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CLINICAL REPORTS OF TWENTY ADDITIONAL CASES OF STERILITY.
264 from organic lesion, than in instances in which no such CLINICAL REPORTS OF TWENTY ADDITIONAL necessity occurs." For if there be greater danger in handling CASES OF STERILITY. the there than must be itself the gut through sac, surely greater danger where constriction is made directly on the gut BY ROBERT LEE, M.D., F.R.S., by the neck of the sac, than where such constriction is caused FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE around tissues the the and so exerts its influence sac, by upon BRITISH LYING-IN HOSPITAL, AND LECTURER ON MIDWIFERY AT ST. case
the neck of the sac, and through it upon the intestines. And this is borne out by the fact that the mortality was greatest in Luke’s cases, in inguinal hernia, where stricture at the neck of the sac most frequently occurs. However, it must be admitted that Mr. Luke has been most successful; fortunate alike in the result of his operations, and in the class of cases submitted to his knife, for few surgeons, if any, can boast, like him, of having operated upon fifty-four unselected cases of hernia without meeting with a single instance of complica-
GEORGE’S HOSPITAL.
(Continued from p. 690, vol. i.)
tion.
Lastly, take Hewett’s cases, thirty-four in number, of which nine died, all having the sac opened. Of these nine there was sloughy intestine in one instance combined with pneumonia; in one, sloughy omentum; in one, portions of sloughy placenta in the uterus, found after death; in one, disease of the brain; in two, the intestine and omentum were left in the sac, in consequence of adhesions; and in one only was there mere peritonitis, combined with intestine of a dark, mahogany colour, but neither thickened nor softened. I need not go further into these details: I trust that I have entered sufficiently into the subject to prove that the mortality, even according to Mr. Gay’s statistics, is not due to opening the sac, but to circumstances totally unconnected with the
operation.
We have here the account of 126 cases, in 86 of which the opened. After deducting the 15 which must have proved fatal, whatever operation had been performed, 71 fair average cases in which the sac was opened remain. Of these eight terminated fatally, or one in nine, whilst, on the other hand, of the forty in which the sac was not opened, after deducting one in which the aorta was ossified, we have 39, of which five terminated unsuccessfully, or one in seven and a half. Through the kindness of Mr. Hamilton and Mr. Puleston I have been enabled to obtain the particulars of 548 cases of strangulated hernia, collected from various sources. Of these the sac was opened in 474, the operation proving successful in 307, unsuccessful in 167. In three the gut was injured in dividing adhesions; sixty-one proved fatal without any complications, and of the remaining 103, in thirty-three the gut was gangrenous; in thirteen it was gangrenous, and had burst; in thirteen the gut was perforated by ulceration; in one the patient had burst the intestine in his endeavours to return it before the operation; in six, the intestine was adherent to the internal ring; in seven, adherent to the sac; in eight, gangrenous omentum; in seven, adventitious bands and adhesions together; in two, double sacs; in two, sacs contained pus; in one, colon was twisted, and could not be returned; in one, Petit’s operation was first tried and failed; in one, patient delirious, in articulo m01’#8; in one, sloughing placenta found in the uterus after death; in one, disease of the brain; in one, ossification of the aorta; in one, encysted hernia of tunica vaginalis, unrelieved; in one, pneumonia, after twenty-three days; in one, constricted intestine at point of stricture; the rectum severely ulcerated from very hot enemata; in one, patient had been operated upon three times, and in another, the patient had taken several doses of crotoni oil, turpentine, &c., before the operation; immediately the gut was liberated, the bowels began to act, and continued to do so, almost without intermission, until she died, twelve hours after. It should be stated, that the condition of parts here given was in almost every instance found at the time of operation, and not merely observed after death; it must consequently be admitted, that the above 103 cases would have equally terminated fatally had Petit’s operation been performed, consequently the number should be calculated at 307 successful, sixty-four unsuccessful, or one in six. On the other hand, the sac was not opened in seventy-four. In five, it failed under circumstances which would have equally influence any operation. I consequently leave those out, and ta.ke unsuccessful cases, in one of which the gut was wounded at seventeen, leaving fifty-two successful cases, or one in four. I I Harley-street, September, 1849. sac was
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...
AN ALTERNATIVE.—A physician in extensive practice, there no concealing the truth, is either a great blessing or a great curse to his neighbourhood.-The Scalpel. is
CASE 61.-On the 28th of August, 1838,I saw a patient, in St. George’s Hospital, forty-two years of age, who had been married fifteen years, and was barren. She had suffered from leucorrhcea for a long period, and great pain about the vagina. She was admitted into the hospital in consequence of being affected with rheumatism. I found, on making an internal examination, that the os uteri was extremely small, not larger than a, pea, and unusually flat, and the aperture scarcely perceptible ; the body of the uterus likewise very small. The vagina was unusually contracted and tender near the orifice. CASE 62.-At Mortlake, on the 24th Sept., 1838, I saw a patient, aged forty-three, who had been delivered of her first child, twenty years before, after avery protracted labour. The placenta, she informed me, was obliged to be removed artificially, and required great force for its extraction. Prolapsus uteri took place soon after the recovery from her confinement, and had been gradually increasing, though almost every variety of pessary had been tried. For some time before she had used as a pessary a lemon, with a piece of tape sewed around it, which had answered better than anything else. It was taken out at night, washed, and left in cold water. She covered it with oil every morning before it was introduced. This patient had never again been pregnant.
