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general required is the introduction of a sufficient plug, of sponge or other soft material, into the vagina, to prevent the chance of bleeding; and the withdrawal of this plug after ten or twenty hours. After, however, the application of the ligature in deligation of a uterine polypus, a considerable amount of continuous care and caution is necessary up to the time at which the pedicle is ultimately divided. “ The patient is," says Sir Charles Clarke, “ to be desired to remain constantly upon her side, and should not be allowed to move from one side to another unless when the practitioner is present. For want of attention to this caution, there is,” he adds, " reason to believe that the canula has been inadvertently pressed against, and its extremity pushed through the uterus of the patient, so as to occasion her death."-(p. 262.) “The woman," as Dr Ramsbotham states, “ will be obliged to keep her bed during the sloughing process; and she ought to be cautioned, upon attending to her natural calls, to beware of any accidental occurrence which might push the point of the instruments against the internal surface of the uterus."' “ As the instrument,” Dr Gooch remarks, “projects out of the vagina, if the patient was, whilst turning from side to side, to sit down upon it, she might impale herself on it,—an accident which, I have heard, once took place, and terminated fatally."—(p. 264.) IV.- Relative chance of Local Irritation of the Vagina and Uterus.
Local lesion and irritation of the vagina and cervix uteri are not liable to follow upon the practice of excision, unless some local injury has resulted in the operation from very incautious manipulation. But in addition to this danger, there is after deligation, other sources of local disease in the sloughing and putrefaction of the polypus before its complete separation ; in the presence of the very fætid and excoriating fluid with which the surface of the vagina and vulva is in consequence constantly bathed ; and in the irritation by the ligature itself, as a foreign body, upon the constricted and ulcerating stalk of the tumour, -not to speak of the constant application to this ulcerated surface of the foul and acrid discharges that issue from the dead and decomposing polypoid structure. The polypus usually swells after the first application of the ligature. “On account," observes Chelius, “ of the increasing bulk of the polyp, it is generally necessary for the first few days (after deligation) to empty the bladder with the catheter, and the rectum by clysters. The symptoms," he further states, “ which may occur after the tie has been made are, violent inflammation and fever, pain, spasm, bleeding, and other symptoms, from the pressure of the swelling polyp. To prevent,” he adds, “the effect of the stinking ichor, repeated injections of decoctions of aromatic herbs must be employed.” ? After the ligature is applied, “When putrefaction
i Dr John Rainsbotham's Practical Observations, vol. ii. p. 468.
has commenced, the discharge from the vagina (to quote the words of Dr Ramsbotham) becomes fætid and highly offensive. . . It is, indeed, the best sign we can observe, as it proves that decay is going on, that the stem is sufficiently compressed to strangulate the vessels which nourished the diseased growth. If ever (he adds) such a discharge did not take place in a day or two, I should be suspicious that the operation would not succeed.” 1
V.-Relative Danger of the two Operations to the Health and Life
of the Patient. Those authors who have written in favour of deligation usually quote one solitary case of death from hæmorrhage after excision, recorded by Zacutus Luzitanus, in the 17th century. It was an instance of the fact that the amount of attendant hæmorrhage is not regulated by the mere size of the polypus; for in the case in question it is stated that the amputated polypus was not larger than an almond. In this instance the operation was performed by an empiric, and no plug or other means for arresting the hæmorrhage appear to have been employed. The patient died, not so much from the operation, as from neglect of all proper means to restrain the hæmorrhage resulting from it. At the same time let me remark, in passing, that the operation of deligation itself is not free from the risk of hæmorrhage, both from the abrasion of the surface of the tumour in working with the canula and ligature, and from the division of the vessels of the stalk, as they are cut through in the process of deligation. “I think," maintains Dr Meigs of Philadelphia, “the ligature is to be preferred to all other modes of extirpation. It is not in every case to be effected without hæmorrhage. I know (he adds) of two cases here in which the hæmorrhage was terrible." S
But the principal danger to health and life in this, as after other surgical operations, is the danger of phlebitis and surgical fever. Is such a consequence more liable to follow upon the instantaneous resection of the peduncle of a polypus, and the subsequent immediate removal of the amputated polypus itself,—or is it more likely to supervene upon the slow process of disjunctive ulceration being set up in the stalk of the polypus by the ligature, while the gangrenous and putrifying polypus itself, is left decomposing in the cavity of the vagina?
