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faced by pregnancy; so that, so early as a month or five weeks, this physical change may be detected.
The symploms which attend this form of retroversion are not, generally speaking, so severe or so well marked as might be expected, or, indeed, as they are described. It is rare for the displaced womb mechanically to interfere with the bladder or the rectum, and as rare for it to press upon and obstruct the veins. Sometimes, however, if a person has been standing for any length of time, especially during menstruation, dysuria ensues, which is relieved by lying down for some hours. The rectum, too, in these cases, generally escapes pressure ; and it is surprising, even when the womb is very solid and bulky, appearing to the finger to fill the cavity of the sacrum, how rarely mechanical constipation ensues. In these cases, as in preg. nancy, there seems to be some mechanism, which, I think, notwithstanding what has been said about it, is yet unexplained, by which the uterus is directed towards the right side of the pelvis, removing it from the rectum. There are, however, a class of cases where engorgement of the womb is associated with hæmorrhoids and bleeding from the rectum, which ought not to be confounded with the present cases; they occur in women whose digestive organs have been long disordered,—who indulge freely in eating and drinking, and take but little exercise,—whose bowels are habitually constipated, and the colon loaded. The urine in these cases is often charged with lithic acid, and, as a consequence of the portal congestion, the hæmorrhoidæl veins swell, and eventually the uterus becomes engorged. Painful and oftentimes copious menstruation occurs in this form of complaint, as Dr. Rigby has so well shown; but the pathology of the two classes of cases is essentially different. In the one, the depraved state of the digestive organs induces engorgement of the womb; in the other, the affection is at first confined to the internal sexual organs,
and any disorder of the general health is slowly induced.
The principal symptoms which I have noticed as the result of the large and retroverted womb have been, an habitual weight in the lower part of the abdomen, and a painful sense of pressure about the sacrum; pain of a dragging kind referred very distinctly to the inguinal canals, but very often only to one of them, with pain in the corresponding hip. There is pain, too, in sitting down, and a feeling as though some body were pressed upwards. If the cervix gets bulky and full, a thick mucous discharge comes on, which frequently is discharged in lumps.
It has been advised in these cases to redress the womb by means of the uterine sound; but I think this expedient is very rarely required. If the forefinger is placed against the anterior part of the cervix, and this part pressed backward, the womb, although large and heavy, may readily be raised and directed forward, and, in the act of reducing it, a sense of its weight and the extent of its displacement is conveyed to the finger. No permanent good, however, is obtained by the operation, as the womb quickly falls back again, and the same symptoms of pressure, which for the moment were relieved,
again come on. I have known a great deal of pain caused by using the sound in the way described ; and, if the womb is held by false membranes, to attempt to overcome the resistance by the sound would be not only painful but dangerous.
In the treatment of membranous dysmenorrhea, with a large, hard, retroverted womb, I have found the plan which was adopted in the case described the most effective. It consists in keeping the patient as much at rest as possible, in regulating the diet so as generally to avoid stimulants, but not to lower the strength, and to give small doses of mercury, so as slightly to affect the gums: two grains of blue-pill, with three of Ext. Conii, night and morning, or five-grain doses of Plummer's pill night and morning, answer the purpose required. On the first appearance of the gums or palate being tender
, I generally give the Liq. Hydrarg. Bichlorid. 3j. in sarsaparilla or bark, which, while it keeps up the action of the mercury, is really a tonic, and improves the general health. If the patient does not bear mercury well, it is well to commence and continue with this last preparation, and a small quantity of blue ointment, with Ext. of Belladonna, may be rubbed at night over the inguinal region. Leeches should be applied to the upper and back part of the vagina once a week. Three or four will in general be sufficient, and I can safely say that they are easily applied, and offer the most effective means that I know of for reducing the womb. Cupping on the loins, or leeching the inguinal regions, are, in my experience, far less useful for the purpose. In the case which I have related the cervix was scarified several times because of the vascular granulations which covered it; but unless a surface of this kind is present, which bleeds freely on being lightly cut, I do not think it a good plan of local depletion. When the size of the womb is reduced by these means, an occasional blister on the sacrum will be found very useful. I have generally found patients obtain great relief by their application. The reduction of the womb may be assisted by warm hip-baths, or the injection of warm poppy-water into the vagina. By following out this plan of treatment, and attending to the general health, I have often succeeded in reducing these large, solid, hypertrophied wombs, with the dysmenorrhea which accompanied them, and the conviction has forced itself upon me, that the cases of fibrous tumour which have been supposed to be cured have really been cases of this kind. When the influence of mercury is obtained, small doses of lodide of Potassiuin, or, what I have found more useful, small doses of the Liq. Potass. Arsen., may be given with advantage. The latter medicine should be administered in the way recommended by Mr. Hunt--on a full stomach, and in decreasing doses.
