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11th. One incision to-day with more than half an inch advance; rather more blood than yesterday, but very little pain. Suffers no pain in the interim between the operations. The stream of urine improves daily; very slight smarting after each incision.
13th. The fourth incision was made to-day in the same manner, with the improvement of introducing a small catheter into the bladder, the first for two years!! In the passage of this instrument, which was allowed to remain a short time in the canal, it was erident that the difficulty was not yet overcome.
The catheter came out of a spiral form, and bent with the point upwards.
The stream of urine improved. More pain during this operation (cutting) than previously, but less blood.
14th. Prepared to use the Letheon, expecting to experience much pain, but on trying the metallic sound I found it would pass very easily, and a voluntary attempt at urinating produced a very good stream. I recommended him to wait a few days to see whether the relief would be permanent. He returned on the 16th, when I found that the sound which had passed so easily before, would not now pass. Some obstruction near the neck of the bladder, though the urine passed very well. I directed him to call on the next day, when I would try a silver catheter.
17th. Neither the sound or silver catheter will pass the obstruction. The parts cut are easily passed, but there seems some impediment still Operated for the fifth time, by simple incision, when on withdrawing the instrument, I dropped the silver catheter into the bladder. About half a drachm of blood followed this incision, and it was more painful than the others, but the passage is apparently complete, and permanently opened. The patient continued to call upon me every few days, and informed me that the silver catheter continued to drop into the bladder. The urine passed as free as ever it had, and not an unpleasant symptom had followed. I directed the occasional use of the silver catheter as a precautionary measure, but I believe it is of no further use. The cure remains complete up to the publishing of this article.
The incisions from withont, which are the next form of incisions to be considered, can scarcely, we think, with the exception of some cases of fistulæ in perineo, be necessary. The plan of Sir B. Brodie, in his case, in which he operated with a modification of Mr. Strafford's instrument, and in which he first made an external incision for the purpose of guiding more surely the instrument, is one which, to say the least of it, as far as the stricture was concerned, was entirely unnecessary; The plan of cutting down upon a sound, and opening the urethra by projecting a trocar-pointed perforator, towards the external orifice of the urethra, is one that is proper in very bad cases of closure of this canal, complicated with one or more fistula.
It does not enter into our present plan to speak of the causes and treatment of fistula in perineo, as connected with stricture. We would merely state in conclusion, that our remarks resolve themselves into the following heads.
1stly. That stricture may exist in one of these forms.—Simple, as the result of recent or present inflammation in the part, producing a contraction of the part.-Confirmed, or that in which a deposit of some kind has taken place outside of the lining membrane of the urethra, so as to infringe upon the diameter of the canal. The most persistent, and formerly considered the most incurable of these forms, being that in which the deposit is cartilaginous.
- Any one of the above forms may be complicated, and frequently is, with spasmodic stricture, which latter may also exist.-Without any permanent deposit.
2dly. That it is a disease, when found in the permanent form, seldom entirely cured by the ordinary means.
3dly. Some three forms of the permanent stricture may be relieved, and sometimes cured by rupture and dilatation.
4thly. That the more persistent forms of the disease had better be cut, whether combined with spasmodic action or not.
5thly. That the merely spasmodic form must be treated according to circumstances.'
On the Causes and Treatment of Abortion and Sterility; being
the result of an extended inquiry into the Physiological and Morbid conditions of the Uterus, fc., &c. By JAMES WHITEHEAD, F. R. C.S. Surgeon to the Manchester and Salford Lying-in Hospital. London, 1847.
Diseases of the Uterus have, of late years, engaged the attention of British and American practitioners in no inconsiderable degree; and we think justly. In the economy of the female, so important a rôle does the uterus play, that everything relating to its diseased conditions cannot but be regarded as of very great importance. Hence the number of treatises which, of late years, have appeared on this subject from the British press, not to speak of the translations from the French.
We well recollect the severe, if not abusive article, which appeared some nine or ten years since in a highly respectable British journal, against Balbirney, on the use of the speculum in uterine diseases. A great change, however, since that period is manifested in British practitioners and authors. Perhaps not a single book comes to us now from that country that does not speak of the speculum and its use as one of the legitimate means of the physician for forming his diagnosis. We are glad of all this. It shows an improved state of the medical mind; it affords proof that no means are to be discarded for accurately ascertaining the condition of any suffering organ; and we feel warranted in saying that, but for the speculum, no man could practice judiciously and properly in diseases of the vagina and uterus.
The above work contains 426 pages. Of these, 180 are upon the subject of menstruation; 159 upon the signs of pregnancy ; 160 upon the causes of abortion, and the remaining 27 upon sterility.
