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OBSTETRICAL SOCIETY OF LONDON. WEDNESDAY, MAY 1ST, 1861.
461 the body in order to admit of the malposition of the forearm. The dimensions of the basis of the head are thus greatly increased, and the projecting elbow hitches on the brim of the pelvis, and prevents the descent of the head.
ST. MARYLEBONE INFIRMARY. DISEASE OF THE MAMMARY GLAND, AND FATTY TUMOUR ON THE SHOULDER; SUCCESSFUL REMOVAL.
COLLOID
ON THE TREATMENT OF CASES OF ABORTION IN WHICH THE MEMBRANES AND PLACENTA ARE RETAINED.
of Mr. HENRY THOMPSON.) BY W. 0. PRIESTLEY, M.D., is THE female breast occasionally the seat of colloid cancer, MYSICI.UT-ACCOUCHEUR TO THE MIDDLESEX HOSPITAL. but rarely so as contrasted with the other species of this disThe author began by observing that when abortion occurs in Cases are noticed by Velpeau, Walshe, Lebert, Sibley, the early weeks, the ovum is frequently expelled without rup. ease. of any of the membranes except the external decidua, Price, and other writers. The growth of colloid cancer is ture because the attachments to the uterine cavity are unstable; usually slow, and when early removed from any external part the mass is then smaller and less difficult to push through the of the body, experience proves that, if not radically cured by os uteri, and the contractile power of the uterus is very feeble. the operation, it is slow to return after excision. In the follow- In the third, fourth, and fifth months the decidual cavity is attaching case no sign of the disease had presented itself for a year obliterated, the placenta has acquired more intimate after removal. When present in the breast during a series of ments to the womb, and the contractile power of the uterus greater, rupture of the membranes commonly takes years it is liable to extend to the internal organs; a striking being before place expulsion. The embryo having escaped, the example of this is related by Lebert. One of the most perfect secundines may speedily follow, or, lying in the os uteri, they illustrations of colloid cancer in the breast is recorded in the may be removed by the finger or some simple instrument. In 8th volume of the " Transactions of the Pathological Society;" a considerable number of abortions, however, in which the foetus and liquor amnii have been voided, the secundines are it may be taken as a typical case. Catherine W , aged sixty-two, admitted into the above not soon extruded ; and after the uterus has made repeated ineffectual attempts to expel them the os uteri closes and action infirmary in July, 1857. Six months ago, without any known ceases. Instances of this kind are common in obstetric cause, a small and rather hard swelling appeared in her left and are often a source of much embarrassment to thepractice, practibreast. It was never very painful. Her health is generally Obstetric authorities differ widely as to the treatment good. She has been robust, and is so now-remarkably so for tioner. her age. The tumour is now as large as a hen’s egg, very hard, which ought to be adopted when the secundines are not thrown non-adherent to deep parts, and slightly involves the skin at off spontaneously, and particularly as to the propriety of£ manual interference. Dr. Denman, Dr. Davis, Dr. Ramsbotham, There is one enlarged gland in the axilla. one point. and Dr. Dewees deprecate any attempts at extraction by the removed the breast in the 13th.—Mr. usual July Thompson hand ; and Mr. Ingleby held that " no manual extraction can bnt not the in the axilla. manner, gland be effected prior to the sixth month." Dr. Burns and Dr. 24th.-Wound healing well. All ligatures removed on the Churchill regard interference in this way as only allowable in 20th. exceptional cases; and Dr. Tyler Smith stands almost alone in Aug. 22nd.-Perfectly well. Oct. 19th.—Mr. Thompson removed a fatty tumour from the recommending the removal of the secundines in all cases of aborleft shoulder, which has increased in size rapidly since the tion where they are retained. The author regarded the quesbreast operation. The enlarged gland does not alter in any tion of treatment as an important one to all obstetric practitioners, as they might be blamed on the one hand for omitrespect. The section of the mammary tumour exhibited a very fine ting a duty they ought to have performed, or on the other hand might be charged with meddlesome practice. He had and characteristic specimen of colloid growth. met with a considerable number of patients who had seriously May 18th, 1855.—The woman remains perfectly well; no suffered from placental retention, and this had induced him of return seen. sign to bring the subject before the Society for the purpose of eliciting opinions as to the proper course which ought to be followed. The dangers and morbid conditions arising from membranous and placental retention were stated to be :1. Flooding; this being sometimes of a very serious character, and the patient being always liable to hæmorrhage so OBSTETRICAL SOCIETY OF LONDON. long as a fragment remains. 2. Decomposition of the uterine contents, leading to local WEDNESDAY, MAY 1ST, 1861. inflammation of the uterus and surrounding tissues, to phleDR. TYLER SMITH, PRESIDENT, IN THE CHAIR. bitis and phlegmasia dolens, and lastly to general poisoning of the system, as evidenced by irritative fever, peritonitis, rheuDR. DRUITT exhibited specimens of a liquid and solid extract matic pains, the formation of abscesses, and even the occurof beef, made under his directions by Brand, of Little Stan- rence of death. 