« 이전계속 »
and minutely to the aperture, where a sufficient cause
CASE OF RIGIDITY OF THE OS UTERI, of obliteration is manifest; carelessness, in this par.
TREATED BY INCISION OF THE CERVIX ticular, I fear, has led to misrepresentation, and been
UTERI. the cause of those errors on which I have presumed to comment. There is reason to apprehend, that in By Thomas BARRETT, M.R.C.S., Batb. transferring accounts of practice from the works of
(Read at the Annual Meeting of the Bath and Bristol Branch ancient practitioners, inaccuracies have taken place,
of the Provincial Medical and Surgical Association.) and routine has misled many men of talent. To clear away obscarities which still invite inquiry, I fear that
It must have fallen to the lot of every practitioner I have fallen into tedious circumlocution; but under.
in midwifery to bave met with cases where the rigid standing that there have been many fatal cases in
state of the os üteri has impeded labour, till the life France, and in our empire, and finding through the
of the patient has been endangered from the consequent press that the taxis, as a first step, is in unirersal use,
exhaustion and long continued pressure. That in a I am anxious still further to interfere, in the belief large majority of cases this rigidity will ultimately that fatality in cases of strangulation will very seldom
yield to the usual remedies of artificial dilatation, occur when my plan of treatment is adopted in the
bleeding, opium, &c., there is no doubt; but it is first instance. It has been very saccessful at the
equally certain that cases bave occurred, where the
rigidits bas been too persistent to allow the passage Brighton Infirmary during many years. Desault, whose abilities were of the bighest order, forbade
of the child, and labour has been only terminated by altogether handling the hernia, aware of its hurtful
extensive laceration, or the separation of the cervix, effects, as asually practiced. Peter Lowe, who was
probably in a state of gangerene, from the long concoeval with the celebrated Sharp, proposed puncturing
tinued pressure on its vessels. The treatment by with needles to discharge the flatus; and lately, Dr.
incision of the os uteri, though some time before the Weatherhead inrented a small trocar, of which there
profession, has, I think, been little practised by them. is a plate in the Lancet, of 1829, for the same purpose,
The successful termination of a case which recently
fell under my observation has assured me of the value both being satisfied of the necessity for removing the bulk. Haller remarked that he knew not how strangula.
and comparative safety of this treatment.
The patient was in her fortieth year, and in labour tion took place. Pott, who devoted so mach labour to
with her first child. I saw her first on Wednesday the question, made the same observation. My con.
morning, Jupe Ist; labour had commenced on the jecture, published in & pamphlet, in 1810, mas, that the sensitive intestine doubled in rushing through the
day previously; the pains were slight, but pretty aperture, was crushed against its tense border, and
urgent; the os uteri just sufficiently dilated to admit the
top of the finger, was very high up, directed backwards, closed under the irritation; thus return of the contents was impeded, a sufficient cause of all the symptoms.
rery rigid, and thick. On Thursday I fonnd the pains
more serere, but the condition of the os unchanged; Qualified surgeous know that the success of almost
the liquor amnii had been discharged, and the head every operation depends mainly on the previous state
presented; the skin was cool, and pulse quiet. of the patient's health, ivdependently of the present
A ailment; erery measure, therefore, which promises to
dose of castor oil, with fifty drops of tincture of opium effect our object without operation sbould be resorted
was giren; free action of the bowels, but no sleep
followed. The next twenty hours produced little change to, whilst the utmost caution should be observed to prevent the practice bitherto always recommended and
in the symptoms; the pains were more serere, but the parsued. Were I not supported by the authority of
state of the os uteri was unchanged; it still would
but admit the point of the finger through its thick and Desault, I feel assured that the reasons I have ad. vanced will satisfy all who patiently examine them.
