« 이전계속 »
when the inflammation is over. In every instance the rule is that the muscular disturbance is coincident with the opposite of vascular excitement—asphyxia, or syncope, or a condition approaching thereunto.
As in epilepsy this condition necessitates a corresponding inactivity in the functions of the nervous system, and this necessity is fully corroborated both by the symptoms during life and the appearances after death. If there has been inflammation of the brain or spinal cord, the tremor, convulsion, or spasm, are found to be before or after, but never during this inflammation. The condition of the muscles is also wanting in tone, and the causes inducing the maladies are never of an exciting character.
Thus, in affections allied to epilepsy, as in epilepsy itself, and in ordinary muscular contraction, the muscles contract, not because they are stimulated, but because they are not stimulated.
The phenomena of periodicity are also thought to furnish evidence of the same kind. The plant exhibits plainer and more numerous evidences of periodicity than the animal, and it does this, it is argued, because it has less of that innate life which enables the animal to be partially independent of the vivifying influences of the heavenly bodies. If man exhibits more evidences of periodicity than he ought to do, it follows therefore that he has lost some or that innate life which is the badge of distinction between him and the plant; and hence the periodicity of epilepsy or of any cognate disorder, is merely a proof that the epileptic or his congener is less vitalized—less stimulated than he ought to be.
If, then, these diseases depend upon the want of that stimulation which naturally belongs to the muscles, it follows as a neces-. sary consequence—what indeed may almost be said to have been proved by experience—that bleeding, purging, and all lowering measures are not calculated to do good, and that the only hopes of benefit must be placed, not upon tonics merely, but upon stimulants. This is the conclusion which is verified by the experience of the author, whose practical remarks, as well indeed as the entire work, we cordially recommend to the attentive consideration of our readers.
The work by Mr Garner, entitled" Eutherapeia," is a popular resume of the general principles of medicine, and its circulation, in this age of charlatanism, is very likely to be beneficial. We were induced to consider it here from observing on the title page that it contained researches in the nervous system. These researches consist in the personal examination, and representation in outline, of the nervous system of several of the inferior animals, but we have not discovered in the text any great novelty either in fact or generalisation.
With regard to the able essay of Dr Peddie on Delirium Tremens,
it originally appeared in our pages, and our readers have been enabled to judge of it for themselves. Its subject-matter is of the highest practical importance, and the additional cases and remarks which the author has introduced into his separate publication add considerably to its original value.
On Stricture of the Urethra and Fistula in Perineo. By James Syme, F.R.S.E., Professor of Clinical Surgery in the University of Edinburgh, etc., etc., etc. Second Edition. 1855.
In the former edition of this work, published in November 1849, the author communicated, as he now tells us, his "early and, of course, crude observations," on the treatment of certain forms of stricture of the urethra and fistula in perineo, by a new method ■which had originated with himself, viz., division of the affected part of the urethra by external incision upon an instrument previously carried through it. It was shown that the operation had afforded relief in several severe cases of stricture, which had resisted the ordinary means of treatment, and that it had hitherto proved almost free from danger in the hands of its inventor. But that the cure would prove permanent was left to be inferred from one single case, viz., that which led to the adoption of this plan of treatment: in all the others spoken of as cured, the operation had been so recently performed as to forbid any deductions from them on this point. And although the first case was a very striking example both of the failure of the means previously in use, and of the success of the new method, after the employment of which the patient continued to enjoy " the most perfect health," without use of the bougie, after the lapse of "several years;" yet, one such case was no sufficient guarantee for the general permanence of the cure, and it was felt that further experience of this operation was required to enable Mr Syme to establish the high claims he had asserted for it.
He has, however, made good use of the extensive opportunities afforded by his practice during the five years that have since elapsed, and the facts which he now places before us are such as to give a totally different character to the work, which, in the present edition, entirely re-written with the exception of the preface, is no longer a mere attempt, to "explain and recommend" a particular method of treatment, but assumes the form of a systematic practical treatise on stricture of the urethra.