3. Sub-involution of the uterus. hope-street, Mayfair. He observed that, next to brandy, no 4. The generation of some of the forms of mole out of the remedy was so essential in the treatment of debility from flooding as the true essence of meat; and, besides, he claimed tissue left in the uterine cavity, and the beamorrhaoe attending the credit of introducing this as a remedy for intense nervous the presence and expulsion of these morbid growths. The entire absorption of the placenta was regarded as un. exhaustion, arising from any cause whatever, whether from grief or mental disturbance, and believed that it possessed certain and not to be counted upon. Cases illustrative of the stimulating effects on the brain. The liquid essence is the several sources of danger were detailed. In considering the various methods of treatment which have pure juice of beef, prepared by heat, of a clear amber colour, and aromatic smell. It contains scarcely any gelatinous matter. been recommended, the author’s experience led him to believe The solid extract is made by drying the essence at a gentle heat, that the effect of the administration of ergot was very uncerand may be kept a long time without spoiling. tain, and that galvanism and injection of water were not to be Dr. MEADOWS exhibited a pelvimeter, the invention of Mr. depended upon. Any form of abortion-forceps which must Earle, which promised to be useful in practice. He also needs be pushed beyond the reach of the finger he regarded as directed the attention of the Fellows to the heart of a child, useless and dangerous. He was thus driven to the conclusion two years old, who had died from idiopathic pericarditis. that the introduction of one or two fingers into the uterus was the safest and best way to remove the retained uterine con. DYSTOCIA FROM DORSAL DISPLACEMENT OF THE ARM. tents. In his hands such manual interference had never been BY J. JARDINE MURRAY, F. R. C. S. (BRIGHTON), followed by any evil results, and a considerable number of cases AND had fallen under his observation. He begged particularly to DR. EASTLAKE, M. R. C. S. be understood as not advocating rash and violent attempts to SOME importance may be attached to the case which formed empty the uterus. Rough and careless manipulation might be the subject of this communication, as the peculiar obstructionfatal to a patient; but the consequences of placental retention to parturition does not appear to have been recorded by anywere so serious that, under ordinary circumstances, less risk obstetrician except Professor Simpson. It consists in one ofFwas incurred by the operation. It was important to effect rethe arms of the infant being displaced backwards across the moval, not only before putrescence began, but before the os occipital region, the arm being thrown upwards in a line withmteri became much contracted ; and if in six hours after the
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462. escape of the embryothe placenta did not follow, it might be removed. The- extraction might be effected sooner than this if much haemorrhage were present. He had found it convenient in operations to place the patient on the back, with the thighs flexed on the abdomen; and while one hand steadied and depressed the uterus externally, the other was with all possible gentleness passed into the vagina. The os uteri was then dilated with the index-finger, and the second finger followed if required. These two fingers formed the best and most sensitive forceps, and although time and care might be necessary to their introduction, their employment was most satisfactory. The administration of chloroform previous to the manipulation afforded great assistance by relaxing the passages and saving the patient from pain. The author had succeeded in removing, the placenta with the hand in some cases days and weeks after the escape of the fcetus; but he had never ventured on any such attempt if inflammatory symptoms and irritative fever had already set in. Where the os uteri was too contracted to permit the introduction of the finger for the removal of a placental mass, its dilatation could be effected by sponge tents, which had the double advantage of staying hsemorrhage and facilitating the passage of the finger. Mr. ROBINS stated a case in which there was much flooding, owing- to retained placenta, after abortion at the third month. Mr. Robins only got away a part of the placenta, the rest being left behind. This was two months ago, and the portion has not yet passed; yet there is no flooding nor symptom of
putrefaction.
Dr. HALL DAvis observed that but little could be added to make Dr. Priestley’s paper more complete than it was. In the early part of his practice he (Dr. Davis) was in the habit, in cases of retained placenta, of trusting partly to nature, and this failing, to injections of warm water into the uterus to wash away putrescent matter. Subsequently he became convinced that it is better to remove the placenta manually, and so effectually prevent either flooding or blood-poisoning. Dr. Davis stated that he had also seen cases where the part of the plaeenta left in utero had become changed into a mole, and so produced great distress, with numerous attacks of haemorrhage, He thought that putrid absorption from retained placenta occurred most frequently where there was haemorrhage. As to absorption of the placenta, he had never met with a case of it in his own practice, and he thought that the possibility of its happening ought to have no effect upon our treatment of these s&ses. In proof of the correctness of Dr. Priestley’s views, Dr. Hall Davis narrated the particulars of two cases, about which he had been consulted, and in which death resulted from bloodpoisoning due to retention of the placenta. Mr. PETER MARSHALL said that at one time he was a sceptic as to the absorption of the ovum; but that he had recently seen a case which convinced him that this did sometimes happ.en. The ovum, in this instance, was felt by two or three experienced practitioners protruding at the os uteri ; yet it did not come away, and the patient recovered favourably. Mr. Marshall said he had also noticed that the rigors which occurred in cases of putrid absorption from retained placenta were often of a periodic character. He congratulated the author upon his n valuable paper. Dr. TYLER SMITH said that, in rare cases, the placenta was But the chance of such an no- doubt absorbed after abortion.