Sometimes the womb has so long been displaced, and is so very hard, that it seems to resist any attempts at cure. I have now a case of this kind under care in a woman æl. 48, who has ceased to men struate for a year and a half. In this, as in similar cases, the metallic stem support described by Dr. Simpson effectually retains the womb in situ, but I have not found this instrument desirable in other cases.
The object generally is not to support a large womb, but to lessen its size, to stop the ovarian excitement which is causing it, and to secure its spontaneous reduction. In these cases much comfort is obtained by an elastic abdominal belt, with a perinæal support.
The views which have been propounded on this subject may be expressed in the following conclusions :
i. There is one form of menstruation rendered extremely painful from the production and casting off of a membrane from the cavity of the womb.
2. That this membrane is not a product of inflammation, or a thick mass of epithelium, but it is formed from the uterine glands just as the decidua is, and is detached and expelled in the same way.
3. That the morbid action does not begin at the uterus, but in the ovary; and the sequence of effects is first ovarian congestion, calling forth a sympathetic growth of the uterine glands, forming a false decidua and uterine engorgement.
4. That this uterine engorgement is oftentimes relieved by a profuse menstrual flux; but if not, the posterior wall of the womb gradually increases in bulk and becomes hard, the balance of the womb is spoiled, and the body falls back, retroverting the womb.
5. That the swelling of the posterior wall, and the falling back of the womb, forms a differential diagnosis between congestion and early pregnancy, the anterior wall enlarging in the latter, and the body of the womb directed forward.
6. That the symptoms of retroverted womb from this cause are not often those of mechanical obstruction to the other pelvic viscera, and they are for the moment relieved by redressing the womb, which may almost always be effected by the finger without the aid of the sound.
7. That the treatment consists in strict attention to the general health, but that the most effectual way of removing the disease with the enlarged womb is by leeching the uterus, and the use of mercury:-London Med. Gáz.
Tuberculous Abscess in the Pancreas.—The rare occurrence of disease of the pancreas renders the following case interesting. The subject of the case was a young female, aged 25, who had for a considerable time been out of health. Four years ago she had suffered for about two months froin severe pain at the lower part of the chest, extending through to the back, which prevented her from lying on her right side or on her back. After the subsidence of this attack she seems to have continued in tolerable health for nearly three years, at the end of which time she became affected with lassitude and debility, uneasiness in the chest and bilious vomiting. The vomiting would sometimes last four or six hours. From this time her skin slowly and gradually became jaundiced, and continued so to the date at which she came under M. Cruveilhier's care, who has recorded the case. She complained at this time chiefly of loss of appetite, and inability to lie on her back in bed unless propped up. Her tongue was moist, and digestion good; but her bowels were obstinately confined, so that she did not require to go to the closet oftener than once in four or five days. The evacuations possessed their natural colour. She had some uneasiness on pressure over the epigastrium. The margin of the liver could be felt below the cartilages of the ribs, and appeared slightly enlarged: some pain was caused by pressure over this organ. The urine was not high coloured, and formed no precipitate on the addition of nitric acid. She had now very little uneasiness in the chest; no cough, palpitation, or headache. Neither by auscultation nor by percussion could any thing abnormal be detected in the lungs or heart. Some slight remedies were made use of. In about a week she became feverish and generally ill, without any known cause: in the evening of the same day she vomited some bile. The vomiting continued next day, and was accompanied by loss of appetite, and severe pain at the pit of the stomach. The pulse was 100, small and feeble. The vomiting was almost incessant for the two following days, when she became extremely exhausted: the pain in the epigastrium was most severe. No evacuation from the bowels had taken place since the commencement of the attack. Tongue dry, furred, white on the dorsum, red at the tip. Pulse 90, small. She died exhausted the same evening.