almost cartilaginous ring; the head pressed firmly
on the anterior part of the cervix; the pulse was full It is of importance to ruptured persons to be capable
and sharp; she had not slept for forty-eight hours. of assisting themselves when suddenly attacked, and
I bled her to twelve ounces, gave her a grain and a the rather, as the means are simple and not dangerous. Although sufficient knowledge may be dedaced from
half of opium, and administered an enema. She slept
a few hours after the bleeding. Early on Saturday the preceding statements, it may be useful to re-state
morning the pains returned very powerfully; the os how important it is to relax the trunk, by raising the
uteri bad lost a little of its thickness, but none of its head, &c., and drawing up the limbs, leaving the body
hardness; it was still tilted bigh up against the proin å passire state during about twenty minutes, or a
montory of the sacrum, but was dilated to about the shivering fit; then to use the band as before recom.
size of a shilling piece. The woman had had anasarca mended, independently of the latter affection. Careful
of the lower extremities to a great extent, for six or observations by myself, and the experience of others to
eight of the latter weeks of pregnancy, and the labia whom I hare referred, assure me, that if the treatment
and external parts in general were very ædematous; I oppose is abandoned, whilst strict attention is bestowed
the vagina was hot and dry. I again bled her, the on the order and means which I propose, strangu.
blood being buffed and cupped, gave another injection lated hernia will lose its terrors, and in almost every
of castor oil and turpentine, which freely emptied the case terminate successfully. . A RETIRED SURGEON OF THE IRISH
bowels, and directed constant steaming with hot water COLLEGE.
to the pudenda, Violent pains continued throughout Brighton, October, 1847.
I the day, the condition of the os remained unchanged;
but the bead was lower down at each pain, the cervix | disappearance ol the caput succedaneum, and tbe being forcibly stretched over it.
still more concluire evidence afforded by the stethoAt this period my friend, Dr. Samuel Edwards, saw scope, 'showed the death of the child, and we determined her with me; there was some tenderness of the upon performing craniotomy.' The os continued abdomen; skin was bot, pulse sbarp and full, and gradually to yield to the diminished bulk of the head, about 100. At his suggestion she was again bled, which each pain forced against it, and the remainder and put under complete nauseation with tartar emetic; of the labour went on steadily progressing, the paips afterwards a full dose of opium, and another emollient continuing regular and patient comfortable, till eleven enema were given; the os uteri and cervix were freely o'clock p. m., when she gare birth to a female child smeared with extract of belladonna. The pulse fell to of the average size. The placenta was expelled in 90; the pains became suspended for many hours, about twenty minutes. No one single unfavourable during which time she occasionally slept, and felt symptom followed to interfere with her speedy and comfortable and easy.
perfect recovery, On Monday morning, June 6th, the pains (forcibly 40, St. James's Square, Bath. expulsory) again recurred. An examination, however, shewed no other change in the state of the os uteri, than that it was a little thinner; it was not more dilated, and still felt almost like a bony ring, and CASES PROM PRIVATE PRACTICE. resisted, as it had all along done, any attempt at artificial By Johx RICHARD WARDELL, M.D., Edin.; dilatation. Towards night considerable constitutional
Late President of the Royal Physical and Hunterian Media disturbance set in; the pulse was 110; skin dry and
cal Societies, Assistant Pathologist in the Royal Infirhot; tongue rather brown; the abdomen tender; mary, Edinburgh, &c. &c. vagina hot and dry; and the system generally irritable.
