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Birmingham Pathological Society, March 2, 1844Author(s): John SimonsSource: Provincial Medical and Surgical Journal (1844-1852), Vol. 8, No. 7 (May 15, 1844), pp.96-99Published by: BMJStable URL: http://www.jstor.org/stable/25497881 .

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96 PUERPERAL CONVULSIONS.

the necessary amount of information and know

ledge, the Government would not have been

justified il blindly adopting his views. We do

not indeed think it necessary that Sir James

Graham should have taken into his councils every

individual physician, surgeon, or general practi tioner, who may deem himself qualified and com

petent to give advice, but his ear ought at least to have been open to large bodies of the profession, and in seeking assistance and counsel from, or

submitting the whole or parts of his intended

measure to the consideration of chartered or other

wise recognized public bodies,there should have been no preference shown, no exclusiveness manifested.

We have been so far led away by these

preliminary considerations as to preclude us

from here entering on either of the two leading

points upon which the Society of Apothecaries think

it necessary to enlarge. Both of them are in

themselves of considerable importance, and the

observations made upon them in "The statement"

deserving of every attention, on account as well of the position of the body from which they emanate, as

the nature of the subjects to which they refer.

The comments to which they naturally give rise

must be reserved for another occasion.

TREATMENT OF PUERPERAL CONVULSIONS. Mr. DRUITT'S reply to Dr. ARNOLD.

TO THE EDITOR OF THE PROVINCTAL MEDICAL AND

SURGICAL JOURNAL.

SIR, Your correspondent, Dr. Arnold, brings against me

the double accusation of " much candour "

and " wrong

principles of treatment;" by which I suppose he means, that I not only do not know how to treat my patients, but am silly enough to tell of it. He is good enough

also to favour your readers with his ideas of the nature

and treatment of puerperal convulsions, which make me doubt seriously whether he is himself acquainted with the disease which he writes about.

My object was to show, that a remedy which is

commonly employed, and which it is certainly natural

to employ, may occasionally produce very serious

inconveniences; and I wished to point out another

remedy which would be a better promotor of secretion, and at the same time be free from the inconveniences

in question. I had no wish to produce the opinions of

authors as an apology for my treatment; nor, in fact, had I any occasion: it was correct, although unfortunate

in one respect. Dr. Arnold, if I understand him right, believes

puerperal convulsions, to depend on an abnormal state of

circulation in the brain, arising from sympathy with

the uterus; he believes it to be a disorder analogous to, or identical with epilepsy or hysteria; that it may also be caused by excessive hemorrhage; and that it,

does not depend on an excess of blood in the whole

system; consequently he would use only local bleeding, mild aperients, cold affusion, and other mild remedies.

I will leave it to your readers to judge whether this

is a fair description of the disease in question, of

which more than one-fourth of the whole number of

cases are fatal. That convulsions may occur during parturition, which are hysterical or anaemic in their

character, and which yield to mild remedies, I readily admit; but the real puerperal convulsions are widely different. They occur at a time when the blood

making powers of the system are exerted to the utmost; when the vessels are full, and the secretions scanty;. and there is no disorder in which blood-letting is so

well borne, or followed by such marked benefit. We

may throw aside all fine spun stories about sympathy. Let us look merely at the turgid countenance, and

comatose aspect, and feel the hard labouring pulse, and

there will be no doubt of the propriety of bleeding. To set at rest, however, the question of the utility

of bleeding in my case, I will merely observe that the

patient is now in the seventh month of her second

pregnancy; and throughout the term there has been a

constant tendency to cerebral congestion and phethora, She is obliged to restrict herself almost entirely to a

fish or vegetable diet, and to abstain from alcoholic

stimulants in any shape. If she transgresses, she is

immediately troubled with giddiness, and bleeding from

the nose; and on one occasion lost a considerable

quantity of blood from the rectum, with relief. This

will speak volumes to any practical man.

I will not notice any other of the points of my treat

ment, which your correspondent thinks he could have

improved upon. I am merely desirous that his erro

neous sentiments, on a very important disease, should

not pass without a hasty comment. I can assure himn

that in any controversy, I should be delighted to have

him for an opponent. I am, Sir, your obedient servant,

ROBERT DRUITT. 6, Bruton Street, London,

April 29, 1844.

BIRMINGHAM PATHOLOGICAL SOCIETY,

March 2, 1844.

JOHN SIMONS, Esq., in the Chair.

