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a ripe plum than any thing else with which I can compare it. The greatest caution was required in passing a very fine director into the neck of the sac, which was very firm, and formed the stricture. Previous to its division, I pressed my little finger gently against it, and felt the pulsation of an artery, which, from its situation, must have been the epigastric. The neck of the sac was divided in a direction upwards, but inclining a little inwards towards the pubes." 77.
At 7, p.m. the bowels had not been opened, there was occasional sickness, the pulse 120, full and strong. V.S. ad 3xxiv. blood not buffed. At 5 o'clock next morning the symptoms continued, with extreme tenderness of the abdomen; castor oil, which had been given, had not operated. V.S. ad 3xxx. Enema, salin. c. tart.-emet. blood much buffed. The symptoms were the same in the evening, and next day the right testicle was swollen. The tenderness of the abdomen was gone-he was very low-the bowels had been opened by the enema, but not since. Ol. ric. 3ss. The oil acted on him very violently, and in the evening his pulse was fluttering, and he seemed to be sinking. It required the utmost attention, with the regular exhibition of wine and water, brandy and water, &c. to enable him to rally. Ultimately the patient recovered completely. In the course of a month after the healing of the wound, the patient was seized with epilepsy. The fits occurred at first every two or three days; but the intervals between them gradually became longer, and under the administration of the pil. cupri ammoniat. they finally disappeared, and there has been no recurrence of them for the last two years.
It is probable, as Mr. Clement remarks, that the depletion resorted to and the debility which it produced were the causes of the epileptic fits. We have seen epilepsy follow great depletion and low living after injuries of the head, and have seen it disappear when tonics and better diet were employed. Whether the depletion was or was not too active in the present case, we will not pretend to say, but we are certain that depletion is sometimes employed too freely after the operation of hernia, as well as after other operations and accidents. Mr. Clement has not seen another instance of affection of the testicle after this operation. We have seen the testis slough after it in a patient in St. George's Hospital. We have also twice seen hernia humoralis after the operation of lithotomy.
The next case detailed by Mr. Clement, is, practically speaking, a very instructive one. The patient was 70 years of age, the hernia femoral, the bowels had not been opened for six days, and symptoms of strangulation had existed for five. On performing the operation the gut was found very livid but firm in structure, the coats indeed being greatly thickened; it was also firmly adherent to the neck of the sac. These adhesions were separated and the gut returned. After the operation the patient was much exhausted, and a cordial with mutton broth was administered. The pulse intermitted on the next day and continued to do so until the patient was out of danger. In the night of the fourth day the patient was seized with a rigor, and on the fifth day presented symptoms of acute pneumonia. The pulse was 94, but intermitting. She was bled to ten ounces, a blister applied, and salines with expectorants exhibited. The pneumonia was checked, and, although some sloughing took place about the wound, the patient was able to walk about in the course of a month after the operation.
Mr. Clement makes some remarks on the intermission of the pulse after the operation. The fact is, that this is a very frequent occurrence after se
veré operations or injuries in elderly persons. We have seen it after the operation for hernia several times, after the operation of lithotomy, after amputation, &c. Some patients recovered, others did not; and although, as we have already stated, we must even look for this symptom in old people almost as a matter of course, yet it is generally an unfavourable symptom. We may mention a case or two out of several to shew that it is by no means a necessarily fatal one. A woman, 70 years of age, had a large 'hydatid' breast removed by Mr. Brodie, at St. George's Hospital. After the operation suppuration occurred in the wound, low symptoms followed, and for many days the pulse intermitted. She recovered. A very old woman had the operation for hernia performed by Mr. Hawkins, in the same hospital. Intermitting pulse succeeded, but the patient recovered from this and from the effects of the operation, although she died bed-ridden some little time afterwards. An old woman fractured the neck of her thigh-bone. Intermissions of the pulse succeeded but ceased under generous diet and stimulants. She died however at the end of a month or six weeks. Elderly persons, or those whose constitutions are debilitated by debauchery are liable to present intermissions of the pulse when attacked by erysipelas, or diffuse cellular inflammation. The symptom is then all but fatal.
CASE 4.-Strangulated Umbilical Hernia-Operation-Death. The patient, a very corpulent woman, aged 70, had been subject to umbilical hernia for many years but never worn a truss. The hernia became larger whilst she was endeavouring to evacuate her bowels, and soon afterwards the usual symptoms were set up. The taxis was thrice employed, she was bled freely, took purgative medicines, had two enemas, and was again bled previous to the operation. When this was performed the tumour was red and inflamed from the handling at the superior part. Mr. Clement made an incision three inches long at the side of the tumour, exposed the sac which was thin and transparent, and found that it contained intestine only. The stricture was at the umbilical opening, almost cartilaginous, and very narrow. It was divided in a direction towards the linea semilunaris. The intestine was of bright red colour; it was gradually returned. There was excessive tenderness over the belly in the evening. She was bled to 15 ozs. and had calomel, &c. On the next day she was bled again to 14 ozs. On the following morning the pulse was fluttering, and on the next morning she died. We find no notes of a cadaveric examination, indeed our author seems to have had few opportunities of obtaining knowledge in this way, if we may judge by the fatal cases already before us. It would be a trite truism to make any observation on the necessity and value of such an addition to a fatal case.
