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PRACTICAL REMARKS ON DYSMENORRHŒA, AND ITS TREATMENT BY CAUSTIC TO, AND DILATATION OF, THE UTERINE NECK.
396 7th.-The new form of opiate had quickly the desired effect and he continued to mend apace, and it was thought un necessary for me to see him after the 20th, Mr. Gorhan’ most kindly undertaking to watch him daily. Mem.—The month of June came in remarkably cold anc unpropitious, and when I was summoned again to see him (June 15th,) the disease had made most fearful and rapid progress, phthisis in its worst form having become fully and unquestionably developed, and unless the high fever that was raging and consuming him was quickly arrested, no hopes could be entertained of regaining the lost ground. I advised his returning to London directly, and prescribed as follows :Tartar-emetic,* four grains; spirit of nitric ether, four drachms compound tincture of camphor, four drachms ; nitrate oi potash, four drachms; water, a pint. Mix. Three table spoonfuls to be taken three times a day. June 22nd.—Much better; still I strongly advised his seeing Dr. Elliotson, whose opinion I was most anxious to have as tc the true physical condition of the lungs. 23rd.-After a most careful and minute examination, Dr, Elliotson noted down as follows:—"All the physical signs oj a large cavity in the upper part of the left lung, with cavernous respiration and cough; pectoriliquy; dull percussion; case hopeless." Dr. Elliotson advised me to give, in addition to the treatment being pursued, one tablespoonful of cod-liver oil
three t.imPC
H
day
The administration
it must not be lost sight of, that throughout the treatment of this case very active remedies were prescribed. Amongst the foremost and most useful I would name tartar-emetic. I know of no remedy that has the power of allaying so well the devastating fever that is destroying the patient. Can cod-liver oil arrest this condition ? I think not. Can the patients be treated successfully without cod-liver oil ? I think they may; although there is not a shadow of doubt,as so well expressed by Dr. Elliotson,-that it is immeasurably superior to any other remedy that has been offered for the treatment of phthisis, provided we regard it in its proper light, and do not expect too much from it. This of course can only be proved on a large scale, by testing it without the assistance of other
patient. Again,
remedies, care being taken to ascertain its effect by acknowledged practical stethoscopists, that the cases are cases of pure phthisis. Had my brother’s case not been properly prepared, prior to administering the cod-liver oil, the result would have been very different. The form of preparation of opium I prefer, is the compound tincture of camphor, and should that fail to arrest the cough, or rather, the alarming fits that often suddenly occur, I prescribe large doses of my solution of vinegar and opium, (see THE LANCET ; and The Medical Gazette for Jan. 17, 1835;) and if that is not enough, and other preparations of opium have failed, I have used with very great advantage, Powell’s aniseed balsam, an excellent combination, though the manner in which it is before the public is highly objec-
of the oil was not commenced for some tionable. Dr. Elliotson informed me he had given the cod-liver days, as improvement was most striking, and especially as the oil freely in two other cases of phthisical cavity of the lungs, first two or three doses seemed sadly to nauseate; this, however, and in both the cavity became reduced, and the health and was overcome by combining it with equal parts of raspberry strength of the patients increased, so that they would hardly allow that anything ails them. In one the cavity had been vinegar. Returned to Minster. immense; it is now only above and behind the clavicle. The As the patient continued to progress most favourably, not pulse in both is still quick. He was lately called to see requiring any change of treatment from the last ordered, I a similar case, attended by Dr. Williams, and the same amount