Mr. Elkington exhibited a specimen of Scirrhus of

the Uterus, which had been complicated during life

with Ovarian Dropsy.

CASE. Mrs. Low, aged 41, a strong active woman, mother

of one child-first felt unwell in January, 1843; she

had dyspepsia and pain in her back, which were relieved

by tonics, &c. In April she had an inflammatory

attack, affecting, she says, the lower part of the belly,

accompanied by fever, pain about the pubic region, constipation, and pain in making water. She was

relieved by leeches and antiphlogistic measures; she

then went into the country and remained there

for some weeks. She consulted me on her return in

September. I learnt that whilst she was in the country

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BIRMINGHAM PATHOLOGICAL SOCIETY. 97

she had had swelling of the right leg, which, from her

description, was probably phlegmasia dolens; obstinate constipation, pains about the pelvis, and a constant

watery discharge from the rectum. She now com

plains of great difficulty in regulating her bowels, and

cannot keep them open without aperients; she says when the motions are figured, they are very small, not thicker than the little finger. She has a frequent

watery discharge from the rectum, which escapes generally when she lies down, and to the amount per

haps of a table-spoonful or two, each time. Whilst she was in the country she states that she was obliged to get up in the night every ten or fifteen minutes to

evacuate the bowels, and that nothing passed but a

small quantity of clear water. On examination extern ally a small circumscribed tumour in the left iliac fossa, about the size of a small orange, imnmoveable and semi

elastic was detected. On examination per vaginam, I found a firm inelastic tumour, occupying the greater part of the cavity of the pelvis; it was low down, hard and

fixed, and seemed to consist of enlargement of the

uterus. It appeared to occupy anteriorly more the

left side of the pelvis, and the left side of the vagina was puckered, as if adhesions were formed. On exami

nation per rectum, the tumour was found posteriorly

larger on the right side, and encroaching very much on

the cavity of the rectum, greatly interfering with the

passage of the faeces. She had very little discharge from the vagina, and that merely an increase of the

natural secretion; there was slight tenderness and

swelling of the lips of the os uteri. She had lost flesh, and was gradually getting thinner She suffered from

a sensation of weight and heaviness in the pelvis, but

not much from pain. The most distressing feature of

the case was obstinate constipation. The legs became

edematous; she gradually got thinner and weaker, became dropsical, increasing to a great size in the belly.

She died Feb. 2, 1844. The treatment was palliative.

Post-mortem, Feb. 3rd. We could only get permission to examine the abdomen. About two gallons of serum

were drawn off from the cavity of the peritoneum. On

opening the abdomen we found the peritoneum lining the parietes covered with numerous small tumours,

varying from the size of a pea to that of a large marble; the omentum was like a bunch of large grapes; the under surface of the liver was studded with them, and the small intestines had also a sprinkling of them.

There were bands of lymph tying the intestines to the

parietes; there was also lymph deposited on the liver

and spleen. With some difficulty we removed the con

tents of the pelvis. On examination we found the

uterus enlarged and very hard, having the true scir

rhous character, the os patulous; the lips swollen, and

upon the anterior lip three small ulcerations, the

largest about the size of a split pea, and superficial. There is a scirrhous growth from each side of the body,

commencing at the upper part of the cervix, and which terminates in a cyst the size of a walnut, filled with

serum; the right Fallopian tube is enlarged, hardened, and firmly united with and forming part of the uterine

tumour; the left Fallopian tube is united with the

surrounding parts; posteriorly, the rectum is adhering to the lower part and middle of the uterus, from which it cannot be easily separated; behind the fundus there

is a portion of the ileum adhering; on the fore part the bladder adhered firmly to the uterus throughout,

and was with difficulty dissected from it; the left

ovary is enlarged to the size of a small orange, forming a cyst filled with fluid; the right ovary has formed a

cyst, which has ulcerated, and discharged its contents

into the rectum. A probe may be passed from the

cyst into the intestine.

It is surprising that she felt so little pain, her suffer

ings being caused chiefly by her size from the effusion.

