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Royal 8vo. pp. xU.— 363. Philadelphia : J. B. Lippincott Co. 1894.

Diseases of the Skin ; An Outline of the Principles and Practice of
Dermatology. By Malcolm Morris, F. R. C. S., Surgeon to the Skin
Department, St. Mary's Hospital, London, etc. In one 12mo volume
of 572 pages, with 19 chromo-lithographic figures and 17 engravings.
Cloth, $3.50. Philadelphia : Lea Brothers & Co. 1894.

Report of the Commissioner of Education for the Year 1890-91.
Volumes I. and II. Washington : Government Printing Office. 1894.

An International System of Electro-therapeutics, for Students, Gen-
eral Practitioners and Specialists. By Horatio R. Bigelow, M. D., and
Thirty-eight Associate Editors. Thoroughly illustrated. In one large
royal octavo volume, 1,160 pages; extra cloth, $6.00 net ; sheep, 17.00
net ; half-Russia, |7.50 net. Philadelphia : The F. A. Davis Co., Pub-
lishers, 1914 and 1916 Cherry street.



bifarar^ ftofaib.



Mb. W. B. Saunders, Medical Publisher, Philadelphia, is pleased
to announce, as in active preparation, his New Aid Series
of Manuals for Students and Practitioners. As publisher of the
Standard Series of Question Compends, together with an intimate
relation with leading members of the medical profession, Mr.
Saunders has been enabled to study, progressively, the essential
desideratum in practical self-helps for students and physicians.

This study has manifested that, while the published Question
Compends earn the highest appreciation of students, whom they
serve in reviewing their studies preparatory to examination, there
is special need of thoroughly reliable hand-books on the leading
branches of medicine and surgery, each subject being compactly
and authoritatively written, and exhaustive in detail, without the
introduction of cases and foreign subject-matter which so largely
expand ordinary text-books.

The Saunders' Aid Series will not merely be condensations
from present literature, but will be ably written by well-known
authors and practitioners, most of them being teachers in repre-



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"704 LITERABY NOTES.

tentative American colleges. This new series, therefore, will form
an admirable collection of advanced lectures, which will be invalu-
able aids to students in reading and in comprehending the contents
of " recommended " works.

Each manual, comprising about 250 pages (5^ x 8 inches), will
be distinguished further by the beauty of the new type ; by the
•quality of the paper and printing ; by the copious use of illustra-
tions ; by the attractive binding in cloth ; and by the extremely
low price, which will uniformly be $1.25 per volume.



The Tbansaotions of the Pan-American Medical Congress.
— The proceedings of the first Pan-American Medical Congress
were compiled by the Secretary-General, Dr. Charles A. L.
Reed, and transmitted to the Department of State in November,
1898. By recent joint resolution of the Senate and House of
Representatives, the manuscript was transmitted to Congress and
a concurrent resolution has been adopted directing the public printer
to print the same. The manuscript is now in the office of the
public printer and will be put to press at once under the super-
vision of the editorial committee, of which Prof. John 6uiteras,of
Philadelphia, is chairman.



The Medical Society of the Women's Medical College of Balti-
more has commenced the publication of a bulletin, in which it is
proposed to publish the papers, cases and proceedings that come
before the society. The first number was issued February 15,
1894, as a four-page double-column quarto sheet. The officers of
the society are : President, Fannie E. Hoopes, M. D., D. D. S. ;
Vice-President, Ida Pollack, M. D. ; Recording Secretary, Sue Rad-
<5liffe ; Corresponding Secretary, Ella J. Reed ; Treasurer, Louise
Eaton.



Messrs. William R. Warner & Company, of Philadelphia,
received the award of a silver medal at the late International
Medical Congress at Rome.

Notice to Contributors. — We are glad to receive contributions
from every one who knows anything of interest to the profession. Arti-
cles designed for publication In the Journal should be handed in before
the first day of the month. The Editors are not responsible for the
views or opinions of contributors. All communications should be
Addressed to the Managing Editor, 284 Franklin St., Buffalo, N. Y.



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Buffalo Medical l Surgical Journal

Vol. XXXIIL JUIiY, 1894. No. 12.

©rlglnaf (sommunlcatlonA.



THE VALUE OF HEGAR'S SIGN OF PREGNANCY.^

By J. W. LONG, M. D., Richmond, Va.,
Professor of Diseases of Women and Children in the Medical College of Virginia.