ought not to be allowed, as it led to haemorrhage, and infection of the system by putrid matter. The number of instruments devised to extract the placenta showed how important the matter was in practice; but nothing yet produced was equal to the hand and finger. He had always taught that in abortions occurring even before the formation of the placenta, the thickened decidua should be removed, if it remained and caused excessive draining, after the passage of the embryo. In the early months, the uterus was only partially developed, so that its expulsive action was comparatively feeble, and the difficulty was often increased by adhesion of the deEidua , and after-birth from disease. In later abortions, he ; always removed the placenta as soon as its retention produced mischief. It was seldom necessary to pass more than one finger to detach and hock down the retained mass. In some cases, the. whole hand required to be passed into the vagina; in others, the uterus was sufficiently low to admit of the passing of the finger without this. Chloroform was often of great value in promoting dilatation of the ostium vaginæ and os uteri, particularly in cases where the retention had lasted several weeks, or even months. He had not seen any mischief follow the removal, but the contrary. The conditions were that the hand should be clean, and the proceeding without violence. He might mention that in cases of flooding after occurrence
at the’ full! term, when the- placenta had been exhe had frequently passed the hand into the uterus to remove portions-of membrane, which were apt to separate from’ the placenta-and remain. in the uterus, or hang from the os. Many of the worst cases of flooding met with in practice were, he believed, of this kind, and to clear out the uterus was the only effectual way of stopping the loss of blood. Dr. GRAILY HEWITT felt himself called upon to say a few words on the subject before the.Society. He believed that the case had been considerably overstated, and that bad effects had been set down as following the retention of the placenta in’ thesecases of abortion, which were really by no means so commonly observed in practice as would- be- supposed from what had been stated. The author himself had been constrained to admit that there are few recorded cases of serious results. The cases brought before the Society by the author, as instances of bad results following retention of the placenta after abortion, were-some of them open to the serious .objection that they did not prove what they were intended to prove. Thus a case was cited, inwbich the patient, who had aborted five years before, and in whom the placenta had not been removed for some few days afterwards, the uterus was found large, retroflexed, and admitting the sound to the extent of six inches. This case was cited as showing one of the evil effects of retention of the placenta. Where wasthe evidence that this condition of the uterus was produced by the retention of the plaeenta for a. few daysfive years before? Other cases related were open, though not so markedly as in this instance, .to objections of an analogous-kind. He had no objection to the procedure recommended in certain properly selected, cases ; but he should consider it a most unfortunate- thing if - this Society gave, sanction to the practice of dilating the os uteri, aad effecting, the removal of the placenta, with more or less force in all cases, where there He was convinced was delay of a few hours in its expulsion. that the effect of the expressiom of suah; an opinion would be most disastrous, and that much injury might be consequently inflicted. It was not easy to convey by pen and ink, and.to all persons alike, an adequate idea of the, degree of force which might be safely used. How the exercise of force in dilatation of the os uteri in cases of abortion might prove inju. rious was shown by the case published in THE LANCET of last year, where the individual (uneducated it is true) ruptured the uterus and vagina in the attempt to remove theplacenta in a case of abortion at the fifth month. Dr. TANNER remarked that when he first saw the title of Dr. Priestley’s paper he thought that most practitioners must now be agreed upon the treatment to adopt in cases where a portion of the placenta was retained, and therefore that to raise a question upon the subject was unnecessary. The discussion, however, which had just taken place proved that the author had not acted unwisely in bringing the matter forward. With regard to his own views, he (Dr. Tanner) might say that they were quite in accordance with those of Dr. Priestley; and, indeed, he had taken much pains to enforce these same opinions in his recent work on the Diseases of Pregnancy. He believed that although after abortion a portion of the placenta or membranes might be left in the uterus and no ill consequences ensue, yet such a fortunate result was exceptional and could not be depended upon. There were two great sources of danger in these cases,-namely, flooding and blood-poisoning. If the portion of placenta remained adherent to the uterine walls, it acted like a polypus and produced flooding, which could only be permanently checked by removal of the foreign body. If the substance became detached and was not expelled., it putrefied; and then there was the fear of purulent absorption, uterine phlebitis, and so on. Dr. Tanner then referred to the report of a case by Mr. Humphreys of Shrewsbury, in the B1’itish Medical Journal for December 1858, in which the retention of a piece of placenta only the size of a shilling had caused fatal flooding; while he also mentioned a somewhat similar instance about which he had been lately consulted, but where recovery occurred after the expulsion of a mass of afterbirth the size of a walnut. He alluded, in conclusion, to the observations of Mr. Marshall as to the absorption of the entire ovum, and stated that he had never yet witnessed anything which would lead him to believe in the possibility of such an He thought that it was sometimes very difficult, occurrence. when a mass was felt at the os uteri, to say whether it was an ovum or a clot of blood; but even allowing the substance in Mr. Marshall’s case to have been an ovum, it might have subsequently passed away without the patient’s knowledge. Dr. PRIESTLEY, in reply, said that the observations of Mr. Marshall, on the periodic character of the rigors in cases of putrid absorption from retained placenta, were interesting, in.
