child having appeared at the vulvæ, remained there, notwithstanding the strength of the pains, for nearly two hours. M. Carpentier then made an incision, not in the raphé, but laterally in the vulva, and this operation was scarcely completed, when a vigorous pain terminated the labour.

The other case was one requiring the employment of the forceps, which were applied without difficulty; but upon the head appearing at the vulva, the operator saw that extensive laceration of the perineum was threatened. He therefore confided the forceps to an assistant, who maintained them in position, while an incision in the vulva was made during a pain. The child was then extracted without any resistance.

It is well known that laceration of the fourchette is very common in first labours, and that in spite of all the precautions taken in supporting the perineum, it is ruptured in some cases as far as the rectum. Would then, asks M. Carpentier, incision of the vulva prevent such accidents, by substituting a surgical operation for a rent made by nature fortuitously and with violence? Insufficient statistics render any conclusion on this question difficult as yet; experience is required to show its true value as an operation. -Revue Medico-Chirurgicale, 1854.

ON THE CONDITION OF THE NECK OF THE UTERUS DURING PREGNANCY.

Such is the title of a memoir read by M. Cazeau before the Société de Chirurgie, and upon which M. Laborie has drawn up a report, with an interest and labour seldom bestowed upon this task, in the learned societies of the continent.

The neck of the uterus, in the pregnant female, has often been subjected to examination, as far as that can be made by touch alone; but it is only of recent date that another method of investigation, in this respect, has been afforded, in the employment of the speculum vaginæ, and it is the results obtained from researches by means of this instrument, that M. Cazeau describes. According to these observations, he states that, in primiparæ as well as in multiparæ, the vaginal portion of the neck of the uterus is of a dark red colour (lié de vin), and, in primiparæ, its whole surface presents a smooth appearance. The os uteri, of which the lips are very soft, is in general more or less rounded, and of a larger size than in the unimpregnated condition. The free portion of the neck in a very few cases exhibits ulcerations, and more frequently granulations of a cherry red colour, and bleeding easily. Among the multipare the neck is larger; the opening is divided into different portions; it is large, and the interior of it admits of being examined. The walls of this

part of the organ are irregular, and present a number of fungous elevations which bleed readily, in the hollows between which are occasionally observed ulcerations of a linear shape, and more or less deep. M. Cazeau regards these ulcerations as of little importance, and disapproves of any treatment for their removal.

MM. Boys de Loury, Costillies, and Coffin, consider the ulcerations of the first period of pregnancy, as having a marked influence in the production of

abortions.

Admitting so far this opinion, M. Cazeau rejects it in its application to the ulcerations of the last months of utero-gestation; and, according to this view, he proposes that no treatment should be adopted in the latter cases. Thus, with the exception of specific ulcers, M. Cazeau considers that the others should not be interfered with, and, unless an excessive tendency to spread were manifested, no local means of treatment should be employed. We give a resumé of the interesting discussion in the Society.

M. GOSSELIN does not consider ulceration of the neck of the pregnant uterus so frequent as M. Cazeau; nor does he think that it exerts any unfavourable influence on the progress of gestation. If such an opinion has been advanced, it probably arose from exclusively attending to ulcerations, and overlooking other morbid conditions existing during pregnancy, and which are the true causes of abortion: such are uterine catarrh, in which the uterus suffers as much as in the evolution of a foetus; leucorrhea; or even constitutional syphilis. There may be added to these the repetition of examinations with the speculum, or the injudicious employment of internal remedies. In short, M. Gosselin believes that the influence of ulcerations of the neck of the uterus in the production of abortion, is very doubtful.

M. DANYAU has investigated, at the Maternity Hospital, the condition of the neck of the uterus in 22 pregnant women. Of that number, 8 presented erosions on the surface, and a fungous condition of the neck; in 6 others the erosions occupied the os tincæ; the remaining 8 exhibited no ulcerations whatever, and the neck of the uterus was merely irregular in shape and of a violet colour. These last cases had reached the final period of utero-gestation. The erosions were generally accompanied by a uterine catarrh. Only two presented this uterine catarrh without any erosion.

M. CLOQUET considers these ulcerations of the neck of the uterus as more frequent in the last month of pregnancy. He does not, however, regard them as true ulcers, but as an enlargement (boursouflement) of the follicles and papillæ of the neck, or as a congested state of these papillæ, with abrasion of the epithelium. He compares them to the strawberry-like surface of certain hemorrhoidal tumours, bleeding like these upon the slightest touch, and secreting a mucous or a muco-purulent fluid. M. Cloquet has never considered it necessary to cauterise them, or to employ any other means than astringent injections in their treatment, when they occasion either discharge or hemorrhage. After delivery these vegetations disappear spontaneously, in the same manner as the hemorrhoids and varicose veins connected with pregnancy.

M. VOILLEMIER has found no ulcerations in a large number of women, arrived at the eighth month of pregnancy, who had been examined by him with the speculum.