PsBHAPS the first problem which confronts every gynecologist^
when called upon to diagnosticate the nature of a pelvic or abdomi-
nal tumor, is that of pregnancy. I am sure it is the first thing which
enters my mind, for I have a painful recollection of being beguiled^
by a designing woman, into passing a probe into a pregnant uterus^
with the natural result of producing an abortion. This occurred
when I was younger than I am now, when I knew more, and was
more credulous of womankind.

Of course, to the man who is willing to simply wait << for Nature
to take her course," it is immaterial as to whether a given tumor is
a pregnant fundus or a fibroid, for " time will tell " ; but to the
man who feels the keen necessity of distinguishing the nature of
these tumors, any sign which may be relied upon is a welcome
addition to his resources.

The ordinary so-called certain signs of pregnancy develop so
kUe^ and many times not at all, that we turn with great expectation
to a sign which promises to indicate with certainty the presence of
pregnancy at an early period.

Hegar's sign consists essentially of a softening and compressi-
bility of the lower zorie of the uterine body. It has been erroneously
stated to be a '^ softening of the upper part of the cervix " ; but
this is not true, for the hard cartilaginous-like cervix can be easily
distinguished from the softened tipsues above. The sign is
obtained by bimanual palpation, the hands being placed in either
of the several positions shown in the cuts taken from Sonntag,
American Journal of Obstetrics y August, 1892.

1. Read at the annual meeting of the North Carolina State Medical Society, May 17, 1894.



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706 LONG : HBGAR^S SIGN OF PREGNANCY.

Fig. 1 shows the intra-vaginal finger pressed into the anterior
yaginal fornix, and the abdominal hand forced down behind the
fundus and in front of the sacrum. In this way the lower zone
of the body of the uterus is grasped between the opposing fingers,
and it is astonishing to find how (apparently) thin the tissues are
at this point. One can feel and distinguish the opposing fingers
as readily as if only the lapel of his coat was interposed between
them. I do not think one can fully realize how soft and bag-like
the lower zone of the body of the pregnant uterus is until he has




Fig. 1.

actually seen, as well as touched, such a uterus while in situ. I
had occasion to see SLndfeel a three months pregnant uterus while
doing a hysterectomy for fibrous tumors, complicated by preg-
nancy. This occurred in the practice of Drs. Cox and Staunton,
of High Point, and is fully reported in the April number of the
Virginia Medical Monthly.

So flaccid was the lower part of the uteVus, that I would not
believe it was not the half-full bladder, until a catheter was intro-
duced, proving the bladder to be empty.

Fig. 2 illustrates the second method of obtaining this sign,
the intra-vaginal finger being behind the cervix, and the abdominal
hand being pushed down between symphysis and fundus.

Fig. 3 shows one hand on the abdomen between the symphysis and
fundus, and one finger in the rectum, with the thumb in the vagina.



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LONG : hsgar's sign of pbsgkakct.



707



•controlling the cervix. This method may be facilitated by hook-
ing down the cerril with a tenaculum. In fact, with the cervix





{^^^^^^^



Fig. 2.



palled down, the sign may be obtained by means of the thumb in
the vagina and the finger in the rectum.



/*



Fig. 3.



When the woman is very tender, or nervous, or the abdominal
walls thick or rigid, it is necessary to employ anesthesia.



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7 08 long: hegar^s sign of prbgnanctt.

This paper is based upon the careful study of nine oases. The
period when this sign may be observed, is from the eighth week to
the sixth month. Other observers claim to have detected this sign
at the fifth week. It hardly seems probable that the softening
can be felt prior to this period, while after the beginning of the
sixth month the uterine globe is so full that it cannot very well be
compressed.

Case I. — Pregnancy diagnosticated at the eighth week. — Case seen
in connection with Prof. L. C. Bosher. Miss J., aged 19, having been
led astray is anxious to know if she is pregnant. Says her periods have
always been scanty and irregular. The last one appeared on March
10th and continued two days. Examination May 12th. Eegar's sign
pronounced and made out by both Dr. Bosher and myself. The fundua
is enlarged antero-posteriorly, which, of itself, is significant; breasts,
enlarged ; areolar dark ; papillae elevated ; patient complains of morn-
ing sickness and believes she is pregnant.