CASE 63.-On the 30th of October, 1838,I saw Mrs. E-, aged forty-two, who had long been married, and was barren.
was a tumour of considerable dimensions between the uterus and rectum. I had seen this case five years before, and the tumour had undergone little or no change. A great quantity of iodine had been taken. CASE 64.-On the 9th Feb., 1839, I was requested to see a lady in the country, who was thirty-two years of age, had been married several years, and was sterile. She had suffered through life from hysteria, and her intellect was somewhat impaired at times. There was great tenderness of the whole hypogastrium; sometimes the abdomen was distended, like a drum; and frequently there was incessant desire to evacuate the bladder, There was violent headach at the monthly periods, and increased irritability of bladder. It
There
supposed she had diseased kidneys, and a great variety of narcotics, tonics, and other medicines had been employed without much benefit. The uterus was healthy. There was a small, moveable, encysted tumour on the left side of the was
vagina.
CASE 65.-On the 17th June, 1839,I saw a lady, aged fortywho was married at twenty-one, and had never been pregnant. The catamenia appeared at twelve, and had been extremely irregular through life. As a child she had been treated harshly, and made extremely unhappy. She had suffered severely from headach, especially in the back part of the head and nape of the neck-sometimes confined to a spot
four,
-with flushing of the face and throbbing of the arteries, disturbed sleep, sense of choking in the throat, and a feeling The greatest as if the blood were boiling in the left arm. benefit was derived from regular exercise in the country, light diet, and saline cathartics, and a few leeches occasionally applied behind the ears. I was not permitted, in this case, to ascertain the condition of the uterine system. CASE 66.-On the 10th Sept., 1839,I saw Mrs. B-, about thirty-five years of age, who had been delivered of her first child three years before. The labour was natural, and no puerperal disease followed. She has enjoyed excellent health during the last ten years, and likewise her husband; but she has never again been pregnant. I have at different times examined the uterine system, and could discover no disease in it of any kind. CASE 67.—On the llth Sept., 1839,I saw Mrs. C-, aged thirty-eight, who became sterile after giving birth to one child sixteen years before. Through the whole of life she had suffered severely from dysmenonrhaea, and was supposed by her medical attendant, when I saw her, to be labouring under stricture of the sigmoid flexure of the colon. There was no stricture or disease of the uterus that I could discover. CASE 68.-On the 24th of September, 1839,I was requested to see a lady, aged twenty-five years, who had been married
265 nearly three years, and had never been pregnant. Soon after and her general health had been seriously impaired. She was marriage, the catamenia became scanty and irregular, and subject to frequent and severe dysenteric attacks, and other accompanied with pain over the sacrum. The lower extre- symptoms, which rendered it probable that the liver was in an mities, without any loss of sensation, became so weak that she unhealthy condition. The catamenia were irregular, and at could neither stand
nor
walk, and it was.believed that she was times
the abdomen had been
so
distended
as
to lead to
a sus-
labouring under some serious affection of the spine, for which, picion of pregnancy, when it did not exist. The os uteri felt issues and the recumbent position were considered absolutely hard, but not rough or irregular; the cervix long, and not ennecessary. It was stated that for four months the uterus had larged ; the body felt heavy and large, and was pressing upon been unusually low in the vagina, and tender; that there was the rectum. An eminent surgeon who had seen the case, was occasional leucorrhoea, and that there was likewise tenderness of opinion that a tumour existed in the posterior wall of the about the bladder and orifice of the urethra. Leeches to the uterus; but I could not be certain of the fact, though the vagina had often been applied with slight relief of these symp- uterus was carefully examined, both by the vagina and rectum. toms. She was stated to be very excitable; to have walked in There was no tumour to be felt above the brim of the pelvis. CASE 72.—On the 8th of October, 1839,I was requested to her sleep when young, but never to have been hysterical. When suffering most, it was, however, observed that a great see a lady, aged fifty-two, who had been married in early life, quantity of limpid urine was voided. On the 25th, I found and lost her husband eight years before. She had never been her lying upon her back on the sofa, unable to move, with a pregnant. About a year after her marriage, she was attacked large open issue at the right side of the spine. The uterus was with some disease of a suspicious character in one of the not enlarged, and the cervix and orifice in a perfectly healthy mammae, which was treated by Mr. John Pearson and Mr. state, the latter rather more contracted than natural, as in some Guthrie, successfully, without an operation. She had spent a sterile women. Vagina much dilated. Passed the catheter, considerable number of years in South Carolina, where her and could discover nothing unusual about the urethra or general health had been much impaired. Within a few years bladder. The impression made upon my mind, after carefully of the time I saw her, she had undergone an operation for and repeatedly examining the symptoms, was, that there was fistula ani; the catamenia had ceased several years. I could discover no disease of the uterus, but the posterior wall of the no disease of the spinal cord, and that the affection of the lower extremities was hysterical, originating in irritation of vagina was pushed down by the rectum, and forced out of the uterine ganglia and nerves, the existence of which a writer the external parts. A pouch seemed to have been formed by afflicted with wilful blindness still affects to deny. I recom- the anterior wall of the rectum and posterior wall of the mended her to allow the issue to heal, to make trial of exer- vagina, and much of the inconvenience from which she was cise and tonic remedies for a short time, and carefully to mark then suffering arose from this cause. CASE 73.