Obrázky stránek
PDF
ePub

the blades to about one half, guarding the os uteri by the introduction of a piece of sponge, and then pushing up the cauterising iron, which came in contact with those portions of the vagina only that protruded between the blades. As yet I cannot say whether this plan is equally or more efficacious than that previously adopted, but it certainly possesses the merit of simplicity.

Now, as to the results of this mode of treatment generally, whilst it would be idle to say, in a disease of this kind, where oftentimes all the soft structures constituting the lower or pelvic walls of the abdomen, namely, the peritoneum, pelvic fascia, levator ani, the perineum and its muscles, are in a state of lesion, that any degree of narrowing of the vagina possible to be produced, would necessarily cure the disease in all cases; yet I feel no hesitation in saying that in many cases it has succeeded where every other means had failed, and in all it has been attended with more or less benefit. It must, however, be combined with strict attention to the recumbent posture for several weeks, and, if necessary, keeping the womb up whilst the parts are contracting by the introduction of a stalk pessary, or small bag filled with astringent powder. The patient must very gradually resume the upright posture and exertion. The use of tonics and aperients, if necessary, wearing a pad or. T bandage, or Hull's utero-abdominal truss, whilst any tendency to prolapse remains, will add essentially to the cure; but the employment of these supports I have insisted upon, as a precaution in all cases, for a mouth or two after the operation, however complete the amendment may have appeared. In some obstinate and most unpromising cases, where no pessary could be retained, in the first instance, I have rested satisfied with inducing such a state of contraction with the cautery as enabled my patients to use pessaries. I do not, however, imagine that the operation of the cautery is confined entirely to the vaginal walls, but rather think the adjacent structures, if they do not undergo a direct change by the extension of the irritation, at least become necessarily altered, and a consequent contraction is induced in them also by their connections and relations with the vagina. For obvious reasons the cases most suited to this plan of practice are women who have passed the period of childbearing; but I have had recourse to it with benefit, and without inconvenience, in young and even unmarried females. Such a practice is only admissible, however, in extreme cases.

In concluding this communication allow me to add, that I have been induced to trespass upon you only from a conviction that it was my duty, as an individual in whom a great public trust is reposed, to inform the profession of any experience already possessed upon a subject now, apparently for the first time, opening upon their attention. I have availed myself, in so doing, of addressing you, because I knew no means so likely to prove effectual in accomplishing my object, certainly none so gratifying to the feelings of, dear sir, yours, most truly and respectfully,

Lying-in Hospital, Dublin,

EVORY KENNEDY.

May, 30, 1839.

BOOKS RECEIVED.

From the Author.—Address delivered to the Graduates of the Philadelphia College of Pharmacy, April 23, 1839. By Joseph Carson, M. D., Professor of Materia Medica and Pharmacy. 8vo. pp. 16. Philadelphia, 1839.

From the Publisher.-The New York Journal of Medicine and Surgery, published quarterly, No. 1., July, 1839. 8vo. pp. 244. New York, 1839. From Dr. C. A. Lee.-The American Journal of Dental Science, for June, 1839, vol. i. No. 1. Edited by Chapin A. Harris, Baltimore, and Eleazar Parmly, New York. 8vo. pp. 24.

[merged small][graphic][subsumed][merged small][merged small][merged small]
[blocks in formation]

ART. I.-CASE OF ABDOMINAL TUMOUR (FIBRO-SCIRRHOUS) CONNECTED WITH THE UTERUS-AUTOPSY AND REMARKS.

BY C. W. PENNOCK, M. D.

Physician to the Philadelphia Hospital, Blockley, (with a lithographic plate.) Eliza Hyson (black), aged 36, married at 19, has never had children, has miscarried four times; in the three first instances between the sixth and seventh months, without any known cause; in a fourth pregnancy, fourteen years since, in the fifth month of gestation, was severely beaten and kicked in the lumbar region, which was followed by abortion the next morning. Since this event she has not been pregnant; the menstrual function, however, has continued until the last three months; no pain was experienced at the usual menstrual period, and the appearance of the secretion was natural. Twelve years since (two years after the beating) a distension of the right lumbar region was observed, which was mistaken for pregnancy; this tumour has gradually increased in size, and now presents an enormous enlargement. It has never been attended with pain, and she came into the hospital in consequence of the weight and inconvenience of the tumour, rather than for any other cause. Transient oedema of the limbs occurred in 1838. In the autumn of 1838 she entered the hospital, and was placed in the wards of Dr. Dunglison, where she remained some months. Being somewhat relieved, she requested her discharge, and, after a short absence, returned: the size of the tumour being much augmented. A few days after her re-entrance, the patient presented the following symptoms:

February 14th, present state.-Slight emaciation; nothing peculiar in the expression of the countenance; intelligence perfect; no cellular infiltration; skin natural; decubitus dorsal, or on the left side; position in bed slightly elevated. Chest well formed. Percussion preternaturally resonant, and respiration feeble beneath right clavicle, elsewhere normal. Percus sion of heart shows it dilated; rhythm of heart nearly normal; slight bellows sound accompanies the first, heard beneath the cartilage of left third rib, and beneath cartilages of second and third ribs on the right side near the sternum. Pulse 80, easily excited, somewhat tense.