shall omit all further notes until Oct. 20th, when he was again carefully examined by Dr. Elliotson, and the following is a verbatim report from his minute-book, which he allowed me to take a copy of on the 12th of November:" Grown stout and strong; was never better; gained five pounds weight in two months. Has taken a gallon of the oil. No dyspnosa; slight cough, but he always had this, and his father also; slight sputa in the morning; percussion good, but some degree still of mucus; a cavernous respiration in the old seat of the physical sign; pulse 100; respiration 20." Returned to the country. Nov. 24th.-Report by letter is as follows.·-" With the exception of a slight cough, I am quite well, and if gaining flesh is an advantage, I have done that. July 25th, I weighed ten stone, five pounds; Sept. 25th, ten stone, ten pounds; Nov. 15th, eleven stone, one pound." He continued to increase in weight, although he had discontinued the oil between Sept. 25th and Nov. 15th. Ordered, disulphate of quinine, half a grain, three times a day. Dec. 15th.-Report is as follows:—"Iam now quite well, and, I think, for many years have not had less cough than I have at the present time. I thought that in all probability I should cough on first rising, for some time, but I get up, and scarcely cough once while dressing. Guess my surprise when the man said,’Eleven stone, six pounds, this time, Sir,’-when weighed last, the 13th inst. I should mention that the quinine has rather tended to lessen the frequency of the pulse, for when I began it, it was as near 80 as possible, but now it scarcely ever beats more than about 75 or 76." Ordered rather to increase than decrease the oil, as it might prove more beneficial during the cold weather than heretofore. Independent of the other favourable symptoms, the increased weight of the patient, and the diminution of the frequency of the pulse, now at a permost
of benefit had been derived from the oil. Still he detected a cavity remaining at the upper and back part of the left lung,. and added, he had not yet seen a perfect cure by the oil. Princes-street, Leicester-square, 1849.
PRACTICAL REMARKS ON
DYSMENORRHŒA, AND ITS TREATMENT BY CAUSTIC TO, AND DILATATION OF, THE UTERINE NECK. BY SAMUEL EDWARDS, M.D., FORMERLY HOUSE-SURGEON TO THE EDINBURGH
LYING-IN HOSPITAL, AND
LATE PHYSICIAN TO THE EASTERN DISPENSARY OF
BATH,
AND
BATH
EAR AND EYE INFIRMARY.
(Uoncluaedfrom p. 371.) -)
CASE 4.-Anne , aged twenty-six, of sallow complexion,, dark hair and eyes, has been troubled with dysmenorrhœa from almost her earliest catamenial period, which took place when she was seventeen years old. She is a servant, and has almost invariably to lay by for a day or two at those times. Her present symptoms are somewhat worse than they used to be five years back, the pains being most distressing, accompanied with occasional clots and shreds of membranous formation; she has always leucorrhoea in the intervals. On examination at this time, I found the neck of the womb larger, harder, and more unequal than natural; the os was of the usual shape, but its lips were irregular. I could introduce a bougie readily into the uterine passage; but on its. return I found a drop or two of blood trickle down through. the os, and she complained of some little pain. Before doing anything further, I waited until the next period, on the in the are minute,) standard, healthy (76 fectly convincing second day of which I again examined, when the pains were of the state of and brother’s proofs satisfactory my patient most distressing. I found the body and neck fuller, and health. touch; and the introduction of the sameRemarks.—As cod-liver oil is becoming a prominent remedy more tender to the bougie (although well oiled) was difficult, and not attempted for phthisis, a few remarks gathered from actual observation without great increase of pain. The uterine passage was evimay prove acceptable. That it has the power, as it were, of blocked up. After emergence from this period, I comdently the disease of at the holding supply bay, by keeping up menced the treatment by introducing the bougie once or nutriment to the system as fast, or faster than the dis- twice a week, well coated with the caustic ointment, and ease is taking it away, under favourable circumstances, once I employed the solid, by means of the porte-caustique. cannot be denied. By favourable circumstances I would I also ordered her, each night, a mercurial alterative, and a imply, the action of other remedies, not to be overlooked, light, bitter tonic once or twice a day. that are imperatively demanded in the treatment of phthisis. The next period was passed over with much diminished The supply of this nutritious matter will be found, no and I had the pleasure and satisfaction of finding, after doubt, to have the power of arresting the further progress pain; third month of treatment, that her complaint had ceased, the or development of tubercle, the development and maturation her health considerably improved. of tubercle being in a ratio with the rapid wasting of the and CASE 5.-Miss A-, a young lady with light hair, and * In phthisis, a most potent remedy, fair, clear complexion, aged eighteen, has been affected with
.