-On the 14th of November, 1839,I saw a lady, their effects. A week had scarcely elapsed before she was I much better; the power of the lower extremities had increased, aged fifty-two, suffering from dyspepsia, who had been marbut unequivocal symptoms of hysteria had manifested them- ried twenty years, and had been barren during the whole selves. On the 14th of March it was obvious that there was period. The catamenia had always been regular till twelve There was no pain about the sacrum, or no spinal disease whatever, but that she was suffering from months before this. hysteria, for which the appropriate remedies were employed. within the pelvis, leucorrhcea or discharge of any kind to lead In this case, artificial dilatation of the os and cervix uteri was to a suspicion that some organic disease had commenced in the employed, though it was not much wanted; but though the uterus, and I did not examine the uterine system. CASE 74.—On the 3rd of December, 1839,saw Mrs. T, affection of the lower extremities has been entirely removed, and the general health restored, the sterility remains. a lady, aged twenty-seven, who had been married eight years, CASE 69.-On the 27th of September,1839,I saw a lady, aged and was barren; the catamenia were perfectly regular, and thirty-seven, who had been married two years and three without pain; she had suffered since the age of thirteen from months, and was sterile, like her sister, whose case has already profuse lencorrheea; she had consulted several eminent pracbeen related. This patient suffered from severe attacks of titioners. She had been advised by one to lose blood from the nervous headach, and, so far as I could discover, was not arm; but this did no good; leeches had repeatedly been hysterical, though her sister was so in a high degree. The applied to the os uteri by another, but without any benefit. The uterus was in a healthy condition, as far as could be catamenia were irregular. CASE 70.—On the 29th of September, 1839, with Dr. Merri- ascertained. There was a small movable encysted tumour in man, I saw a lady, aged thirty-seven, who had been married at the right labium, near the periu2etun, but it was too deeply the age of twenty-four, and had given birth to three children situated for an operation. Whether this tumour had occaat the full period, in rapid succession. An abortion then took sioned much inconvenience was uncertain. CASE 75.—On the 10th of December,1839,I saw a lady with place, without any obvious cause, which was followed by a singular train of nervous symptoms, by dysmenorrlioea, and Dr. Duffin, who had been married several years, and had the expulsion from the uterus, every month, of a membrane never been pregnant. There was a soft tumour in the right which resembled, in a striking manner, the uterine decidua or labium, which had first been observed seven or eight months decidua vera. One surface-the inner-was smooth, and pre- before, and which felt like a piece of intestine, but was not. sented numerous small orifices; the outer surface was rough, It was very slightly painful occasionally, and a little throbbing with soft tufts, and showed a reticulated texture, but no open- and smarting was felt in it, which prevented her from ever inrs like those on the inner surface. I was informed that this forgetting that it was there. It did not, however, prevent her had taken place regularly during thirty months, and there from walking. On the llth, it v.-as opened and dressed from were several large bottles exhibited, which were filled with the bottom. A hæmorrhage afterwards took place of rather these membranes. On the 4th of October, a membrane was ’, an alarming character, but it was suppressed by pressure and expelled without pain, and I had an opportunity of examining’;, cold, and the case ultimately did well. CASE 76.—Mrs. P-, aged thirty-three. December 17, it in the recent state. The outer surface, which had been in contact with the uterus, was rough, and covered with a thin 1847, eleven A.M. Married fourteen years; never pregnant layer of coagulated blood. The inner surface was smooth, till now. Has suffered much during pregnancy. Labour with deep depressions and openings, like the inner surface of commenced upwards of seventy-four hours since. Pulse good; the decidua vera; but this membrane, though presenting a no headach nor delirium; tongue moist, but white. No tendersimilar appearance, was essentially different, as it was not an ness of abdomen; os uteri high up, thin, half dilated; head preorganized membrane. How this disordered state of menstrua- senting; liquor amnii flowing, and a great quantity of meconium. tion originated, was not explained; the uterus was not en- Child has not been felt to move for several days.—Four P.M.: larged, and I could perceive no tumour within the pelvis con- Pulse rapid; tongue loaded; great thirst; meconium escaping nected with the uterus, as several practitioners had represented. abundantly; os uteri still imperfectly dilated; head above the There was an unusual projection of the lumbar vertebrae, and brim of the pelvis; labour-pains strong, but produce little effect tenderness; but whether this had recently taken place, or had on the head, the bones of which are overlapping one another commenced in early life, was not certain; indeed, the memory greatly. There being no doubt about the death of the child, and intellectual faculties of this patient appear to be much and believing that the condition of the mother required deimpaired, and it was obvious no rational plan of treatment livery, I opened the head, and extracted it without much would be adopted or persevered in for any length of time, and difficulty. The child had been dead some time; the funis was how this case has proceeded during the last ten years I have so soft that it broke on employing the slightest traction. The never been able to ascertain. placenta not having been expelled in half an hour, and some CASE 71.-On the 2nd of October, 1839,I saw a occurring, I passed up the hand, and removed it lady,giving haemorrhage without difficulty. It was impossible to account for the stethirty-six, who become sterile sixteen years before, after birth to two healthy children. Subsequent to the last confine- rility in this case during fourteen years, and I have not been ment she had been exposed to great fatigue on the Continent, informed whether pregnancy again took place.
J
aged
266 a
CASE 77.—On the lst of January, 1840,I was consulted by lady, aged twenty-five, who had been married five years, and
was
sterile.