He

M. GERDY has observed soft fungous erosions on the neck of the uterus in pregnant women; these erosions disappeared after the accouchement. considers that the engorged state of the veins from the sinking of the uterus, accounts for the violaceous colour of the vulva, the vagina, and the neck, and recommends the horizontal posture, with the view of relieving this

engorgement.

M. HUGUIER believes that four different affections of the uterus require to be considered separately; these are, catarrh, granulations, ulcerations, and the fungous condition of the neck.

1st, Catarrh. This occurs in nearly all women when advanced as far as the

last month of pregnancy, and, according to M. Huguier, proceeds from an increase, with or without inflammation in the mucous follicles, of the gelatiniform secretion, natural at this period.

2d, Granulations. He divides these into three varieties, one formed by an hypertrophied state of the papillæ and mucous membrane, and co-existing with granular vaginitis. Another consists of true vegetations, and co-exists with analogous vegetations on the vaginal walls or vulva. A third kind are situated round the os, and consist in an hypertrophy of the mucous follicles, or an accumulation of mucus within their cavity.

3d, Ulcerations. These he considers rare during pregnancy, but simulated by other states of the os and neck, from the muco-purulent fluid often lodging about it at this period.

4th, Fungous state of neck. This condition M. Huguier alleges to be the consequence of, and, in fact, inherent to pregnancy, and to consist in an inflamed, softened, and swollen state of the parts in the neighbourhood of the os tincæ. He considers these conditions as of trivial importance, and employs means of the most simple nature for their treatment.-Union Med., April 21,

1855.

Part Fourth.

MEDICAL NEWS.

MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH.
SESSION XXXIV. 1854-55.

February 4th, 1855.—WILLIAM SELLER, M.D., President, in the Chair.
ON LOCAL BLOOD-LETTING IN CHRONIC METRITIS. BY J. MATTHEWS DUNCAN, M.D.

(This paper was inserted in the last Number.)

In the conversation which ensued, several members thought that Dr Duncan had overstated the amount of blood drawn by a single leech (one ounce), and the average was considered to be two to three drachms. Professor Miller, however, remarked that everything depended on the locality; that whereas externally only two drachms might be obtained, on an internal mucous surface, one ounce was a fair average, and more was likely to follow by oozing. The President remarked that the old opinion was that the usual quantity was two ounces from an external surface, and parts favourable to their application, and he certainly thought that the smaller quantity was more frequently obtained than the larger.

Dr M. Duncan, in answer to Dr A. Wood, said that leech-tubes were still much in use in London and Edinburgh. With regard to the quantity of blood furnished by leeches he had merely mentioned the ordinary calculation, and did not speak from special observation.

Mr Struthers entirely agreed with the principles laid down in Dr Duncan's paper. Besides, there was no small risk of leeches opening some of the large veins in the vagina which possessed no valves, and would afford a large flow of blood. In his own observations on local blood-letting, he had no intention (as some thought) of making an alteration in our practice. His inquiry had been strictly an anatomical one, but its result went to confirm the established mode of treatment.

The President was inclined to believe that the application of leeches might exert a counter-irritant as well as a derivative action, and in his opinion no

theoretical view should influence our treatment of disease, unless the practical men also gave in their adherence to it.

ON THE DIFFERENTIAL DIAGNOSIS OF PNEUMONIA AND PLEURISY. BY W. T.

GAIRDNER, M.D.

It

Dr Gairdner said that he proposed to consider how far we possessed the means of accurately distinguishing those acute diseases of the chest which were at present described as separate nosological forms of disease. The inquiry was one of great interest; pneumonia, for example, had for years been regarded as the acute disease by which we tested our systems of treatment. was important, therefore, to know whether we could so mark it off as to be able, with sufficient accuracy, to make numerical statements as regards its cure by different remedial agents. Again, pneumonia was the disease on which homoeopathy and other late systems of treatment rested their claims, and in the treatment of which they boasted their great success. Up to the eighteenth century, we found pleurisy occupying the same relation to medical literature as pneumonia does now. Did this difference of names depend on a change in the nosological type of diseases, or was it not rather a change in the ideas of the observers, who applied different names to the same disease? He (Dr Gairdner) believed the latter to be the true explanation. A fallacy, too, of common occurrence was, that when we have ascertained a pneumonia to be present, a series of such cases can be submitted to treatment, and the results tabulated on the supposition that the cases are similar. Now, in his opinion, pneumonia in all cases was not such a clearly definable disease, and, even if we could distinguish it, we would not be any nearer the solution of the question, as it is a disease which varies infinitely, and requires for each case a separate adaptation of treatment. That pneumonia presents, even to well-informed and honest physicians, unusual latitude for diagnostic variations, Dr Gairdner illustrated by a copious enumeration of the various chances of error which must be taken into account; among which, special reference was made to pulmonary collapse, cases of which, from the identity of the physical signs, might be easily classed as pneumonias; and to bronchitis, in the course of which pneumonia so frequently supervened and escaped detection. The differential diagnosis of the two diseases was dwelt upon, and it was shown that in many cases the practitioner was necessarily foiled in his differential diagnosis. Should again there be an arbitrary exclusion of cases where the two diseases were complicated, we should have a very large proportion of the most dangerous and fatal forms of pneumonia got rid of, and the value of our tables so far vitiated. Again, one man might include and another exclude cases of pneumonia modified by some peculiar constitutional tendency, as fevers of specific type, Bright's disease, syphilis and gonorrhoea, delirium tremens, diabetes and tubercle.