delivery
pelled,
effecting
463 asmuch as they showed that some analogy existed to instances did not influence the mortality. The author strongly depreof blood-poisoning from other causes. Dr. Davis’s remarks as cated the administration of chloroform sprinkled on a handto the greater proclivity of patients to putrid absorption who kerchief, &c.; basing this not only on the observed fact that a suffered from haemorrhage concurrent with putrid discharge, highly-charged atmosphere (five per cent., Snow; eight per were also deserving of notice. He (Dr. Priestley) confessed his cent., Lallemand, Perrin, and Duroy) was fatal to animals, but surprise that Dr. Hewitt, who had read the paper to the also on the circumstance that of all the cases which he had Society, should have so far misunderstood it as to suppose it collected only two were mentioned as occurring where a proper recommended the introduction of the hand into the vagina inhaler had been used. Of 51 cases, 3S declared their danger by sudden stoppage ot when the placenta was simply lying in the os uteri, and easily removable by other means. The paper was entirely devoted the pulse ; 5 deaths occurred in which there was manifested to those embarrassing cases in which the placenta and mem- great muscular excitement, collapse immediately following. branes were entirely included within the uterine cavity, and These were all strong men in the prime of life. Sudden vomitin which the efforts of the uterus were insufficient for their ex- ing and then death occurred twice; congestion of the face was pulsion. Nothing Dr. Hewitt had advanced had shown that the most marked sign in 6, and cessation of breathing in 8 the secundines could be left in the uterus for a prolonged cases. He considered death to occur from asphyxia and syn period after abortion without risk to the patient. His objec- cope. In animals, it occurred from palsy of respiration; in tions did not affect the question at issue. Nor could the fears men, occasionally from this cause, but more frequently from he expressed as to the safety of manual extraction be weighed palsy of the heart, the respiration outliving it. After death a against the results of practice which had been elicited in the constant sign is fulness of the right chamber of the -heart, discussion. One of the principal objects of the paper of the though less frequent in men than in the lower animals. Fluidity evening was to evoke the opinions of men who had large expe. of blood and a dark colour are seen invariably. His conclurience on an important point of every-day practice, and he sions were1. In animals, death occurs by asphyxia, and begins in the (the author) had been gratified by finding that the weight of opinion expressed in discussion was decidedly in favour of the brain. 2. In man, death occurs by asphyxia or syncope, and begins proposals he had submitted for the approval of the Society. in the brain, heart, or lungs. He strongly recommended artificial respiration (taking care clear the mouth of mucus, and to bring the tongue well to WESTERN MEDICAL AND SURGICAL SOCIETY. and galvanism to the phrenic nerve, as the proper forward), FRIDAY, MAY 3RD, 1861. remedies. MR. L. T. CUMBERBATCH, V.P., IN THE CHAIR. THE annual meeting was held this evening, when the followofficers were elected for the session 1861-62 :-President : Dr. Seaton. Vice-Presidents: Dr. Fincham, Mr. -Legoatt, Mr, Cumberbatch, Mr. James Lane. Council: Mr. Mould, Dr. Marcet, Dr. Barclay, Mr. Scannell, Dr. Cahill, Mr. Pollock, Dr. C. G. Brown, Dr. Anstie, Dr. Stacpoole, Dr. Love, Mr. Bannister, Mr. C. Hunter.-Honorary Secretaries: Dr. Baines, Mr. Milner. Honorary Librarian: Mr. T. Dickinson.Auditors: Mr. F. W. Pettigrew, Mr. Godwin. The Report of the Council and Auditors’ Report were read and adopted. After the usual vote of thanks to the retiring officers for their past services, Mr. BARNES exhibited the
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Reviews
and
Notices of Books.
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STOMACH OF A PATIENT, who had destroyed himself by taking six drachms of essential oil of bitter almonds and six drachms of tincture of opium. He
The Modern Treatment
of Syphilitic Diseases, both Primary
and Secondary; comprising the Treatment of Oonfirmed. and Constitutional Syphilis by a safe and successful Method. With numerous Cases, Formulas, and Clinical Observations. By LANGSTON PARKER, late Surgeon, and now Honorary Surgeon, to the Queen’s Hospital, Birmingham. Fourth Edition, pp. 403. London: Churchill. 1860. A Practical Treatise on Diseases of the Urinary and Generative Oi-gans of both Sexes, including Syphilis. By WILLIAM ACTON, M.R.C.S. Third Edition. pp. 608. London:a Churchill. 1860.
[SECOND NOTICE.] WE shall able works.
allude to a few of the chapters of these valuMr. Acton, in the first part of his book devoted narrated the particulars, and remarked upon the congested ap- to unspecific diseases, treats of the discharges in a full and pearance of the mucous membrane at the cardiac extremity of I satisfactory manner; but we cannot comprehend why he should the stomach. No congestion was elsewhere apparent. use the word blennorrhagia for discharges in general, as well as those affecting females; and gonorrhwa for the same disease FRIDAY, APRIL 19TH. in men. This is apt to create misapprehension. Both terms MR. THOMAS KEEN, V.P., IN THE CHAIR. are etymologically wrong; but it would be wise to -make a choice, and adhere to it for both sexes. Dr. SANSOM read a paper , We must also find fault with the’following definition’of ON DEATH FROM CHLOROFORM. balanitis:—" Balanitis consists of inflammation and patchy The author considered that, at the highest estimate, the deaths excoriation of the glans penis and lining of the prepuce, aawmfrom chloroform to the number of inhalations bore the propora panied by muco-purulent discharge." (p. 41.) The glans tion of 1 to 10,000. Various considerations, however, concurred to. show that this should be very much more favourable. In ; penis is seldom inflamed; but the inflammation attacks its the first place, it -was very probable that several of the deaths mucous membrane, which latter.is continuous posteriorly with were from shock or fright, and not from chloroform; and in .the membrane lining the prepuce, and anteriorly with the ’furtherance of this view was the fact that half of the number membrane of the urethra. at the meatus. This fact mucous of deaths occurred before the commencement of the -operation for which the chloroform had been inhaled. Another avoidable establishes the close analogy between spurious gonorrhœa. (ba,circumstance increasing the death-ratio was supposed to be lanitis) and gonorrhoea seated on the mucous membrane of the carelessness and laxity in the administration of the vapour. urethra. Circumstantial records of 34 cases of death which have occurred Nor can we agree with Mr. Acton, that the predisposing since the publication of Dr. Sava’a.work were presented, which cause of balanitis is the existence of the prepuce. In this way the author combined with those recorded in that volume, and offered analyses of the most salient points. In cases of death, we might say that granular conjunctiva, or else conjunctivitis, the proportion of males to females was about two to one, and. recognises for its exciting cause the existence of the eyelid. this seemed to the author strange, since the anaesthetic was so Circumcised individuals suffer from balanitis also. The truth largely used in midwifery. The average age in the fatal cases .is, however, that a narrow prepuce, or uncleanliness, strongly Was thirty to forty. It certainly seemed that the strong and to balanitis ; as a large meatus predisposes to healthy stood a worse chance than the debilitated; but of all predisposes states of the system, chronic or acute alcoholism disposed the gonorrhoea. The quotation from Ricord, which we find after the definition :most to death. Extensive disease of the lungs occasionally we have just criticized, is a joke; and one of the kind from which death disease of to the-heart probably asphyxia; disposed now
ST. MARYLEBONE INFIRMARY. DISEASE OF THE MAMMARY GLAND, AND FATTY TUMOUR ON THE SHOULDER; SUCCESSFUL REMOVAL.