Of the chapters upon menstruation and signs of pregnancy, it has not been our good fortune to see exactly the reason of publication ; certainly not for occupying more than one-half of the volume. This part could have been onnitted, we think, without detriment to the remaining portion of the work, though it would certainly have diminished the size of the volume. Still, these chapters are not without interest, and will bear reading.
In speaking of the function of the Ovaries, the researches of Lee, Bischoff and Raciborski, and others, are mentioned; but we find no mention of Pouchet of Rouen. This eminent physiologist, as long ago as 1835, taught the positive theory of the fecundation of the mammifera. His views, since published, are summed up in ten fundamental physiological laws and three accessory. Raciborski and Bischoff's subsequent labours are bui confirmations of Pouchet's laws.
Spurious Menstruation-Pseudo-Pregnancy. Three cases are given, together with the constitutional signs of this condition of the uterus. In all three, disease of the organ existed; and the anthor lays down the rule that it is invariably associated with a morbid state of parts situated external to the uterine cavity, generally of its cervix and labia, sometimes of a portion of the vaginal mucous membrane.
Suppressed Menstruation. A few interesting cases under this head are given-at the close of one of them, in which severe hysteric syınptoms were present, and which terminated fatally, the author remarks:
“Hysteric affections are generally said by writers to be unattended with danger. Speaking of this form of disease, a moderh author (Watson) says: “It is a dreadful announcement to have to make to a father or mother that their child is epileptic, whereas hysteria, though it is sufficiently distressing, is attended in nine hundred and ninety-nine cases out of a thousand, with no ultimate peril to body or mind.' On the contrary, my belief is, that a greater amount of irreparable mischief has its origin in this class of affections in the adult female, than in derangement of any other system of organs, not excepting those of digestion and assimilation."
We are not sure that this is not a little too broadly stated; nevertheless, we feel confident that, at the commencement of menstruation, and for some years afterwards, hysteric affections are not to be regarded as of no moment, especially if, while the catamenia become obstructed from any cause, hysteric symptoms manifest themselves, the patient is in danger; for menstrual metastasis to the brain and spinal marrow may ensue, a condition of things almost always fatal.
CHAPTER 4th.-On the last Menstrual Crisis.-Endo-uteri, tis the author considers as one of the diseases liable to affect women at this period; but it is also found at other periods of life, and is not unfrequently the cause of dysınenorrhæa.
By Endo-literitis, we are to understand an inflammation of the lining membrane of the uterus in part, or entire.
“ In cases of endo-uteritis the body of the uterus is somewhat enlarged and painful under pressure of the finger; the cervix is slightly hypertrophied, but not so painful as the upper part of the organ, and it is generally free from abrasion. The only evidence of the existence of the disease capable of being revealed by the speculum, is the presence of the bright red ring surrounding the verge of the os uteri, together with the escape therefrom of the
characteristic fluid product, or of a small quantity of blood, which, by becoming incorporated with the vaginal mucous in its transit outwards, appears at the os externum in the form of sanies."
“The constitutional symptoms are, rigors and febrile excitation, which varies in intensity according to the severity of the local inflammation, or the peculiar constitutional susceptibility of the individual; lassitude; sense of fulness; weight and tenderness of hypogastrium; fixed pain in the inguinal region, occupying one or both sides ; disordered digestion; irritable bladder ; spinal irritation and convulsive affections."
Treatment of this affection. Leeches to the hypogastrium, or over the upper part of the sacrum ; the exhibition of remedies to subdue the febrile action. When all febrile excitement is subdued, a more tonic plan should be pursued. Considerable benefit may be derived from injecting within the uterus, a weak solution of nitrate of silver in combination with ext. conii.
“R. Argent. Nitrat. gr. vj.
Exi. Conii 3j.
Aq. destill. 3j
Misce fiat injectio.” Or by the introduction of an ointment of the same material.
“R. Argent. Nitrat. gr. x.
Unguent Cetacei zss.
Liquoris Plumbi 3ss.
Misce, fiai Unguent.” “The latter form is applied by means of a small piece of lint fixed upon the end of a long probe, and fastened to the handle of the iustrument with a thread, with a view of securing its safe withdrawal. Not only does no disturbance or discomfort of any kind ensue upon the employment of these local measures, but, on the contrary, a beneficial change is often evident after the first application; and I have witnessed the suspension of pain to be instantaneous. The operation of injection is done with the aid of the speculum, by means of a long syringe, similar to Clarke's female syringe, having a nearly straight tube, with but one hole at its extremity. If carefully managed, from one to two drams of the remedy (which may be composed of different materials, varied in form and strength according to circumstances) will pass within the organ at each operation, most of which returns almost immediately. The temperature of the fluid, previous to being used, should be raised to 90° F."