Abdomen enormously distended by an internal tumour; the measurement from the symphyses of pubis to the ensiform cartilage, three feet; circumference round the umbilicus four feet eight inches. Percussion is flat, with the exception of right lumbar region near the spine, where it is resonant. In the epigastric and upper part of umbilical region, abdomen soft, elsewhere hard; hard globular masses, resisting pressure, felt in different portions of abdomen, particularly in the hypogastric, right iliac, and lumbar, extending up to right hypochondriac; fluctuation caused by palpation, on left side of

tumour, none anteriorly, imperfectly felt on right side. Appetite good; constipation; some difficulty in urining. Pulsation of femoral arteries distinct, but feeble.

In examination per vaginam, the finger is introduced with difficulty, from pressure of tumour filling the greater part of the cavity of the pelvis; the os tincæ found towards the right iliac crista, soft, and unchanged-neck not obliterated the tumour, by strong pressure, may be raised, but upon withdrawing the hand, it sinks heavily downwards.

(Treatment palliative-mild cathartics, simple nutritious diet, hip baths, fomentations to abdomen, &c.)

On the 20th, fluctuation was observed in the upper and lateral portions of the abdomen, conveying the sensation of the existence of a slight effusion of fluid between the external parietes and tumour; no pain on pressure; pulse rather more tense, 90 per minute; skin of natural heat. Patient was directed to drink an infusion of juniper berries. . bacc. juniperi 3j. bitart. potassæ 3ij. aquæ Oj. in the day, and pulv. Doveri grs. viij. at night. The fluid diminished very sensibly in a few days. No marked fever was at any time observed; patient remained almost constantly in a recumbent posture, not, as she frequently stated, from pain, but in consequence of the weight and sense of distension when sitting. Emaciation and debility rapidly increased.

Absence from the city prevented my seeing the patient during the last week of her life. My friend, Dr. Barnes, resident physician, reports, that on the 1st of March she had a severe chill, followed by fever, pain in the abdomen, great dyspnoea, and the physical signs of peritonitis and pneumonia. All means of relief proved unavailing, and this acute attack caused death in less than thirty-six hours from its commencement.

Autopsy fifty hours after death.-Frame, medium size; much emaciation; no effusion into cellular tissue.

Abdomen-Greatly enlarged, of an irregular globular form, measuring thirty-one inches and a half from pubes to ensiform cartilage; circumference over umbilicus, where distension is greatest, fifty-one inches. Percussion of abdomen flat, except in epigastric region, where it is resonant. Abdomen soft, except in hypogastric and right lumbar regions, where a hard, irregular, semicircular mass is felt, resembling a fœtus at term; a globular mass is also felt to the left of umbilicus; fluctuation by palpitation in umbilical region.

Opening the abdomen two quarts of fetid bistre-coloured fluid escaped. Peritoneum and omentum thickened, covered with numerous bright scarlet patches, and are firmly united by bands to contiguous organs. Raising the omentum, a large globular tumour is seen, by which the intestines are displaced and forced into epigastric region; this tumour, sixteen by fourteen inches, occupies the whole of the hypogastric, umbilical, and greater part of lumbar regions, is anterior to the uterus, to the body of which it is firmly connected. United to this large tumour, at its inferior and left lateral margin, is another tumour, which projects into the cavity of the pelvis, and rests principally in the left iliac fossa. The tumours are firmly attached to the parietes of the abdomen and pelvis by membranous bands, and are covered externally by the peritoneum, which is much thickened, of a dark red colour, and interspersed with patches of minute arterial vessels. The large tumour on its right lateral margin is united in an extent of two inches with the cellular coat of the fundus and body of the uterus. Cellular tissue connects the peritoneal coat with the proper capsule of the tumours, which is of a pearl colour, hard, fibro-cellular, and a line in thickness. Near the connection of the tumour with the uterus cellular tissue is very abundant; it contains numerous meshes of blood-vessels, principally veins, is deeply injected, and resembles muscular fibre. The tumour, somewhat irregular and lobulated, is of unequal firmness, in some spots soft to the touch, in others, hard and resisting; evident fluctuation exists over the softer portions

« PředchozíPokračovat »