COLLOID
ON THE TREATMENT OF CASES OF ABORTION IN WHICH THE MEMBRANES AND PLACENTA ARE RETAINED.
of Mr. HENRY THOMPSON.) BY W. 0. PRIESTLEY, M.D., is THE female breast occasionally the seat of colloid cancer, MYSICI.UT-ACCOUCHEUR TO THE MIDDLESEX HOSPITAL. but rarely so as contrasted with the other species of this disThe author began by observing that when abortion occurs in Cases are noticed by Velpeau, Walshe, Lebert, Sibley, the early weeks, the ovum is frequently expelled without rup. ease. of any of the membranes except the external decidua, Price, and other writers. The growth of colloid cancer is ture because the attachments to the uterine cavity are unstable; usually slow, and when early removed from any external part the mass is then smaller and less difficult to push through the of the body, experience proves that, if not radically cured by os uteri, and the contractile power of the uterus is very feeble. the operation, it is slow to return after excision. In the follow- In the third, fourth, and fifth months the decidual cavity is attaching case no sign of the disease had presented itself for a year obliterated, the placenta has acquired more intimate after removal. When present in the breast during a series of ments to the womb, and the contractile power of the uterus greater, rupture of the membranes commonly takes years it is liable to extend to the internal organs; a striking being before place expulsion. The embryo having escaped, the example of this is related by Lebert. One of the most perfect secundines may speedily follow, or, lying in the os uteri, they illustrations of colloid cancer in the breast is recorded in the may be removed by the finger or some simple instrument. In 8th volume of the " Transactions of the Pathological Society;" a considerable number of abortions, however, in which the foetus and liquor amnii have been voided, the secundines are it may be taken as a typical case. Catherine W , aged sixty-two, admitted into the above not soon extruded ; and after the uterus has made repeated ineffectual attempts to expel them the os uteri closes and action infirmary in July, 1857. Six months ago, without any known ceases. Instances of this kind are common in obstetric cause, a small and rather hard swelling appeared in her left and are often a source of much embarrassment to thepractice, practibreast. It was never very painful. Her health is generally Obstetric authorities differ widely as to the treatment good. She has been robust, and is so now-remarkably so for tioner. her age. The tumour is now as large as a hen’s egg, very hard, which ought to be adopted when the secundines are not thrown non-adherent to deep parts, and slightly involves the skin at off spontaneously, and particularly as to the propriety of£ manual interference. Dr. Denman, Dr. Davis, Dr. Ramsbotham, There is one enlarged gland in the axilla. one point. and Dr. Dewees deprecate any attempts at extraction by the removed the breast in the 13th.—Mr. usual July Thompson hand ; and Mr. Ingleby held that " no manual extraction can bnt not the in the axilla. manner, gland be effected prior to the sixth month." Dr. Burns and Dr. 24th.-Wound healing well. All ligatures removed on the Churchill regard interference in this way as only allowable in 20th. exceptional cases; and Dr. Tyler Smith stands almost alone in Aug. 22nd.-Perfectly well. Oct. 19th.—Mr. Thompson removed a fatty tumour from the recommending the removal of the secundines in all cases of aborleft shoulder, which has increased in size rapidly since the tion where they are retained. The author regarded the quesbreast operation. The enlarged gland does not alter in any tion of treatment as an important one to all obstetric practitioners, as they might be blamed on the one hand for omitrespect. The section of the mammary tumour exhibited a very fine ting a duty they ought to have performed, or on the other hand might be charged with meddlesome practice. He had and characteristic specimen of colloid growth. met with a considerable number of patients who had seriously May 18th, 1855.—The woman remains perfectly well; no suffered from placental retention, and this had induced him of return seen. sign to bring the subject before the Society for the purpose of eliciting opinions as to the proper course which ought to be followed. The dangers and morbid conditions arising from membranous and placental retention were stated to be :1. Flooding; this being sometimes of a very serious character, and the patient being always liable to hæmorrhage so OBSTETRICAL SOCIETY OF LONDON. long as a fragment remains. 2. Decomposition of the uterine contents, leading to local WEDNESDAY, MAY 1ST, 1861. inflammation of the uterus and surrounding tissues, to phleDR. TYLER SMITH, PRESIDENT, IN THE CHAIR. bitis and phlegmasia dolens, and lastly to general poisoning of the system, as evidenced by irritative fever, peritonitis, rheuDR. DRUITT exhibited specimens of a liquid and solid extract matic pains, the formation of abscesses, and even the occurof beef, made under his directions by Brand, of Little Stan- rence of death. 3. Sub-involution of the uterus. hope-street, Mayfair. He observed that, next to brandy, no 4. The generation of some of the forms of mole out of the remedy was so essential in the treatment of debility from flooding as the true essence of meat; and, besides, he claimed tissue left in the uterine cavity, and the beamorrhaoe attending the credit of introducing this as a remedy for intense nervous the presence and expulsion of these morbid growths. The entire absorption of the placenta was regarded as un. exhaustion, arising from any cause whatever, whether from grief or mental disturbance, and believed that it possessed certain and not to be counted upon. Cases illustrative of the stimulating effects on the brain. The liquid essence is the several sources of danger were detailed. In considering the various methods of treatment which have pure juice of beef, prepared by heat, of a clear amber colour, and aromatic smell. It contains scarcely any gelatinous matter. been recommended, the author’s experience led him to believe The solid extract is made by drying the essence at a gentle heat, that the effect of the administration of ergot was very uncerand may be kept a long time without spoiling. tain, and that galvanism and injection of water were not to be Dr. MEADOWS exhibited a pelvimeter, the invention of Mr. depended upon. Any form of abortion-forceps which must Earle, which promised to be useful in practice. He also needs be pushed beyond the reach of the finger he regarded as directed the attention of the Fellows to the heart of a child, useless and dangerous. He was thus driven to the conclusion two years old, who had died from idiopathic pericarditis. that the introduction of one or two fingers into the uterus was the safest and best way to remove the retained uterine con. DYSTOCIA FROM DORSAL DISPLACEMENT OF THE ARM. tents. In his hands such manual interference had never been BY J. JARDINE MURRAY, F. R. C. S. (BRIGHTON), followed by any evil results, and a considerable number of cases AND had fallen under his observation. He begged particularly to DR. EASTLAKE, M. R. C. S. be understood as not advocating rash and violent attempts to SOME importance may be attached to the case which formed empty the uterus. Rough and careless manipulation might be the subject of this communication, as the peculiar obstructionfatal to a patient; but the consequences of placental retention to parturition does not appear to have been recorded by anywere so serious that, under ordinary circumstances, less risk obstetrician except Professor Simpson. It consists in one ofFwas incurred by the operation. It was important to effect rethe arms of the infant being displaced backwards across the moval, not only before putrescence began, but before the os occipital region, the arm being thrown upwards in a line withmteri became much contracted ; and if in six hours after the
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Medical Societies.