I believe that no physician or surgeon acquainted with modern pathology will have any difficulty in answering, that the danger of phlebitis is much greater under the latter circumstances than under the former. The recorded experience of some of those who have written in favour of the ligature, shows strongly enough the occasional liability under deligation to the occurrence of irritative fever and is ternal inflammations, from phlebitis and the absorption of puto: and purulent matter from the vagina. Dr Hamilton mentions thro cases of death which he had seen follow the removal of uterine pole by ligature. “On a close inquiry,” observes Mr Arnott, “I fia that even those who use it (the ligature) acknowledge that occasionally cases have been met with, where the ligature in cutting it: way through, has excited irritation and fever, and even death. Tv cases have been described to me by the practitioners concerne where this occurred, and in casually referring to the interestin works of Boivin and Duges I find two similar ones." In his le tures on fibrous tumours of the uterus, Dupuytreno states, “ I pusi sess eight or ten observations of women who have perished, fiue veritable poisoning and absorption of pus, after the application « the ligature for uterine polypus.”
i London Medical Gazette for 1835, p. 435. ? Praxis Medica, lib. ii., Obs. 86.
s Meigs' Females and their Diseases, p. 255. See also Examples in Colombat de l'Isere's Ttaitè des Maladies des Femmes, p. 817.
NEW SERIES.-N0. I. JANUARY 1855.
I have myself seen a woman die with a ligature still fixed around the partially divided neck of a uterine polypus; and other cases where severe but not fatal attacks of phlegmasia dolens and phle bitis followed deligation. Twelve or thirteen years ago, on a patient of Dr Edgar's of Berwick, I applied a silver wire ligature to the neck of a large polypus, and tightened it from time to time, accort ing to the usual rules. In the course of a few days the polypus wa dead and putrifying; there was much heat and irritation in the vagina ; and the patient's pulse became rapid under the irritative fever that followed. On strongly tightening the ligature to erpedite as much as possible the total amputation of the polypus. the wire broke; and the canula and wire slipped off. I imme diately proceeded to remove the polypus by excision instead of making any renewed attempt at deligation; and the result was to me very striking and satisfactory. Within twenty-four hours the local irritation had greatly subsided, and the constitutional disturbance entirely disappeared. From that time to this I have operated on many uterine polypi, but never again by the process of slow deligation. And the more that I have seen of the practice of removing large pediculated uterine polypi by excision, the more deeply has the conviction grown upon my mind, that this method is very superior to the usual method followed in this country, of the removal of them by the canula and ligature.
1 Hamilton. Pract. Observ., p. 37.
2 Arnott in Lond. Med. Gazette, 1836, p. 412. See also notices of two other cases of death from uterine phlebitis after deligation, in Cyclopedia of Practical Medicine, vol. iv. p. 393.
3 Lecons Orales. Brussels ed., 1826, p. 237.
ARTICLE III.- On the Treatment of the more Common Forms of
Skin Diseases met with in Edinburgh. By John LlUGHES
cine, and of Clinical Medicine, in the University of Edinburgh. SINCE the addition of a ward for skin diseases to the clinical department of the Royal Infirmary, I have had ample opportunities of determining what are the more common forms of cutaneous eruption met with in this city, and of trying various kinds of treatment. A short account of the results of my experience in this department, excluding the eruptive fevers, may not be unacceptable to my medical brethren.
