DILATATION. OF THE URETHRA BY SPONGE TENT neglect of depletion, that I consider Dr. Fife's theory of hooping-cough as too exclusive to be a safe guide in practice, for congestion is so common, and inflammation (in which case alone he admits its necessity,) is so rare, a complication, that I greatly fear if we postpone our depletion till our patient has exhibited unequivocal symptoms of inflammation, our remedy will be applied too late to be efficacious. The same principle should be kept in view in treating the complications,-viz., that pertussis is a congestive and not an inflammatory disease, except at its commencement; and even if inflammation do supervene, it is not of a nature to be treated by violent antiphlogistic remedies. In conclusion, I would beg to recall to the notice of the profession, a plan that I have found signally useful in all complaints of the lungs, of children and infants especially, viz., to change their position in sleep, in order that the blood may not gravitate too much to one side from lying too long upon it. The researches of Dr. Alison, in shewing the effects of inflammation in impeding the circulation of the blood through the capillaries of the lungs, and of M, Andral, in proving the tendency of congestiou to terminate in solidification, afford the true explanation of the benefit of this practice. I am, Sir, your obedient servant, T. OGIER WARD. Kensington, Sept. 6, 1847. EMPLOYMENT OF SPONGE-TENT TO DILATE THE URETHRA IN THE FEMALE. TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SURGICAL JOURNAL. SIR, In the last number of the Journal, Mr. Worthington relates a case of successful extraction of a calculus from the bladder of a female by Weiss's dilator, and states, "that the process of dilatation was commenced at eight o'clock in the morning, and that at the end of every two hours he visited the patient for the purpose of giving the screw of the instrument from a quarter to half a turn." Having understood from those who have employed that instrument, that it occasions much pain, I have never used it in my own practice, but have preferred dilating the urethra with sponge-tent, which I have always found a safe, effectual, and easy mode of accomplishing the object. I have twice succeeded in this way in extracting a female catheter which had accidentally slipped into the bladder, with so much ease, that I should always adopt the same plan with confidence, for the removal of calculus or any other foreign body. The plan was as follows:-A sponge tent somewhat larger and longer than a female catheter was passed into the bladder, and allowed to remain eight or ten hours, by which time the urethra was sufficiently dilated to admit the passage of the finger readily into the bladder, and the introduction of a pair of forceps, by which the catheter was removed without any difficulty. In the first case the patient was not aware that the accident had happened; the catheter remained in the bladder fifteen days without producing any irritation, and the extraction was so easily effected | 509 that she was not conscious that any operation had been performed, and the bladder regained its power immediately. In the second, the catheter was retained seventeen days, during the whole of which period it occasioned much pain and irritation ; nevertheless, on the fourth day after the extraction, the incontinence of urine ceased entirely. I have repeatedly found the sponge-tent extremely useful in opening the neck of the uterus for the purpose of exploring its cavity, and for the removal of tumours. The introduction gives but very slight pain, and the dilatation is so gradually effected, as scarcely to be felt. JONATHAN TOOGOOD. Torquay, October 12, 1847. I herewith send the Mortality and Sick Registers, &c., for the second quarter of the present year. grIt will be seen, by a comparison with the first quarter, that there has been a considerable decrease, both of sickness and mortality, (258 and 38, instead of 353 and 44.) There has also been a striking diminution in the number of births, (34 instead of 54.) The principal decrease has been under the head pulmonary diseases, (31 and 7, instead of 80 and 15.) The sick register also shows a marked falling off in the number of fever cases, (42 instead of 72;) whilst the mortality table exhibits an increase under the same head, (7 instead of 1.) The decrease in the sick register is chiefly seen in the female column; the number of females being 79, that of males only 16, less than during the first quarter. The numbers under the head of diseases of the digestive organs are the same (68,) in the sick table as during the first quarter; in the mortality register there is a slight increase (7 instead of 6,) under the same head. Of the six months, January was the most sickly, (160;) June the most healthy, (71;) the other months differed but little from each other, (93 to 100.) The above table is compiled from the Parish Register, and the List of Cases which have occurred in my own practice. FRANCIS BUCKELL, M.R.C.S. This foregoing Table and the Table of Births which follows, are taken from the Parish Register of Romsey. REGISTER OF BIRTHS. :: : w :: :: 21 : : 2 2 4 19 19 16 10 12 38 47 17 CASES FROM PRIVATE PRACTICE. By JOHN RICHARD WARDELL, M.D., Edin.; Late President of the Royal Physical and Hunterian Medical Societies, Assistant Pathologist in the Royal Infir mary, Edinburgh, &c. &c. (Continued from page 549.) On a perusal of the first of these cases, it is seen that the patient was a young and somewhat chloroticlooking girl. The affection, as in children, came on with great suddenness. There was a degree of attendant spasm in the muscles proper to the chest, as evinced by the sensation of constriction experienced when full inspiration was attempted. The stethoscope at once proved that