’
t
462. escape of the embryothe placenta did not follow, it might be removed. The- extraction might be effected sooner than this if much haemorrhage were present. He had found it convenient in operations to place the patient on the back, with the thighs flexed on the abdomen; and while one hand steadied and depressed the uterus externally, the other was with all possible gentleness passed into the vagina. The os uteri was then dilated with the index-finger, and the second finger followed if required. These two fingers formed the best and most sensitive forceps, and although time and care might be necessary to their introduction, their employment was most satisfactory. The administration of chloroform previous to the manipulation afforded great assistance by relaxing the passages and saving the patient from pain. The author had succeeded in removing, the placenta with the hand in some cases days and weeks after the escape of the fcetus; but he had never ventured on any such attempt if inflammatory symptoms and irritative fever had already set in. Where the os uteri was too contracted to permit the introduction of the finger for the removal of a placental mass, its dilatation could be effected by sponge tents, which had the double advantage of staying hsemorrhage and facilitating the passage of the finger. Mr. ROBINS stated a case in which there was much flooding, owing- to retained placenta, after abortion at the third month. Mr. Robins only got away a part of the placenta, the rest being left behind. This was two months ago, and the portion has not yet passed; yet there is no flooding nor symptom of
putrefaction.
Dr. HALL DAvis observed that but little could be added to make Dr. Priestley’s paper more complete than it was. In the early part of his practice he (Dr. Davis) was in the habit, in cases of retained placenta, of trusting partly to nature, and this failing, to injections of warm water into the uterus to wash away putrescent matter. Subsequently he became convinced that it is better to remove the placenta manually, and so effectually prevent either flooding or blood-poisoning. Dr. Davis stated that he had also seen cases where the part of the plaeenta left in utero had become changed into a mole, and so produced great distress, with numerous attacks of haemorrhage, He thought that putrid absorption from retained placenta occurred most frequently where there was haemorrhage. As to absorption of the placenta, he had never met with a case of it in his own practice, and he thought that the possibility of its happening ought to have no effect upon our treatment of these s&ses. In proof of the correctness of Dr. Priestley’s views, Dr. Hall Davis narrated the particulars of two cases, about which he had been consulted, and in which death resulted from bloodpoisoning due to retention of the placenta. Mr. PETER MARSHALL said that at one time he was a sceptic as to the absorption of the ovum; but that he had recently seen a case which convinced him that this did sometimes happ.en. The ovum, in this instance, was felt by two or three experienced practitioners protruding at the os uteri ; yet it did not come away, and the patient recovered favourably. Mr. Marshall said he had also noticed that the rigors which occurred in cases of putrid absorption from retained placenta were often of a periodic character. He congratulated the author upon his n valuable paper. Dr. TYLER SMITH said that, in rare cases, the placenta was But the chance of such an no- doubt absorbed after abortion.