Case II. — Pregnancy diagnosticated at the ninth week. — S. D., an
intelligent colored girl of 18 years, single, no child, one abortion at
third month, comes to get something to <* bring on her spells." Says
she has '*took cold.'^ Periods always regular, last one occurring
November 24, 1898. Examination January 81, 1894. Slight cervical
tear, os patulous and contains plug of mucus ; mucosa soft. Lower zone
of body compressible, the opposing fingers being easily felt through the
uterus. Confronted with the diagnosis of pregnancy, she admitted
intercourse. This girl returned at the third month fully convinced
that she is pregnant

Case m. — Pregnancy diagnosticated at the third month. — Case
seen with Dr. D. A. Stanton. Young colored woman; married, but hus-
band has been in the asylum for a year. Has missed three periods.
Examined under chloroform Decembet* 26, 1893. ffegar^s sign made
out with finger in rectum, thumb in vagina, and cervix hooked down.
Confronted with pregnancy, admits intercourse. Diagnosis verified by
operation (hysterectomy for fibrous tumor and pregnancy) on the same
day.

Case IV. — Pregnancy diagnosticated at three and a half months. —
Case seen with Prof. J. A. Hodges. Mrs. H., aged 31, two children,
last one eighteen months old. Periods reappeared in May, 1893, and
continued at irregular intervals until January 10, 1894, when last one
stopped. Has no nausea or any symptom of pregnancy, except, pos-
sibly, a little enlargement of breasts and abdomen. Examination May
2d, Eegar^s sign pronounced. Vaginal discoloration, and cervical
changes present. Fundus markedly enlarged.



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LONG : hsgjlb's sign of pbsgnanct. 709

Case Y. — Pregnancy diagnosticated between the third and fourth
months, — Dispensary case. C. £., colored, aged 35 years, married
eight years, four children, last pregnancy five years ago. Examined

. Has missed three periods. Eegar's sign, Smali

fibroid on posterior surface of fundus.

Case YI. Pregnancy diagnosticated between third and fourth
^months. Dispensary case. J. J., colored, aged 27 years, single, three
children, two abortions. Last pregnancy two years ago. Examined
. Has missed three periods, ffegar^s sign.

This case was the subject of a' clinical lecture delivered before
the Summer school at the hospital of the Medical College of Vir-
ginia. Drs. J. Allison Hodges, Oeorge Boss, W. Augustus Lee
and William P. Mathews were present, examined the patient, and
all made out the sign without any trouble.

Case YII. — Pregnancy diagnosticated at the fourth month, — ^This case
was a private patient of Prof. Johnston^s, and came with the evident
purpose of deceiving him, as her history and sequel will show : Mrs.
L. O., aged 25, married at 16, had a child one year later, aborted at
third month one year after birth of child. About this time her husband
left her and has not been with her since. Health good as a rule, except
occasional attacks of kidney colic. Says that last June, while living in
Philadelphia, she was accidentally pushed from a stoop and fell down six
or eigrht stone steps, falling on her back, hurting her badly. Was in
bed three months and had to be kept continually under opiates, so great
was the pain. Her period came on the last of June, and again in July,
but has not appeared since (six months). After getting out of bed she
applied to several prominent physicians in that city, all of whom diag-
nosticated ovarian •♦trouble" or ♦* tumor," and advised a celiotomy.
This she declined and returned to Richmond, and later placed herself
under Dr. Johnston^s care, saying she had made up her mind to have
the opei*ation done, and desired him to operate. January 17th Dr.
Johnston asked me to see the case with the view of diagnosis. The
patient states further that she has paroxyms of pain occurring at irreg-
\ilar intervals, sometimes daily, sometimes several days apart ; one just
before Christmas threw her into a convulsion, as did another one on
January 1st, since which time she has had no paroxysm of pain. She
complains of profuse fetid leucorrhea, which is worse at times. She
was so tender I could not make a satisfactory examination. I could
cliscover a tumor, but could not make out what it was, so with her con-
aent we gave her chloroform. Under anesthesia we determined :
absence of leucorrhea, cervix hard, mucosa soft, os patulous and con-
tains plug of mucus, fundus size of four months pregnancy, Hegar'^s
Mgn marked, fibroid size of lemon and with broad face situated on right



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710 LONG : hegar's sigx of pregnjlnct.

side of fundus. This patient was of such good standing that it was with
difficulty I persuaded Dr. Johnston to confront her with pregnancy, hut
finally he did. She denied it indignantly, hut the doctor was emphatic,
and finally she admitted intercourse in September, just four montha
prior to date of examination. She was sent out of the hospital and mis-
carried ten days afterward.

