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STRANGULATED FEMORAL HERNIA, WITH ENTIRE ABSENCE OF LOCAL PAIN.
66 the respiratory wave of the abdomen over the uterine wall, though it may be probably difficult to say Since my first paper I have added much to my whether it be all one portion of a double uterus or the single previous knowledge, and have found the information thus uterus drawn over by adhesions to the side. It may, indeed. obtained of very great practical value in the diagnosis of be quite possible to have both a normal pregnancy and an both normal and complicated pregnancy. Additional cases extra-uterine concurrently; and here again we are also. with remarks have been brought before the International in a position to decide and discriminate the one from the Medical Congresses, and published in their Transactions. other. Since these publications other interesting cases have In twin pregnancy it not infrequently occurs that oneoccurred in my practice, affording fresh evidence of the ovum has died, dwindles, and becomes somewhat solidified, value our knowledge of these contractions gives us in un- producing a want of symmetry in the form of the uterus; ravelling conditions otherwise puzzling or insoluble. A and this particularly if the other ovum at the same time is selection of these, in illustration, will be given in this paper. affected with hydramnios, so that there is much difficulty But first it may be helpful to make a brief sketch of our in making out the actual condition. In such a case we present position. In the first place, it is proper to point out are generally able to notice that when the uterus becomesthat where the uterus is beneath the fourth month of preg- firm the whole of the irregular swelling becomes a firm nancy it is much to be preferred that we employ both ex- spheroid, and thus the several parts are proved to be within. ternal and internal palpation; after this time this is not so the same walls, which can only be the uterine; while palpanecessary. If it be undesirable, as when we merely suspect tion and the stethoscope will reveal the dual contents. When the uterus is over-distended, as by hydrops amnii, we. pregnancy in single girls or women, to employ external examination, the outline of the uterus will generally be are to a large extent unable to detect the contractions, and thesufficiently defined if we place one hand over the lower diagnosis between this state and ovarian dropsy must be abdomen, one edge slightly resting on the pubes, and then made out by other means. In distension by the large and. causing the person to inspire freely and frequently. We rapidly growing vesicular mole (hydatiniform degenerationshall easily perceive its presence by the resistance of the of the chorion) I have noticed these contractions occur as in uterus; and by continuing our observation sufficiently a natural pregnancy. However, in mole conceptions of thelong we shall detect any variation which may occur in solid kind (apoplectic ovum, &c.), or where the feetus has been its solidity. For although sometimes the variation may blighted and the whole ovum become more substantial, thenot be very marked even at the fourth month of pregnancy, uterus often continues for a long time firmly contracted,. yet the flaccid stage is often so complete that all sensation and thus we have a state which may be imitated by a soft of resistance is lost except to very careful bimanual exami- fibroma, though in this latter complaint the menses arenation. It may here be noted that when our hand is first generally excessive and frequent, but generally not postplaced over the uterus, this organ may be in a state of con- poned or absent for a month or two, as is the case traction, and consequently firm; or it may be flaccid, so most frequently in mole conceptions. In fibroma themuch so as not to be easily recognised. It is only by wait- menses are, as I have just said, in excess, either in time oring patiently that we can determine the variation. The quantity, or both, except in those cases where the loss is. time occupied in this can be passed in inquiries concerning very great and the anaemia profound. But these fibromas other matters. Supposing, then, that a single young are generally not of recent origin, there is commonly a long lady is brought to us for amenorrhoea of four or five history. It has been stated, though I myself have nevermonths’ duration, and an increase in the size of the yet observed it, that there is an alteration of density in cases abdomen has been noticed by the friends, an easy of soft uterine fibroma. If this be the case, it must be rare, opportunity is afforded us of making a superficial ex- and taking the histories into account we are not likely toamination, and thus, without implying any suspicion, be misled. It would be only in cases of mole conception or we can ascertain, first, whether there be any swelling in the blighted ovum in the earlier months of pregnancy that theuterine region; and, secondly, if there be, whether it be point would arise. In normal pregnancy the complete persistently firm or of varying density. Should the latter flaccidity of the walls during the relaxed state is quitebe the case, we know of no other condition coupled with different from the simple alteration of