CASE OF

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DILATATION.

TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SURGICAL JOURNAL.

SIR,

On Tuesday, the 17th of August, two stone operations took place at the Lowestoft Infirmary, one patient was a boy, 8 years old, the other a female, aged 19, from the neighbourhood of Cromer. As the calculus removed from the female was of rather large dimensions, and accomplished with great facility by means of dilatation, I am induced cursorily to notice the case in your Journal.

Many of our best surgeons are divided in opinion as to the safest mode of extracting calculi from the female bladder. There are some who deem an incision the best practice, and who assert that the use of the knife is less frequently followed by incontinence of urine than when dilatation is employed. Stone in the female bladder not being of frequent occurrence, experience does not permit me to offer a decided opinion on the subject. I am enabled, however, to state, that in a couversation which I had the privilege of holding with Mr. Crosse, of Norwich, a few days after the operation, he informed me he had had repeated experience of both ways of proceeding to relieve a female patient of stone in the bladder; and that he was fixed in the opinion that dilating is to be preferred to incision, when the calculus is of moderate size, and even when the size of the foreign body cannot be satisfactorily estimated, or is believed to be large, he prefers commencing by the dilating process, until the finger can be freely admitted into the bladder, when cutting can then be practised to the extent required. The dilatation, he moreover remarked, should be effected slowly, and most gradually, and uniformly; when these rules have been observed, he has known the power of retaining the urine permanently re-established after the removal of calculi, the smallest circumference of which measured from four and a half to five inches.

In the case which came under my own notice I employed Weiss's dilator. The process of dilatation was commenced at eight in the morning; at the end of every two hours I visited the patient for the purpose of giving the screw of the instrument from a quarter to half a turn. By six in the evening the urethra was sufficiently dilated to enable me with facility to introduce the index finger of my left hand into the bladder, and to feel a calculus, which I judged to be of considerable size. By the aid of a pair of moderate-sized lithotomy forceps, I easily embraced it, and then cautiously and gradually commenced its extraction, which was effected at the end of about half an hour. It proved to be of the mulberry kind, of an egg shape; its longest circumference measured four inches and a quarter, its shortest three inches and three quarters, and it weighed exactly

an ounce.

For about ten days after the operation there was more or less incontinence, but after that period it gradually decreased, and the urine could be retained

Nothing particular occurred in the course of the operation performed upon the boy. A calculus was extracted, composed of the triple phosphate, which weighed one drachm.

I may here remark, that upon every occasion in which I have been called upon to cut for the stone, I have scrupulously avoided the employment of any kind of gorget, and that the last twelve patients, whose ages have varied from sixty-eight down to two and a half years, have been operated upon successfully. I remain, Sir,

Your obedient servant,

W. C. WORTHINGTON, F.R.C.S., Senior Surgeon to the Lowestoft Infirmary. September 14, 1847.

CASE OF CATARACT OCCURRING IN
EARLY LIFE.

By AUGUSTIN PRICHARD, Esq., Surgeon, Bristol. (Read at the Annual Meeting of the Bath and Bristol Branch of the Provincial Medical and Surgical Associa tion, held at Bristol, July 22nd, 1847)

At the December quarterly meeting of this Associa tion, in the year 1845, I had the honour of introducing to the notice of the gentlemen present a country lad, 17 years of age, who had been the subject of congenital cataract, and upon whom I had operated about three days previously. The case terminated by the boy having fair sight with one eye, sufficient to enable him to work in the fields by digging potatoes, and to look after horses. Beyond this he had no ambition, and he was so satisfied with his acquirements that I could not induce him to learn a single letter. I have recently been fortunate enough to meet with a much better case, which I will lay before the Society, relating all the particulars as I noted them down at the time, with the remarks of the patient in her own words.

Ann Harris, aged 27, was brought from Abersychan, beyond Pontypool, to the Eye Dispensary, and was admitted a patient on the 16th of June.

She had good sight when she was born, but in her. third year she had a severe attack of small-pox, which destroyed the left eye, and from that time the right began to fail. The right eye also suffered from the same attack, which has left a slight central corneal opacity behind it.