Soon after
marriage, the catamenia became
scanty and irregular, and she suffered much from sickness in the morning, sense of bearing-down, and pain in the lower part
of the spine and sacrum, extending down the left thigh. No leucorrhcea. She had occasionally also fainting fits, with the sensation of a ball in the throat, and other symptoms of hysteria. In earlier life she had regular hysterical fits. During three years, cohabitation had been accomthe previous panied with much pain. I examined the uterine organs, and could discover no disease in them of any kind. There was no obstruction in the os and cervix. During three years, this lady had taken medicine of every description in large quantities, steel, .aloes, myrrh, mineral waters, &c., without the slightest benefit, and had used all sorts of bathing. CASE 78.-On the 28th of January, 1840, with Dr. Scott, of Stratton-street, I saw a lady, aged forty-one, who had become barren after giving birth to one child, nineteen years before. She had continued to enjoy good health till the beginning of 1839, when pain was often experienced about the sacrum and coccyx, usually commencing in the evening and lasting all night, and accompanied with irritation of the bladder, and very frequent desire to pass urine. Menstruation continued, but in sparing quantity; symptoms not then aggravated; no leucorrhcea. The uterus was in its natural situation. The orifice not diseased, nor the vagina, but the anterior part of the cervix was enlarged, hard, irregular, and painful when
pressed. CASE 79.—On the 30th of March, 1840,I was consulted by a French lady, aged thirty, who had been married in very early life, and soon after had two living and one dead child. Ten
years had elapsed, and pregnancy never again took place, though she had been twice married. Some time before I saw her, she had been examined with the speculum, at Paris; great numbers of leeches were applied to the os uteri; and afterwards, caustic, in the French fashion; but without the slightest benefit The catamenia were regular; there was no she had almost constant pain and sense of leucorrhoaa; weight in the region of the uterus. The uterus was larger than natural; its orifice was irregular, redder, harder, and more tender than natural. There was no abrasion of the membrane covering the lips of the os uteri. I did not attempt to reduce the hardness and morbid sensibility of the orifice, by repeating the leeches and caustic. Quiet, mild alteratives, saline cathartics, with soothing injections, were prescribed, with decided relief of all the symptoms. CASE 80.-In the month of September, 1846, Mr. Woolmer, of Victoria-square, prevailed upon a young married lady to consult me. I was informed that she lived unhappily with her husband, and that a physician of eminence whom she had seen had recommended a separation and divorce, on the ground of the impotency of her husband. The husband had protested against the justice of the decision, and had appealed to Mr. Liston on the subject. A separation was, however, about to take place, when I saw the lady, and ascertained that the vagina, near the orifice, was so firmly contracted, that the finger could not possibly be introduced. A small bougie was at first passed with difficulty, and occasioned pain and hæmorrhage. In two months, the dilatation was completely effected of different sizes; pregnancy took place; and she by was in due time delivered by me of a son, at the full period, after a natural labour. She has again been recently delivered, after a natural labour. Savile-row, Sept. 1849.
duration of labour was five hours. The funis was about four inches in length, and the placenta, pale, friable, and natural in size, was unadherent to the sac, which contained the viscera of the abdomen, and a small portion of the heart. The mother imagined herself to be eight months’ pregnant, and does not attribute the deformity to a fright or other cause. During gestation she had not felt the movements of the child so strong as she had experienced them on former occasions. The foetus weighed three pounds and three ounces. The head, neck, and upper limbs were well formed; the chest wa distorted, and from the lower and fore part of it was a swelling, covered partly by skin, and to a small extent by the sac. This enlargement was formed by the displaced heart. The skin of the abdomen was deficient in a line extending from the margin of the thorax to the quadratus lumborum of either side, and proceeding thence along the cristse ilii and brim of the pelvis to the pubes. To this line was attached the sac spoken of, a pinkish margin, indicating its union with the skin. Within the sac were the abdominal viscera, whilst below, and on the right side, it presented a wide opening, which exposed the cavity of the cæcum. An artery and vein formed the vessels of the funis; they separated below the pouch, the former passing to the right, and the latter curving around the sac to the left. A large spina bifida occupied the lower half of the back. The inferior extremities were conjoined, a groove before and behind marking the line of union; they wereboth so twisted upon their axis, that the patellæ were directed immediately backwards, and the legs might hence be flexed forwards upon the thighs. The form and position of the abdominal viscera were plainly to be distinguished through the sac, which was divisible into two layers, the outer being, probably, part of the amnion, and the inner evidently constituting the parietal peritonaeum. On slitting up this membranous reservoir to turn it aside, it was slightly adherent in several situations, by what appeared to be recently effused lymph, to the parts it contained.
found
but
bougies
DESCRIPTION OF A
FŒTAL
MONSTER, WITH EVENTRATION. CANTON, ESQ., F.R.C.S.,
BY EDWIN
DEMONSTRATOR OF ANATOMY AT
THE CHARING-CROSS HOSPITAL MEDICAL SCHOOL.
THE following case occurred in the practice of Mr. CliapAbdominal viscera: The liver, A, in form and size might man, of Hounslow. Mrs. A- was confined for the thir- well be likened to the adult human kidney, placed transteenth time; an interval of five years and a half having oc- versely across the upper part of the abdominal cavity, and curred between the present pregnancy and the preceding one. having the convex border projecting forwards. Above, it is Her children were naturally formed. A month previous to hollowed out to support the heart, whilst immediately below her confinement, a slight haemorrhage took place, and from it are the stomach, duodenum, and spleen; the right and left that time to the date of labour, the amount of blood lost con- ends project into the corresponding hypochondriac regions, tinued to increase in quantity. The head presented naturally, and are in contact with the supra-renal capsules. The galland, when it had passed into the world, delay ensued from bladder is well-formed, and normally placed. The lobulus the presence above it of a sac, which having become ruptured Spigelii is largely developed, lying under, and projecting bewith the escape of fluid, both foetus and placenta were im- yond, the left lobe, whilst between the two is a deep fissure, mediately expelled. The child lived upwards of an hour; the which curves to the right, and then backwards, to form the .
the neck of the sac, and through it upon the intestines. And this is borne out by the fact that the mortality was greatest in Luke’s cases, in inguinal hernia, where stricture at the neck of the sac most frequently occurs. However, it must be admitted that Mr. Luke has been most successful; fortunate alike in the result of his operations, and in the class of cases submitted to his knife, for few surgeons, if any, can boast, like him, of having operated upon fifty-four unselected cases of hernia without meeting with a single instance of complica-
GEORGE’S HOSPITAL.