density, and it is thertamenorrhcea which presents these features; and thus we that the foetal parts can be felt generally without difficulty" have sufficient grounds to go further into the matter, and (To be concluded.) to proceed, if necessary, to propose an internal examination. Even should no change of size have been observed, external palpation can generally be obtained. I think it will be fully recognised as a great advantage that we are thus able to obtain decisive proofs of pregnancy before suggesting the possibility of its existence, or before alluding to the MEDICAL, SURGICAL, OBSTETRICAL, AND subject at all. Not only in the recognition of pregnancy, but also and THERAPEUTICAL. particularly are we assisted by making use of our knowledge of these contractions when it is attended by complications. Where we have a mural fibroma, we are able, by STRANGULATED FEMORAL HERNIA, WITH ENTIRE ABSENCE OF LOCAL PAIN. watching the condition of the uterus during these alterations of density, to distinguish generally between the BY OSCAR B. SHELSWELL. portion occupied by the pregnancy and that by the tumour. But where there are many tumours and the pregnancy early, ON Sunday, Nov. 20th, I was called to see Mrs. H-,. this is not so easy-sometimes it is impossible. In a rapidly growing ovarian tumour the diagnosis between it and a aged forty-nine, suffering from very severe abdominal pain, gravid uterus is important, and in the majority there is con- especially on the left side and around and above the siderable difficulty; but by the signs I have given there will umbilicus; vomiting and constipation were also present.. generally be a tolerably easy solution of the question. These symptoms had commenced on the previous day. I Where pregnancy occurs in a normal uterus along with the presence of an ovarian tumour, we are enabled in like found on inquiry she had had the usual energetic doses of purgatives recommended by sympathising neighbours, but. manner to decide which swelling is the uterus and which is the ovarian growth. So also, where an extra-uterine the constipation continued. She had a "lump"in the right pregnancy is suspected, we can decide against the sup- groin, to which she paid little attention, however, as thereposition if we observe the swelling change in density, for of was no pain in it. It was of irregular shape, and felt very course no such change takes place in extra-uterine conhard, except at the lower part; no impulse on coughing.. ception ; but it is obvious that we must not be too hasty in The diagnosis of hernia was aided by a history of its sudden assuming that because we cannot for a time feel this sign disappearance some weeks previously. Slight taxis was the pregnancy is extra-uterine, for the uterus sometimes if tried, without causing the least pain. Next day, as the very quiescent, and therefore extended observation will be sickness increased in severity, and the vomit was very offensive, I decided to operate. She had had no pain in required before the negative can be taken as a positive. In cases where a double uterus is present and one side is the hernia at all ; and even immediately preceding the slightest pain was caused by impregnated, there may be a suspicion of extra-uterinE administration of ether not the foetation ; but if the tumour, which would be on one side examining the hernia-all the pain, and that very severe, alter its density, we shall be certain the ovum is within thE being felt as before on the left side of the abdomen and:
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Clinical Notes:
67 lower limb was flexed in the usual manner, the hand and forearm intervening between it and the abdomen. Rigor mortis was marked in all the limbs of the child. The third stage of labour presented no difficulty. The patient made an uninterrupted recovery, and was dismissed on the ninth day of puerperium.
above the umbilicus. The sac was [opened, - around &nd but only omentum seen. On passing my finger to the ring, however, a small knuckle of bowel was felt tightly nipped. I divided the constriction, returned ,the bowel, ligatured the omentum, and cut a portion off. The vomiting and pain entirely ceased after the operation. The temperature has been normal ever since, except on the first two days, when it was slightly raised. The bowels acted naturally on the ninth day, and with the exception of .some suppuration, owing to the omental ligature, the patient has progressed well. The interesting point in the above case is the entire .absence of local pain. Mr. Birkett., referring to strangulated hernia, saysthe tumour is painful when touched." And Mr. Bryant writes: "The hernial tumour will be tense and .painful"; but he qualifies this by a later passage: "The local signs are often slight," and refers to a case where he "reduced a femoral hernia by taxis, strangulated for a hundred hours in a man who was unconscious of its ,presence till a few hours before." The perfect freedom from local pain in the case of Mrs. H-, even to the period immediately preceding the operation, is therefore, I think, sufficiently uncommon to render it of interest.
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CASE OF SEVERE POST-PARTUM HÆMORRHAGE SUCCESSFULLY TREATED BY INTRA-VENOUS INJECTION OF SALINE FLUID. BY BLAGDON RICHARDS.