When she was admitted the left eye was completely sunk; the right presented a fully-formed white cataract, with the corneal opacity, and a remarkably healthy and active iris. She has been blind (or nearly so,) for twenty-four years out of the twenty-seven which she has lived. She could make out the colour of objects when held very close to her eyes. She is very intelligent and quick, and her memory is good. She has been in the habit of doing all the baking and washing of her mother's house, and her mother whose sight is now failing from old age, is accustomed to

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28th. It is now rather difficult to find a common article which she does not recognize. I held up one of my gloves with the fingers spread out, and asked her what it was. She was puzzled for a time, but at last she guessed "a pair of gloves.". Now this she had not seen before, but she knew the form of the hand and its colour, and she could see that the glove was not my hand, for I held it up to her, and she could also see that it had the shape of the hand. And thus within little more than a week after the operation, she could put together her experience so as to make out that the object which I held before her was a glove, or as she called it, "a pair of gloves."

July 2nd. A fortnight after the operation. I found her walking in the court. She could see the flowers, and could count the buds upon a rose tree at the distance of a few feet; and she could see the yellow anthers of a white lily, and the separate petals.

5th. She took a walk through the city and was very much interested by seeing the shoes, hats, watches, &c., in the shop windows, She pointed them out herself, and knew them at once, and described them to me afterwards, expressing great pleasure at being able to distinguish them.

8th. She was shewn a dove : she soon learnt to know it, and she could distinguish the ring round the neck. She expressed great delight that the first bird which she saw should be a dove, as she had heard so much about the dove and Noah's ark. She can see the windows of the houses at a considerable distance, and could distinguish that some were open and others shut, and she could see something moving in one of them, this was a child at play.

12th. She continually says that she is ashamed to look any one in the face. Whenever she attempts it she begins to laugh. When she was shewn a portrait painted in oils, of the size of life, she could distinguish the eyes and nose, but she began to laugh in the same way. Among the plates in a work upon Natural History, she recognized at once the picture of a bird, and pointed out its head and tail, (for she had learnt birds, having seen a dove,) but she could not tell a fish. From a drawing-room window she pointed out a horse and carriage, passing up the street, and said that there was a lady in the carriage. I shewed her the picture of an Indian, with a thick club in his hand; she said it was a man with an umbrella.

It is now upwards of a month since the operation, and the state of her eye is as follows:-There is a portion of perfectly clear pupil in the centre, and at the external part of the pupil, through which she sees. The most solid piece of the lens is below, and is gradually diminishing by absorption. The corneal opacity is in statu quo, and seems to be of but little consequence. The sight improves considerably from one week to another; a four-inch convex glass, which brings the rays to a focus upon the retina, very much improves the powers of vision, with it she can see to distinguish large letters from one another, although she does not as yet know any of them.

in two or three months' time, when the lens may be expected to be absorbed, and then she will be furnished with a suitable glass, and I feel no doubt that if no unforseen accident occurs, she will learn to read and· ́ write in a very short time, and to do everything by p her sight, as well as she has hitherto done by means:** of the sense of touch.

OBSERVATIONS ON PLACENTA PRÆVIÀ.

By JOHN JONES, Esq., Surgeon, Derby,

(Read before the Provincial Medical and Surgical Associa tion, at the Anniversary Meeting, at Derby, Thursday, August 5th, 1847.)

It is upwards of seventy years since the following rules of obstetrical practice were promulgated in this country by the late Dr. Rigby-1. That în cases of hæmorrhage, caused by presentation of the placenta, the safety of the mother, and probably that of the child, can only be secured by early and cautious delivery, by the operation of turning. 2. When hæmorrhage occurs during labour, without presentation of the placenta, rupturing the membranes is usually sufficient to restrain it.

From the time of Dr. Rigby's invaluable "Essay on Uterine Hæmorrhage," published in 1775, till recently, the above rules have been considered the established and only authorized guides of practice under circumstances of the most appalling responsibilities in which the practitioner can be placed; and in ínnumerable instances, supported by the assurance that security can only be obtained by turning, he has performed the important duties imposed upon him with firmness and efficiency; and in most cases when the operation has been judiciously and cautiously · performed, has been the happy means of rescuing the mother, and not unfrequently her offspring, from inevitable death.

"

"On this subject," Dr. Blundell observes, the general rule is that you should introduce your hand into the uterus as soon as you safely may, and that, you should abstract the child by the operation of turning, On this point there can, I presume, be no difference of opinion amongst competent judges, at least in the present state of knowledge, so that the mind is not here, as sometimes, distracted or disturbed amongst a variety of practices, each of which may : have nearly equal claims to its adoption."