It is true that the operation for umbilical hernia in aged women succeeds but seldom. But we think it also true, or at all events probable, that the active depletion and other treatment adopted prior to the operation were not calculated to increase the chances of success in the present case. Mr. Clement has always found umbilical hernia to consist of portions of the colon with omentum, and never saw small intestine in the sac. In a fatal case of umbilical hernia which we lately witnessed, small intestine was contained in the sac, and we should not think this circumstance usually so rare as it has proved in Mr. Clement's practice.
"Two reasons induced me to make the first incision on the side of the tumour, and not along its upper or most prominent surface. The principal one was the
inequality or irregularity of the peritoneal sac which is usually met with at the front of the rupture: indeed it generally happens that the several parts are so much consolidated that the true sac cannot be easily distinguished, although I do not agree with some writers who suppose that it is entirely wanting, or does not extend upwards so far as to form an entire covering to the contents of the tumour. The second reason was, the red and inflamed condition of the integu ment covering the front of the rupture, produced by the repeated and long-continued use of the taxis. If an incision were made in that part, I thought the wound would not heal by the first intention, but in all probability would be followed by sloughing: a circumstance much to be dreaded, and more particularly in this species of hernia.
I once saw a very celebrated surgeon operate in a case of large umbilical hernia :-he made an incision along the whole length of the tumour, and afterwards opened the sac to its fullest extent. An immense quantity of omentum and intestine was immediately exposed; the convolutions of the latter were exceedingly troublesome; and I well remember that two pairs of hands were required to confine them before the operator could venture to divide the stricture, and when this was accomplished, a considerable length of time elapsed before every portion of the bowel could be replaced within the abdomen." 106.
There is one danger in making the division of the stricture laterally, and that is the liability to wound the internal branch of the epigastric artery. Perhaps this is in general of little moment. We fancy that the notion of a peritoneal sac being absent in umbilical hernia is unfounded.
The next case is also instructive. The patient, Mrs. M., aged 77, very thin but active, had symptoms of strangulation in a previously reducible femoral hernia for seven days before Mr. C. saw her. In performing the operation he met with considerable difficulty in consequence of the firm adhesions of the sac and its contents. Feeling omentum above he scratched through the sac into the omentum, and pushed a bistoury up to the stricture through its substance but close to the sac. The adhesions of the omentum
to the lower part and sides of the sac were necessarily torn through before the gut could be exposed. It was small, livid, but firm. It adhered to the bottom of the sac; the adhesions were divided and the intestine returned. After the operation the patient was so exhausted as to require stimulants and support. She rallied, but again sank in a day or two afterwards into an alarming state of depression, from the effects of a dose of castor oil. From this she was happily recovered, and was perfectly well in less than a month after the operation.
Here this article must terminate, not for want of other and equally useful cases, but for want of space on our parts for their insertion. Those which we shall find most adapted for our purpose will be noticed in the Periscope department. The nature of the work will be apparent to our readers; it is a plain unvarnished record of the experience of an active and practical provincial surgeon. Would that his brethren and coadjutors in all parts of the kingdom would follow his example, and rescue their names from something like the reproach of inactivity, we mean on the score of communicating their knowledge to the world, which now attaches to them. These are times for all men to bestir themselves, and the period is approaching when the field for professional exertion and professional honours must be laid more open than it is at present. Let the surgeons of the empire prove that they are worthy of attention, and if prepared to demand, they will obtain it.
A TREATISE ON RETENTION OF URINE, CAUSED BY STRICTURES IN THE URETHRA; AND ON THE MEANS BY WHICH OBSTRUCTIONS OF THIS CANAL MAY BE EFFECTUALLY REMOVED. By Theodore Ducamp, Doctor of Medicine of the Faculty of Paris, &c. &c. Translated from the French, with Notes and Additions, by William M. Herbert, M.D. Octavo, pp. 219-five Plates. New York, 1827.
We believe we may assert, without fear of contradiction from those who are well informed upon the subject, that the diseases of the urinary organs are at present better understood and better treated in this, than in any other country. The works of Hunter, Home, Wilson, Bell, and the recent papers of Brodie, in the surgical department, with the modern chemical investigations of foreign, as well as British chemists and physicians, and last, not least, the labours of Dr. Prout, have increased our information and improved our practice in a degree almost unprecedented, in so short a space of time and in so difficult an investigation. It is generally imagined that our treatment of strictures is superior to that of the same disease by the French surgeons; and from what we have read, as well as from what we have heard, we imagine that the preference is a just one. The employment of force and violence is too much abused by the French, and one great object of the work we have now before us is to discountenance this very abuse. The following quotation, from Deschamps, gives an instance of violence on the part of one of the ornaments of Gallic surgery.