Case VIII. — Pregnancy diagnosticated at four and a half months. —
This case also occurred in Dr. Johnston^s service. Mrs. H., age about
80, a most excellent lady, mother of one child two years old. The only
periods she has had since the birth jof her child occurred in April, July
and October (15th) of last year. For nearly a year she has suffered
with pain and soreness in left ovarian region, now has a marked
abdominal enlargement. She has had no morning sickness, no enlarge-
ment of breasts, no appearance of milk, indeed nothing to cause her to
suspect pregnancy. March 6th, Dr. Johnston asked me to examine her.
It was necessary to use chloroform. We found : cervix hard, mucosa,
soft, OS patulous and contains plug of mucus, fundus enlarged. Regards
sign present, left cystic oophoro-salpingitis. Both patient and husband
were delighted with the diagnosis of pregnancy, which was confirmed
two weeks later by quickening.

Case IX. — Pregnancy of Jive or six months in which I failed to get
the sign, — Case seen with Dr. Bulla, of Randolph. Mrs. K., a lady
living in North Carolina ; age 35 ; married sixteen months ; no children ;
periods always regular and very profuse until June, 1898, the flow waa
scanty, but began again in July and was nearly continuous until the
middle of October, when she passed a large quantity of clots and shreds,
whereupon her abdomen, which was the size of a four or five months
pregnancy, rapidly subsided to normal size. After this her periods did
not appear again until February, since when she has had a continuoua
bloody flow. She has had no enlargement of breasts, no nausea, and
does not believe she is pregnant. Examination, March 17th, under
chloroform, when we discovered : cervix pushed to left side, mucosa
soft, OS patulous, fundus size of four and a half or five months preg-
nancy, rythmical contractions of fundus, hard tumor size of fundus,
situated behind and to the right, numerous small tumors in and around
upper part of cervix and lower zone of body, Hegar^s sign could not be
elicited, due either to presence of the tumors, or to the advance stage
of pregnancy. Diagnosis : pregnancy and fibroid tumors. The second
night afterward the woman miscarried.

My conclusions then are :

1. That between the second and fifth months Uegar's sign of
pregnancy is one of great value, its presence always indicating
pregnancy.



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BOBINSON : PERITONITIS OB INFECTION. 711

2. It is applicable to any case where the abdominal walls are
thin and flaccid enough to grasp the nteras between the two hands^
as detailed above.

3. Fibroid tamors are the most misleading complication (two
cases, supra).

4. Anesthesia is often necessary.

Since reading this paper before the North Carolina Medical
Society, at Greensboro, May 11 ^ 1894, 1 was asked to examine :

Case X. Mrs. H. ; age, 22 ; periods painful and profuse ; last one,
February 20th, lasting four or five days. Never pregnant and does not
believe she is pregnant now. Examination under chloroform, May 18th,
found Hegar's sign ; also mucosa soft, fundus size of three months pref^*
nancy and areola slightly darker than normal. Diagnosis : pregnancy
of three months.

412 East Grace Street.



WHAT KILLS THE PATIENT— PERITONITIS OR INFEC-

TION?

Bt BYRON ROBINSON, Chicago, 111.

In conversation with a gynecologist the other day, he remarkeci
that his patient died on the fifth day from peritonitis. A curious
view prevails among physicians that peritonitis causes death ; that
if peritonitis can only be avoided the patient is safe. The dread
of many a physician is peritonitis ; as if the patient hung on a.
thread and peritonitis would snap it ruthlessly asunder. A few
careful autopsies on patients who have died from peritonitis would
soon dispel this illusion. One sees bands, adhesions and barriers
of exudate here and there. Partitions and departments have been
formed in the abdominal cavity. Pools of pus have been coralled
and circumscribed. Viscid, jelly-like substances surround ill-
appearing localities. The most angry complaining viscera have
become the most imbedded and fixed. Yet the physician says the
patient died of peritonitis. What a grand mistake. The peritonitis
made wonderful efforts to save the patient's life, or had it not been
for the peritonitis the patient would have long before passed to
the tents on the greensward whose curtains never swing backward.
An example will suffice to illustrate that peritonitis attempts
to save life instead of destroy it :

Mrs. A. came to the hospital with hernia strangulated for three
days. Pulse 110, and shortly after the operation temperature 103. The



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712 BOBINSON : PERITONITIS OB INFECTION.