397 from the period of her first being unwell, 1st. A naturally-contracted os or cervix uteri. 2nd. A contracted or strictured condition of the passage which occurred at the age of fifteen years and a half. At the first periods these acute pains were considered the result through the neck of the uterus, from previous inflammation of inflammatory action, and the warm bath, leeches, and anti- and ulceration. monials were exhibited, with the effect of relieving her con3rd. From inflammatory congestion of the substance and siderably. Each subsequent period was attended with the lining membrane of the body or neck of the uterus, and sometimes of both, with or without ulceration, giving rise to temsame pain, which, however, had rather increased during the past nine months. Prior to her applying to me, internal porary obstruction of the passage. 4th. Obstruction of the passage, from tumours or morbid remedies had repeatedly been had recourse to, without any but temporary relief. My attention having been previously growths. From my investigations, I incline to the belief that if the drawn to a contracted condition of the uterine passage, as a cause of this disease, and seeing no other cause to account subjects of dysmenorrhoea are carefully examined, one or for it, as the other ordinary remedies had been applied in other of these causes will be found to exist, as the produce!* vain, I immediately proposed an examination, which, after of this painful disease. The third cause, I believe, is often the lapse of another month, and a period of great agony, was associated with the second, especially at the monthly periods, acquiesced in. A small speculum being introduced, I found and will therefore explain why, in such a case as spoken of the cervix healthy in its density and appearance. The os by Ashwell, lie should have cured the stricture without dimiuteri was very, very small, and round-not tench-mouth-like, nishing the menstrual suffering. With regard to the first as usual-it appeared more like a slight depression, than an cause, few authors seem to have paid much attention to i.t, oc opening. I attempted to pass the smallest bougie or probe I to the valuable cases brought forward by the late Dr. Macinhad, and found a great difficulty in getting it beyond half an tosh, but on what grounds it is difficult to conceive, when he inch forward. Contented with this, as a cause of the disease, brings beforethe profession twenty-four decided cures out of I determined to pass the bougies two or three times a week. twenty-seven instances he met with and treated, where he For the first week I was obliged to keep to the same-sized believed the cause to be entirely the result of a contracted as instrument, which, however, I was able to pass along, each or strictured canal. Capuron, in his writings, believes ill the time, considerably further; after which I was able to increase cause, but considers it a rare one. Ryan, Churchill, Aslkwell, the size (had I wished it, or thought it desirable) every third and Waller, all mention the subject, the latter, however or fourth time. only to remark,We cannot speak of this plan from personal The first period after the treatment was commenced passed experience, never having given it a fair trial, but it seems difficult to explain the effect by the cause supposed." Drover with as much, if not more, of pain, which I attributed to the irritation and swelling produced; but it was satisfying Ashwell, in his very able treatise, states " that he believes to my mind that the pain was considerably diminished after the views of Dr. Macintosh are more correct than are genethe first two days, which had not been the case formerly. rally supposed, and should not be disregarded." He speaks The next period was attended with a much less degree of of one case where he satisfied himself that narrowing of the pain, which put my patient in good heart with the treatment canal existed, which he cured, but without relieving the dyfithat was being pursued, and gave her encouragement to put menorrhoea, as just mentioned, and he remarks, " in another case I was more successful, and Dr. Ryan entirely cured one up with it. It will not be necessary to detail the case more minutely; of the very bad forms." I have now treated with success fom sufficient to say, that the uterine passage, in the course of cases where the disease was clearly referable to this cause, but three months, was considerably and permanently dilated, and my experience would lead me to say, that as a cause it is not that the dysmenorrhoea diminished with the dilatation. At so frequent as the second and third. I have at the present the end of four months (during the latter month the bougie time under my notice, two cases (in sisters) suffering from was only passed occasionally) she considered herself