ON December 19tb, 1887, I attended Mrs. H-, aged thirty-four, in her eighth confinement. There was a history to the effect that on previous occasions difficulty had been experienced in the removal of the placenta. The child was born at 9.30 A.M., and as attempts to express the placenta, secundem artem, failed, I removed it with the hand; but upon examination calcareous degeneration of the placenta was observed, and it was evident that a portion remained still adherent to the uterus. The haemorrhage was continuous, and the uterus would not respond suffiVERY RARE PRESENTATION IN MIDWIFERY. ciently to manual stimulus to justify the hope that the BY R. ADAMS BREWIS, M.D. EDIN. patient might recover without some further assistance. The pulse was now almost imperceptible, the woman blanched, MR. BORHAM of Fulham relates a case of very rare pre- restless, but conscious. Brandy and ergot were administered sentation in midwifery in THE LANCET of Oct. 15th, 1887, at short intervals in small doses, and I telegraphed to his transfusion apparatus. Upon his and more recently Mr. Buchanan of Glasgow has narrated a Mr. Jennings to bring arrival Mr. Jennings concurred with me that the remains of similar case. These cases remind me of the following one the placenta should be extracted from the uterus, which was that came under my care in the Glasgow Maternity Hospital. effected, stupor having been induced by the inhalation of a Mrs. F---, aged twenty-nine, of short stature (a multi- little chloroform to facilitate the procedure. The uterus para), was admitted on January 17th, 1885, at 6.5 A.M. being now quite empty, the organ was packed with small Previous obstetrical history: She states that in her previous lumps of ice, and manual pressure upon its fundus entrusted labours the after-birth was always difficult to get away. to the nurse. It was now observed that the pulse was small This was not the case in her last confinement, which took and very quick, but its frequency was not noted. Great ,place in this hospital in October, 1883. Present labour: thirst was complained of, and we thought that the condition Delivered on Jan. 19th, 1885, at 4.45 A.3f. Head, left hand, of the patient indicated the necessity for intra-venous injecfunis, and left foot presented. Position of head, left occipito- tion of fluid. Sixteen ounces of saline fluid (temperaanterior. Duration of first stage, two hours; second, an ture 98° F.) were accordingly injected, about noon, into the hour and fifty-five minutes; third, twenty minutes. Child cephalic vein of the right arm. Signs of increased animation ,(male) dead; full period; weighed 81 lb. ; length 22 in. The were coincident with the intra-venous injection, and the placenta weighed 1¼ lb. ; length of umbilical cord, 27 in. ; feeling of thirst considerably lessened. The frequency of the placenta and membranes were entire. The patient thepulse was reduced to 100, and its character approached the .says she last felt the movements of the child on the normal. This patient has made an uninterrupted recovery. evening of January 16th; but they had been very feeble for four days previously. At 8 P.M. on January 18th no CASE OF MAGGOTS IN THE EAR. foetal heart sound could be heard; the finger could be inBY WM, J. PILLEY, L.R.C.P. LOND., M.R.C.S. serted into the os and a firm body felt; this was supposed to be the head, and abdominal palpation supported this ,position. The patient was removed from the labour room to M. R-, a domestic servant recently arrived in the colony, a small adjoining ward, as other cases were going on. awoke on Oct. 31st feeling pain in the left ear. The pain Labour pains began at 1 A.M. on Jan. 19th. At 3 A M. the steadily increased, although she applied poultices. Three .nurse came and said that the membranes had ruptured, that the os was well dilated, and that a hand and a loop of days later she consulted me, complaining of intense pain in umbilical cord were in the vagina. On examination it was the left ear. On introducing a speculum moving white found to be the left hand, and the funis did not seem to be bodies could be seen. The ear was syringed, with the result ,pressed upon, though it was pulseless. A hard rounded body that three maggots (iarvse of the common blow-tly) were was felt high up, but whether head or shoulder was not removed. On again examining the canal with a speculum determined, though after examination by abdominal pal- the sides were found to be slightly ingested, as also was the pation it was considered to be the head. Dr. Samuel Sloan, membrane. Iodoform was blown into the ear, after which the visiting physician, was sent for, and arrived at 4.15 A. Nl:. all symptoms soon disappeared. ’On examination he found a large loop of umbilical cord I am not aware whether this kind of case is rare or otherin the vagina, the left hand and arm in advance of the wise, but can quite imagine how easy it is for the eggs of head; head in left occipito-anterior position and in the the blow-fly to become deposited in the ear during sleep, cavity of the pelvis; a foot lying across the upper part of especially