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phatic calculi it is always met with to a considerable and obstinate extent, the urine being acid in the former and alkaline in the latter case.

Of the 135 stone cases, in 13 no operation was performed on account of an extreme degree of consecutive disease of the urinary organs, and a disordered condition of the general system. In 122 cases operations were resorted to, although in some of the instances under very unfavourable circumstances, inasmuch as chronic nephritis, obstinate catarrh of the urinary passages, and various other ill consequences of the presence of calculus were present. Whenever by proper care and treatment the symptoms of these diseased conditions were ameliorated, and the state of the general health became materially improved, the operation was undertaken upon the old maxim, anceps remedium melius quam nullum, in several cases with success, but in 5 others with a fatal issue. In 2 of these cases there was found a high degree of excentric hypertrophy of the calices of the kidney and ureters, and in two others renal atrophy. In 1 case the right ureter, excessively dilated, had become affixed to the cæcum through prior exudation; an intercommunication had formed between the two parts, and through this aperture a lumbricus had passed along the ureter into the bladder. That a diseased condition of the urinary organs should not always contra-indicate an operation, the Professor has had many opportunities of learning in the course of his practice. Even abundant purulent deposit may indicate disease of only one kidney, and the individual be saved by the operation, through the other kidney still performing its functions. The neglected and complicated conditions of the cases that usually are brought to the author's clinic have led to his resorting to lithotrity in a comparatively small number, being compelled to abstain from it on account of the excessive hyperemic irritability of the bladder, and the frequent attacks of inflammation. For the same reason his lithotrity operations have been less successful than the general statistics of the operation would lead us to expect. Of the 122 operations, 92 were lithotomy and 30 lithotrity; 11 of the former cases (11.95 per cent.), and 5 of the latter cases (1666 per cent.) dying. Of the 11 deaths after lithotomy, 5 took place from chronic disease of the kidney, and 1 from epidemic typhus, the remaining 5 succumbing to inflammation of the bladder and peritoneum coming on from the third to the fifth day after the operation. Strictly speaking, these were the only cases which died as the immediate consequence of the operation when performed in suitable cases, reducing the mortality in fact to 5:43 per cent. Of the 5 deaths following lithotrity, 1 took place from phthisis, 2 from chronic renal suppuration, and 1 from recent nephritis; 2 of the deaths alone were in fact directly referrible to the operation, giving the mortality of 666 per cent. Fistulous openings into the rectum, or infiltration of urine, did not take place after any of the lithotomy operations; but extraction, on account of the large size of the stone, being very difficult in several cases, peritoneal and vesical inflanı mation not infrequently followed, and in 5 instances terminated fatally. With the exception of 7 cases, the stone was extracted entire in all. The diameter of the largest stone in the collection measures two inches five lines, in 5 calculi it was somewhat above two inches, and in 24 it varied between one inch and one inch and a half. The heaviest stone extracted weighed 3iss gr. x. and the lightest gr. xvii. It may be noted that among the 135 cases, I only was a female, and she was treated by lithotrity.

Professor Balassa recommends, after all bleeding has ceased, the application of some oiled strips of linen rag along the track of the wound, he having found it a good precautionary measure for the prevention of infiltration of urine, or the irritation of the lips of the wound by this fluid, especially when they have been much contused during the extraction of a large stone.