well, the dysmenorrheea from this cause, but who will not submit to last period having given her but trifling annoyance. On two any but palliative treatment. Professor Simpson, my respected subsequent occasions, also, I am informed the same freedom midwifery instructor, has, I am informed, in some cases where from pain existed. The only internal remedies given were dilatation has proved difficult, had recourse to incision of the tonics, with liquor-potassae at first, subsequently combined neck of the uterus. Of this plan I have no experience whatwith one of the mineral acids, and an occasional pill of hen- ever, nor can I imagine a case where it can be necessary, (and surely such an operation ought not slightly to be takea bane, colocynth, and blue-pill. the sound or bougie is steadfastly emCASE 6.-The above case introduced me to another similar, ployed, and the lunar caustic used occasionally, to aid. in a young lady, of twenty-one years of age. The Of the second cause, I have met with several rhoea, without membrane, had existed from the commencement above briefly related, being one. The symptoms of her menstruating life, (which was late, being beyond ninethe the commencement of the dysmenorteen years old,) but had increased during the twelvemonth. The uterine passage in this case was likewise much con- rI’oea were those of ulceration of the cervix, and without cloubt extending into the uterine neck. Although in this case tracted, but not quite so much as in the above, yet I found a were no indications of present inflammation at the greater difficulty in dilating the passage. I consequently had recourse to the nitrate of which had the desired effect, of my first seeing her, yet it is worthy of remarks, that the but with the annoyance of at first occasioning a good deal of case under the bougie alone did not go on satisfactorily. It is therefore, in these instances alone, sufficient to cure the pain and irritation in the system; this, a cessation for a not, strictured part, for if it depends, as I believe, upon prior an with the exhibition of occasional week, night, put a an end to. This case terminated favourably, but still not and although you may cure the contracted quite so satisfactorily as the other. She has since had some condition of therefore, the cervix yet the next period may give rise to little annoyance, although only for a few hours prior to mensame effects, membrane is altered in its action struation none, however, as before, during the some means, and I believe the nitrate of silver, locally by week. This patient’s health considerably improved, and the to be the best. It will be seen that in the foregoing discharge has increased in quantity and improved in appearance. applied, cases I have used the nitrate in the solid form, or that at Remarks.—I have met with and treated another case of ointment. At first, I used it as an injection, with extract of dysmenorrho3a with membranous formations, of which I have conium, but found frequently such severe pains to follow from notes, but being, in most of its particulars, so similar to those the distention of the womb, that I have entirely laid them above given, I feel it would be but repetition of language to aside. In the womb never impregnated, the ointment or relate it; suffice it to say that I satisfied my mind that the solid nitrate will not produce (generally speaking) one half internal membrane of the body and neck was in a diseased the painful effects of an injection of three grains of the same state, accompanied, at the periodical flow, with an almost to an ounce of water. On using the latter for the first time,. I closed condition of the whole cavity, and that the use of the have, with one exception, found it to produce a smart attack nitrate of silver, together with the employment of the bougie, of pain, lasting many hours, precisely similar to that of dyshad effected a cure, not forgetting, however, to lay due stress menorrhcea. Whilst speaking on this matter, I may remark, on the internal administration of mercury, and vaginal supwhat has been omitted in the cases, that I have found it -a-dvisable to commence the treatment a day or two after menpositories of iodine and mercury. My opportunities have not been few of seeing this disease struating, and, for the first time at all events, to desist fraas. iluring the past eight or nine years, and my observation it at least from four to seven days prior to an expected re-
dysmenorrhoea
dysmenor-
past
in hand,) provided
case No. 2, of patient prior to
tirne
there
silver,
opiate at
commencing;
having been peculiarly directed towards it, I have been led to believe that dysmenorrhœa depends upon the following pathological causes: -
instances;
inflam-
mation, tendency to such may still exist at the monthly periods, the
unless the
turn.