the disease was not in the chest, but in the larynx, notwithstanding the sense of pain in the chest, and this was the partial closure of the glottideal chink. The bleeding produced relief by its induction of general relaxation. On the night of the 8th inst., she had no return, nor on the morning of the 9th were there any pyrexial symptoms indicative of the existence of inflammatory action. The paroxysms which subsequently came on during that day, were in a moment, and during their continuance, as seen from the reports, there were hysterio-epileptical symptoms, in addition to those immediately produced by the asphyxial con dition under which she laboured. It has been said that damp and cold have nothing to do with the production of laryngismus stridulus, and that croup, on the contrary, is mainly brought on by these conditions. It is quite clear from the above cases that the first of these statements is incorrect, as in both instances wet and cold were the exciting causes. The girl, Cooper, had been employed most of the day on which her illness commenced in pumping and carrying water out of the house, which had come in during a great flood of an adjacent stream, and her feet had been wet for some hours. The boy stated, that the day before his attack he was thoroughly wet, and on the following morning he had in a great measure lost his voice. The instance of John P supplies a good example of one of those cases but rarely observed, of distinct hysterical symptoms in the male. When such become manifest in this sex, (the male,) it is about puberty, when the generative organs, and the body generally, undergo a great change, or in the persons of nervous and excitable young men, though cases have been recorded of distinct hysteria occurring in a stout plethoric man. Sydenham, Hoffman, Whytt, Ferriar, Villermay, Georget, Conolly,* etc., favour the opinion that undisputed hysteria may occur in the male; when in this sex it is never, however, so unequivocally developed as in females, perhaps owing to the greater mobility which there is in the latter than the former. The present writer knows a married gentleman, of two or three and thirty years of age, who at times is Dr. Copland's Med. Dict.," Art. Hysteria, Sec. 40. decidedly hysterical, being often somewhat melancholic, highly irritable, has the globus hystericus, etc., rendering no doubt, whatever, as to the nature of the affection. During the paroxysms John P presented much the same kind of symptoms as the girl Cooper. There was slight lachrymation, a sensation of choking, a wild incoherent-like tossing, with great difficulty of breathing, and a congested state of the countenance, which demonstrated asphyxial symptoms. The hands were suddenly clinched, and the inferior extremities involuntarily moved in convulsive twitches, and he intimated that he felt a painful tightness at the chest and throat. From these facts, then, it would be difficult to dispel the opinion of there being evidence of true hysteria present, with whatever other conditions associated. Respecting the treatment of the two cases, it is quite undeniable that medicines which produce a ready sedative and antispasmodic effect upon the nervous system constitute the class of remedies most correctly indicated. Our object is to overcome the morbid irritability which there is in the nervous centres, and when the paroxysmal attacks have subsided, to strengthen the system by means of tonics, of which the mineral kind are the best, especi◄ ally the preparations of iron. Both it is observed were bled. Blood-letting was had recourse to on two accounts,-first to relieve the congested state of the vital organs, especially the lungs, which had been induced by the imperfect aëration of the blood, as evinced by congestion of the features, sense of suffocation, incoherence, etc.; secondly, to promote general muscular relaxation, thus overcoming the spasmodic rigidity in the muscles proper to the larynx, and therefore averting the dangers of immediate suffocation. Unless absolutely indicated by the imminent peril of the patient, there can be no doubt whatever that the abstraction of blood in chlorotic women is not good practice, and indeed we should then always avoid having recourse to the lancet when other remedies can be safely substituted, for the more we bleed the greater will become that mobility of the nervous system, which is the prelude to, or perhaps the main cause of, these conditions. It is true, however, as all men of experi< ence must acknowledge, that under these kind of affections, delicate young women will occasionally endure, not only with impunity, but be benefitted by the loss of large quantities of blood. An instance illustrative of this assertion was suplied during the last few weeks. Martha Ca young woman, aged 23, hair dark, of somewhat waxy complexion, and hitherto of delicate health, was, after having rigors and slight nausea, attacked with very acute pain in the abdomen, which was increased on the gentlest pressure. The pulse was full, quick, and of good strength; the skin rather hot, but not dry. Perceiving her chlorotic condition, and being informed by her mother that the abstraction of a very small quantity of blood, not more than four ounces, a short time previously, had induced a most alarming syncope, I was led to give a large This case terminated in fever, and might be con is it a very uncommon thing for the initiatory stage of fever to assume such complications in pale chlorotic looking girls. dose of calomel and opium, and ordered sinapisms, bot applications, etc., to the abdomen and inferior extremi-sidered as hysteria engrafted upon that disease; nor ties. She still complained of much pain, and in a very distressing manner tossed about in bed, whilst the appearance of the countenance and her general aspect