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application of the ligature, its calibre is found somewhat diminished. The author has never found the coagulum absorbed; and, examined four months after the ligature, it has continued quite distinct, and of good size, the arterial coats retaining their characters and thickness. If the observations of Jones, Béclard, and Scarpa be attentively examined, it will be found that, led away by the physiological error, that tissues adnit of transformation, they have mistaken the decoloration and condensation of the coagulum for a fibrous transformation. When the artery is examined two or three months after it has been tied, if the coagulum reaches to or near the first collateral, the calibre of the artery will be found preserved up to this point. If a large space intervenes, as in the case with the carotids, the calibre of the vessel undergoes sensible diminution. This contraction is frequently very sensible at the end of fifteen days, and as the contraction of the clot takes place much more slowly, the artery presents opposite to it a bulging, which eventually disappears.
Having traced the normal development of the coagulum, M. Notta next proceeds to give some account of its pathological conditions. These he has already described in his thesis in relation to their influence on the production of secondary hæmorrhage. They are three in number-viz., arrest of development, putrid dissolving, and purulent dissolving; but although the same alterations are met with in animals, they are so less frequently. In but two instances out of twenty-one cases was arrest of development observed, and that was seen twice in the same animal. In another instance the putrid dissolving of the coagulum was observed, and in two the purulent dissolution.
The description of the effects of the ligature upon the two ends of the vessel is given at considerable length. We subjoin a portion of the account:
“ When a ligature is applied in the course of an artery, the portion of the vessel actually embraced by the thread mortifies, suppurative inflammation tends to eliminate it; and when the small eschar has become quité detached, the two ends of the artery, now completely separated, become retracted by virtue of their elasticity, the interval of a variable extent which exists between them being filled up by the sheath of the vessel, which is open and communi. cates externally by the wound made in the soft parts. The walls of this sheath become inflamed and thickened, their internal surface being covered with fleshy granulations, secreting pus. The inflammation of the sheath spreads to the surrounding cellular tissue, which becomes indurated to a distance of several millimetres, or one or two centimetres beyond the extremity of the two ends of the artery. Amidst this induration, the arterial coats preserve their normal colour and thickness, and remain exempt from inflammation. In the dog, the artery, when it has been well isolated, is divided from the third to the fifth day; and after the sixth day I have always found it divided.” (p. 493.)
In some few cases in the human subject (but never in the author's experiments on animals), the falling ligature has attached to it two small arterial cones, produced by the sphacelation of the artery at the point where the ligature was applied. In both the same result follows division of the artery and retraction of its ends.
The interval of separation sometimes only amounts to one or two millimetres, and then the two ends of the vessel may become so intimately united as to render it impossible to determine the point at which the ligature was applied. In an example of ligature of the external iliac, performed fifteen years since, a fibrinous coagulum obliterated the artery from the hypogastric to the femoral profunda, and it was impossible to determine the point at which the vessel had been tied. In general, the separation varies between one and several centimetres, the sheath communicating after a time with the exterior only by a fistulous track. It is usually about the tenth day that the wound becomes thus reduced to one or two fistulous openings, which close in a period varying from the fifteenth to the twenty-fifth day. The cicatrization of the external wound should be delayed until we are certain that the deeper-seated portion is entirely closed, otherwise the pus contained in the sheath cannot obtain issue.
IV. On the Elephantiasis of the Arabs, and especially as affecting the Scrotum. By Clor BEY; with a Report by Baron H. LARREY.-Clot Bey's paper consists chiefly in the narration of four instances of large elephantiasis of the scrotum, for which operations were resorted to. Baron Larrey's Report assumes the size and form of a monograph upon the subject, and is executed with great ability, giving a résumé of the entire literature of the subject powhere else to be found.
The Physiology and Treatment of Placenta Prævia; being the Lettsomian Lectures for
1857. By ROBERT BARNES, M.D. (Lond.), Physician to the Royal Maternity
Charity, &c.—London, 1858. pp. 208. It would be difficult to overrate the value of Lectures like the Croonian, Lettsomian, and similar institutions. If reasonable care be exercised in the selection of the lecturer, they afford to the profession in the metropolis a full and well-digested development of the subjects of the course, or perhaps the first announcement of new discoveries or novel theories; whilst to the lecturer, the prominent position gratifies a laudable ambition, and gives him the advantage of an educated audience of high scientific character-a tribunal at once indulgent and exact, before whom he may fearlessly unfold his views, and from whose criticism he is sure to derive benefit. Many admirable illustrations in support of this view may be within the memory of our readers, and one, the most recent and not the least important, it is our duty and pleasure to bring before them at present.