(Continued from p. 690, vol. i.)
tion.
Lastly, take Hewett’s cases, thirty-four in number, of which nine died, all having the sac opened. Of these nine there was sloughy intestine in one instance combined with pneumonia; in one, sloughy omentum; in one, portions of sloughy placenta in the uterus, found after death; in one, disease of the brain; in two, the intestine and omentum were left in the sac, in consequence of adhesions; and in one only was there mere peritonitis, combined with intestine of a dark, mahogany colour, but neither thickened nor softened. I need not go further into these details: I trust that I have entered sufficiently into the subject to prove that the mortality, even according to Mr. Gay’s statistics, is not due to opening the sac, but to circumstances totally unconnected with the
operation.
We have here the account of 126 cases, in 86 of which the opened. After deducting the 15 which must have proved fatal, whatever operation had been performed, 71 fair average cases in which the sac was opened remain. Of these eight terminated fatally, or one in nine, whilst, on the other hand, of the forty in which the sac was not opened, after deducting one in which the aorta was ossified, we have 39, of which five terminated unsuccessfully, or one in seven and a half. Through the kindness of Mr. Hamilton and Mr. Puleston I have been enabled to obtain the particulars of 548 cases of strangulated hernia, collected from various sources. Of these the sac was opened in 474, the operation proving successful in 307, unsuccessful in 167. In three the gut was injured in dividing adhesions; sixty-one proved fatal without any complications, and of the remaining 103, in thirty-three the gut was gangrenous; in thirteen it was gangrenous, and had burst; in thirteen the gut was perforated by ulceration; in one the patient had burst the intestine in his endeavours to return it before the operation; in six, the intestine was adherent to the internal ring; in seven, adherent to the sac; in eight, gangrenous omentum; in seven, adventitious bands and adhesions together; in two, double sacs; in two, sacs contained pus; in one, colon was twisted, and could not be returned; in one, Petit’s operation was first tried and failed; in one, patient delirious, in articulo m01’#8; in one, sloughing placenta found in the uterus after death; in one, disease of the brain; in one, ossification of the aorta; in one, encysted hernia of tunica vaginalis, unrelieved; in one, pneumonia, after twenty-three days; in one, constricted intestine at point of stricture; the rectum severely ulcerated from very hot enemata; in one, patient had been operated upon three times, and in another, the patient had taken several doses of crotoni oil, turpentine, &c., before the operation; immediately the gut was liberated, the bowels began to act, and continued to do so, almost without intermission, until she died, twelve hours after. It should be stated, that the condition of parts here given was in almost every instance found at the time of operation, and not merely observed after death; it must consequently be admitted, that the above 103 cases would have equally terminated fatally had Petit’s operation been performed, consequently the number should be calculated at 307 successful, sixty-four unsuccessful, or one in six. On the other hand, the sac was not opened in seventy-four. In five, it failed under circumstances which would have equally influence any operation. I consequently leave those out, and ta.ke unsuccessful cases, in one of which the gut was wounded at seventeen, leaving fifty-two successful cases, or one in four. I I Harley-street, September, 1849. sac was
I
-
——
’
—
—
.-
...
AN ALTERNATIVE.—A physician in extensive practice, there no concealing the truth, is either a great blessing or a great curse to his neighbourhood.-The Scalpel. is
CASE 61.-On the 28th of August, 1838,I saw a patient, in St. George’s Hospital, forty-two years of age, who had been married fifteen years, and was barren. She had suffered from leucorrhcea for a long period, and great pain about the vagina. She was admitted into the hospital in consequence of being affected with rheumatism. I found, on making an internal examination, that the os uteri was extremely small, not larger than a, pea, and unusually flat, and the aperture scarcely perceptible ; the body of the uterus likewise very small. The vagina was unusually contracted and tender near the orifice. CASE 62.-At Mortlake, on the 24th Sept., 1838, I saw a patient, aged forty-three, who had been delivered of her first child, twenty years before, after avery protracted labour. The placenta, she informed me, was obliged to be removed artificially, and required great force for its extraction. Prolapsus uteri took place soon after the recovery from her confinement, and had been gradually increasing, though almost every variety of pessary had been tried. For some time before she had used as a pessary a lemon, with a piece of tape sewed around it, which had answered better than anything else. It was taken out at night, washed, and left in cold water. She covered it with oil every morning before it was introduced. This patient had never again been pregnant.
