Thomas Radford

Further Observations on the Caesarean Section.

cedema of the legs was entirely gone. He passed urine in the prescribing-room; and repeated examination by my clerks and myself showed that the albumen had quite disappeared. The patient has not attended since, from which I infer that he continues well. He had presented himself regularly at the hospital the previous three months, and the urine was regularly examined. The albumen was observed to be slowly diminishing in quantity, but it had never been absent from the secretion. It appeared, in this case, that the kidneys had received a sudden impulse to healthy action. In another case, that of John B., aged 25, who had been under my care for two years continuously for acute, passing into chronic albuminuria, the albumen, which had long been stationary, began to decrease rapidly in amount under the influence of the same treatment. The effect of a powerful dose of atropia upon the kidneys in chronic albuminuria is well seen in the analyses above given. It will be observed that there was a decided diminution of the albumen during the operation of the medicine. The result by the operation of belladonna in these cases must be accepted as the best proof of the condition of the blood-vessels generally during that operation. It is quite clear that there is no impediment from contraction of the arteries on the one hand, or from dilatation of the capillaries on the other, to the flow of blood through the kidney. On the contrary, it appears that the vessels of the gland are aroused by the action of the drug into a healthy state of excitement; a condition highly favourable for the nutrition of the organ, and the removal of chronic disease. As a means of promoting oxidation of the blood, belladonna will doubtless prove of essential service in the uric and lactic acid diatheses. I have employed it in rheumatic fever with marked success. I inject the fiftieth or fortieth of a grain of the atropia salt into the integument over the affected joint, as soon as the first indication of inflammatory action arises in the part. The anodyne action is so direct, speedy, and enduring, that the use of opium, which, excepting for its anodyne and hypnotic actions, is decidedly objectionable in this disease, is altogether unnecessary. The subcutaneous use of atropia in other acute diseases is a wide field for inquiry, and promises, as far as my observations extend, to be a most interesting and encouraging one.

A Successful Case of Caesarean Section: With Remarks.

efforts of nature than to any particular treatnment. We likewise every now and then have a patient in whom cEdema of a limb remains for a long time after the fracture is firmnly united. Thte last imDperfection which attracts attention, and this sometimes continuies to give intimation of a weakened state of the limb for life, is a preternatural sensitiveness to atmxospheric changes, which often amounts to pain. The patient is reminded of his former accident by uneasy sensations, or aching at the seat of the fracture during windy weather, or at the cotmmencement of a thaw. The joints in the neighbourhood of a broken bone often remain stiff for a cornsiderable period, and thie tendons are long in recovering the free play in their synovial sheathis. Soine of these stiff joints whlichi hare been examiined, were fournd to have undergone changes similar to those caused by inflammiiiiation; that is to say, the synovial surfaces were coated with lympb, united by adlhesions, and, in a few instances, the articular cartilages were mnore or less extensively removed by absorption and ulceration. I do not miean to say that these changes always, or even comnmonly, take place, but it is well to be aware of their occurrence now and then, especially as they do not seem to be attended with the symriptoms usually accompanying the inflamamatory affections of joints. I do not know that you can facilitate tlje recovery of these joints by any otber means than friction, bathing with warum water, active and passive movements of the limb, and the use of flannel.

Observations on the Cæsarean Section and on Other Obstetric Operations

On the MIaternal and Infantile Afortality. HAVING, in the preceding chapter, placed before my readers a full and trustworthy statistical account of the results of the Cesarean section in the cases in w%hich this operation has been performed ill Great Britain and Ireland, I shall next endeavour to prove wlhat the causes are whicli have occasioned such a fearful fatality of the mothers, and how far they unavoidably belong to the operation. I shall then speak of the infantile deaths and their causes. To satisfactorily and faithfully accomplish this investigation, the mnind ought to be free frorn all partiality in favour of the Caesarean section and from all prejudice against it. The deductions on which we seek to establish practical principles ought, as far as possible, to be drawn from well established facts. However true this rule in general is, there is more or less difficulty in strictly observing it on the subject now under our consideration. Most of the cases, in my humble judgment, have been related more for the object of swelling the already fatal list, than for the purpose of pointing out the mischief which existed previously to the operation, and the real causes of death.