Dr. Robert Barnes, whose previous labours have been bighly appreciated by the profession, was appointed Lettsomian lecturer for 1857, and having arrived at some novel conclusions concerning placenta prævia, he chose that for the subject of his lectures, and he has now republished them in the volume before us, with an appendix of cases in illustration.
As the truth of these views must, indeed can only, be tested in practice, it is of course too soon to pronounce any positive judgment upon their merits; but we can say, in truth, that not only are they very interesting and ingenious, but that if confirmed by further observations, they will have a most important influence upon practice. Our present purpose is to lay these views before the reader, with the grounds upon which they are based, and their practical application, together with such remarks of our own as we may deem necessary. But previously, we may take the liberty of mentioning that the ordinary opinion as to the hæmorrhage in placenta prævia is, that it arises necessarily (hence the term “ unavoidable hæmorrhage") in consequence of the separation of the placenta from the cervix uteri, whilst the latter is undergoing the process of dilatation; that the source of the discharge is the exposed uterine sinuses; that the extent of the detachment is indefinite, and the hæmorrhage limited mainly by the pressure against the child.
Now, from this view of the extent of detachment to which the placenta is exposed in such cases, Dr. Barnes dissents entirely. In his opinion, “ There is an anatomical and physiological limit to the extent of placenta liable to detachment during the expansion of the womb. This is why, after a certain stage of the labour, no fresh bleeding surface is exposed.” And, taking Sir C. Bell's anatomy of the uterus as his basis, Dr. Barnes illustrates his physiological problem as follows:
"The inner surface of the womb may be divided into three zones or regions by two latitudinal circles. The upper circle may be called the Upper Polar Circle. Åbove it is the fandus of the uterus. This is the seat of fundal placenta--the most natural position. It is the Zone or region of safe attachment. The lower circle is the Lower Polar Circle. It divides the cervical zone or region from the meridional zone. The space comprised between the two circles is the region of lateral placenta. When attached to this region, the placenta is not liable to previous detachment. It may, however, cause obliquity of the uterus, transverse position of the child, lingering labour, and disposition to retention of the placenta and postpartum bæmorrhage. Below this circle is the cervical zone—the region of dangerous placental attachment. All placenta fixed here, whether it consist in a flap overreaching downwards from the meridional zone, or whether it be the entire placenta, is liable to previous detachment. The mouth of the womb must be pulled open to give passage to the head. This enormous contraction or retraction of the longitudinal fibres is incompatible with the preservation of the adhesion of the placenta, which is within its scope. In every other part of the womb, there is an easy relation between the contractile limits of the muscular structure and that of the cohering placenta. Within the cervical region this relation is lost. The contraction of the uterine tissue is in excess." (p. 77.)
The extent of this “ lower polar circle,” Dr. Barnes thinks, may be described by a circular line three inches distant in all parts from the os uteri.
Assuming, then, that the detachment is limited to this extent, in what way is the hæmorrhage from this surface restrained ?
“By precisely the sanie inechanism as that which stops the flooding after normal detachment of the placenta from its normal seat at the fundus. The longitudinal fibres of the lower segment must contract to pull open the mouth. Expansion, dilatation of the mouth is contraction of the cervix. This contraction, by shortening the cervical portion of the womb, casts off the placenta, and exposes the ruptured mouths of the utero-placental vessels. The first effect is, bleeding. The second is, to stop the bleeding. The contraction goes on either actively or passively, and tonically in most cases; and then further contraction constricts the orifices of the vessels-closes them; it is hæmostatic. If hæmorrhage be renewed, it does not proceed, except under circumstances of excessive muscular relaxation-the passive bæmorrhage of Dr. Chowne from the surface bared by the preceding active contraction: it proceeds froin a fresh zone or arc further than the os, bared of placenta by another contraction. This zone or arc is, in its turn, in like manner' scaled; and there is another pause in the flooding. Zone after zone is thus bared by recurring contractions, and successively sealed up, until that physiological limit, that line of demarcation between normal and abnormal placental implantation, the boundary line of placental detachment, which I claim to have discovered, has been reached. This zone attained, the labour is a natural labour.” (p. 54.)