This case points out the necessity of carefully ascertain

ing the condition of the uterus in all cases of ovarian

dropsy, before attempting any operation for the removal of the ovarian cyst. It clearly shows the

co-existence of the one with the other. Which was the

primary seat of disease, the uterus or the ovaries, it is

difficult to say; but it is probable that the uterus was

the first to take on disease, from the extent to which

the whole of that organ was affected, and the extensive

adhesions formed between it and the adjacent parts. It is probable the reason she suffered so little pain, was

in consequence of the ulcerative process having so

recently commenced. If the ovarian cyst had grown more rapidly, and acquired a larger size before the

uterus had become so decidedly diseased, and before

the general health had suffered to such an extent, it is

possible that an attempt might have been made to

remove the cyst. It demonstrates the necessity of

great caution and nice discrimination in such cases, as

well as the risk and danger of an operation. Mr. Elkington then presented to the society a

specimen of corroding ulcer of the cervix and os

uteri.

He gave the following account of the case:-Mrs.

Doley, aged 44, has had one child and one abortion:

first felt poorly about Christmas, 1842. A few months

before that time she was a plump, healthy, young

looking woman. In March, 1843, she had pain in her

back, and observed a coloured vaginal discharge. She

consulted my brother, Mr. John Elkington, about the

end of April; at that time she was beginning to get

thinner, complained of aching in her back, and that

her appetite failed her. The uterus was so low down, that my brother was able to see the os uteri without

the aid of the speculum. He says there was a large fissure on the right side of the anterior lip of the

os uteri, and nearly two-thirds of the anterior lip at

that early period was destroyed. About a fortnight after she was seen in consultation with Dr. Ingleby, and examined with the speculum.

The ulceration was distinctly seen, and found to be

rapidly increasing. It was declared to be corroding ulcer. From this time the speculum could not be

used, the attempt to use it causing great pain and some

hemorrhage. The ulceration gradually extended. On

examination per vaginam no hardness surrounding, nor fungoid growth from the surface of the ulceration

could be detected. On making an examination per

vaginam, the finger in passing over the ulceration did

not give much pain. She suffered a martyrdom of

pain, was scarcely ever free from it, and could only obtain relief by the constant use of opiates. She had at times retention of urine, and obstinate constipation. The vaginal discharge varied in quantity, colour, and

quality. Sometimes it was copious, at others, slight; sometimes very offensive, at others not at all so. On

examining per vaginam, at different times, no parti cular hardness of the surrounding structures could be

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98 . BIRMINGHAM PATHOLOGICAL SOCIETY.

detected by the finger. About ten days or a fortnight before she died (which was in February last) she had an attack of peritonitis, this was relieved by warm

applications, injections, &c. She then became drowsy, comatose, and apparently easy, so that her friends

thought she was getting better, and requested another consultation.

Post-mortem-External aspect; great emaciation. The abdomen only was examined. The intestines were pale, the rectum, caecum, and colon very much distended by scybala; the pelvic viscera were with

great difficulty removed; the rectum was adhering to the back part of the vagina; the ileum to the

upper and back part of the body of the uterus; the

whole of the cervix and os uteri were destroyed. There is no appearance of fungoid growth from the surface

of the ulceration; it has an even granular surface; the ulceration had extended into the cavity of the

abdomen, and destroyed a portion of the ileum where it adhered to the body of the uterus; the fundus and

body of the uterus are very little, if at all enlarged, and apparently not altered in structure; there is no

particular hardness of the uterus; there is a small

patch of redness at the fore part of the fundus; there is a considerable deposit of hardened matter in the cellular structure at the sides of the pelvis, more par ticularly on the right side, and which has all the

appearance of true scirrhus. It surrounded and

greatly obstructed the termination of both ureters, causing great increase in their size, and also consi derable distension of the pelvis of each kidney, the

right being enlarged to the size of a hen's egg; the

right ureter nearly as large as one of the small intes

tines; on the inside of the bladder, opposite the termination of the right ureter, are pearly white bands of scirrhous matter; the lumbar and mesenteric glands were enlarged, but soft, and when cut into presented the appearance of the internal structure of the spleen, both in colour and consistence. It may be well to observe that the mother of Mrs. D. had uterine

disease, and had suffered from a swelling on the left side of the belly, just above the groin, accompanied by a purulent greenish offensive discharge for nearly three years before her death. She died at 62.