ought not to be allowed, as it led to haemorrhage, and infection of the system by putrid matter. The number of instruments devised to extract the placenta showed how important the matter was in practice; but nothing yet produced was equal to the hand and finger. He had always taught that in abortions occurring even before the formation of the placenta, the thickened decidua should be removed, if it remained and caused excessive draining, after the passage of the embryo. In the early months, the uterus was only partially developed, so that its expulsive action was comparatively feeble, and the difficulty was often increased by adhesion of the deEidua , and after-birth from disease. In later abortions, he ; always removed the placenta as soon as its retention produced mischief. It was seldom necessary to pass more than one finger to detach and hock down the retained mass. In some cases, the. whole hand required to be passed into the vagina; in others, the uterus was sufficiently low to admit of the passing of the finger without this. Chloroform was often of great value in promoting dilatation of the ostium vaginæ and os uteri, particularly in cases where the retention had lasted several weeks, or even months. He had not seen any mischief follow the removal, but the contrary. The conditions were that the hand should be clean, and the proceeding without violence. He might mention that in cases of flooding after occurrence
at the’ full! term, when the- placenta had been exhe had frequently passed the hand into the uterus to remove portions-of membrane, which were apt to separate from’ the placenta-and remain. in the uterus, or hang from the os. Many of the worst cases of flooding met with in practice were, he believed, of this kind, and to clear out the uterus was the only effectual way of stopping the loss of blood. Dr. GRAILY HEWITT felt himself called upon to say a few words on the subject before the.Society. He believed that the case had been considerably overstated, and that bad effects had been set down as following the retention of the placenta in’ thesecases of abortion, which were really by no means so commonly observed in practice as would- be- supposed from what had been stated. The author himself had been constrained to admit that there are few recorded cases of serious results. The cases brought before the Society by the author, as instances of bad results following retention of the placenta after abortion, were-some of them open to the serious .objection that they did not prove what they were intended to prove. Thus a case was cited, inwbich the patient, who had aborted five years before, and in whom the placenta had not been removed for some few days afterwards, the uterus was found large, retroflexed, and admitting the sound to the extent of six inches. This case was cited as showing one of the evil effects of retention of the placenta. Where wasthe evidence that this condition of the uterus was produced by the retention of the plaeenta for a. few daysfive years before? Other cases related were open, though not so markedly as in this instance, .to objections of an analogous-kind. He had no objection to the procedure recommended in certain properly selected, cases ; but he should consider it a most unfortunate- thing if - this Society gave, sanction to the practice of dilating the os uteri, aad effecting, the removal of the placenta, with more or less force in all cases, where there He was convinced was delay of a few hours in its expulsion. that the effect of the expressiom of suah; an opinion would be most disastrous, and that much injury might be consequently inflicted. It was not easy to convey by pen and ink, and.to all persons alike, an adequate idea of the, degree of force which might be safely used. How the exercise of force in dilatation of the os uteri in cases of abortion might prove inju. rious was shown by the case published in THE LANCET of last year, where the individual (uneducated it is true) ruptured the uterus and vagina in the attempt to remove theplacenta in a case of abortion at the fifth month. Dr. TANNER remarked that when he first saw the title of Dr. Priestley’s paper he thought that most practitioners must now be agreed upon the treatment to adopt in cases where a portion of the placenta was retained, and therefore that to raise a question upon the subject was unnecessary. The discussion, however, which had just taken place proved that the author had not acted unwisely in bringing the matter forward. With regard to his own views, he (Dr. Tanner) might say that they were quite in accordance with those of Dr. Priestley; and, indeed, he had taken much pains to enforce these same opinions in his recent work on the Diseases of Pregnancy. He believed that although after abortion a portion of the placenta or membranes might be left in the uterus and no ill consequences ensue, yet such a fortunate result was exceptional and could not be depended upon. There were two great sources of danger in these cases,-namely, flooding and blood-poisoning. If the portion of placenta remained adherent to the uterine walls, it acted like a polypus and produced flooding, which could only be permanently checked by removal of the foreign body. If the substance became detached and was not expelled., it putrefied; and then there was the fear of purulent absorption, uterine phlebitis, and so on. Dr. Tanner then referred to the report of a case by Mr. Humphreys of Shrewsbury, in the B1’itish Medical Journal for December 1858, in which the retention of a piece of placenta only the size of a shilling had caused fatal flooding; while he also mentioned a somewhat similar instance about which he had been lately consulted, but where recovery occurred after the expulsion of a mass of afterbirth the size of a walnut. He alluded, in conclusion, to the observations of Mr. Marshall as to the absorption of the entire ovum, and stated that he had never yet witnessed anything which would lead him to believe in the possibility of such an He thought that it was sometimes very difficult, occurrence. when a mass was felt at the os uteri, to say whether it was an ovum or a clot of blood; but even allowing the substance in Mr. Marshall’s case to have been an ovum, it might have subsequently passed away without the patient’s knowledge. Dr. PRIESTLEY, in reply, said that the observations of Mr. Marshall, on the periodic character of the rigors in cases of putrid absorption from retained placenta, were interesting, in.
delivery
pelled,
effecting