VIII. On the Treatment of Hernia by Electricity. By Dr. CLEMENS.
(Deutsche Klinik, No. 34.)

This paper is the first of a series the author intends publishing upon the therapeutical application of electricity—a subject that has engaged his attention for some years past. He first employed this agent in the treatment of inguinal hernia in 1850, and has frequently had recourse to it since then. The hernia being reduced, and the patient placed in the semi-recumbent position, the ball of the conductor is carried as far into the hernial canal as possible, and the application of the electricity continued during five minutes, its power being increased day by day. After a few séances the mouth of the ring becomes diminished in size, the finger is introduced with more difficulty, and the hernia will not descend so easily as heretofore. The electricity, too, exerts a very beneficial effect upon the peristaltic intestinal motions, augmenting and regulating these, and thus preventing the same relaxed portion of intestine from always lying opposite the hernial aperture. A state of obstinate constipation becomes changed for one of regular action, and many old disordered conditions of the abdominal cavity become relieved. When the hernia has been recently produced, no means act with so much certainty and rapidity; and a case is referred to of a young man who acquired double inguinal hernia during an effort to raise a heavy burden, and which was completely cured after twenty séances, although these were not commenced until a week after the accident. Under its agency recent hernia is rapidly returned; but the author has not yet tried it in a case of complete incarceration. Among the 27 cases in which it has been resorted to, none have manifested the slightest ill consequences. Dr. Clemens prefers static electricity to galvanism, and administers it by means of the Leyden phial.

Another application of electricity by the author consists in a galvanic hernia truss, for a description of the construction of which we must refer to his paper. By its agency a feeble but constant galvanic stream is kept applied to the ring, and large hernias soon become easily retained which before had resisted the largest trusses and the strongest springs. Of late the author has constructed a pile of silver and copper coins, and the effects of so small an apparatus have often surprised him.

IX. On Diphtheritis of the Palpebral Conjunctiva. By M. MAGNE.

(L'Union Médicale, No. 100.)

M. Magne, in this paper, calls attention to the affection described under the same name by A. von Graefe,* and which seems, like other diphtheritic diseases, to be acquiring prevalence of late years. Thus, M. Magne describes four cases that have occurred to him since 1853, while a thirty years' practice at a wellfrequented clinic has furnished no other examples; and M. Sichel, during the same period of time, amidst the thousands of cases of ophthalmia that have come under his notice, only recollects two instances of pseudo-membranes forming in the palpebral conjunctiva, independently of the action of heat or caustics. M. Magne believes that the comparative frequency with which MM. Chassaignac and A. von Graefe are said to have met with the disease arises from a confusion in names. The affection they describe was not, in fact, characterized by a true pseudo-membrane, but by a mere mucous or muco-purulent concretion, which was so slightly adherent as to admit of removal by injection, sponge, forceps, or even the fingers, forming a juxtaposition rather than an adhesion. The concretion removed, the conjunctiva is red and sometimes granular, but its surface is always uniform. In the affection now described, however, which may be justly styled palpebral croup, there is a true pseudo-membrane, an al* See British and Foreign Medico-Chirurgical Review, vol. xx., p. 267.

buminoso-fibrous tissue intimately blended with the conjunctiva, and which cannot be removed in a single piece, but must be scratched or scraped off, leaving the conjunctiva bleeding at the points whence it has been removed. It is also soon reproduced. It is a disease which especially affects children, and seems to be connected with a general condition of the system, rather than of a mere local nature. It would not seem to be contagious, for in the four cases here recorded but one eye was affected, although the other eye was frequently exposed to the contact of the diseased secretions. It is a very severe affection, but it is curable. The treatment chiefly to be relied upon consists in the application of leeches, the injection of solution of nitrate of silver, and the internal administration of the chlorate of potass.

X. On a New Mode of Operating for Cancer of the Lip. By Professor
O'Shaughnessy. (Indian Annals of Medicine, July, p. 435.)

Professor O'Shaughnessy observes, that when cancer of the lip is confined to a limited spot, it is easily removed by the ordinary V-shaped incision, but that this procedure does not suffice when the whole lip, and perhaps one or both commissures, are involved in the disease. In a case which occurred in his own practice, the cancer not only occupied the whole lower lip, but the right commissure and a part of the upper lip also, on that side. "I thought nothing could be done in such a case, until the plan struck me of making a lip by detaching a triangular portion of the cheek on either side of the mouth, in the following manner:-The whole of the diseased lip to be removed by making two incisions meeting at a point in the centre of the chin, the cheeks then to be divided by two horizontal incisions extending from the angle of the mouth on either side, and continued backward as far as the masseter muscles; these to be joined, at their posterior extremities, by two oblique incisions carried upwards and backwards, from either side of the chin, leaving two triangular flaps to be dissected forwards, so as to admit of the apposition of the edges of the V-shaped gap left by the removal of the cancer." An excellent lip was in this way made, and most of the lines of incision had united by the first intention, when about the tenth day the patient was carried off from the effects of retention of urine.