After giving, in his usual powerful style, a vivid description of "the evils originating from this fruitful source of misery," Mr Syme proceeds to divide strictures with reference to their symptoms and treatment, into—1. Imaginary; 2. Slight; 3. Confirmed; 4. Irritable; and 5. Contractile;—
"Imaginary strictures constitute a large proportion of the cases that occur in practice. They generally depend upon an erroneous idea of the patient, sugpested by some irritation of the urinary organs, or debility in the expulsive power of the bladder, and encouraged either through unskilfulness of the surgeon, who attributes the pain and difficulty resulting from his awkward use of instruments to contraction of the passage, or through the culpable delusions of rapacious quacks whose appropriate field is the remedy of diseases that have Do real existence. Such cases explain the good effects attributed to various modes of treatment, which, if the stricture were real, would prove useless, impracticable, or injurious."—P. 10.
"It is a remarkable fact that strictures frequently pass into the most confirmed state without the patient being aware of their existence;" and "not unfrequently the first intimation of there being something wrong is afforded by the formation of a perineal abscess," regarding the pathology of which the author expresses the opinions he has been long known to entertain, and which he supports, as in the former edition, by arguments which appear to us incontrovertible.
"The truth seems to be, that the irritation of the stricture, or the means employed for its remedy, occasions inflammation in the textures adjacent to the urethra, which, sooner or later leading to suppuration, gives rise to an abscess separated from the canal of the urethra merely by its lining membrane, but thickly covered externally by the fascia and integuments of the perineum. In obedience to the law of progressive absorption induced by the pressure of purulent matter, spontaneous evacuation is nevertheless much more apt to take plxce outwardly than inwardly, although the resistance of the fascia tends to render the passage tortuous and directed towards the hip, scrotum, or anus, instead of the nearest point, which of course coincides with the raphe. In no long time after the matter is thus discharged, or through an incision anticipating this event, ulcerative absorption establishes an opening in the thin denuded portion of mucous membrane that constituted the urethra wall of the abscess, and then the urine escaping in more or less quantity, renders the fistula in perineo complete." —P. 13.
Slight strictures, and the majority of the confirmed class, yield to dilatation, which may be effected " through the use of various means, such as retaining a succession of catheters in the bladder, or introducing bougies frequently for lengthened periods. There is, however, no occasion to place the patient under any such restraint, since the object in view may be more simply, safely, and effectually accomplished by passing bougies with intervals of three or four days, withdrawing them immediately after their introduction." We rejoice in the reiteration of this doctrine, which the author has taught for many years, and are only astonished that the practice of surgeons docs not more generally testify to its truth. Nothing can be more reasonable than the momentary introduction of instruments, when the mode of action of dilatation is rightly understood; and this is placed by our author in its true light, not as a mere mechanical process for stretching the contracted part—like "the finger of a glove," but as a means of exciting just sufficient action to cause the absorption of the material effused into the urethral coat:—
"Any sort of stretching which exceeds the degree requisite for this purpose, so far from doing good, will, therefore, probably increase the evil by reinducing the irritation productive of contraction; and mere distension of the canal, by the permanent retention of catheters, must not be confounded with the real widening which results from a restoration of the urethral coats to their natural state of capacity and tenuity.
"To effect dilatation with this view, the best means are unquestionably metallic bougies, and those made of Berlin silver seem decidedly preferable to any other, as they take a fine polish, are not liable to rust, and being hollow, are guided more lightly than tlie plated steel instruments used in London, while their moderate expense does not place them beyond the reach of ordinary employment."—Pp. 14, 15.
For our own part, we could never see why silver catheters were preferable to bougies for the smallest sizes; on the contrary, it is in small instruments that the greater firmness of bougies is of most importance, while at the same time, it may be remarked, that bougies, besides being cheaper, are more durable, and, what is of no small importance, more easily kept clean than catheters.
"Pain and bleeding, when bougies are passed, are certain indications of the procedure being faulty. The bougie should be rather suspended than held between the tips of the fore and middle fingers, and gently urged on by the thumb, while the fingers of the left hand rest on the perineum to assist in determining the proper course of the instrument. Stretching of the penis and forcible clutching of the bougie are sure signs of awkwardness and incompetency in this department of surgery.
"It is unnecessary to say anything as to the preposterous plan of taking casts of the stricture by pressing upon it the extremity of a soft plaster bougie, since any one at all conversant with the subject must be satisfied that such a procedure can produce no result better than deception of either the practitioner
or the patient However often the introduction of instruments
may be required, the greatest care should be taken to avoid all attempts to gain an advance by force in opposition to unfavourable circumstances.