in a country so infested with flies as is Queensland. the forehead, the heel being on the right side of the forehead, the toes on the left. The head being in the cavity THE POISONING OF THE MANCHESTER REGIMENT.of the pelvis, and the uterus being evidently firmly contracted on the body of the child, it was deemed safer to We noticed some months ago a report that appeared in some apply forceps, when, if gentle traction did not suffice, the of the up-country Indian papers of attempts to poison the head was to be perforated. Sir James Y. Simpson’s forceps Manchester Regiment at Agra. An inquiry has led to the were easily applied, and the child delivered in about five discovery that they had been drinking beer which contained minutes with very moderate traction, the arm coming first. a large quantity of arsenic, and it is believed that they owed ’The foot that was lying across the forehead receded some- their lives simply to the accident of the poison not having what when traction was applied, so that when born it lay been stirred up from the bottom of the cask. The beer drawn on the left side of the thorax. The attitude of the child was from the cask was comparatively pure, but the dregs connow well seen; the left hand and arm stretched in advance I tained enough arsenic to poison the regiment. An examiof the head; the left leg fully extended on the front of the nation of several casks disclosed the fact that the wood was child; the right upper arm lay by the side of the child, saturated with the poison, and it appeared that they had the forearm and hand being flat on the abdomen; the previously been used for holding arsenic.
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make
on
uterus.
Clinical Notes:
67 lower limb was flexed in the usual manner, the hand and forearm intervening between it and the abdomen. Rigor mortis was marked in all the limbs of the child. The third stage of labour presented no difficulty. The patient made an uninterrupted recovery, and was dismissed on the ninth day of puerperium.
above the umbilicus. The sac was [opened, - around &nd but only omentum seen. On passing my finger to the ring, however, a small knuckle of bowel was felt tightly nipped. I divided the constriction, returned ,the bowel, ligatured the omentum, and cut a portion off. The vomiting and pain entirely ceased after the operation. The temperature has been normal ever since, except on the first two days, when it was slightly raised. The bowels acted naturally on the ninth day, and with the exception of .some suppuration, owing to the omental ligature, the patient has progressed well. The interesting point in the above case is the entire .absence of local pain. Mr. Birkett., referring to strangulated hernia, saysthe tumour is painful when touched." And Mr. Bryant writes: "The hernial tumour will be tense and .painful"; but he qualifies this by a later passage: "The local signs are often slight," and refers to a case where he "reduced a femoral hernia by taxis, strangulated for a hundred hours in a man who was unconscious of its ,presence till a few hours before." The perfect freedom from local pain in the case of Mrs. H-, even to the period immediately preceding the operation, is therefore, I think, sufficiently uncommon to render it of interest.
right right
CASE OF SEVERE POST-PARTUM HÆMORRHAGE SUCCESSFULLY TREATED BY INTRA-VENOUS INJECTION OF SALINE FLUID. BY BLAGDON RICHARDS.
ON December 19tb, 1887, I attended Mrs. H-, aged thirty-four, in her eighth confinement. There was a history to the effect that on previous occasions difficulty had been experienced in the removal of the placenta. The child was born at 9.30 A.M., and as attempts to express the placenta, secundem artem, failed, I removed it with the hand; but upon examination calcareous degeneration of the placenta was observed, and it was evident that a portion remained still adherent to the uterus. The haemorrhage was continuous, and the uterus would not respond suffiVERY RARE PRESENTATION IN MIDWIFERY. ciently to manual stimulus to justify the hope that the BY R. ADAMS BREWIS, M.D. EDIN. patient might recover without some further assistance. The pulse was now almost imperceptible, the woman blanched, MR. BORHAM of Fulham relates a case of very rare pre- restless, but conscious. Brandy and ergot were administered sentation in midwifery in THE LANCET of Oct. 15th, 1887, at short intervals in small doses, and I telegraphed to his transfusion apparatus. Upon his and more recently Mr. Buchanan of Glasgow has narrated a Mr. Jennings to bring arrival Mr. Jennings concurred with me that the remains of similar case. These cases remind me of the following one the placenta should be extracted from the uterus, which was that came under my care in the Glasgow Maternity Hospital. effected, stupor having been induced by the inhalation of a Mrs. F---, aged twenty-nine, of short stature (a multi- little chloroform to facilitate the procedure. The uterus para), was admitted on January 17th, 1885, at 6.5 A.M. being now quite empty, the organ was packed with small Previous obstetrical history: She states that