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Well, be it so. We are willing to take the catheterism of the trachea as a fait accompli though that of the individual bronchial tubes seems to us somewhat to lack evidence. This done, there comes the question, “cui bono ?”—for whose benefit? That of the patient, or that of the physician? We wish to avoid prejudice, but we cannot help regarding the attempt to heal a tubercular cavity by irrigating or scalding the whole surface of the bronchial mucous membrane with a solution of nitrate of silver (gr. xl. to zj), with much the same feelings with which we should view a proposition to cure an ulcer on the leg, or an obstinate sinus in the groin, by a general shower-bath of the same material.
The Pathology and Treatment of Leucorrhæa. By W. TYLER
Smith, M.D., etc. London, 1855.
Having had much satisfaction in perusing Dr Smith's memoir on uterine and vaginal discharges, as presented to the Royal Medical and Chirurgical Society, we have looked forward with desire to see the present work, which is founded upon the researches above-mentioned. The volume is of very great value; it contains matter of importance which is really original; although for the most part the anatomical, microscopical, and chemical observations introduced into the work have been previously recorded. The author deserves much credit for having, with great care and intelligence, investigated the subject of his work for himself, described it distinctly, and impressed its importance upon the professional mind.
The first chapter contains an account of the minute anatomy of the mucous membrane of the uterine neck and of the vagina. The villi of the mucous membrane covering the vaginal portion of the uterine neck are carefully described and beautifully figured, as also the peculiar mode in which they are surrounded and covered by scaly epithelium.
The second chapter is a very full account of the abundant glandular structures in the cervical canal, and of their arrangement. This is the part to which Dr Smith desires to attract attention, as the common seat and source of leucorrhea. The anatomy, function, and disease of this important part are indeed the whole theme of the book. It appears to us, however, that by using certain terms he has come to believe, certainly very erroneously, that it has been neglected by previous authors in their writings on that affection. If he will turn to the work of Dr Henry Bennet, for example, he will find it very particularly insisted upon that the mucous follicles, or gland's, of the cervix are frequently, the seat of disease. The researches of Dr Smith are valuable and important so far as they are positive observations of structure and function, or descriptions of leucorrhæa; but, in pathology, the chief point in liis views is the
translation of inflammation and abrasion of the uterine cervix into cervical leucorrhæa. If the glandular structure of the cervix be secreting an excessive quantity of mucus, and that mucus be not natural in its characters, if this be accompanied with swelling, pain, and tenderness; if in addition, there be present, redness of the vaginal part of the cervix, denudation of the villi of the same part, or ulcerative destruction of them, then, surely, in all these cases there is no error in speaking of inflammation and abrasion. To our author, nevertheless, we are indebted for an unprecedentedly scientific and accurate description of these conditions.
Since Dr Bennet's last edition appeared, but before Dr Smith's work, the Croonian Lectures of a distinguished Fellow of the College of Physicians in London, on ulceration of the os uteri, had been published, but without our author having given them sufficient attention. If he had done so, he would certainly have assigned a much more modest scope than he does, to the pathology of affections of the uterine cervix. The man who wishes to make a decided advance in the pathology of the ordinary uterine ailments, must have studied carefully the recent works of Henry Bennet and of Tyler Smith, but must take the conclusions, negative as they are, of Dr West (whose work we lately reviewed), and with these as his text and stand point make progress in this difficult investigation. The work before us is, indeed, born a little after its time, but is not therefore less valuable or welcome. It is the finishing, or topstone, to a pillar which has been much looked at and discussed during its erection. As far as our present means and appliances can go in the investigation of leucorrhea, so far they have nearly gone. This is the last step.
In the third chapter the healthy secretions of the genital passages are ably and admirably described. The sebaceous follicles of the vulva secrete an acid, oily, odorous matter. The glands of Duverney are believed to secrete in sexual excitement an abundant fluid, which is discharged at the ostium vaginæ; it forms the female semen of some ancient authors. The vaginal canal is coated by a rather scanty, acid, milky fluid, consisting of a hyaline plasma containing abundance of scales of the flat or squamous epithelium of the passage, with detritus of the same. The cervical canal is generally filled with transparent brilliant viscid secretion, of a yellowish tint, and alkaline reaction, and consisting of a plasma containing mucus globules. In the lower part of the cervix this secretion of its numerous glands may contain squamous particles derived from the os uteri, or that part of the vagina with which it may be in contact, and the acid secretion of these latter parts sometimes destroys the transparency of this part of the plug of cervical mucus, by coagulating the albumen in it. In pregnancy the lower part of this plug becomes often indurated, white, and tough, and Dr Smith seeks to found upon this fact, and our power of seeing it through the speculum, a new sign of pregnancy. In speaking of this he forgets to estimate
its value as an indication. It must be worthy of very inconsiderable confidence. For, it is often absent in pregnancy; it is often present without pregnancy. Lately we removed an enormous plug of this white inspissated mucus from the hypertrophied cervix of a non-pregnant womb. The plug of pregnancy is dry, tough, and incapable of solution, and comes away with or before the show, which consists of fresh mucus poured out consentaneously with the advance of the healthy relaxation of parts. The plug itself cannot be said to form the show.