This case presents points of interest and importance. The character and almost constancy of the pain, the

origin and progress of the disease, and its association with disease of the surrounding structures, would lead one to conclude that it was a case of ulcerated scirrhus. But on the other hand we must bear in mind there is no enlargement nor change of structure in the fundus or body of the uterus, and that the ulceration was almost the first symptom observed, and was not pre ceded nor accompanied by any tangible or discernible

hardening of the uterus. The character of the ulce ration when first seen, its progress and appearance as

observed at different times, as well as its condition after death, justify the opinion, that it was corroding ulcer of the cervix and os uteri. I am aware the

opinions of our best authors on the subject are

opposed to such a conclusion. Dr. Ashwell

says, " there is less pain than in cancer of the

womb, from which it also differs in there being no indurated deposit, no immobility, and no fungoid growths in the seat of the ulceration." Dr. Lever

says, " one singular feature is peculiar to this disease,

that there is no deposition of new morbid matter, either in the uterus itself, or in its neighbouring parts." Sir C. Clarke says, "after death there will appear abundant evidences of the destructive process, but no

hardness, no thickening, no deposit of new matter."

Notwithstanding the formidable array of evidence

against such a conclusion, I cannot help considering this as a case of corroding ulcer. Viewing it as a

malignant ulceration, following inflammation of a

specific character, I see no reason why it might not

exist with, or be followed by, deposition of hardened

matter, in the surrounding structures, and more

particularly in the cellular membrane. I think it

possible it might occur in a person with a cancerous

diathesis. Because such has not hitherto been found

to be the case, we are not justified in concluding that

it cannot occur. The opinion of Madame Boivin and

A. Dugs appear to coincide with this view: they say, in their excellent work on diseases of the uterus and

its appendages, translated by Heming:-" But it is

of ulceration, originally seated in the uterus, and

originally ulcerous, that we now speak; we merely

premise that the localcharacters, as well as the general

effects, are absolutely the same in ulceration carried to

its highest degree, whatever may have been its cause, whether it have or have not been preceded by tumours or

deep-seated disease. In the latter case, certain symp toms, peculiar to cancerous tumour, may indeed still

exist; but we must add that the tumefaction and

change of texture may also (though less frequently) be secondary to the progress of cancer essentially and

originally ulcerous." p. 264.

The preparation exhibited may be interesting in

another point of view; in reading us a lesson of

caution as regards the operation of excising the cervix

uteri for ulceration, &c. If excision had been prac tised in this instance, at an early period of the disease, it is very possible the result might not have been suc

cessful, owing to contamination of the cellular structure.

Mr. J. Russell, jun., exhibited a specimen of colloid

cancer, taken from the face of a man. For the parti culars of the case, which are as follows, we are indebted

to Mr. Clayton, one of the dressers of the hospital: John Fenton, aged 71, a widower, by trade a steel

worker, of good general health, consulted my father early in May for a tumour in the left cheek. About

two months previously his attention had been called

to a small lump near the anterior edge of the left

masseter muscle: it was as large as an almond, hard, and perfectly free from pain. The integument covering it was not discoloured. It enlarged rapidly, and in two months was as large as a small egg. When

examined by my father and myself, its 'shape was

somewhat pyramidal, with a base of tolerably firm consistence; but at the apex, where it was soft, obscure fluctuation could be felt. I believe iodine was recom

mended, but without benefit; and a puncture having been made with an exploring needle, nothing but blood flowed out. At this period of the case the tumour was moveable on the subjacent parts, and unattached to the skin, which was quite free from discolouration. Subsequently it grew more rapidly, and became the seat of shooting pain extending towards the ear. The skin became attached, and

acquired a reddish tinge. He was admitted into the

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GLOUCESTER INFIRMARY. 99

hospital, June 24; the increase in the size of the tumour proceeding rapidly, and the attachment of it to the skin becoming more general and intimate.

At his admission, he is described as a hale old man, in good flesh; his health not affected, his appetite good, bowels regular, pulse 76, soft. His nights were disturbed by acute pain in the tumour shooting towards the ear. The pain was less severe by day, but was

brought on by handling the tumour, although it was

free from tenderness.

The tumour was as large as an orange; it occupied the left side of the face, reaching fiom the zygoma to the inferior edge of the lower jaw, and from the angle of the jaw behind, forwards to within an inch of the

symphysis. Its surface was smooth and rounded, the skin covering it was of a pink hue, but not traversed

by enlarged veins, and adhered to the tumour. It was

soft, elastic, and fluctuating, on its most prominent part; the base and the part nearest the chin was firm, and had a solid feel. It seemed to be loosely con nected to the parts on which it lay. It did not cause

any paralysis of the muscles of expression; none of the neighbouring absorbents were enlarged.