"Yet however carefully and skilfully this process may be conducted, disagreeable consequences, such as rigors, are apt to result from it, and the risk of such occurrences will of course be greater, when there is any impropriety
on the part of either the patient or the surgeon But whatever
may be the difficulties and danger of the simple dilating process, they are trivial when compared with those attending the use of caustic; which, even if it should happen to be correctly applied to the seat of contraction, must expose the patient to the risk, not only of immediate irritation, but also of subsequent inconvenience from cicatrisation of the ulcerated part."—Pp. 16-19.
With regard to the treatment by internal incision, Mr Syme states, that besides being uncertain and dangerous in the first instance, "so far from lessening the disposition to contract, the internal incision rather increases this morbid tendency, so as seriously to aggravate, instead of alleviating the disease;" and this he infers partly from his own experience, but more from extensive opportunities which he appears to have had of ascertaining the results of that of other surgeons. He comments, with deserved severity, on the strange proposal of M. Reybard to " rip open the canal with a certainty no less unerring than relentless," by a lancet blade pointing forwards instead of backwards, as in Mr Stafford's instrument, and contained in a sheath so large as to be capable of introduction only into strictures such as would be readily amenable to dilatation;
NEW SERIES.—NO. IV. APRIL 1855. 2 T
and he gives, in an appendix, a reclamation addressed by himself to the Imperial Academy of Medicine of Paris, who in 1852 awarded the Argenteuil prize to M. Reybard, on the recommendation of a committee, whose Report mentioned Mr Syme's operation as one not to be compared with that of M. Reybard.
The Boutonni6re operation is based on the supposition of the existence of impermeable strictures, in which Mr Syme does not believe.
But there remain certain forms of stricture that will not yield to dilatation, and require some other treatment, and these
"May be distinguished as unyielding, irritable, and contractile. In the unyielding form dilatation, though it may be carried on to some extent, is sooner or later arrested by resistance of the tough texture at the seat of eontraction ; and if attempts are made to remove this obstacle by forcible distension, the most serious consequences are apt to ensue. In the irritable condition, while all the symptoms of stricture are presented in an extreme degree of severity, the gentlest introduction of instruments is sure to produce great aggravation, not only at the time, but for days afterwards; so that the patient is distracted between desire to obtain relief, and dread of the effects resulting from means employed with this view. In the contractile, or spasmodic stricture, as it is usually called, no difficulty is experienced in dilating the canal to its proper capacity ; but unhappily with little benefit—the patient still making water laboriously, painfully, and frequently—by drops, or in a dribbling stream, which is liable to complete obstruction, through the influence of any local or constitutional disturbance affecting the urinary organs.
"For the treatment of stricture in these three forms, whether existing singly or combined together, the means of remedy hitherto employed have proved quite unavailing ; and the patients thus afflicted are deserving to be regarded as a great discredit to surgery. If poor, they frequent hospitals until dismissed by desire from despair of relief, or are declared incurable, or fall victims to practice more zealous than discreet. If rich, they run the gauntlet of European skill—having bougies introduced—caustic applied—internal incisions inflicted; and so on, until with broken health, disappointed hopes, and perhaps empty purses, they retire in dreary seclusion from society to carry on a dangerous and ineffectual system of palliation through means of the various apparatus collected in the course of their wanderings. That this is not an imaginary or overdrawn picture, must be admitted by every practitioner who possesses any considerable field of observation; and will also appear from the cases to be found in any large hospital."—Pp. 25, 26.
In these cases the method devised by Mr Syme is to be employed :—
"The peculiar and fundamental principle of which is to divide the stricture completely by an external incision—not at random, as by the procedure formerly in use—but with certainty and accuracy, through the assistance of a grooved director passed fairly through the contracted part of the canal. This obvious distinction has been strangely overlooked, and the operation which I have proposed has been held responsible for the disastrous effects of the very methods which it was intended to supersede, so that individuals, societies, and journals, have paraded the deadly statistics of groping in the perineum without a guide, or opening the urethra behind the stricture, as arguments against adopting a proposal which afforded perfect security from the dangers of these proceedings. It is much to be regretted, that through such misconceptions, the relief placed within their reach has been withheld from many unfortunate sufferers ; and I venture to express the hope, that any impression so produced, will no longer be permitted to oppose the progress of improvement in this department of surgery.