With respect to the third cause, it, with the foregoing, consider by far the most common of dysmenorrhœa; certain
398 it is that I have met with the membranous formations alone with this third cause, whether the individual has been ple-
habit, or the contrary. Inflammatory congestion and ulceration, however, of the lining membrane of the uterus is not sufficient of itself to produce dysmenorrhosa. I have had thoric in
many, many cases which prove this. One case of a lady on whom I was called in consultation by Dr. Bowie, of Bath, and whom I subsequently attended since my residence in London, showed this; the whole of the lining membrane of the cervix was diseased, and the disease I have reason to believe extended into the body. The whole uterus was enlarged and indurated. The uterine canal, however, was large, so that the largest Hexible male bougie I had, passed readily. This lady, neither at the monthly periods nor at other times, complained of acute pains of any kind; in fact, I used to tell her I thought her case went to prove there were no such things as uterine nerves at all ! for although I repeatedly introduced ten, fifteen, and twenty grains of nitrate of silver into the uterus, by means of the yet no pain or uneasiness was In cases 3 and 4, the cause was evidently ever complained of. traceable to inflammatory congestion, &c.; both were accompanied with the expulsion of membranous shreds, the true nature of which has engaged much discussion. For my own part, I look upon them as the proceeds of a diseased mucous taking on the same peculiar form of action which is sometimes seen in other mucous membranes, to wit, those of the urethra, trachea, and intestines, and producing effusion of organizable lymph. The case No. 4 presents the more chronic form of the disease, and, as is not unusual, had induced an indurated condition of the cervix, which can alone be to a chronic form of inflammation. It is well to bear this ascribed in mind in cases of habitual dysmenorrhœa in individuals at all possessed of a cancerous diathesis. I cannot help feeling convinced, from the experience I have had, that all these cases with membranous formations are traceable to the third cause specified; for although, during the periodical intervals, the inflammatory condition is not in an active state, yet the disordered condition of the mucous membrane, I believe, does ,exist in a quiescent form. Now it is known to every one that at the monthly periods, the uterus, even in a healthy condition prior to, and during the time of its parting with, its periodical -flow, is in a congested state; this, therefore, independently of other causes, will suffice to light up the inflammatory mischief, the whole mucous membrane swelling and assuming that peculiar action which produces these anomalous formations. In each of the cases of this kind that I have examined, I have found the uterine passage blocked up by inflammatory I believe I am supported swelling; and in favour of my by almost all authors in asserting, that the pains are almost invariably more severe in proportion to the size and number of the masses thrown off. In turning consideration to the character of the pains, it is next to impossible not to observe that they present almost all the characters of those of the womb, in its efforts to expel its natural burden. " They resemble those of labour; the patient bears down with considerable effort, and after many abortive attempts, a paroxysm of uterine suffering is relieved by the expulsion of a small concrete clot,
porte-caustique,
membrane,
views,
detached portion of membrane."* In reference to the cause No. 4, one case alone has occurred under my care, but which I took but little notice of at the time: it was in a young woman about the age of thirty. She had for a year or two complained of weakness, lumbar pain, with leucorrhcea, for which she had been under treatment without benefit. Within three or four months of my seeing her, she had suffered pains at her period of menstruation, sometimes more severe than at others, but not sufficient to lay her by. The menses had been both more frequent and copious during the prior eight months. On examining, I found .a small polypoid growth about the size of a hazel nut, blocking up the os. It was attached about quarter of an inch up the passage. I at once removed it by torsion, applying caustic to the root. My patient got well, and with its removal ceased the monthly pains. Now whether the obstruction was the cause of the pains, or the irritation produced by its presence, it is difficult to say. I am inclined to think that both operated to induce the effect. It appears to me unnecessary to extend this paper (which is intended alone as a practical one) by any remarks as to the modus agendi of the nitrate of silver upon the mucous membrane of the womb. Its action in other parts is sufficiently well known, and the same is applicable here, especially in most diseases of the mucous tissues atlecting secretion, and also in - external ulcerations. It has long been known to cure " that r a
* Ashwell, Dicases cf Females.
inflammation of the cervix uteri depending on increased irritability of the part." I am inclined to think that the nitrate of silver acts as a local tonic, of no small importance in the cure of the above disease. Upper George-street, Bryanstone-square, March, 1849.