QUARTERLY

REPORT ON MIDWIFERY.

BY ROBERT BARNES, M.D. LOND.

PHYSICIAN TO THE ROYAL MATERNITY CHARITY.

I. PATHOLOGY OF THE UNIMPREGNATED FEMALE.

1. On the Cure of Vesico-Vaginal and Vesico-Uterine Fistula. By Dr. Gustav SIMON. (Monatsschr. f. Geburtsk., July, 1858.)

2. A New Procedure for Plugging the Vagina. By M. MONTAMIER. (L'Union Méd., Dec., 1858, and Gaz. d. Hôp., Sept. 1858.)

3. Medicinal Trials of Carduus Marie, Carduus Benedictus, and Onopordon Acanthium. By LOBACH. (Verh. d. Phys. Med. Ges. zu Würzburg, viii., 3, 1858.)

4. Ovarian Cyst in a Puerperal Woman cured by Spontaneous Rupture_and Discharge through the Colon. By Dr. LUMPE. (Zeitsch. d. Ges. d. A.

zu W., No. 22, 1858.)

5. Cancer of the Fundus and Body of the Uterus perforating the Rectum. By Dr. HARRIS. (North Amer. Med. Chir. Rev., Sept. 1858.)

6. Report of a Case of Inversion of the Uterus successfully reduced after Six Months. By Dr. WHITE. (Am. Journ. of Med. Sc., July, 1858.)

1. Ar a meeting of physicians held at Darmstadt in 1857, Dr. Gustav Simon

detailed the methods he had pursued in the treatment of vesico-vaginal and vesico-uterine fistulas, and submitted eight of the patients who had been operated upon, to examination. Of 19 fistulæ treated, 10 had been completely healed; in 5, cure was nearly complete; 1 was abandoned as incurable; 2 women died after operation. One case was a vesico-uterine fistula-that is, the fistula passed from the bladder into the cavity of the uterine neck, without injury to the vagina; the urine passed through the os uteri. The incontinence of urine was cured by the obliteration of the os uteri, which was effected by uniting the split and freshened lips together by seven sutures. The woman retains her urine. The communication between bladder and uterus persists; menstruation is entirely effected through the bladder. The woman remained well two and a half years after the operation.

In a second woman, the anterior lip of the os uteri was destroyed, with a part of the vaginal wall of the bladder, so that a deep vesico-utero-vaginal fistula resulted. This fistula was healed by using the posterior lip of the os uteri as a flap to be united to the walls of the bladder. In this woman also the menstrual secretion passes through the bladder. The woman is well three years after the operation.

In a third woman, a large fistula extended from the neck of the bladder to the os uteri. Dr. Simon split the os uteri and covered the loss of substance by means of the so-made moveable anterior lip, and united it to the walls of the bladder. This woman is well three years after the operation, and has borne a living child since.

In five other women, in whom vesico-vaginal fistulæ, varying from the size of a bean to that of a shilling, existed in various parts of the vesico-vaginal wall, cure was effected by the union of the walls of the bladder.

Others in whom the fissure was very small, were healed by cautery alone. In three cases, the fistule were so large, that the deficiency included the entire bas-fond of the bladder to the urethra, so as to render the attempt to unite the borders of the fistula hopeless. In these cases Dr. Simon resorted to an operation to be presently described, which he calls the cross-obliteration of the vagina. Two women subjected to this operation have found their condition so much bettered, that both in sitting and at night they can hold their urine and void it at pleasure, and follow their occupations.

In the case of the only incurable fistula, the woman had a very large opening, the sphincter vesicæ being wanting.

The two women who died had fistula of medium size in the vicinity of the os uteri. In one who died of pyæmia seven days after the operation, the walls of the bladder had united. In the other, who perished seventeen days after the operation from suppuration in the cellular tissue between the bladder, uterus, and rectum, and consequent perforation of the peritoneum, the wall of the bladder had become united with the freshened anterior lip of the os uteri. In the operation upon the first patient, the uterus had been drawn down by Museaux's hook-forceps, in the second not.