"Desault, who had the reputation of the greatest skill and dexterity in the introduction of the catheter, and who has chiefly emboldened surgeons by his example to employ force for this purpose, deviated, like others, and even very widely, from the axis of the canal. The following fact is a remarkable proof of it it is related by M. Deschamps, to whom it was communicated by M. Garre. Being called in the year 1795 to a patient who had great difficulty in making water, he (M. Garre) was much surprised to find him make use of two chamber pots, the one to receive the urine which flowed by the usual course, and the other to catch that which was voided by the anus. He learned from the patient, that in an attack of retention of urine, which he had suffered, Desault found great difficulty in passing the catheter, and therefore had had recourse to force, by which he succeeded in evacuating the bladder. There can be no doubt that in this case, the point of the instrument had perforated the mucous membrane of the urethra and the rectum, and afterwards passed through the intestine, again to enter the bladder above the prostate. Cases like this would appear very interesting to compare with the precept above inculcated-but unfortunately, these are not the cases which usually embellish our journals. (Deschamps.)
Traité historique et dogmatique de l'operation de la taille. Vol. I. p. 238.” 63.
Our object is not to analyze this treatise, nor even to offer a formal critique upon it. The author proposes a new plan of treating strictures, and we shall merely present this to our readers as briefly as we are able. Their treatment he considers as essentially founded on a two-fold indication: to destroy the morbid disposition of the parts which form the stricture, and to reNo. XXXIII.
duce them to a level with the rest of the canal. In order to effect the destruction of the stricture, the author recommends caustic as the most efficient means, and the dangers and inconveniences which have hitherto occasionally followed its employment, have been owing, he thinks, to the manner of using it. The caustic should come in contact with nothing but the stricture, but should touch it, from within outwards, throughout its whole extent. For instance, if the stricture should be seated at the upper part, the caustic should be applied to that only, and so on. It must be obviously necessary to ascertain the exact site of the stricture, previous to following this recommendation.
"It is important to determine with precision at what distance from the orifice of the glans, the stricture we propose to treat is situated. For this purpose the canal must be explored with a catheter of middle size, in order that it may pass readily through the sound parts of the urethra, and be arrested by the first stric tured point that it encounters. It is customary to employ a plaster bougie on which a mark is made with the nail near the orifice of the glans. I make use of a hollow bougie of gum-elastic, of the size No. 6, on which are marked the divisions of a foot rule. On introducing this bougie, I always know the distance to which it has penetrated the urethra; and when it is stopped by a stricture I perceive immediately that such stricture is at the distance of so many inches and lines from the orifice, which I note down.
Having ascertained this point, I immediately proceed to the examination of another, which is the situation of the opening in the stricture. In order to do this, I take an impression of the stricture in wax, and I obtain in relief the form of its interior extremity. For this purpose I make use of the following instrument, which I call an exploring catheter. I have catheters of the Nos. 8, 9, and 10, open at both ends, and marked with the divisions of the foot; the anterior opening of these instruments must be about half the size of the other; I take a bit of sewing silk, and having tied several knots in it, and dipped them in melted wax, I round off the wax in the manner represented in fig. 7, plate I. By means of a bit of edging I pass the silk into the catheter, entering at the larger opening; when it has reached the other opening, the bulb formed by the knots covered with wax is detained, while the silk passes on and forms at the extremity of the catheter, a pencil of fine downy threads, both soft and strong; or else I pass the bit of flat silk through four little holes situated near the end of the instrument, and uniting them together in a knot, I afterwards spread them out in the form of a pencil. This pencil is soaked in a mixture composed of equal parts of yellow wax, diachylon, shoe-maker's wax, and resin; I take a sufficient quantity of it to enable it when rounded off to equal the bulk of the catheter. I let this moulding wax grow cold, and softening it between my fingers, roll it upon some hard polished surface. I cut this kind of bougie added to the gumelastic canula, at about two lines from the extremity of the latter, and round off the wax like the end of a catheter. By this arrangement, the moulding wax, mingled with the filaments of silk, becomes incorporated with them, and cannot fall off. I introduce one of these catheters into the urethra, and after I have arrived at the stricture, I leave the instrument in its place for a few moments, in order that the wax may have time to grow warm and soften, when the catheter is pushed forward; the wax being thus pressed between the catheter and the stricture, fills all the sinuosities of the latter, enters its opening, and, in a word, is moulded according to its figure. The catheter being completely withdrawn, I find at its extremity the form of the stricture.
If the projection of wax which has entered the stricture, be in the middle of the lump of the same material which terminates the catheter, I perceive that the projecting parts which constitute the stricture, are equally distributed around