REMARKS ON CONSTITUTIONAL SYPHILIS.
By GEORGE
L.
COOPER, Esq., F.R.C.S.E.,
SURGEON TO THE BLOOMSBURY (Continued from
p.
DISPENSARY, &c.
422, vol. ii.
1848.)
IN a former paper, I endeavoured to lay before the profession few incidental remarks on constitutional syphilis; and on proceeding with the subject its interest much increases, but intricacies and difficulties by no means diminish; yet notwithstanding the curious and perplexing histories which have been written on this form of disease, it behoves every admirer of science and philanthropy to think and speak for himself, "laudatur ab his, culpatur ab illis," in other words, to exercise those faculties, the gift and blessing of our divine Creator, whereby the depths of learning have been fathomed, and the hidden treasures of knowledge and experience unfolded to the human eye. How often do we see those whose opportunities are most frequent and brilliant, not only cast aside the proffered gem of observation, but close their powers of comparison and description against a searching and inquiring world: humble may be the produce of his labours, and far distant any hopes of success, as in the words of the immortal
a
Shakspere :The ample proposition that Hope makes In all designs begun on earth below, Fails in the promised largeness; checks and disasters Grow in the veins of actions highest reared, As knots, by the conflux of meeting sap, Infect the sound pine, and divert his grain, Tortive and errant, from his course of growth."
The subject of constitutional syphilis, although abstruse, is yet important in the highest degree to the welfare and happi. ness of the general community. Notwithstanding the deep
unflinching attention it industry, how much remains
has received at the hands of investigated, which time alone, aided by the exertions of talent, can ever unfold, or unravel those mysteries of Nature; still Science, like the morning sun, must shine, and cast into the lowest abyss, to rise no more, the ignorant, and the perverter of truth and honesty. The contagiousness of constitutional syphilis, under circumstances, as explained on a former occasion, will scarcely admit a dissenting voice, but many points relating to this matter require further consideration prior to a final decision: indeed, little do I uphold, with any certainty, the theory entertained by a distinguished author on this subject, expressive of a latent morbid poison traversing the circulating channels of a male once affected by secondary syphilis, but subsequently, regardless of time or appearance, capable of engenderiing a similar disease in the foetus, should pregnancy follow a connexion, the female escaping contamination, is not in accordance with experience or practical observation, for every surgeon must have witnessed, and can bear ample testimony to, facts in refutation of this doctrine. Indeed, without entering into the theory of absorption by the uterus or Fallopian organs, daily occurrences on this point at once demonstrate and settle the question. Numerous instances to the reverse I could produce, were it requisite, showing the offspring of a father free from, and who were never affected by, the syphilitic taint. The fact of infants exhibiting veneral spots and fissures at an early period after their births, is unfortunately of too common occurrence; but inquiry leads to the development of truth, and generally points out the origin and source of this evil to be nearer home. I am fully aware that constitutional syphilis will lie latent for many years without any ostensible appearance, and at the expiration of a lengthened period, burst forth with much virulence; but the question of contagiousness in a latent and tranquil condition requires proof for our satisfaction or belief. If credited as a genuine fact, and worthy of record, no quarantine laws could enforce a sufficient purification, where demanded, previous to the sacred ties of matrimony. The susceptibility of some persons more than others to the ravages of constitutional syphilis, is a well-known circumstance, inasmuch as we find habits and temperaments so widely differing, more or less influencing the tone and general health of the individual, independent of the treatment exercised whilst under the primary forms of syphilis; and I firmly believe that with respect to all the appearances of this disease, and
to be
three t.imPC
H
day
The administration