Eczema is by far the most common disease met with, both in its acute and chronic forms. The local treatment I have found most efficacious is that which I recommended, in the August number of the Journal for 1849. It consists in keeping the affected part moist, with lint or linen saturated in a very weak alkaline solution, consisting of soda subcarb. 3ss. to a pint of water. For this purpose it is necessary to cover the moistened lint with oil silk, or gutta percha sheeting, which should well overlap the lint below, so as to prevent evaporation. The usual effect is soon to remove all local irritation, and especially the itching or smarting so distressing to the patient; to keep the surface clean, and prevent the accumulation of those scabs and crusts, which in themselves often tend to keep up the disease. After a time, even the indurated parts begin to soften, the margins of the eruption lose their fiery red colour, and merge into that of the healthy skin, and, finally, the whole surface assumes its normal character.
In private practice, it is often a matter of great difficulty to secure a proper application of the lotion. Individuals are slow to accept : the idea that constant moisture of the part is absolutely necessary
for the treatment, and hence vigilant superintendence and frequent visits are requisite, in order to watch the progress of the case. Even in the hospital constant watchfulness is necessary, to see that nurses properly cover the eruption; and when, as sometimes happens, this task is given to the patients themselves, it almost always fails. Then there are some portions of the surface which it is very difficult to keep moist and well covered, such as the face and axillæ. But, by carefully adapting lint and gutta percha sheeting, attaching strings to the edges of the latter, so as to keep the whole in its place, I have never failed in ultimately carrying out my object.
In addition to stating what I have found to be useful, it is important to say what I have, on careful trial, ascertained to be useless or injurious. Perhaps no remedy is more generally employed in this and a variety of other skin diseases than citrine ointment, an application that I have always found to irritate and make eczematous eruptions worse. At the same time, there are some very chronic forms of the disease, which I have been told are cured by this
preparation, but what these are I have never been able to ascertain. Indeed, all greasy applications whatever, in the majority of cases, are useless, and the patients themselves inform me, are very 6 heating." In some rebellious chronic instances, I have thought the oil of cade, has been beneficial, applied locally, although I have not yet tried it sufficiently often, to recommend it strongly. In a few cases of acute eczema, I have tried the freezing process recommended by Dr Arnott, but the salt of the frigorific mixture, and the cold itself, has caused apparently so much agony that I have been deterred from using it, especially when the emolient moist alkaline application is so efficacious. This mode of treatment, however, undoubtedly demands further trial, and I propose to report a more extended experience of it on some future occasion.
Herpes.- This disease generally runs its course in about fourteen days, and requires no treatment whatever, further than an acetate of lead lotion to allay the smarting. It is not very common.
Scabies occurs very frequently, and is cured by a host of remedies. A strong lather, made of common soft soap and warm water, twice a day, answers very well. The question with scabies, is not what remedy is useful, but which will cure it in the shortest period. The most extensive experience at St Louis las shown, that the sulphur and alkaline, or Helmerinch's ointment cures itch, on an average, in seven days. That sulphur, however, is not the active remedy, I have satisfied myself of by experiment. Soft soap, as we have seen, which contains alkali, and even simple lard, if pains be taken to keep the parts constantly covered with it, will cure the disease as soon as sulphur ointment. I have tried the Stavesacre ointment, recommended by M. Bourguinon, in only a few cases, but found it to answer very well. Its superiority, however, over other applications, I am not yet prepared to admit.
Pemphigus. This is rather a rare disease, and when chronic, coming out in successive crops, is very rebellious. Two cases which entered the Infirmary last winter were cured in a few weeks, by the weak alkaline wash, applied as in the case of eczema, combined with generous diet.
Impetigo.—This affection in all its forms is very common, and is best treated by the weak alkaline wash, exactly the same as in eczema. In the chronic forms which attack the chin of men, constituting one of the varieties of mentagra, the same treatment cures the most rebellious cases, if the moisture be constantly preserved. For this purpose the hair must be cautiously cut short with sharp scissors. and the razor carefully avoided. If the side of the cheek covered by the whisker be attacked, removal of the hair from thence also is essential to the treatment. A bag or covering accurately adapted to the part affected must be made of gutta percha sheeting, and tied on with strings. This may be covered with a piece of black silk, to allow the individual to go about and carry on his usual occupations. In this way I have frequently seen chronic impetigo of the chin, of from