CASE 63.-On the 30th of October, 1838,I saw Mrs. E-, aged forty-two, who had long been married, and was barren.
was a tumour of considerable dimensions between the uterus and rectum. I had seen this case five years before, and the tumour had undergone little or no change. A great quantity of iodine had been taken. CASE 64.-On the 9th Feb., 1839, I was requested to see a lady in the country, who was thirty-two years of age, had been married several years, and was sterile. She had suffered through life from hysteria, and her intellect was somewhat impaired at times. There was great tenderness of the whole hypogastrium; sometimes the abdomen was distended, like a drum; and frequently there was incessant desire to evacuate the bladder, There was violent headach at the monthly periods, and increased irritability of bladder. It
There
supposed she had diseased kidneys, and a great variety of narcotics, tonics, and other medicines had been employed without much benefit. The uterus was healthy. There was a small, moveable, encysted tumour on the left side of the was
vagina.
CASE 65.-On the 17th June, 1839,I saw a lady, aged fortywho was married at twenty-one, and had never been pregnant. The catamenia appeared at twelve, and had been extremely irregular through life. As a child she had been treated harshly, and made extremely unhappy. She had suffered severely from headach, especially in the back part of the head and nape of the neck-sometimes confined to a spot
four,
-with flushing of the face and throbbing of the arteries, disturbed sleep, sense of choking in the throat, and a feeling The greatest as if the blood were boiling in the left arm. benefit was derived from regular exercise in the country, light diet, and saline cathartics, and a few leeches occasionally applied behind the ears. I was not permitted, in this case, to ascertain the condition of the uterine system. CASE 66.-On the 10th Sept., 1839,I saw Mrs. B-, about thirty-five years of age, who had been delivered of her first child three years before. The labour was natural, and no puerperal disease followed. She has enjoyed excellent health during the last ten years, and likewise her husband; but she has never again been pregnant. I have at different times examined the uterine system, and could discover no disease in it of any kind. CASE 67.—On the llth Sept., 1839,I saw Mrs. C-, aged thirty-eight, who became sterile after giving birth to one child sixteen years before. Through the whole of life she had suffered severely from dysmenonrhaea, and was supposed by her medical attendant, when I saw her, to be labouring under stricture of the sigmoid flexure of the colon. There was no stricture or disease of the uterus that I could discover. CASE 68.-On the 24th of September, 1839,I was requested to see a lady, aged twenty-five years, who had been married
265 nearly three years, and had never been pregnant. Soon after and her general health had been seriously impaired. She was marriage, the catamenia became scanty and irregular, and subject to frequent and severe dysenteric attacks, and other accompanied with pain over the sacrum. The lower extre- symptoms, which rendered it probable that the liver was in an mities, without any loss of sensation, became so weak that she unhealthy condition. The catamenia were irregular, and at could neither stand
nor
walk, and it was.believed that she was times
the abdomen had been
so
distended
as
to lead to
a sus-
labouring under some serious affection of the spine, for which, picion of pregnancy, when it did not exist. The os uteri felt issues and the recumbent position were considered absolutely hard, but not rough or irregular; the cervix long, and not ennecessary. It was stated that for four months the uterus had larged ; the body felt heavy and large, and was pressing upon been unusually low in the vagina, and tender; that there was the rectum. An eminent surgeon who had seen the case, was occasional leucorrhoea, and that there was likewise tenderness of opinion that a tumour existed in the posterior wall of the about the bladder and orifice of the urethra. Leeches to the uterus; but I could not be certain of the fact, though the vagina had often been applied with slight relief of these symp- uterus was carefully examined, both by the vagina and rectum. toms. She was stated to be very excitable; to have walked in There was no tumour to be felt above the brim of the pelvis. CASE 72.—On the 8th of October, 1839,I was requested to her sleep when young, but never to have been hysterical. When suffering most, it was, however, observed that a great see a lady, aged fifty-two, who had been married in early life, quantity of limpid urine was voided. On the 25th, I found and lost her husband eight years before. She had never been her lying upon her back on the sofa, unable to move, with a pregnant. About a year after her marriage, she was attacked large open issue at the right side of the spine. The uterus was with some disease of a suspicious character in one of the not enlarged, and the cervix and orifice in a perfectly healthy mammae, which was treated by Mr. John Pearson and Mr. state, the latter rather more contracted than natural, as in some Guthrie, successfully, without an operation. She had spent a sterile women. Vagina much dilated. Passed the catheter, considerable number of years in South Carolina, where her and could discover nothing unusual about the urethra or general health had been much impaired. Within a few years bladder. The impression made upon my mind, after carefully of the time I saw her, she had undergone an operation for and repeatedly examining the symptoms, was, that there was fistula ani; the catamenia had ceased several years. I could discover no disease of the uterus, but the posterior wall of the no disease of the spinal cord, and that the affection of the lower extremities was hysterical, originating in irritation of vagina was pushed down by the rectum, and forced out of the uterine ganglia and nerves, the existence of which a writer the external parts. A pouch seemed to have been formed by afflicted with wilful blindness still affects to deny. I recom- the anterior wall of the rectum and posterior wall of the mended her to allow the issue to heal, to make trial of exer- vagina, and much of the inconvenience from which she was cise and tonic remedies for a short time, and carefully to mark then suffering arose from this cause. CASE 73.