A Few Practical Observations on Abortion, &c

tions, hurriedly put together, on abortion, a subject of the highest imnportance to the m-ledical, but miore especially to thie obstetrical practitiotner. It is not, however, my intention to enter into a detailed account of thuis accident on the l)resent occasion, bIut I slall only miiake a few remarks on the moral responisibility connected with this suibject, and also suggoest a fev pr-acticatl hints, which miiay be useful to guide the youing or itnexperienced practitioner in hiis prognosis and treatment.

Postscript to "Further Observations on the Caesarean Section".

excision of the knee, it is especially important to prevent bleeding from the various small arteries that are divided for, unless this be carefully done, blood will collect in the wound, between and behind the bones, after the patient is in bed, will lead to suppuration, and be a source of much trouble. To prevent this evil, I sometimes found it necessary to tie several vessels; and the presence of these ligatures with the portions of tissue strangulated by them was certainly a disadvantage. In the last two cases in which I lhave performed this operation, I have gladly availed myself of torsion of the arteries, and have been well satisfied with the result. Still, a greater number of cases of this and other operations are necessary, to test properly the value of this mode of closing the arteries. The plan which I adopt is, as you arc aware, for the smaller arteries, to use a pair of clasp-forceps, whicb, at the end, are rather broad, and provided with fine interlocking blutnted teeth, by means of which the artery is held securely during the twisting. This I continue till the coats are quite torn through, and the forceps are thereby set free. In the case of the larger arteries, I found, by experiment on the dead body, that these forceps divided the coats of the vessel, and tore their way out too quickly; so that, when I injected water into the artery by a syringe it soon, under very slight force, separated and obliterated the folds of the inner coat, which had been caused by the torsion, made its way under the outer coat, and burst through that coat. I tried other forceps of different shapes, and found that the pair of strong narrow-bladed hinge-forceps, which I show you, and which I have been in the habit of using to extract bone in operations for necrosis, answered the purpose better than any others that I have yet used. They resemble somewhatt strong dressing-forceps; but the handles arc large, giving good purchase, the blades meet closely, and the transverse ridges and furrows near the ends are well adapted, so that they hold the end of the artery tightly without tearing it. You see when I seize with these forceps the end of this femoral artery which I took from a subject yesterday, hold it tightly and twist it, that, although the forceps are not sufficiently broad to cover and pmbrace the whole diameter of the artery, yet they hold it firnly and retain their hold till the entire end of the vessel has been twisted off. The renmaining part presents a conical twisted end, which unfirls itself to some extent, but not entirely, and remains completely closed. I now throw water into it; and not till I have used considerable force do the compressed folds of the inner coat yield, separate, and permit the water to pass beneath the outer coat, which again is so sealed by the twisting, and so stronig, though thin, that it offers considerable resistance before it gives way-a resistance muclh greater than would be required to withstand the pressure of the blood in the living artery. I twist other portions of artery in the same manner. They are all firmly closed. Cutting them open, we find the inner coat more or less lacerated and contused, its surfaces squecezd together and thrown into folds, and held in close contact by the twisted outer coat, which forms coils, terminating in a cone or point at some distance beyond the termination of the inner coat. In some instances, I have found the inner coat detaclied from the outer by the squeezing that occurs during torsion, aid more or less reflected into the artery so as to present its divided edge tc a4P hl-. You will, from this explanation and these experiments upon portions of artery (and I have made several observations upon the dead body corresponding with these), understand what takes place when an artery is twisted. The inner thick, elastic coat is thrown into folds, which are crushed or squeezed together so as to block up the channel of the artery; it then gives way, aiid is torn through, and is held in its position by the outer coat, which resists longer, and undergoes still fturther twisting and squeezing together of its structures, so that when it is finally torn through, it retains its twisted condition, and continues to exert pressure upon and give support to the inner coat. I have just had an opportunity of examining a popliteal artery which was twisted in a young man after amputation six weeks ago. It was perfectly closed, was contracted, and surrounded by toughish strtcture for some little distance. Its intemal coat was wrinkled near the end, and showed some traces of ecchymosis. You have probably observed that the attention to the blood-vessels after operations has occupied rather more time than it did wvhen we used the ligature; and torsion has certainly, in my hands, proved somewhat more difficult than the ligature, requiring more care, more patience, and more perseverance. It is necessary to include the vessel itself in the forceps; for it is useless to twist the surrounding tissues ; and it is not alwaqrs easy, when blood is flowing, to make sure of the exact point from which it flows. Often, therefore, when I have been twisting, I found that my efforts were of no avail, because I lhadl inot seized the exact orifice of the vessel. Even when the vessel is seized, the ininer coat is liable to slip from between the blades of the forceps, the outer coat only being retained and subjected o the torsion; andl this is not to be reied on. When, however, I have been sure of havnig seized an artery and properly twisted it, I have not known any further bleeding to take place from it; and if it be carefully done, torsion is, I think, a valuable means of securing small and medium-sized arteries, such as the tibials, facial, etc., and by reducing the number of ligature-threads, it will be found to promote early healing of wounds. Whether it will prove to deserve our confidence in the case of the larger arteries, I am not so sure; but I should say that the doubt is founded rather upon what I have found in experimenting upon the dead subject than on what I have observed in the living; and it may be that better appliances andl more experience may justify a greater reliance upon its eflici ency. The experiments which I have shown you to-day upon pieces of artery, and those which some of you have seen me make upon the dead body, have proved to youi that much care is needed in the selection of proper forceps, and in so seizing and holding the endi of the vessel that its inner coat does not slip from between the blades during the twisting; and it will have occurred to you that in the living subject it is not easy to make sure of doing this as it should be done, or to feel certain in any instance that the artery has been properly twisted. The only rule I can lay down is to use all care in the process, especially in grasping the orifice of the artery, and to examine well the remaining torn end after the foreeps have been set free by the torsion, so as to ascertain, if possible, whether the vessel is completely closed. I do not wish you to go away with the impression that the trials of different modes of preventing hwmorrhage from arteries have been made without due consideration, or that the conducting them has been unattended with anxiety. In the early years of my professional career, I was severely tried by some cases in which bleeding occurred and recurred after operations. These cases produced a deep impression iupon me, and nmade me extremely cautious and careful in securng blood-vesscls, particularly in the mode of applying the ligatures, and watchful in sponging the surface and examining the tied vessels before closing the wound; and I would not have been induced to try acupressure or torsion had I not been also strongly impressed witlh the great importance of using all means to obtain early union of the wounds after operations, or rather, I would say, immediate union of the whole or large part of a wound after an operation. There is no doubt that the success of operations will be increased in proportion as we can attaini that result ; and the prospect of attaining it must depenid a good deal upon the mode in which the vessels are secured ; the first desideratutm being to prevent bleeding; the second, to do it in such a manner as shall least interfere with the healing process. The ligature effects the first object completely; but is so far open to objection with regard to the second, as to justify the cautious trial whether other modes which promise better as regards the healing process may uot be equally effective in stemming the blood-currents from the arteries.