(Continued from page 661.) It must be admitted that the state of the patient at this time was one calculated to excite considerable
The time intervening belween the swallowing of the apxiety. She had been in labour for five days, but poison and its effects becoming apparent has been the state of the os uteri opposed coinpletely, as it did known to vary considerably, and very much depends in the first day of the labour, the possibility of the upon whether a solid or a liquid have been taken, the birth of the child. The usual remedies sedulously former of course requiring a longer period than the lat. applied, and anxiously watched, had exercised noter, that is until the drug becomes reduced to a solvent influence in overcoming the difficulty; and though till state. Poisoning by laudanum is always more speedy this time the constitutional symptoms had caused
than by opium. In this case it is seen the symptoms no uneasiness, still now they began to show themselves
supervened in the course of a few minutes, which in such a form as to urge the necessity of the adoption
was unusually quick; in an instance which is not of some measure by which the labour might be terini. pated; the pains too, were violent and forcing, and the
recollected that occurred in Edinburgh, the effect came head
on in from twenty minutes to half an hour. It is widely-stretched cervix, that I dreaded with each pain, often from half an hour to an hour before very marked some fearful laceration. At this time the child was indications are present. living; but even had it been dead, to bare practised The period at which death generally takes place, embryotomy through such an undilated and undilatable differs under apparently like circumstances, but is most os uteri would have been as difficult to the operator as frequently from ten to twelve hours; in the case referred dangerous to the mother.
to in the nortbern metropolis, the patient, a woman, It was in this state that Dr. Edwards proposed an I died in about four hours and a half, and there is every incision of the edge of the os uteri, and though my
my reason to suppose that the instance which has called owo experience taught me nothing of the practice, iny
forth these imperfect remarks, inferring from the fearful confidence in his judgment remored any doubts I may bave entertained of its desirableness. The operation
| degree of collapse into which she was thrown, would, was performed in the manner detailed by Dr. Lever, I had not the proper expedients been had recourse to, in a similar case published by bim. The knife used hare perished in a shorter time still. The poison always was a probe-pointed bistoury, and the two incisions kills the young with more rapidity than the adult, were made each side the mouth of the womb. The owing to the greater sensibility of the sensorial funcpatient complained of no pain; some bleeding followed tions, aud the more speedy and grave manner is the division. In two hours the constitutional symp-, which a return is made upon the vital organs. toms were materially relieved ; the pulse was at 90,
Regarding the quantity requisite to destroy life, so
R and the skin cool; abdomen less tender, and irritability
| far as my own researches have discovered from the calmed. An examination four hours after the operation
various authorities on this subject, the dose taken by showed but little change in the state of the os, but
this girl, and by which there is every reason to suppose after a time it began slowly but certainls to dilate, she would have been killed, if she had been left to the and at eleven o'clock in the forenoon of Tuesday, (the effects of the poison, is the smallest quantity to be seventh day of labour,) its disc was rather larger than followed by such grave results which I can find recorded. half-a-crown. The corrugated state of the scalp, the Certainly not more than one hundred drops bad
been taken. The mistress of the louse had the five or six and twenty years of age. When brought half-ounce vial in her possession, and, as stated in the into the waiting room of the hospital, sbe was deeply case, not quite one half had disappeared ; and when comatose, and though there were then no proofs begond it is considered tbat a few drops had been used by the symptoms, it was evident she was in a state of herself for the tooth-ache, this would certainly be poisoning. It appeared from subsequent inquiries tbe utmost quantity. On calling for the bottle at the that she had gone into a dram-shop, called for some next visit, she had unfortunately destroyed it, which whisky, and unobservedly added the fatal potion. la is the reason that the portion taken is not now exactly no great length of time she dropped into a deep sleep. mentioned. “The smallest fatal dose of the tincture and then helplessly fell from her seat. The pupils ia an adult which I have found recorded,” says Mr. were contracted, face livid, pulse slow, skin cool, Taylor, "is two drachms. This case is reported by Mr. breathing laborious and somewhat stertorous. On Skae, in the Edinburgh Medical and Surgical Journal, raising an arm or a leg it fell listlessly into its former for July, 1840. The patient was a robust man, aged position, in all the passivensss of unconscious prostras fifty-six. He swallowed the tincture at ten in the tion. Without loss of time I introduced the stomacho, evening, and died under the usual symptoms on the pump, and threw in most of a quart of tepid water, following morning, the case thus lasting only twelve which was immediately pumped out again, and thus hours."*
the process was repeated to the third time, by which There are certain idiosyncracies which it is impos. means the organ was thoroughly lared out, and such sible for human wisdom to foretel, where death is noxious matters as remained extracted. She was then produced with that which to another would be but placed in a warmed bed, being too much prostrated an innocuous, or even an effectless dose; for instance, to be walked about,) and for three hours I tried erery in the example of Martha C , mentioned in the remedy that might be deemed of service, but without remarks on the two cases of spasına glottidis. That avail, as she died, as before stated, in about four hours. patient under spasmodic disease, took with impunity, and a half after having taken the mortal draught. or indeed without producing much impression of any When making an examination of the body, I recollect description, a quantity of opiates under wbich this that Dr. Craigie was standing by me in the pathological girl would inevitably have perished.