-On the 14th of November, 1839,I saw a lady, their effects. A week had scarcely elapsed before she was I much better; the power of the lower extremities had increased, aged fifty-two, suffering from dyspepsia, who had been marbut unequivocal symptoms of hysteria had manifested them- ried twenty years, and had been barren during the whole selves. On the 14th of March it was obvious that there was period. The catamenia had always been regular till twelve There was no pain about the sacrum, or no spinal disease whatever, but that she was suffering from months before this. hysteria, for which the appropriate remedies were employed. within the pelvis, leucorrhcea or discharge of any kind to lead In this case, artificial dilatation of the os and cervix uteri was to a suspicion that some organic disease had commenced in the employed, though it was not much wanted; but though the uterus, and I did not examine the uterine system. CASE 74.—On the 3rd of December, 1839,saw Mrs. T, affection of the lower extremities has been entirely removed, and the general health restored, the sterility remains. a lady, aged twenty-seven, who had been married eight years, CASE 69.-On the 27th of September,1839,I saw a lady, aged and was barren; the catamenia were perfectly regular, and thirty-seven, who had been married two years and three without pain; she had suffered since the age of thirteen from months, and was sterile, like her sister, whose case has already profuse lencorrheea; she had consulted several eminent pracbeen related. This patient suffered from severe attacks of titioners. She had been advised by one to lose blood from the nervous headach, and, so far as I could discover, was not arm; but this did no good; leeches had repeatedly been hysterical, though her sister was so in a high degree. The applied to the os uteri by another, but without any benefit. The uterus was in a healthy condition, as far as could be catamenia were irregular. CASE 70.—On the 29th of September, 1839, with Dr. Merri- ascertained. There was a small movable encysted tumour in man, I saw a lady, aged thirty-seven, who had been married at the right labium, near the periu2etun, but it was too deeply the age of twenty-four, and had given birth to three children situated for an operation. Whether this tumour had occaat the full period, in rapid succession. An abortion then took sioned much inconvenience was uncertain. CASE 75.—On the 10th of December,1839,I saw a lady with place, without any obvious cause, which was followed by a singular train of nervous symptoms, by dysmenorrlioea, and Dr. Duffin, who had been married several years, and had the expulsion from the uterus, every month, of a membrane never been pregnant. There was a soft tumour in the right which resembled, in a striking manner, the uterine decidua or labium, which had first been observed seven or eight months decidua vera. One surface-the inner-was smooth, and pre- before, and which felt like a piece of intestine, but was not. sented numerous small orifices; the outer surface was rough, It was very slightly painful occasionally, and a little throbbing with soft tufts, and showed a reticulated texture, but no open- and smarting was felt in it, which prevented her from ever inrs like those on the inner surface. I was informed that this forgetting that it was there. It did not, however, prevent her had taken place regularly during thirty months, and there from walking. On the llth, it v.-as opened and dressed from were several large bottles exhibited, which were filled with the bottom. A hæmorrhage afterwards took place of rather these membranes. On the 4th of October, a membrane was ’, an alarming character, but it was suppressed by pressure and expelled without pain, and I had an opportunity of examining’;, cold, and the case ultimately did well. CASE 76.—Mrs. P-, aged thirty-three. December 17, it in the recent state. The outer surface, which had been in contact with the uterus, was rough, and covered with a thin 1847, eleven A.M. Married fourteen years; never pregnant layer of coagulated blood. The inner surface was smooth, till now. Has suffered much during pregnancy. Labour with deep depressions and openings, like the inner surface of commenced upwards of seventy-four hours since. Pulse good; the decidua vera; but this membrane, though presenting a no headach nor delirium; tongue moist, but white. No tendersimilar appearance, was essentially different, as it was not an ness of abdomen; os uteri high up, thin, half dilated; head preorganized membrane. How this disordered state of menstrua- senting; liquor amnii flowing, and a great quantity of meconium. tion originated, was not explained; the uterus was not en- Child has not been felt to move for several days.—Four P.M.: larged, and I could perceive no tumour within the pelvis con- Pulse rapid; tongue loaded; great thirst; meconium escaping nected with the uterus, as several practitioners had represented. abundantly; os uteri still imperfectly dilated; head above the There was an unusual projection of the lumbar vertebrae, and brim of the pelvis; labour-pains strong, but produce little effect tenderness; but whether this had recently taken place, or had on the head, the bones of which are overlapping one another commenced in early life, was not certain; indeed, the memory greatly. There being no doubt about the death of the child, and intellectual faculties of this patient appear to be much and believing that the condition of the mother required deimpaired, and it was obvious no rational plan of treatment livery, I opened the head, and extracted it without much would be adopted or persevered in for any length of time, and difficulty. The child had been dead some time; the funis was how this case has proceeded during the last ten years I have so soft that it broke on employing the slightest traction. The never been able to ascertain. placenta not having been expelled in half an hour, and some CASE 71.-On the 2nd of October, 1839,I saw a occurring, I passed up the hand, and removed it lady,giving haemorrhage without difficulty. It was impossible to account for the stethirty-six, who become sterile sixteen years before, after birth to two healthy children. Subsequent to the last confine- rility in this case during fourteen years, and I have not been ment she had been exposed to great fatigue on the Continent, informed whether pregnancy again took place.
J
aged
266 a
CASE 77.—On the lst of January, 1840,I was consulted by lady, aged twenty-five, who had been married five years, and
was
sterile.