CASES IN MIDWIFERY.

limb. after fist walking. Has never had rheumatic fever. His father was athmatic. .aupection. Chest anteriorly tolerably symmetric; comparative depression of right supra-clavicular space; very slight visible impulse in situ, and a little to the outer line of the nipple. Impulse distinct in epigastrio; distension of brachial and cervical veins, the latter rapidly distend on downward pressure, but empty to a certain extent during inspiration. No abnormal pulsation of superficial arteries. Bombing of the chest posteriorly. Palpation. Distinct impulse in epi&astrio; no frdmisemewt. Pulse full, soft, and regular. Percunion. Pulmonary sound abnormally full; lungs lower than natural; area of heart difficult to apprecitte accurately from the encroachment of the lung. Auwultation. At the base of the heart, a diastolic murmur is heard, of maximum intensity, short, hoarse, exactly resembling the crumpling of parchment. The murmur ascends the aorta, and is audible in the carotids, most distinct in the left; it entirely replaces the second sound of the pulmonary artery. The first sound is distinct at both cartilages. From the base, this parchment-like diastolic sound is conducted vertically downwards to the epigastrium with considerable intensity; but in this region both the first and second sounds acquire the character of friction sounds-hoarse whiffing. This murmur is audible over all the right anterior surface of the chest, and over the left as far as the axilla; it is also transmitted obliquely to the apex, where it is gradually lost towards the inferior axillary region; here both sounds have a slight character of murmur. Lungs. Occasional inspirmtory refle sonore and snoring expiratory murmur; rdlte muqueux d grosses bulles during expiration at the bases. [To be continued.]