July 5th. On puncturing the tumour with a bistoury,

only a small quantity of blood escaped, and a soft

gluey substance protruded from the wound. The

operation of removal was at once performed. The base of the tumour adhered intimately to the bucci nator and masseter muscles. The upper part of the

parotid was exposed, and the process of the gland which accompanies the duct was indurated, and

required removal. The softness of the tumour, and its intimate adhesion to the parts in which it was

imbedded, rendered the dissection difficult. The whole of the disease appeared to hare been removed. The tumour was enclosed in a slim but dense cellular

cyst, and consisted of two portions; one soft, pulpy, and adhesive, like glue, contained in numberless cysts, having an amber colour, and forming the great bulk of the swelling; the other solid but not hard, of whitish

colour, resembling firm brain; this firmer portion formed the base of the tumour.

For five days his face went on favourably, but on the 10th of July the wound became painful, red, and hard; a poultice was applied, and the discharge continued pro fuse for several days, when a small fungoid elevation pro truded itself through the wound; this was cauterized

with potassa fusa, but it increased with rapidity. Repeated attempts were made to destroy it with potassa fusa, chloride of zinc, and twice with the actual cautery, but without success. On the 9th of August, a month after the first operation, the tumlour was again removed; it was composed of the same soft gummy masses as at first. For three weeks the granulations appeared so firm and healthy that hopes were entertained that the disease was eradicated, but on the 28th, a fungous

mass again appeared. The remedies before alluded to

only aggravated the mischief; the mass was included in a ligature, but with no better success. Latterly it grew with great rapidity; hemorrhage repeatedly occurred to a large extent; he became greatly emaciated, and complained of much pain at the lower part of the

fungus, and in the epigastric region. He died December

22nd, worn out by pain, by hemorrhage, and by a

profuse feetid discharge, more than five months after the first operation, and four months after the second.

Sectio cadaveris, thirty hours after death; body much emaciated ; a large fungous mass occupied the

left side of the face; it resembled in appearance softened brain; it extended from the lobe of the ear

nearly to the symphysis of the lower jaw, and down

wards as low as the pomum Adami; it was intimately connected with the muscles of the face, but did not

enter into their substance; it was attached to the

periosteum, covering the angle of the lower jaw, which

was very thin and discoloured, though the bone itself

was free from disease, and passed upwards on the

internal surface of the inferior maxillary bone.

Chest.-The lungsperfectly healthy. The endocardium

of the left auricle of the heart thickened and opaque, the valvular apparatus natural, but both the coronary arteries were extensively ossified, one of them being converted into a complete bony tube.

Abdomen.-Liver small and friable; its capsule very

opaque; the gall-bladder thickened and hard;. it

contained about two teaspoonsful of a yellowish fluid, of the consistence of pus, and there were two calculi in

it, filling up a large portion of its cavity. A consi

derable quantity of bile was found in the stomach. All

the other viscera perfectly healthy; not a trace of

the disease existed in any other organ of the body.

Dr. Blakiston exhibited to the Society a specimen of dilatation of the thoracic aorta, which was taken

from a gentleman, aged 45, of very active habits. He had

been slightly troubled with cough on lying down, and

with dyspncea for two years, which symptom had

greatly increased during the last four months, during which time he had not lain down, and constantly leaned forward. When thus leaning the respiratory

murmur was heard in the upper part of the right lung, but when he stood upright, it ceased. From this

circumstance the existence of a moveable tumour in

front of the trachea was made apparent. There was no

abnormal sound, nor any thrill in pulsation. He died

coughing violently. The aneurism was caused by dila

tation of the arch of the aorta, particularly about the

origin of the arteria innominata, was rather larger than a full-sized orange, and adhered chiefly to the

trachea for three inches, just above the bifurcation, and over-lapped the right bronchus, particularly its first

and upper branch, but did not adhere to the parietes of

the chest.

TO THE EDITOR OF THE PROVINCIAL MEDICAL AND,

SURGICAL JOURNAL. SIR,

I am instructed by the Medical Board of this Insti

tution to request the favour of your giving insertion

to the accompanying, in the Provincial Medical and

Surgical Journal. I have the honour to be, Sir,

Your obedient servant, E. G. HILL, Secretary.

Gloucester Infirmary, May 11, 1844.

GLOUCESTER INFIRMARY. Medical Board, May 10, 1844.

Present:

Da. EVANS. MR. FLETCHRR.

DR. FLETCHER. MR. BUCHANAN.

MR. WILTON. MR. WOOD.

On the consideration of a published report of certain

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