A third woman died under Dr. Simon's care, after making a considerable division of a strong adhesion of the vaginal walls. She died on the sixth day of cedema of the lungs following on pyæmic pneumonia, before the operation proper for the fistula had been undertaken.

The operation performed by Dr. Simon consists in the free freshening of the edges of the fistula, and union by the knotted sutures.

We will now describe briefly his operation of cross-obliteration of the vagina. It consists in this-that the remains of the vesico-vaginal wall are brought into union with the freshened hinder wall of the vagina, or bladder with rectum in a transverse direction. Thus a receptacle for the urine is formed, which is embraced by the upper part of the vagina, the roof of the vagina, and the defective bladder, and directs the urine into the urethra. A portion of the

vagina below the seat of the operation remains as before. The operation is so carried out, in cases where the deficiency of the bladder is so very great, that of the hinder wall of the bladder only the urethra remains, that the upper edge of the remaining urethra is freshened over a space of two to three centi metres, and on the level of this edge, especially on the side and posterior wall of the vagina, a similar extent is freshened in like manner. The apposition of the wound is effected by six or seven sutures. With a very bent needle the wound made in the vagina is transversed and surrounded by one thread. The freshened part of the rectum-wall and the hinder edge of the urethra are thus united when the loops of the suture are brought together. The closure of the vagina forms a transverse-often, on account of the great yielding of the recto-vaginal wall, an arched line. Dr. Simon extols the advantages of this operation over the other methods, episiorrhaphy and transplantation for obliterating the vagina. It promises greater certainty in healing, it is free from danger, since only superficial mucous parts are divided, and so far answers the purpose, that it prevents incontinence of urine and preserves a portion of the vagina, and exerts no after bad influence. This operation he has performed three times, with so much success as to have only very small fistulae remaining. By it the greatest deficiencies of the bladder may be remedied.

2. M. Montamier recommends a modified form of Gariel's air-pessary for plugging the vagina. He urges, and with truth, the objections to the simple air-pessary, that it is apt to slip, that it fails to compress perfectly the os uteri, and does not admit of the application of medicaments to the uterine neck. He covers the air-pessary with a linen-cap which admits of being tied on by a slip-knot; on the summit of the cap a layer of fine sponge is sewn. The pessary thus armed completely fills the vagina, without its being necessary to over-distend it; and the sponge can be saturated with any liquid thought desirable.

3. M.Lobach relates his experience of the uses of the Carduus Maria, Carduus Benedictus, and Onopordon Acanthium. He says the seeds of the Carduus Mariæ have a surprising efficacy in arresting uterine hemorrhage. Not only does this remedy check the discharge at the time, but by continued use pre vents the return, and this in cases where krameria, sesquichloride of iron, phosphoric acid, tannin, &c., had failed. It especially operates in cases where the floodings are associated with portal obstruction, diseases of the liver and spleen, hemorrhoids, &c., but not where the flooding depends on wounds, ulcerations, or heterologous formations. It may be used in the form of decoc tion or tincture.

4. The case of ovarian dropsy related by Dr. Lumpe illustrates one of the modes in which this disease is sometimes spontaneously cured. A weakly pluripara had exhibited since her second labour pain in the left ovarian region. After the third week, the abdomen remained perceptibly enlarged, and an ovarian cyst that admitted of being grasped was formed. At the same time a smart peritonitis occurred. To diminish her suffering, a puncture was made, and some fluid withdrawn; this was greyish-green, curdy, distinctly smelling of fæces. Her condition mended, but soon the cyst grew to its former size. A second puncture was determined on, when, without obvious cause, diarrhoea set in, and daily increased with colicky pains. At first the evacuations were of a fæculent brown, gradually paler, and lastly of the same colour as the contents formerly drawn from the cyst by puncture. These discharges persisted for nearly five weeks, when the woman recovered, and might be considered completely cured. Rupture was apprehended. The diagnosis between retroversion and a descent of an ovarian cyst was doubtful. The appearance of the

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