operation removed a gangrenous gut strangulated by Poupart's and
Gimbernat^s ligaments. The gut was reduced so far as Poupart's liga-
ment was concerned, but the strangulation was not relieved for a second
constriction tightly embraced the gut-loop from the chronic imflamma-
tion, which had existed for three years previous. Abdominal section was
made and the loop in intestine forcibly pulled out from the inside of the
peritoneal sac. Six inches of the blackened bowel resected and a
Murphy^s button inserted. The peritoneal redness, the vascular con-
:gestion, the deranged pulse and temperature, showed that she had peri-
tonitis. The lower half of the peritoneum presented the suffused tint
•of a setting sun. The patient quickly rallied. The temperature
became normal, the pulse became 80 and she was hungry. All was
going well until about the seventieth hour, when a sudden disturbance
Arose and she became pale. The temperature fell to 98, the pulse flew
up to 140. She became restless. Tympanitis rapidly arose and she
died about ninety hours after the operation. The autopsy revealed a
perforation at the side of the button on the distal side of the mesentery.

The aatopsy, performed by Dr. Brown, of the Post-Graduate
School, revealed only a few sqaare inches of what one would call
peritonitis, but several sqaare inches of dull, dark peritoneum
around the seat of perforation. No adhesions were formed.
What killed this patient — peritonitis or infection ? It is easy to
answer that infection was the head and front in the cause of death.
If peritonitis could have arisen, the woman's life might have been
saved by barriers of exudate. Inflammation is the mode that the
peritoneum takes to preserve life. Peritonitis is the standing
army against the invasion of infection, and the omentum is like a
man-of-war, ready at a moment's notice to go to the points of peri-
toneal infection to capture the invader. Observe, for a moment,
the three regions of the peritoneum where infection invades —
namely, between the colon and diaphragm, around the appendix and
in the pelvis, — and note how adhesions promptly check invasions.

Few autopsies are done without peritonitic adhesions being found
4n the pelvis around the cecum or in the region of the gall-ducts.
In such cases, life was absolutely saved by inflammation, by peri-
tonitis throwing out barriers of exudates, — advance guards against
foreign invasion of merciless soldiers, whose sole purpose is
destruction and death. Now, turn attention to the small intes-
tines, around which are found but few exudates or adhesions, for
the simple reason that death occurs before peritonitis can form
barriers to stop death on its way, which is simply infection (the
«olon bacillus). If the peritoneum on the small intestines had



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BOBIVSON : PEBITONinS OB IKFECTION. 713

time to inflame, it would throw oat exudates to sarroand and cap-
tare the invader. Peritonitis woald save life by starring oat the
infections invader by co)*alling him in a limited space, e. g.y a pool
of pus, whence sterility of the pathogenic microbe arises. Modem
research asserts that microbes are the cause of peritonitis, but the
adhesions, bands and exudates show how hard the peritoneum tries
to stop the advances of such enemies of mankind. If it were not
for peritonitis death would soon end the scene* But, while blood
corpuscles swarm to the seat of invasion and quickly attempt to
surround the infectious invader by burying him with the dead of
the battle, infection is only conquered by being buried in the
ddbris of its own devastation. As a proof that peritonitis saves
life, observe that the most favorable cases of abdominal section
are those where collections of pus are circumscribed. The infec-
tion has been checked by peritonitis, e. g., in the pelvis, around
the cecum, or gall-bladder. The circumscribed invader has been
starved out by cutting off supplies of food or space. Hence, infec-
tion is the dreaded foe, while peritonitis is the savior of life.

Peritonitis builds solid forts around the ends of the Fallopian
tubes, the appendix and the gall-bladder, which alone insure liberty
of life to the viscera. We are just beginning to interpret the
wonderful workings of the peritoneum. I was once infected in
my finger, and my whole arm readily served as a test-tube of cul-
ture medium in a few hours. There was no peritoneum to protest
by inflaming against the invader, and I was soon delirious.
Finally, the white blood-corpuscles arose in sufficient numbers to
overcome the intruders and starve them out. It required some
six weeks to rout the infectious invader. A peritoneum would
have likely coralled the infection by an exudate in a few days.
Peritonitis tends to save life. Infection tends to destroy it.
34 Washington Stbeet.



The Mabbiagb of Syphilitics. — In general the advice to syphi-
litics would be not to marry, but Dr. William G. Porter believes in
doing the syphilitic justice, and for this reason he looks at the
subject with very lenient eyes. He divides the disease into the
benignant, the moderate and the malignant variety. The stages
explain themselves. The first form recovers with no treatment,
while the second and third need a skilful physician's advice, and
after all disappearance of the symptoms the patient may safely
marry in two years. — Maryland MedicalJoumal,



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Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 71 of 78)