it must not be lost sight of, that throughout the treatment of this case very active remedies were prescribed. Amongst the foremost and most useful I would name tartar-emetic. I know of no remedy that has the power of allaying so well the devastating fever that is destroying the patient. Can cod-liver oil arrest this condition ? I think not. Can the patients be treated successfully without cod-liver oil ? I think they may; although there is not a shadow of doubt,as so well expressed by Dr. Elliotson,-that it is immeasurably superior to any other remedy that has been offered for the treatment of phthisis, provided we regard it in its proper light, and do not expect too much from it. This of course can only be proved on a large scale, by testing it without the assistance of other
patient. Again,
remedies, care being taken to ascertain its effect by acknowledged practical stethoscopists, that the cases are cases of pure phthisis. Had my brother’s case not been properly prepared, prior to administering the cod-liver oil, the result would have been very different. The form of preparation of opium I prefer, is the compound tincture of camphor, and should that fail to arrest the cough, or rather, the alarming fits that often suddenly occur, I prescribe large doses of my solution of vinegar and opium, (see THE LANCET ; and The Medical Gazette for Jan. 17, 1835;) and if that is not enough, and other preparations of opium have failed, I have used with very great advantage, Powell’s aniseed balsam, an excellent combination, though the manner in which it is before the public is highly objec-
of the oil was not commenced for some tionable. Dr. Elliotson informed me he had given the cod-liver days, as improvement was most striking, and especially as the oil freely in two other cases of phthisical cavity of the lungs, first two or three doses seemed sadly to nauseate; this, however, and in both the cavity became reduced, and the health and was overcome by combining it with equal parts of raspberry strength of the patients increased, so that they would hardly allow that anything ails them. In one the cavity had been vinegar. Returned to Minster. immense; it is now only above and behind the clavicle. The As the patient continued to progress most favourably, not pulse in both is still quick. He was lately called to see requiring any change of treatment from the last ordered, I a similar case, attended by Dr. Williams, and the same amount
shall omit all further notes until Oct. 20th, when he was again carefully examined by Dr. Elliotson, and the following is a verbatim report from his minute-book, which he allowed me to take a copy of on the 12th of November:" Grown stout and strong; was never better; gained five pounds weight in two months. Has taken a gallon of the oil. No dyspnosa; slight cough, but he always had this, and his father also; slight sputa in the morning; percussion good, but some degree still of mucus; a cavernous respiration in the old seat of the physical sign; pulse 100; respiration 20." Returned to the country. Nov. 24th.-Report by letter is as follows.·-" With the exception of a slight cough, I am quite well, and if gaining flesh is an advantage, I have done that. July 25th, I weighed ten stone, five pounds; Sept. 25th, ten stone, ten pounds; Nov. 15th, eleven stone, one pound." He continued to increase in weight, although he had discontinued the oil between Sept. 25th and Nov. 15th. Ordered, disulphate of quinine, half a grain, three times a day. Dec. 15th.-Report is as follows:—"Iam now quite well, and, I think, for many years have not had less cough than I have at the present time. I thought that in all probability I should cough on first rising, for some time, but I get up, and scarcely cough once while dressing. Guess my surprise when the man said,’Eleven stone, six pounds, this time, Sir,’-when weighed last, the 13th inst. I should mention that the quinine has rather tended to lessen the frequency of the pulse, for when I began it, it was as near 80 as possible, but now it scarcely ever beats more than about 75 or 76." Ordered rather to increase than decrease the oil, as it might prove more beneficial during the cold weather than heretofore. Independent of the other favourable symptoms, the increased weight of the patient, and the diminution of the frequency of the pulse, now at a permost
of benefit had been derived from the oil. Still he detected a cavity remaining at the upper and back part of the left lung,. and added, he had not yet seen a perfect cure by the oil. Princes-street, Leicester-square, 1849.
PRACTICAL REMARKS ON
DYSMENORRHŒA, AND ITS TREATMENT BY CAUSTIC TO, AND DILATATION OF, THE UTERINE NECK. BY SAMUEL EDWARDS, M.D., FORMERLY HOUSE-SURGEON TO THE EDINBURGH
LYING-IN HOSPITAL, AND
LATE PHYSICIAN TO THE EASTERN DISPENSARY OF
BATH,
AND
BATH
EAR AND EYE INFIRMARY.