So far, we think that these extracts give a pretty full and correct view of Dr. Barnes's physiology; and with regard to the limitation of the detachment, in lateral placenta at least
, we are inclined to agree with him, for the following reasons-viz., that as the detachment in the lower zone proceeds from the necessity of the cervix being dilated, whether mechanically or by muscular effort—in order to allow the child to pass ; so the figure and expansion of the uterus above the lower zone show this to be unnecessary, and the only effect of uterine action here would be contraction. No doubt the effect of this contraction must be to detach the placenta, more or less; but it will not do this till near the end of labour, just as we believe happens in all cases of normal labour.
Nor do we doubt that the cause assigned may arrest the hæmorrhage; still we should not be inclined to reject the pressure of the child or the entire contents of the membranes when pressed downwards against the placenta, as another influential cause; but the real practical question is-Can we rely upon either with confidence sufficient to supersede more active interference? How far must we assume complete uterine action (labour pains) to be present in order to the complete effect? Again, when the hæinorrhage has ceased, shall we be justified in considering the patient free from the danger of any further bleeding from the old exposed surface? These questions, out of many others of great importance, bring us to the cases upon which Dr. Barnes bases his theory. He adduces a number of examples in which hæmorrhage occurred before or near the time of delivery, and in which it ceased after a time, and did not recur, the labour often terminating naturally; and he contrasts these with others in which death resulted from forced delivery. Now, we must take the liberty of remarking of some of them, that there is no evidence of these being placenta prævia at all; and of the others, that they were all cases of lateral placenta, where this organ came down to the edge, or partly over the os uteri. There is not a single case, as far as we see, of central implantation, and yet it is in these cases that there is most difficulty and most danger, and where, at least in the large majority of cases, the labour could not merge into a natural one--even if the hæmorrhage were stopped by Dr. Barnes's or any other method. And unless experience had shown positively that artificial detachment would surely arrest the hæmorrhage, should we not in such cases increase the mischief without promoting the delivery ?
We would wish to speak cautiously on a subject of such importance; and where facts are not sufficiently numerous to enable us to decide, Dr. Barnes is entitled to the benefit of these doubts, and we trust that his future investigations may resolve them.
As to the source of the hæmorrhage, notwithstanding the very high anthority of Dr. Simpson, we have no hesitation in agreeing with Dr. Barnes in attributing it mainly to the uterus, and not the placenta ; and although we are as unable to explain the causes of placenta prævia as previous writers, we cannot go so far as Dr. Barnes, when he says, " that it is a matter of doubt whether there be one part of the superficies of the chorion more especially destined to be developed into placenta than the rest,” for to whatever part of the uterus it may be attached, we are quite satisfied that the portion of the chorion to be developed into placenta” is that part in the inner surface of which the umbilical cord is inserted. We have seen an example of the contrary, and the lotus perished immediately.
But a very important practical point is the diagnosis. Dr. Barnes has given the signs which are considered reliable by Levret, Gendrin, Cohen, and Morean, and then announces his own conclusions :
"1. The general signs, such as flattening of the abdomen, division of the abdominal tumour, and especially swelling and pain on one side of the pelvis, pointed out by Leyret, should lead to minute exploration by the finger and stethoscope. 2. Abortions, disease of the placenta, dead children, and placenta prævia in former pregnancies, should also lead to minute physical exploration." (p. 34.)
We cannot say that we are inclined to attach much importance to any of these signs, with onc exception. If they excite suspicion, they may lead to further investigation, which may yield fruit. A pulsation at the os uteri
, not synchronous with the mother's pulse, or (the child being alive) our being unable to feel " ballottement," as Gendrin suggests, would certainly give ground for suspecting placenta prævia; but neither might be found, if the placenta only came down to the edge of the os uteri. The occurrence of hæmorrhage at the seventh or eighth month, as mentioned by Moreau and others, if there be no external cause, is a very suspicious symptom, and ought immediately to lead to an investigation with the stethoscope, which we regard as by far the most valuable means of exploration. We have repeatedly decided between “ accidental” and “unavoidable" hæmorrhage by its assistance. The placental murmur can be heard at any part of the anterior half of the uterus, and by a little management, when somewhat posteriorly
Now, let us consider the practical application of Dr. Barnes's theory. He states that in cases of complete placental presentation, and in those of partial where the flooding is unusually profuse, we have to choose between two methods forced delivery and artificial detachment of the placenta." As regards the latter, some,
With Kinder Wood, would detach the placenta in those cases of exhaustion where foroed klelivery cannot be had recourse to without peril to the life of the mother; or with Dr. Radford, in those cases, also, where the os is partially dilated, when the membranes are ruptured, and where strong contraction exists-a condition, I presume, considered to contra-indicate turning; and also in cases of narrow pelvis. Others extend their faith in this method to the full latitude of the precepts of Dr. Simpson.”