The fourth chapter contains an excellent description of two forms of leucorrhæa; the first vaginal in its source, and called epithelial from its containing abundance of the squamous particles of the surface of that canal; the second cervical in its origin, and called mucous from its consisting essentially of a fluid containing mucus globules, but often containing epithelial scales derived from the vaginal surface over which it passes.
“In cervical or mucous leucorrhæa, the glandular portion of the canal of the cervix uteri is the chief source of the discharge. This form of leucorrhea is, when simple and uncomplicated, the result of a morbid activity of the glandular cervix. A follicular organ, which should only take on an active condition at certain intervals, becomes, from a variety of causes, constantly engaged in profuse secretion. Instead of the discharge of the plug of mucus at the cata. menial period, an incessant discharge is set up. This discharge, it cannot be too often repeated, is a special glandular secretion, elaborated by the glands of the canal of the cervix uteri. In the first instance the leucorrhæal discharge consists of nothing more than an unusual quantity of the elements found in the healthy mucus of the cervical canal. Quantities of mucus corpuscles and oily particles, with particles of epithelium entangled in the viscid alkaline plasma which gives the inucus its clearness and consistence, are found. The clear mucus is seen at the os uteri, sometimes adhering to the os itself, at others extending through the vagina, and presenting at the os externum in the form of a string, and also lying upon the walls of the vagina, in the curdy or creamy state to which it is reduced by the action of the vaginal acid. The presence of oily matter in the discharge from the cervix is constant, and so is the presence of occasional particles of scaly epithelium, which, as I have before remarked, appears to ascend from the vaginal portion of the os and cervix. I should state that, in obtaining matter from the cervix for microscopical examination, I have always used a bivalve speculum, free from grease or oil, dilating the os uteri as much as possible by the expansion of the valves, in order to get the secretion of the cervical canal without the admixture of any vaginal mucus. In making an examination in a case of cervical leucorrhæa of recent origin, when the disorder consists merely of a hyper-secretion of the mucous follicles, without any manifest lesion of structure, the cervical discharge hanging at the os uteri, or adhering to the vaginal portion of the os uteri, is almost always viscid and transparent. It may be drawn out with the forceps as a long tenacious string of the utmost clearness. The chief exception is in cases of pregnancy, where, from the highly acid condition of the vaginal mucus, the lower part of the plug of mucus is whitened and curded before its exit from the os uteri.”—Pp. 54, 55.
“In vaginal or epithelial leucorrhea, the seat of the discharge is in the muco-cutaneous lining of the vagina, and the portion of this membrane reflected over the external surface of the cervix to the margin of the os uteri. In strictly vaginal leucorrhæa, there may be no discharge whatever issuing
from the canal of the cervix, and in some cases the secretion of the cervix seems almost suspended, the os uteri appearing drier than natural, and no mucus being visible between the labia uteri. In others, the cervical glands are excited by the condition of the vagina, and secrete copiously, a mixed epithelial and mucous leucorrhæa from the union of the two kinds of discharge being the result. The discharge in vaginal leucorrhea may arise chiefly, either from the lower portion of the vaginal membrane, or from that part which is reflected over the cervix; but in severe cases the whole surface of the vagina is involved. The secretion in these cases generally consists entirely of epithelium in every possible phase of development, mixed with acid mucous plasma. A portion of the secretion diluted with a little water, and placed under the inicroscope, is seen to consist of myriads of epithelial particles, in the form of mere nuclei, young scales which have not reached their full development, and perfect scales. If the case be acute, there are no old and broken scales, such as are found in the healthy secretion, the epithelium being separated too rapidly in the formation and flow of the discharge to admit of their coming to maturity and wearing away in the vagina. In mild cases, when the separation is more slow, ripe and well worn scales are sometimes present. When the vaginal form of leucorrhæa becomes very severe, the villi become affected, and not only is epithelium separated with extraordinary rapidity, but pus is formed upon the irritable sub-epithelial or villous surface, which when mixed with the epithelial matter can hardly be distinguished from the mucus corpuscles of the cervix mixed with scaly epithelium. The state of the vagina, as seen by the eye, will, however, remove all doubt as to the nature of the discharge in these cases. A further complication of vaginal leucorrhoea may