In the pneumonia of the old authors, we had cases of pleurisy included; and Laennec considered the cases of pneumonia which he tabulated as more favourable for treatment, as by his improved methods of diagnosis he was able to separate the pleurisies from the pneumonias. And yet, of late years, the opinion had gained ground that the statistics of pneumonia would be improved by the addition of a few cases of pleurisy, which was a less fatal disease. The differential diagnosis of the two diseases, pneumonia and pleurisy, was criticised in detail; in the cases where the two affections are combined, Dr Gairdner believed it to be extremely difficult to indicate in a satisfactory manner to what extent the pneumonic and to what extent the pleuritic elements respectively were present. From an analysis of 41 cases of pneumonia occurring in hospital practice, it appeared that in only 8 was pleurisy absent, and of these 8 cases there were 6 where there was incipient broncho-pneumonia; in one there was incipient abscess, and in one there was hemorrhage of the lung. There was not a single case of fully formed and fatal pneumonia unaccompanied by a considerable amount of pleurisy. In 47 cases of pleurisy and fibrinous dropsy, there were only four cases of uncomplicated pleurisy. It resulted from these

considerations, that acute uncomplicated pleurisy and pneumonia occurred so seldom that any attempt to separate them in diagnosis must fail, as the elements for such a distinction did not exist in practice.

The President said he was glad to take this opportunity of stating his entire concurrence in the views of Dr Gairdner on collapse of the lung; this he did the more willingly, as in a paper which he(the President) had had the honour of reading to the Society, he had opposed the doctrines of Dr Gairdner on the subject. From Dr Gairdner's theory of emphysema he was still, however, compelled to enter his dissent.

May 2d, 1855.-WILLIAM SELLER, M.D., President, in the Chair.

CASE OF FATAL HEMORRHAGE, AFTER AN OPENED ABSCESS OF THE NECK. BY
JAMES MILLER, ESQ.

The patient was a laundry-maid, aged 41 years, and was admitted into the Royal Infirmary on the 3d of August 1854. A swelling on the right side of the neck had been first noticed about seven weeks before; and shortly thereafter Mr Miller first saw her, and found a hard indolent swelling low down in the neck, and with no impulse, which he considered to be an ordinary chronic enlarged gland. It was of firm consistence; and, some time before, supposed to be a tumour, its removal by the knife had been recommended. Mr Miller prescribed the local and internal exhibition of iodine, and sent her home. Some weeks afterwards, however, she returned; the integuments over the swelling were now red and swollen, and deep fluctuation could be made out. Formerly, the swelling lay above the clavicle, it had now extended below that bone, which almost ran midway through it. The danger of the case was fully recognised and explained to the patient. On admission, she felt weak and fatigued, complained of her breathing, and of a sick faint feeling. Beef-tea and wine in small quantity were ordered; and fomentations to the neck.

August 4.-She felt better. After careful examination with the stethoscope, the abscess was opened; Mr Miller at the time explaining, to the clerk and pupils, the risk of secondary hæmorrhage, that was inevitably incurred, by subsequent ulceration. The pus evacuated was considerable in quantity, and healthy in character. She felt relieved by the incision. Beef-tea was continued on account of difficulty in swallowing. 8 P.M.-The patient complained of pain in the abscess. There was no discharge. She was still weak and faint. She spat a good deal, but no blood. The abscess appeared to have shifted its position towards the mesial line.

August 5.-Noon. She had slept ill. The abscess was tense. By means of a probe, a quantity of foetid pus was discharged. Lint was placed in the wound, and the poultice continued. 8 P.M.-She felt easier. There was little discharge. She had spat a good deal. Nothing remarkable was observed in the sputa; there was no blood. The power of swallowing had returned.

August 6, 1.30 P.M.-She was easier, and looked better. There was healthy free discharge from the wound. At 5 P.M. (third day since the abscess was opened), she was seized with a fit of spitting of blood. Vomiting of blood ensued, and at the same time it flowed from the nose and from the wound. Her danger was imminent: she had cold sweats, involuntary discharge of fæces; and her pulse was very low. Wine was administered, the poultice was removed, and lint alone applied. 8.30 P.M.-There was no more hæmorrhage. Her sputa was slightly tinged. The pulse was very low. She complained of a feeling of pain in the right arm. The wound was again closed. At 9.30 P.M. another fit of vomiting came on. Clots of blood, apparently from the stomach, were expelled; and she died, partly of weakness and partly of suffocation.

The dissection, which was hurried, revealed a healthy condition of the various cavities. A large abscess had formed on the anterior aspect of the common carotid, and had made its way down to the level of the vessels. It had opened into the common carotid, about its middle. There was also a smaller abscess

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