theatre, and he observed to me before removing the In this case, where vomiting supervened so imme. viscera, that but seldom were the morbid appearances in diately after the poison had been swallowed, the amount these cases of real importance, and it often happened retained, and which was followed by such grave con- that little or no diseased changes were manifest, at sequences, must needs have been very small indeed, least such as seemed fully to account for the fatal and when reflected upon, in a medico-legal point of termination. Dr. Craigie had witnessed the autopsies view, becomes of some interest. No other bottle could of many cases of poisoning by opiates, and such was be found containing poison; and from enquiries made the result of what he had noticed. at the shops, it was pretty evident that she had not ! On removing the calvarium considerable Fascular procured more than that in the aforsaid half-ounce turgidity was most obrionsly apparent, the superficial vial; besides, in her subsequent confession, all other | vessels being dark, tortuous, and distended with renoid. parts of her story were found to be correct. She stated looking blood. Exposing the centrum ovale, numerous that she had placed the vial in a glass on the shelf in the bloody puncta were demonstrated, and in fine, the whole bar, there the bottle was discovered; that she had eocephalic mass was considerably engorged. There was taken it in rum,-the odour of that spirit had previously not much serum infiltrated into the ventricular carities, been distinctly recognized; other unimportant details which probably was dependent upon the short period in were also substantiated, it is therefore fair to infer which death had been induced; in cases wbere they linger that the whole of her statements were true, and thus lon from twelve to twenty hours, serouserodation is more the conclusion, with regard to the quantity swallowed, commonly observed. The lungs were quite anormal is a correct one. There would have been no utility in their characteristics, being intensely surcharged with in, nor likelihood of, ber telling one part of her tale dark venoid blood, and the right ventricle of the heart truly, and the other false, and especially regarding to was loaded with a gory semifluid mass. The stomach her, an unimportant particular. People when they presented no traces whatever of disease. equivocate, and speciously depose evidence, always These are, I believe, the most frequent morbid appearhave some ulterior object in view,-some point to be ances, and sometimes sanguineous extrapasation is gained : bere there could be pone...
found, resulting, of course, from the encephalic vascular It may not perhaps here be considered out of place, obstruction which is induced. “ The principal morbid to give a few particulars relative to the case above appearances," says Dr. Traill, "are great turgescence alluded to, and that occurred in the north. It was in of the vessels of the brain, and sometimes serous 'effu. : the person of a plethoric young woman, of apparently sion between its membranes, or in its ventricles; but • Taylor's "Manual of Medical Jurisprudence," page 221. someti
Page 221. I sometimes no morbid appearance can be detected in
tre bead; the lungs are gorged with blood; the confirm us in our decision in wbat such most properly somach rarely appears inflamed ; the blood is found consist, and especially if some of those late physi. Atid in the heart, and the body runs rapidly to decay."*ological discoveries which have been made are at the “The stomach and intestines," says Mr. A. S. Taylor, same time remembered. If we are to regard the “present no unnatural changes. There is greater or less perrous system as baring three distinct functions, or fulness of the cerebral vessels, but even this is often so as being divisible into three other systems,-the rital, slight as to escape notice unless attention be particularly sensorial, and muscular, properly so called, we can directed to the brain."+ Again, that author says, “In then more correctly account for the manner in which a case which proved fatal in fifteen hours, examined at death is proximately induced, and decide better as to Guy's Hospital, a few years since, the ressels of the head the way in which the fatal termination is most likely to were found unusually turgid throughout; on the sur-be averted. The sensorial functions being affected, face of the anterior part of the left hemisphere there whatever impressions are made upon these, are in an was an ecchymosis, apparently produced by the effusion exact ratio to the sum of such impressions transmitted of a few drops of blood; there were numerous bloody to the other two functions,-piz., the muscular and points on the cut surface of the brain; there was no vital; when, therefore, from whatever cause, the senserum collected in the ventricles; the stomach was sorium is rendered unequal to the due exercise of its quite healthy. This may be taken as a fair example of functions, as by a direct loss of sensorial power, which the post-mortem appearances in poisoning by opium." an agent like the one now spoken of is capable of pro