The practice of turning in placental presentation, if adopted sufficiently early, not too hastily, and with all necessary caution, is very generally successful. That fatal cases should occasionally occur where such great dangers exist cannot be matter of surprise. The life of the patient in these cases is peculiarly in the hands of the practitioner; if he is inexperienced, too anxious or timid, has never before attended a case

of placenta prævia, and the rule of practice is not clearly defined and well understood by him,-if his mind is distracted or disturbed by having a variety of practices presented to it, each of which may have equal claims to adoption, he becomes undecided, vacillating, and temporizing,-he delays adopting the mode which affords the best chance of saving the life of his patient, and allows her to sink without having been delivered, or, perhaps, performs the operation of turning when her energies are too far expended, and under such a state of exhaustion, his very haste to deliver accelerates the fatal catastrophe.

The usual causes of failure in performing the operation of turning are:-1. Waiting too long for the dilatation of the os uteri before commencing the operation. 2. Too great haste in performing the operation.

1. Waiting too long for the Dilatation of the Os Uteri. However unanimous the profession has hitherto been in considering turning the right practice in

placenta prævia, teachers of obstetrics have differed as to the proper time for performing the operation.

The following directions are given by professors: Dr. Hamilton says, "If possible, delivery should never be attempted till the os uteri be dilated, and the membranes begin to protrude." Dr. Burns says, "Whenever we find the os uteri softer, and in any degree more open than its usual state, and it admits the finger to be introduced easily within it, we may deliver safely, and if the hæmorrhage be continuing ought not to delay." Dr. Merriman observes, "It is necessary that there be a certain degree of softness and dilatability in the uterus; but the dilatability is not always to be judged of by the actual dilatation of the part, for sometimes in hæmorrhage, the os uteri will be very capable of being dilated by art, though it hardly seems sufficiently open to admit a single finger." Dr. Lee says, “It is seldom safe to attempt delivery by turning before the os uteri is so far dilated that you can easily introduce the points of the four fingers and thumb within it, however soft and relaxed it may be. Until dilatation has commenced and proceeded so far, I am convinced there are very few cases in which the operation will be required or completed without the risk of inflicting some injury on the os uteri."

That such discrepancy of opinion should exist amongst the teachers of midwifery on a subject of so much importance, is greatly to be lamented, and must tend to produce in the practitioner indecision and delay, at a time when firmness, promptitude, and decision can alone give security to his patient.

As the hæmorrhage usually occurs between the sixth and eghth month of pregnancy, and there is no probability of preserving the life of the child before the seventh month, it becomes desirable, of course, to postpone delivery till after that period; therefore, if the os uteri be but slightly patent, the hæmorrhage recurring but not continuing long, delay might be justifiable and we might rely on the plug and other usual means for restraining the hæmorrhage. But as the reasons for delay refer principally to the safety of

the child, and the life of the mother is continually in danger till delivery is effected, if the os uteri be soft and dilatable, although it may not admit more than a single finger, and if the hæmorrhage continue unabated, and consequently the danger urgent, the operation of turning should immediately be performed. Hæmorrhage has a direct tendency to relax the os uteri and render it more dilatable, consequently a rigid os uteri, co-existing with dangerous hæmorrhage, might be considered a rare occurrence, and can seldom be sufficient cause for delay when the hæmorrhage exists to a dangerous extent.

2. Too great haste in performing the Operation of Turning.—If delivery has been delayed till the energies of the system are greatly expended, and symptoms of exhaustion are induced, the danger of turning becomes proportionably great ; and inconsiderate haste in effecting delivery under such circumstances, is not unfrequently followed by the speedy death of the mother, after having given birth probably to a dead child. As the introduction of the hand into the uterus usually

restrains the hæmorrhage by exciting uterine contraction, and also by mechanical pressure on the placenta, there can be no just cause for haste; on the contrary, the safety of the patient depends on the slow, cautious, and deliberate efforts in performing the operation of turning, so as to effect delivery without

reference to time, but solely with the view of supporting to the utmost extent the nearly exhausted energies.

Eleven cases of placenta prævia have come under my immediate observation, out of which only one terminated fatally.

The first occurred many years since, in which the hæmorrhage produced such a state of exhaustion, that I expected the patient would have died during the operation of turning. Very cautiously introducing my hand, scrupulously avoiding haste, alternately working and resting, and thus allowing time for the energies to

be recruited, which in this case was of the utmost

importance from the extreme exhaustion of the patient, and after continued efforts of about fourhours duration, delivery was at length effected. She following year was again pregnant, and safely delivered recovered without any unfavourable symptoms, and the of a healthy child, without the occurrence of any untoward circumstance.

In another case the hæmorrhage had occasionally recurred for some weeks previous to delivery, but was of short duration. At length it became more profuse, and was accompanied by symptoms of labour; the os uteri was dilated to about the size of a shilling, soft and dilatable. Turning was easily effected, and the mother was safely delivered of a living child.