CASES IN MIDWIFERY: WITH REMARKS

But these affections may possibly be only functionally nervous; they are not always connected with organic changes in the nervous centres. Contracture is sometimes congenital, but more commonly consecutive to nervous diseases, either with organic alteration, or rurely nervous. This latter kind, which I have ascertained, as well as French physicians, by dissection, is termed by the latter (Rilliet and Barthez,) the essential contracture, which I have seen as the consequence of convulsions, purely nervous. Most commonly we see this state of permanent contracture of the flexors, connected with only a degree of paralytic weakness of the affected extremity or extremities. Complete paralysis, on the contrary, of the flexors as well as extensors, is almost always the result of transudation or softening, If this takes place in one hemisphere of the brain, then the paralysis extends over the whole length of the opposite half of the body, from the muscles of the face to those of the foot. The anus, soon after birth, offers an abnormity which we call atresia ani, or imperforate anus, sometimes without the least opening, at other times there is a small opening, leading to the rectum. I have seen no more than eight similar cases in the whole extent of my practice. The pi olapsus ani, a frequent consequence of dysentery in children, shows us a part of thle mucous membrane of the rectum. As there is always a degree of strangulation caused by the sphincter, a considerable passive congestion is necessarily present in the prolapsed mucous membrane; but sometimes we perceive a swollen surface, with much granulous appearance, the follicles swollen or ulcerated, which are all symptoms of inflammation. On the contrary, redness at the orificium ani, with erosions or ulceration, is most commonly the consequence of the irritating quality of discharge, or of uncleanness, and is seldom dependent on pure intestinal inflammation. I have been satisfied that the latter circumstances gives sometimes rise even to luxuriations like flat tubercles, independent of syphilis; and these luxuriations at the orficium are frequently surrounded by eczematous eruptions and ulcerations, extending over the contiguous parts of the thighs; this is in particular the case in scrofulous children abandoned to uncleanness. I have succeeded in curing hundreds of similar cases without antiphlogistic means. The skin.-You need not to be referred in this place to the various chronic and acute eruptions of the skin; these, and ulcerations, or any other local affections of the derma, are easily recognizable, and have their more or less clear signification, local and constitutional. The red foetal colouration of the skin sometimes persists for some weeks after birth; and I remember a case where a practitioner took it for erysipelas. Cyano8is, if the consequence of the abnormal persistence of the foetal blood-communications, gets its full signification by auscultating, in which case a bellows murmur will never fail. But I bave seen cases of cyanosis in children dependent upon gastric disorder, or rather derangement in the portal system. Yellow colouration, if primary, denotes bilious derangement, but frequently after erysipelas cr erythema follows a degree of icterus during the course of recovery, which yellowness is without signification. Palenes8 of the skin, with proportional want of redness of the mucous membrane of the eyelids, the tongue, and lips, signifies chlorosis, which I met with in some cases even about the second year of age, and ascertained it by auscultation and the presence of the carotid soufle. The temperature of the skin, dryness, or perspiring state, heat or coolness of it, are of the same signification as in adults, only that there is more variability of temperature in children. The high degree of dry and burning skin, proper to typhoid or putrid fevers, I never met with in the first years of childhood. Next we shall speak of the pulse and then of some other symptoms.

On the Means by Which Uterine Haemorrhage Is Suppressed without Artificial Assistance.

目的 研究摄入含糖软饮料和果糖与男性痛风发生风险之间的关系。 设计 历时12年的前瞻性队列研究。 地点 医务人员随诊研究。 参与者 46393例无痛风病史的男性，通过填写经验证有效的食物频度调查表，提供他们摄入软饮料和果糖的信息。 结局评估指标 符合美国风湿病学院痛风调查标准的痛风新发病例。 结果 在12年的随访中，共报告新发痛风确诊病例755例。含糖软饮料摄入增多和痛风危险性升高相关。与每月饮用不足一份含糖软饮料相比，每周饮用5～6份的人发生痛风的多变量相对危险度是1．29（95％可信区间1．00～1．68），每天一份的是1．45（1．02～2．08），每天两份或两份以上的是1．85（1．08～3．16；趋势P值=0．002）。无糖软饮料和痛风发生的危险性无关（趋势P值=0．99）。摄入果糖每增加五分之一，相应的痛风发生的多变量相对危险度为1．00、1．29、1．41、1．84和2．02（1．49～2．75；趋势P值〈0．001）。摄入果糖的其他主要来源，比如所有种类的果汁或富含果糖的水果（苹果和橘子），也和痛风发生的风险升高相关（趋势P值〈0．05）。 结论 前瞻性数据提示摄入含糖软饮料和果糖与男性痛风发生风险升高显著相关。另外，富含果糖的水果和果汁也可以增加其危险性。无糖软饮料和痛风发生的危险性无关。