463 asmuch as they showed that some analogy existed to instances did not influence the mortality. The author strongly depreof blood-poisoning from other causes. Dr. Davis’s remarks as cated the administration of chloroform sprinkled on a handto the greater proclivity of patients to putrid absorption who kerchief, &c.; basing this not only on the observed fact that a suffered from haemorrhage concurrent with putrid discharge, highly-charged atmosphere (five per cent., Snow; eight per were also deserving of notice. He (Dr. Priestley) confessed his cent., Lallemand, Perrin, and Duroy) was fatal to animals, but surprise that Dr. Hewitt, who had read the paper to the also on the circumstance that of all the cases which he had Society, should have so far misunderstood it as to suppose it collected only two were mentioned as occurring where a proper recommended the introduction of the hand into the vagina inhaler had been used. Of 51 cases, 3S declared their danger by sudden stoppage ot when the placenta was simply lying in the os uteri, and easily removable by other means. The paper was entirely devoted the pulse ; 5 deaths occurred in which there was manifested to those embarrassing cases in which the placenta and mem- great muscular excitement, collapse immediately following. branes were entirely included within the uterine cavity, and These were all strong men in the prime of life. Sudden vomitin which the efforts of the uterus were insufficient for their ex- ing and then death occurred twice; congestion of the face was pulsion. Nothing Dr. Hewitt had advanced had shown that the most marked sign in 6, and cessation of breathing in 8 the secundines could be left in the uterus for a prolonged cases. He considered death to occur from asphyxia and syn period after abortion without risk to the patient. His objec- cope. In animals, it occurred from palsy of respiration; in tions did not affect the question at issue. Nor could the fears men, occasionally from this cause, but more frequently from he expressed as to the safety of manual extraction be weighed palsy of the heart, the respiration outliving it. After death a against the results of practice which had been elicited in the constant sign is fulness of the right chamber of the -heart, discussion. One of the principal objects of the paper of the though less frequent in men than in the lower animals. Fluidity evening was to evoke the opinions of men who had large expe. of blood and a dark colour are seen invariably. His conclurience on an important point of every-day practice, and he sions were1. In animals, death occurs by asphyxia, and begins in the (the author) had been gratified by finding that the weight of opinion expressed in discussion was decidedly in favour of the brain. 2. In man, death occurs by asphyxia or syncope, and begins proposals he had submitted for the approval of the Society. in the brain, heart, or lungs. He strongly recommended artificial respiration (taking care clear the mouth of mucus, and to bring the tongue well to WESTERN MEDICAL AND SURGICAL SOCIETY. and galvanism to the phrenic nerve, as the proper forward), FRIDAY, MAY 3RD, 1861. remedies. MR. L. T. CUMBERBATCH, V.P., IN THE CHAIR. THE annual meeting was held this evening, when the followofficers were elected for the session 1861-62 :-President : Dr. Seaton. Vice-Presidents: Dr. Fincham, Mr. -Legoatt, Mr, Cumberbatch, Mr. James Lane. Council: Mr. Mould, Dr. Marcet, Dr. Barclay, Mr. Scannell, Dr. Cahill, Mr. Pollock, Dr. C. G. Brown, Dr. Anstie, Dr. Stacpoole, Dr. Love, Mr. Bannister, Mr. C. Hunter.-Honorary Secretaries: Dr. Baines, Mr. Milner. Honorary Librarian: Mr. T. Dickinson.Auditors: Mr. F. W. Pettigrew, Mr. Godwin. The Report of the Council and Auditors’ Report were read and adopted. After the usual vote of thanks to the retiring officers for their past services, Mr. BARNES exhibited the
ing
Reviews
and
Notices of Books.
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STOMACH OF A PATIENT, who had destroyed himself by taking six drachms of essential oil of bitter almonds and six drachms of tincture of opium. He
The Modern Treatment
of Syphilitic Diseases, both Primary
and Secondary; comprising the Treatment of Oonfirmed. and Constitutional Syphilis by a safe and successful Method. With numerous Cases, Formulas, and Clinical Observations. By LANGSTON PARKER, late Surgeon, and now Honorary Surgeon, to the Queen’s Hospital, Birmingham. Fourth Edition, pp. 403. London: Churchill. 1860. A Practical Treatise on Diseases of the Urinary and Generative Oi-gans of both Sexes, including Syphilis. By WILLIAM ACTON, M.R.C.S. Third Edition. pp. 608. London:a Churchill. 1860.
[SECOND NOTICE.] WE shall able works.
allude to a few of the chapters of these valuMr. Acton, in the first part of his book devoted narrated the particulars, and remarked upon the congested ap- to unspecific diseases, treats of the discharges in a full and pearance of the mucous membrane at the cardiac extremity of I satisfactory manner; but we cannot comprehend why he should the stomach. No congestion was elsewhere apparent. use the word blennorrhagia for discharges in general, as well as those affecting females; and gonorrhwa for the same disease FRIDAY, APRIL 19TH. in men. This is apt to create misapprehension. Both terms MR. THOMAS KEEN, V.P., IN THE CHAIR. are etymologically wrong; but it would be wise to -make a choice, and adhere to it for both sexes. Dr. SANSOM read a paper , We must also find fault with the’following definition’of ON DEATH FROM CHLOROFORM. balanitis:—" Balanitis consists of inflammation and patchy The author considered that, at the highest estimate, the deaths excoriation of the glans penis and lining of the prepuce, aawmfrom chloroform to the number of inhalations bore the propora panied by muco-purulent discharge." (p. 41.) The glans tion of 1 to 10,000. Various considerations, however, concurred to. show that this should be very much more favourable. In ; penis is seldom inflamed; but the inflammation attacks its the first place, it -was very probable that several of the deaths mucous membrane, which latter.is continuous posteriorly with were from shock or fright, and not from chloroform; and in .the membrane lining the prepuce, and anteriorly with the ’furtherance of this view was the fact that half of the number membrane of the urethra. at the meatus. This fact mucous of deaths occurred before the commencement of the -operation for which the chloroform had been inhaled. Another avoidable establishes the close analogy between spurious gonorrhœa. (ba,circumstance increasing the death-ratio was supposed to be lanitis) and gonorrhoea seated on the mucous membrane of the carelessness and laxity in the administration of the vapour. urethra. Circumstantial records of 34 cases of death which have occurred Nor can we agree with Mr. Acton, that the predisposing since the publication of Dr. Sava’a.work were presented, which cause of balanitis is the existence of the prepuce. In this way the author combined with those recorded in that volume, and offered analyses of the most salient points. In cases of death, we might say that granular conjunctiva, or else conjunctivitis, the proportion of males to females was about two to one, and. recognises for its exciting cause the existence of the eyelid. this seemed to the author strange, since the anaesthetic was so Circumcised individuals suffer from balanitis also. The truth largely used in midwifery. The average age in the fatal cases .is, however, that a narrow prepuce, or uncleanliness, strongly Was thirty to forty. It certainly seemed that the strong and to balanitis ; as a large meatus predisposes to healthy stood a worse chance than the debilitated; but of all predisposes states of the system, chronic or acute alcoholism disposed the gonorrhoea. The quotation from Ricord, which we find after the definition :most to death. Extensive disease of the lungs occasionally we have just criticized, is a joke; and one of the kind from which death disease of to the-heart probably asphyxia; disposed now