In the latter category we certainly cannot include ourselves, nor are we as yet prepared to agree fully with Drs. Radford and Wood.
Dr. Barnes does not propose always to interfere promptly in the earlier cases, but to wait for some time until the os uteri is expanded
" It may be justifiable to trust some time to the plug; but if the symptoms are too urgent for delay, one or two fingers may be at once passed through the os. Seek to deterınine which side of the uterus bears the great bulk of the placenta ; feel for the edge of the placenta on the opposite side; rupture the membranes during a pain; tear the membranes freely from the border of the placenta, and sweep the finger round half the circumference of the os uteri internum, so as to detach the placenta completely from that side of the uterus to which the lesser portion adhered. This done, there is nothing to prevent the os uteri from expanding, and carrying the liberated portion of the placenta over to the side where the bulk of the organ adheres. Nature herself will do the rest." (p. 105.)
“If the hæmorrhage should continue or be renewed with urgency, I propose as the next step, the total cervical detachment of the placenta. The detachment must be carried further, by sweeping the finger round between the placenta and uterus on that side to which the main bulk of the organ adheres. In this manner, the whole of that part which had been seated in the cervical zone will have been detached..... Now, this detachment will not of itself stop the hæmorrhage. We may, I think, tranquillize our minds as to the effect on the mother, of that small portion that will escape from the detached placental surface. But the uterine vessels may pour forth blood until the hæmostatic resources of nature or art come into play. The resources of nature are those I have before described; continued contraction of the muscular structure of the womb, the contractile action of the coats of the uterine arteries, and the formation of coagula in their mouths. In the majority of cases these resources are sufficient; the hæmostatic process may, however, be further assisted by plugging again. A method of plugging is recommended by high authority, which appears deserving of attention. Moreau advises the application of a lemon, the end of which has been cut off, to the os uteri, and to retain this “in situ,' by firm pressure through rags or a sponge. The acid juice favours coagulation, as well as the pressure and retention of the blood. The soaking of the sponges or rags, used for plugging, in vinegar, is a common practice, but it seems to be reasonable that more powerful styptics should be used. I suggested some time ago the injection of the sesquichloride of iron. . . . . By these proceedings I have described, we may reasonably hope, in the vast majority of cases, that the hæmorrhage will coase. If it should not, time will have been gained, the os uteri may have become soft and dilated, and in the event of its being felt to be necessary to resort to forced delivery, this operation may be performed with comparative ease and safety.” (p. 107.)
These extracts, we think, give a very fair account of Dr. Barnes's proposal, and we have preferred using them to giving the substance in our own words. In order, however, to a fair appreciation of this new procedure, it will be well to classify the principal cases of unavoidable hæmorrhage met with in practice. 1. Let us suppose a case in which the hæmorrhage occurs at the seventh month, to a considerable extent, without pains and without dilatation or dilatability of the os uteri. 2. Or a case at the full period of pregnancy, without pains, the os uteri being soft, and the edge of the placenta coming down to the edge of the os uteri (lateral placenta). 3. A case, similar to the last, with labour pains, and the placenta coming down to the edge of the os, or perhaps a little beyond it. 4. A case of central implantation of the placenta. Let us see how far our present experience would justify our depending upon Dr. Barnes's method.
1. We quite agree with Dr. Barnes in repudiating “ forced delivery” in the first class of cases : it would be attended with great danger, and in our opinion is quite unnecessary. As the uterus is filled and the membranes unbroken, internal hæmorrhage is almost impossible to any serious extent, so that the plug may be unhesitatingly used ; and if the vagina be thoroughly filled, external hæmorrhage is almost equally impossible. The best material for plugging we have ever tried, is finely-carded cotton wool
, and the easiest and least painful mode of introducing it is by means of a cylindrical speculum. Under this treatment, we believe that in most cases the hæmorrhage will be arrested for a time.
2. But if it should not, and if it should become alarming, whether premature or at the full term of pregnancy, Dr. Barnes advises the detachment of the placenta. Now, in cases where there are no pains—where there is no effort at uterine contraction-are we sufficiently sure of the success of Dr. Barness plan to warrant our depending upon it! If the result were tolerably certain, it doubtless has great advantages; but if it fail,