Dr. Radford on the Operation of Craniotomy

and relaxing the muscle, whilst I rotated the humerus, strongly inwards, but without success. I next straightened the arm, and holding it by the wrist, I rotated it inwards as far as I could, and then with a sweep carried it across the chest, whilst, with my left hand on the deltoid muscle, I pressed the head of the bone downwards and outwards, and the tendon reLurned to its groove with a very erident snap. I next displaced the tendon on to thle outer or greater tubercle, when, by rotating the arm outwards with my right hand, and drawing the hend of the bone downwards and outwards with my left, I reduced it, but I found it was more easily restored to its proper position by taking hold of the wrist with my right hand, and placing my left in the axilla; with the latter I pressed the head of the bone gently outwards, wilist with the former I supinated the hand and rotated the arm strongly outwards, at the samue time bringing it to the side of the body, my left hand serving As a fulcrum in the axilla. By this means the deltoid was put upon the stretch, and its anteriorfibres, upon the insertion of which the biceps tendon lay, evidently assisted the latter into its groove. I next endearoured to ascertain in what position of the arm the tendon would remain most securely in its place. Accordingly, I flexed the forearm, and placed the hand in the position of pronation across the chest, when the tendon became again displaced, as it did immediately the head of the humerus was rotated inwards, althoughi the forearm was extended; but when I extended the forearm, placed the lhand supine, and separated the arin from the side, it remained properly in its place, being now bound down by the tendon of the pectoralis major. I am fully aware, in these experiments, that the subject being dead I did not encounter that opposition froin the capsular muscles which I should in all probability have niet with in a living patient; but, making every allowance for this, I am still in hopes that what I have here endeavoured to explain to you, may serve to place the treatment of these accidents on some surer basis than mere conjecture, and that henceforth you may have some rule to guide you. We have seen that the head of the humerbs is drawn up against the acromion process, and that the greater tubercle striking against that process, when the arm is separated from the side, prevents its being raised beyond a very acute anigle. I should advise you to adopt the following method, should you find the plan, as recommended by Mr. Bromfield, fail. I am not aware of any particular symptom by which we can be giuided with any certainty as to when the tendon is dislocated inwards, or when outwards; but, as a result of iny experiments, I shoiuld imagine that it is more frequently dislocated inwards than outwards, the inclination ofthe head of the humerus, and the greater projection of the larger tubercle, being unfavourable to the latter displacement. Place your patient on a low chair, and let an assistant fix his scapula by pressing upon the superior angle and costa; then separate the patients arm from his side, as far as you can; keep his hand in the prone position, and make extension downwards and outwards from the wrist, until you have somewhat withdrawn the head of the bone frota the acromion process. Now let an assistant sit down on the floor, underneath the ,injured arm, and clasping both is hands over the deltoid muscle, draw the head and neck of the bone downwards and a little backwards, wiilbt you rotate the head of the bone inwards and backwards in the glenoid cavity, by making the patients arm describe a circle, tcarrying it backwards, upwards, forwards, and inwards, across the chest. Should you have reason to suppose that the tendon is displaced outwards, separate the arm as far as you can from the body, and let an assistant nmake extension in that direction best calculated to remove the head of the bumerus from the acromial process, that is, downwards and outwards. Unless this be done, in either form of the dislocation the bicipital tendon remains pressed up by the lbead of the humerus against the acromial process, and is obviously prevented from returning into its natural position. Next place your left hand well up in the axilla, and direct your assistant, whilst he keeps up the extension, to rotate the arm strongly outwards, and at the same time to .bring it to the patients side. Having reduced it, lgenstly separate the arm from the patients side; keep it steadily rotated outwards, and the hand supine; place a long splint, which extends fromn the shoulder to the fingers, along the back of the arm and hand, and also a pad or compress in front, over the bicipital groove. Fix the whlole with a roller evenly and carefully applied, and place your patient on his back in bed, where he had better remain until you consider that the parts have become sufficiently firm to prevent a recurrence of the accident. The reason why I recommend you to separate the arm from the side after reduction, is, that by so doing you place the pectoralis major muscle upon the stretch, and consequently make its broad tendinous insertion press more closely and directly over the bicipital tgroove. In my experiments, the difficulty was not so great in reducing, as in keeping the tendon -in its place when ,reduced, and certainly the plan wlhich I am now advocating appeared both to Mr. Bainbridge and myself to be the most efficacious.