Comparing the accounts given by these authors, as to ducing, the two other functions are not efficiently the lesions discoverable in poisoning by narcotics, with performed-are carried on anormally, and their action, the particulars respecting the inspection made by through such morbid impression, deteriorated by the myself, the reader at once perceives that they very agent in question, may be entirely suspended, and of much resemble each other, and doubtless the conclu- course, death ensue. Eminent physiologists in this and sions arrived at by these two eminent medico-legalists, other countries bave shewn that respiration is caused by, are mainly right, and as a general view, are in accord and under the immediate influence of, three distinct ance with facts. It seems rather surprising that the functions,—the sensorial, vital, and muscular functions: latter should have passed over a condition which is that it is a compound and voluntary action. Now, perhaps quite as often present as the vascularity of the when the sensorium is affected, sensibility diminished brain,-riz., the pulmonary engorgement which is there or destroyed, the function of respiration becomes com80 frequently detected. Dr. Traill rery properly mensurately disordered or wholly ceases, because this notices tbis lesion in his enumeration of the chief action cannot be carried on without the stimulus of appearances.
the sensorial functions, the respiratory muscles otherReturning to the case of Ann H- , so sudden wise cease to act, and the vital functions, properly so was the operation of the poison, that when I saw her, called, also cease. Respiration being a voluntary act, certainly not more than balf an bour afterwards, she the loss of sensation is also followed by the loss of was so prostrated that it would bave been quite impos- pain, and when the sensation of pain no longer obtains sible to make her walk about; and Mr. Cole, who in our bodies, the respiratory muscles, as said, no saw the patient a few minutes before, affirmed the longer are urged to their natural exercise; hence cons same, on which account the remedial measure of con- gestion in the vital organs, and if continued, death, stantly keeping the body in action was not attempted. The brain, spinal marrow, and lungs especially, become The line of treatment, it will be seen, was such as is overloaded, and thus they then also superadd to the generally had recourse to in these instances, consisting deleterious states already noxiously existent in the in keeping up, as much as possible, the circulation, and system. The capillaries fail to normally propel never allowing the patient to sink into repose. For their contents unless stimulated by arterial Aluid, some time the efforts threatened to be inoperative, but which appears from the philosophical investigations of ultimately the lividity became less apparent, the sur- M. le Gallois, Wilson Philip, and certain other experiface warmer, the countenance more natural, when mentalists, to be their proper and only stimulus; incoherent murmurs were elicited, and at the expiration therefore when the blood is no longer duly arterialized, of two or three hours she was considered beyond congestion must result in the vilal organs, from danger.
the cause now given. The nervous influence so As all rational systems of treatment should as much necessary to all the vital processes of our bodies, and as possible be founded upon the observation of, and which is the proper and indispensable stimulant of the the inferences deduced from, demonstrative facts, a vital organs, properly so called, cannot be generated by, review of the morbid appearances discovered in the or eliminated from, the central organs of the nervous case wbich occurred in the north, may perhaps tend to system, unless these organs are unaffected in their
functions; but when they receive a morbid impres• Traill's " Medical Jurisprudence,"P, 132. lsion from the operation of some noxious agent, as a + Taylor's" Mapual," p. 43.