The liver was found rather larger than natural ; its right lobe firm in texture, and of a peculiar greyish green colour throughout. About two ounces of dark green bile were contained in the gall-bladder. The glands in the neighbourhood of the stomach were enlarged, softened, and infiltrated with a blackish matter. Those near the pancreas were also enlarged, and filled with tuberculous matter. The pancreas was about natural in size. Within its last half, or tail, was found an abscess, capable of holding a small hen's egg. It was filled with thick purulent matter, and its cavity was lined by a thick and tough, greyish, organised membrane, within and around which were numerous softened tubercles. External to the abscess the tissue of the pancreas was spread out, and appeared atrophied. The right half of the pancreas was dark coloured, but healthy in structure. The pancreatic duct was entire. Two small cretaceous masses of tubercles were found in the spleen, and two similar ones in the apex of the left lung. Traces of recent violeni inflammation were found in the stomach, the duodenum, and for a short way down the jeju. num.-Ibid. from Gaz. des Hôpitaux.
MANCHESTER PATHOLOGICAL SOCIETY. Detection of Sugar in the Expectoration of Patients affected with Diabetes.-Dr. Francis presented to the Society a specimen of sugar which he had obtained, a few days previously, from the expectoration of a man the subject of diabetes mellitus.
The patient, aged 25, for upwards of a year suffering the ordinary symptoms of this disease, and at present much wasted in flesh, had, during the last six months, shown signs of advancing pulmonary phthisis. The expectoration latterly had amounted to little less than VOL. X.
24 ounces daily, and, on the day which furnished the specimen submitted to examination, had even exceeded that quantity. It was composed of an abundant white, frothy, tenacious mucus, holding in suspension little sounded masses of opaque yellow material.
In order to the detection of sugar, the expectoration was, first of all, treated freely with strong alcohol, which coagulated much of the albuminous matters. Distilled water was then added, and, after agitation and digestion for a short time, the whole was thrown upon a filter, and a clear watery fluid readily passed through.
A small portion of this fluid reduced the protoxide of copper when tested after the manner recommended by Trommer, and another portion underwent fermentation over mercury.
The remainder was evaporated in a waier-bath to dryness, the residue broken up into fragments, and digested for several hours in alcohol, which was then filtered. The alcoholic solution thus obtained was of a yellowish tint, clear, and decidedly sweet to the taste. On evaporation, it left the considerable quantity of sugar now produced to the Society, and which will be found partly crystalline, of a rich sienna brown colour, strong honey-like odour, and intensely sweet taste.
A fluid ounce of the expectoration, after dilution with water, yielded by fermentation a trifle more than 2 cubic inches of carbonic acid, which would be equivalent to 24 grains of sugar, or 50 grains to the imperial pint.
The urine passed at the time of the examination contained sugar; its specific gravity was 1032, and its average standard for some days has been about 1035. The quantity passed was much less than formerly.
Dr. Francis had detailed at length the account of the process he had used, because, so far as he knew, the presence of sugar in the expectoration of diabetes had not previously been sought; at any rate, he could find no allusion to the subject in the Sydenham Society's edition of Simon's Animal Chemistry, which, with the notes of its accomplished editor, may be assumed to have brought our knowledge in such matters up to the present time.
In addition to the above case, he had, within the last two days, had the opportunity of examining the expectoration of another man who was under treatment two years ago with diabetes, and who, in addition to this, is now far advanced in phthisis. Here the expectoration was more scanty, and consisted of purulent matter, rendered tenacious by an admixture of rust.coloured secretion from a little local pneumonia. In this case an ounce of sputa contained so much as about seven grains of sugar.
It might be found, he thought, when closer attention came to be given to the subject, that there were other organs than the kidneys habitually playing an active part in the removal of the sugar which was accumulating in the blood during the progress of diabetes. There were, at least, some grounds for believing such might be the case from the results just detailed, and, if so, the quantity of sugar