Soon after
marriage, the catamenia became
scanty and irregular, and she suffered much from sickness in the morning, sense of bearing-down, and pain in the lower part
of the spine and sacrum, extending down the left thigh. No leucorrhcea. She had occasionally also fainting fits, with the sensation of a ball in the throat, and other symptoms of hysteria. In earlier life she had regular hysterical fits. During three years, cohabitation had been accomthe previous panied with much pain. I examined the uterine organs, and could discover no disease in them of any kind. There was no obstruction in the os and cervix. During three years, this lady had taken medicine of every description in large quantities, steel, .aloes, myrrh, mineral waters, &c., without the slightest benefit, and had used all sorts of bathing. CASE 78.-On the 28th of January, 1840, with Dr. Scott, of Stratton-street, I saw a lady, aged forty-one, who had become barren after giving birth to one child, nineteen years before. She had continued to enjoy good health till the beginning of 1839, when pain was often experienced about the sacrum and coccyx, usually commencing in the evening and lasting all night, and accompanied with irritation of the bladder, and very frequent desire to pass urine. Menstruation continued, but in sparing quantity; symptoms not then aggravated; no leucorrhcea. The uterus was in its natural situation. The orifice not diseased, nor the vagina, but the anterior part of the cervix was enlarged, hard, irregular, and painful when
pressed. CASE 79.—On the 30th of March, 1840,I was consulted by a French lady, aged thirty, who had been married in very early life, and soon after had two living and one dead child. Ten
years had elapsed, and pregnancy never again took place, though she had been twice married. Some time before I saw her, she had been examined with the speculum, at Paris; great numbers of leeches were applied to the os uteri; and afterwards, caustic, in the French fashion; but without the slightest benefit The catamenia were regular; there was no she had almost constant pain and sense of leucorrhoaa; weight in the region of the uterus. The uterus was larger than natural; its orifice was irregular, redder, harder, and more tender than natural. There was no abrasion of the membrane covering the lips of the os uteri. I did not attempt to reduce the hardness and morbid sensibility of the orifice, by repeating the leeches and caustic. Quiet, mild alteratives, saline cathartics, with soothing injections, were prescribed, with decided relief of all the symptoms. CASE 80.-In the month of September, 1846, Mr. Woolmer, of Victoria-square, prevailed upon a young married lady to consult me. I was informed that she lived unhappily with her husband, and that a physician of eminence whom she had seen had recommended a separation and divorce, on the ground of the impotency of her husband. The husband had protested against the justice of the decision, and had appealed to Mr. Liston on the subject. A separation was, however, about to take place, when I saw the lady, and ascertained that the vagina, near the orifice, was so firmly contracted, that the finger could not possibly be introduced. A small bougie was at first passed with difficulty, and occasioned pain and hæmorrhage. In two months, the dilatation was completely effected of different sizes; pregnancy took place; and she by was in due time delivered by me of a son, at the full period, after a natural labour. She has again been recently delivered, after a natural labour. Savile-row, Sept. 1849.
duration of labour was five hours. The funis was about four inches in length, and the placenta, pale, friable, and natural in size, was unadherent to the sac, which contained the viscera of the abdomen, and a small portion of the heart. The mother imagined herself to be eight months’ pregnant, and does not attribute the deformity to a fright or other cause. During gestation she had not felt the movements of the child so strong as she had experienced them on former occasions. The foetus weighed three pounds and three ounces. The head, neck, and upper limbs were well formed; the chest wa distorted, and from the lower and fore part of it was a swelling, covered partly by skin, and to a small extent by the sac. This enlargement was formed by the displaced heart. The skin of the abdomen was deficient in a line extending from the margin of the thorax to the quadratus lumborum of either side, and proceeding thence along the cristse ilii and brim of the pelvis to the pubes. To this line was attached the sac spoken of, a pinkish margin, indicating its union with the skin. Within the sac were the abdominal viscera, whilst below, and on the right side, it presented a wide opening, which exposed the cavity of the cæcum. An artery and vein formed the vessels of the funis; they separated below the pouch, the former passing to the right, and the latter curving around the sac to the left. A large spina bifida occupied the lower half of the back. The inferior extremities were conjoined, a groove before and behind marking the line of union; they wereboth so twisted upon their axis, that the patellæ were directed immediately backwards, and the legs might hence be flexed forwards upon the thighs. The form and position of the abdominal viscera were plainly to be distinguished through the sac, which was divisible into two layers, the outer being, probably, part of the amnion, and the inner evidently constituting the parietal peritonaeum. On slitting up this membranous reservoir to turn it aside, it was slightly adherent in several situations, by what appeared to be recently effused lymph, to the parts it contained.
found
but
bougies
DESCRIPTION OF A
FŒTAL
MONSTER, WITH EVENTRATION. CANTON, ESQ., F.R.C.S.,
BY EDWIN
DEMONSTRATOR OF ANATOMY AT
THE CHARING-CROSS HOSPITAL MEDICAL SCHOOL.
THE following case occurred in the practice of Mr. CliapAbdominal viscera: The liver, A, in form and size might man, of Hounslow. Mrs. A- was confined for the thir- well be likened to the adult human kidney, placed transteenth time; an interval of five years and a half having oc- versely across the upper part of the abdominal cavity, and curred between the present pregnancy and the preceding one. having the convex border projecting forwards. Above, it is Her children were naturally formed. A month previous to hollowed out to support the heart, whilst immediately below her confinement, a slight haemorrhage took place, and from it are the stomach, duodenum, and spleen; the right and left that time to the date of labour, the amount of blood lost con- ends project into the corresponding hypochondriac regions, tinued to increase in quantity. The head presented naturally, and are in contact with the supra-renal capsules. The galland, when it had passed into the world, delay ensued from bladder is well-formed, and normally placed. The lobulus the presence above it of a sac, which having become ruptured Spigelii is largely developed, lying under, and projecting bewith the escape of fluid, both foetus and placenta were im- yond, the left lobe, whilst between the two is a deep fissure, mediately expelled. The child lived upwards of an hour; the which curves to the right, and then backwards, to form the .