in her previous lumps of ice, and manual pressure upon its fundus entrusted labours the after-birth was always difficult to get away. to the nurse. It was now observed that the pulse was small This was not the case in her last confinement, which took and very quick, but its frequency was not noted. Great ,place in this hospital in October, 1883. Present labour: thirst was complained of, and we thought that the condition Delivered on Jan. 19th, 1885, at 4.45 A.3f. Head, left hand, of the patient indicated the necessity for intra-venous injecfunis, and left foot presented. Position of head, left occipito- tion of fluid. Sixteen ounces of saline fluid (temperaanterior. Duration of first stage, two hours; second, an ture 98° F.) were accordingly injected, about noon, into the hour and fifty-five minutes; third, twenty minutes. Child cephalic vein of the right arm. Signs of increased animation ,(male) dead; full period; weighed 81 lb. ; length 22 in. The were coincident with the intra-venous injection, and the placenta weighed 1¼ lb. ; length of umbilical cord, 27 in. ; feeling of thirst considerably lessened. The frequency of the placenta and membranes were entire. The patient thepulse was reduced to 100, and its character approached the .says she last felt the movements of the child on the normal. This patient has made an uninterrupted recovery. evening of January 16th; but they had been very feeble for four days previously. At 8 P.M. on January 18th no CASE OF MAGGOTS IN THE EAR. foetal heart sound could be heard; the finger could be inBY WM, J. PILLEY, L.R.C.P. LOND., M.R.C.S. serted into the os and a firm body felt; this was supposed to be the head, and abdominal palpation supported this ,position. The patient was removed from the labour room to M. R-, a domestic servant recently arrived in the colony, a small adjoining ward, as other cases were going on. awoke on Oct. 31st feeling pain in the left ear. The pain Labour pains began at 1 A.M. on Jan. 19th. At 3 A M. the steadily increased, although she applied poultices. Three .nurse came and said that the membranes had ruptured, that the os was well dilated, and that a hand and a loop of days later she consulted me, complaining of intense pain in umbilical cord were in the vagina. On examination it was the left ear. On introducing a speculum moving white found to be the left hand, and the funis did not seem to be bodies could be seen. The ear was syringed, with the result ,pressed upon, though it was pulseless. A hard rounded body that three maggots (iarvse of the common blow-tly) were was felt high up, but whether head or shoulder was not removed. On again examining the canal with a speculum determined, though after examination by abdominal pal- the sides were found to be slightly ingested, as also was the pation it was considered to be the head. Dr. Samuel Sloan, membrane. Iodoform was blown into the ear, after which the visiting physician, was sent for, and arrived at 4.15 A. Nl:. all symptoms soon disappeared. ’On examination he found a large loop of umbilical cord I am not aware whether this kind of case is rare or otherin the vagina, the left hand and arm in advance of the wise, but can quite imagine how easy it is for the eggs of head; head in left occipito-anterior position and in the the blow-fly to become deposited in the ear during sleep, cavity of the pelvis; a foot lying across the upper part of especially in a country so infested with flies as is Queensland. the forehead, the heel being on the right side of the forehead, the toes on the left. The head being in the cavity THE POISONING OF THE MANCHESTER REGIMENT.of the pelvis, and the uterus being evidently firmly contracted on the body of the child, it was deemed safer to We noticed some months ago a report that appeared in some apply forceps, when, if gentle traction did not suffice, the of the up-country Indian papers of attempts to poison the head was to be perforated. Sir James Y. Simpson’s forceps Manchester Regiment at Agra. An inquiry has led to the were easily applied, and the child delivered in about five discovery that they had been drinking beer which contained minutes with very moderate traction, the arm coming first. a large quantity of arsenic, and it is believed that they owed ’The foot that was lying across the forehead receded some- their lives simply to the accident of the poison not having what when traction was applied, so that when born it lay been stirred up from the bottom of the cask. The beer drawn on the left side of the thorax. The attitude of the child was from the cask was comparatively pure, but the dregs connow well seen; the left hand and arm stretched in advance I tained enough arsenic to poison the regiment. An examiof the head; the left leg fully extended on the front of the nation of several casks disclosed the fact that the wood was child; the right upper arm lay by the side of the child, saturated with the poison, and it appeared that they had the forearm and hand being flat on the abdomen; the previously been used for holding arsenic.
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