occur, as when portions of the vaginal surface are so abraded that blood globules escape and mix with the other constituents of vaginal discharge. The vaginal secretions now described are those most commonly found in vaginal or epithelial leucorrhæa ; but there is another form of vaginal discharge which deserves consideration. In that already mentioned, the secretion consists of epithelial matter thrown off from the surface in such a state of separation that the scales are in a confused mass, the fluid portion being exuded from the vessels of the villi or papillæ below the epithelium. But in the second form of epithelial disorder, to which I now refer, the epithelium is thrown off in large shreds or pieces, in which the pavement-like arrangement of the scales is perfectly preserved. These laminæ frequently have upon them marks of the rugæ of the vagina, and somewhat resemble the cuticle, in cases of acute desquamation of the surface of the body. The under surfaces of these masses are also rough from the indentations of the vaginal papillæ. Sometimes, on making a specular examination in these cases, the whole surface of the vagina is seen covered with a white coating, which may be removed by a forceps in membraneous pieces of considerable extent and thickness. This affection may be attended with a slight discharge from the sub-epithelial surface ; but in many cases the vagina does not contain more secretion than usual, or it may be unnaturally dry. In all epithelial affections of the vagina the discharge is acid ; but the acidity is particularly marked in this the membraneous form of leucorrhæa, as it may be termed. Some of the instances in which I have seen this affection in its most marked form have been in cases of pregnancy. I have sometimes had patients bring me a mass as large as a walnut, consisting of pieces of the epithelial coat of the vagina rolled up like paper ; or I have seen a tumblerful of water rendered perfectly thick with the quantity of shreds removed from the vagina by a single injection.”-Pp. 57–59.
Of the accuracy of these observations it is easy to satisfy any one. But Dr Smith must be cautious lest he carry his microscope into regions where it cannot stand. In severe cases of-call it leucorrhæa, or inflammation, or abrasion of the cervix, or what
you will, there will be mixed with the discharge many pus globules, which are notoriously very difficult to distinguish from mucus glo bules. We might then suppose a glass given to the microscopist, having in the field some scales old and young, with mucus and pus globules, and it would be a sad puzzle to him to say what was the seat of the disease. The microscope is very useful in its own place. Its uses in practice in cases of leucorrhæa are nil. In all cases when the distinction between cervical and vaginal discharges is possible, it will be more securely done by the naked eye than by aid of the microscope.
The fifth chapter, on the sequelæ of leucorrhæa, is one of the most valuable and interesting. It shows beautifully the progress of the leucorrhæa of Smith, of the inflammation of others, from abrasion of the epithelium and laying bare of the villi, to ulceration or destruction of the villi, and lastly of the subjacent tissues. The last result of the irritation is hypertrophy
These first five excellent chapters contain almost all that is posi. tive in the book, and certainly form the chiefly valuable part of it. In the next two chapters our author enters upon the subject of leucorrhæa as a phenomenon in secondary syphilis, and discusses the question of the communicability of secondary affections. No new point is established, and little additional confirmation given to old views, except the expression of our author's well-weighed judgment.
In the eighth chapter the ovula nabothi are described, and reasons given for believing that they are not obstructed follicles of the cervix uteri. The necessity of distinguishing various appearances confused under this name is well pointed out.
The ninth and tenth chapters enter at length into the usual concomitants of leucorrhæa. Their chief fault lies, as we have already pointed out, in ascribing too much to the affection of the cervix. Of this our author appears himself to become occasionally conscious. For after describing t'le connection between leucorrhæa and sterility, he takes care to overthrow all he has said, by adding that no difference can be discovered between that affection in women who breed well and in those who are sterile, an observation which should have led him to see the unsatisfactory nature of his original conclusions. The connection of leucorrhæa with disorders of menstruation are equally incompletely given, and the author ignores altogether the only real form of membranous menstruation.
The work ends with two very good chapters on the causes and treatment of leucorrhæa. It is a book which ought to be in the hands of all interested in obstetrical studies. The whole profession must be gratified to see the true spirit of science carried into the troubled questions in regard to leucorrhæa, and to observe the great progress recently made in the investigation.