Darcotic poison for instance, the results as above enume-ness of the above-maintained doctrine is borne out by. rated epsue, and this agent, it is quite possible, may practice, is given in the pumber of this Journal for primarily act upon the vital and muscular, as we know November 3rd, and which is quoted from the Lancet. it does upon the sensorial system.
On referring to this example, which occarred in the From what has been advanced then, it is quite obvious Middlesex hospital, the reader must be further conthat our endeavours should be zealously directed vinced of the beneficial effects wbich in these instances towards the maintenance of the sensorial functions, result from the agent in question.] because we know of no antidote to this poison, and! In conclusion, relative to the case now given, the because the legitimate inferences of the views now following facts may be reiterated :-lot. The symptoms stated, seem to demand such conclusions. The patient, supervened with unwanted suddenness. 2ndly. The whose body I examined in Edinburgh, undoubtedly quantity of laudanum really retained must have been died in part as from asphyxia, because it was related very inconsiderable, rendering it surprising that sucb that the lungs were intensly congested, and there was fearful symptoms should follow so small a portion of præternatural pascularity and obstruction in the other the poison. 3rdly. The spirit in which it was taken vital organs. It has been ascertained by certain did not appear to exert the retarding influence ascribed experimentalists, both in this and other countries, that to it by Christison and others. Lastly. The pupils the nervous influence is, in all its appreciable qualities, were dilated, one more so than the other, which is identical with, and its phenomena similar to, an agent contrary to what is by far most usually the case,-- viz., in inanimate nature-viz., electricity; and that this their contraction. agent, when applied to those organs whose office is
(To be continued.) the transmission of the nervous influence from the central organs of the nervous system, bas the power of stimulating to their normal action those organs upon
PROVINCIAL which life immediately depends, commonly called the M edical & Surgical Journal. vital organs, even when the sensorial functions are very evidently impaired; this, therefore, seems a
WEDNESDAY, DECEMBER 15, 1847. proper remedial measure to be employed in cases like to this now particularly considered. A powerful In our last number se introduced a proposal
In our last number we introduced a proposal Darcotic, as observed, makes such a morbid impres- by Mr. Hunt, of Herne Bay, under the sanction sion upon the whole of the organs, constituting
of the Council of the Provincial Medical and the nervous system, that their proper functions are gravely altered, and that stimulus--the nervous | Surgical Association, for an investigation into influence—is no longer secreted by, if such term may the “ Medicinal Action and Effects of Arsenic." bere be used, nor consequently transmitted for, the We now beg to invite the attention of the carrying on of the vital processes. If then, the heart members of the Association to the inquiry and lungs can for a time be artificially carried on, or materially assisted by this agent from
proposed by Mr. Crompton, of Manchester.
inanimate nature, that is, until the poison ceases to exert its
The notice to members in some late numbers of pernicious effects, and the circulation thus continued,
the Journal has already made the subject of this great hopes of recovery might tbus be entertained, investigation-a Report on Burns and Scaldsand doubtless some fatal terminations averted. The intrusted by the Council to Mr. Crompton, circulation might also be considerably assisted at sufficiently known. We proceed to insert the same time by means of artificial inspiration, and better. addressed to the President, and the Ĩ
President of the Council of the Association, capillaries would receive a greater quantity of their proper stimulus, and free the vital organs in their which contains a full exposition of the views action. I am fully aware tbat both the former and of Mr. Crompton. This letter concludes with the latter bare been recommended, nor is there any-a series of questions, to which it is hoped thing new in these remarks; the only design in that the members of the Association will making the previous desultory observations, is to shew
severally return such answers as their know. that such remedial measures are founded more upon a rational basis than may be generally admitted, and if
| ledge and experience may enable them to do. possible, wbere these cases occur, to strenuously recommend their adoption. In the Edinburgh hospital I remember an instance in which voltaic electricity was eminently serviceable. [Since this case was sent to the press, an excellent illustration that the correct