manifested characteristics of that protean maladyhysteria; yet these were so mixed up with other symptoms, and of such an anomalous description, as to leave some degree of doubt as to the diagnosis The opiate was repeated within an hour, although she would now instead have been bled, had it not been at Some few months ago a young lady was suddenly taken with violent spasmodic pains in the epigastrium, and she also bore considerable doses of opium, nor was she relieved until blood-letting was also employed: her case too terminated in fever. When it is recollected the particular solicitation of the mother, who begged that according to the Cullenian theory the brain and earnestly that I would try any other means except blood-letting, at the thoughts of which she was con- spinal marrow are the first organs which become siderably agitated, owing to the circumstance before affected with the poisonous agent, it may easily be mentioned. She now had what was equivalent to conceived that the organic nervous influence will nearly 100 drops of laudanum, but without producing participate in the morbid impression, and that the scarcely any relief; I therefore determined to bleed, by manifest characters of such impression will be dea large orifice, to syncope, if the pain did not abate on a less powerful impression being made on the circula- termined mainly according to particular predispositions tion. This, it was to be anticipated from the mother's of certain parts; hence where there is great mobility statement, might be done by a slight loss of vital fluid.of the nervous system, and proclivity to hysteria, this Twenty-four ounces were, however, taken before much complaint would be likely to become developed during benefit was produced, or the pulse markedly affected; the disturbance created in the system in incipient she then became for some few minutes faint, and afterfever. wards expressed herself as better. Two grains of To return to the question of blood-letting in the cases powdered opium were given, with five of calomel, and in the course of two or three hours she was much particularly under consideration. I am fully aware, easier, the tenderness in a great measure having as has already been advanced, that to bleed chlorotic vanished. On the following morning another paroxysm patients for their anomalous pains, as a general rule, is came on, which fomentations, etc., alleviated. The neither in accordance with physiological and pathoblood was not in the slightest degree buffed or cupped, logical deductions, nor borne out by experience; yet, and the crassamentum was proportionately less than in instances like that of Cooper, where considerable normal. Two days subsequent to this a hurrying message intimated that she had again very suddenly spasmodic action existed in a vital part-the airbecome affected with pain, indeed the informant said passages, and that of Martha C, where the she was dying. On reaching the house several of the muscles proper to the respiratory functions were in neighbours were assembled to witness, in their opinion, a rigid fixity, tending in both cases to asphyxía, a the fast approaching struggles of dissolution. The less evil is had recourse to, in order to prevent a greater; pain had now migrated to the chest, and she gave for in cases of such emergency, our main object is to expression to her suffering in piteous cries, which were most distressing to those around. She felt so tight avert present danger, and relieve existent suffering. about the chest and throat, that she was as if suffo- It was requisite, as observed, to produce an immediate cating, and on each imperfect expansion of the thorax and powerful impression upon the heart's action, and violent lancinating pain was experienced. The counte- thus by lowering the circulation, overcome the renance was anxious, expressive of much obstruction in sistent spasm in the muscles directly essential to life, the circulation, and although the pulse was of tolerable which could only be done by copious depletion. That strength, yet a general review of the case impressed me with the conviction of her being in a precarious conthe practice was correct seems evident, from the sucdition. Profiting from the experience of her last cessful results by which it was followed. Whenever attack, and from such not having much confidence in we bleed, we should ever be guided by the condition any other methods except the lancet, it was at once of the pulse, and in all of these cases it was of good determined to overcome by the induction of syncope strength; and it may be taken as a general rule, when the spasmodic rigidity which there was in the muscles it feels hard, as it did in these intances, (depending proper to the respiratory functions. Another large basin of blood was taken with immediate advantage, upon visceral engorgement,) the lancet is indicated. although the relief was not so continuous as might Proving that the blood was highly venoid, the first have been desired. Other adjuvants, as calomel and portion of that emitted from the arm of John P, opium, an antispasmodic enema, composed of turpen- was of a tarry description, and so inspissated, that tipe, solution of morphia, and the foetid tincture, it would scarcely flow from the vein. sinapsims to the dorsal region of the spine, fomentations, etc., were employed. It may here be remarked that there was now no pain in the abdomen, but the affection was solely located in the thorax, extending to the throat. She had one or two other attacks, and was treated in a similar manner. The anti-spasmodics employed in both cases were of essential service. The strong liquor of ammonia applied to the throat was exceedingly useful, and tended to cut short the paroxysm. The inhalation of the vapour of hot water, impregnated with laudanum proved |