(Uoncluaedfrom p. 371.) -)
CASE 4.-Anne , aged twenty-six, of sallow complexion,, dark hair and eyes, has been troubled with dysmenorrhœa from almost her earliest catamenial period, which took place when she was seventeen years old. She is a servant, and has almost invariably to lay by for a day or two at those times. Her present symptoms are somewhat worse than they used to be five years back, the pains being most distressing, accompanied with occasional clots and shreds of membranous formation; she has always leucorrhoea in the intervals. On examination at this time, I found the neck of the womb larger, harder, and more unequal than natural; the os was of the usual shape, but its lips were irregular. I could introduce a bougie readily into the uterine passage; but on its. return I found a drop or two of blood trickle down through. the os, and she complained of some little pain. Before doing anything further, I waited until the next period, on the in the are minute,) standard, healthy (76 fectly convincing second day of which I again examined, when the pains were of the state of and brother’s proofs satisfactory my patient most distressing. I found the body and neck fuller, and health. touch; and the introduction of the sameRemarks.—As cod-liver oil is becoming a prominent remedy more tender to the bougie (although well oiled) was difficult, and not attempted for phthisis, a few remarks gathered from actual observation without great increase of pain. The uterine passage was evimay prove acceptable. That it has the power, as it were, of blocked up. After emergence from this period, I comdently the disease of at the holding supply bay, by keeping up menced the treatment by introducing the bougie once or nutriment to the system as fast, or faster than the dis- twice a week, well coated with the caustic ointment, and ease is taking it away, under favourable circumstances, once I employed the solid, by means of the porte-caustique. cannot be denied. By favourable circumstances I would I also ordered her, each night, a mercurial alterative, and a imply, the action of other remedies, not to be overlooked, light, bitter tonic once or twice a day. that are imperatively demanded in the treatment of phthisis. The next period was passed over with much diminished The supply of this nutritious matter will be found, no and I had the pleasure and satisfaction of finding, after doubt, to have the power of arresting the further progress pain; third month of treatment, that her complaint had ceased, the or development of tubercle, the development and maturation her health considerably improved. of tubercle being in a ratio with the rapid wasting of the and CASE 5.-Miss A-, a young lady with light hair, and * In phthisis, a most potent remedy, fair, clear complexion, aged eighteen, has been affected with
.
397 from the period of her first being unwell, 1st. A naturally-contracted os or cervix uteri. 2nd. A contracted or strictured condition of the passage which occurred at the age of fifteen years and a half. At the first periods these acute pains were considered the result through the neck of the uterus, from previous inflammation of inflammatory action, and the warm bath, leeches, and anti- and ulceration. monials were exhibited, with the effect of relieving her con3rd. From inflammatory congestion of the substance and siderably. Each subsequent period was attended with the lining membrane of the body or neck of the uterus, and sometimes of both, with or without ulceration, giving rise to temsame pain, which, however, had rather increased during the past nine months. Prior to her applying to me, internal porary obstruction of the passage. 4th. Obstruction of the passage, from tumours or morbid remedies had repeatedly been had recourse to, without any but temporary relief. My attention having been previously growths. From my investigations, I incline to the belief that if the drawn to a contracted condition of the uterine passage, as a cause of this disease, and seeing no other cause to account subjects of dysmenorrhoea are carefully examined, one or for it, as the other ordinary remedies had been applied in other of these causes will be found to exist, as the produce!* vain, I immediately proposed an examination, which, after of this painful disease. The third cause, I believe, is often the lapse of another month, and a period of great agony, was associated with the second, especially at the monthly periods, acquiesced in. A small speculum being introduced, I found and will therefore explain why, in such a case as spoken of the cervix healthy in its density and appearance. The os by Ashwell, lie should have cured the stricture without dimiuteri was very, very small, and round-not tench-mouth-like, nishing the menstrual suffering. With regard to the first as usual-it appeared more like a slight depression, than an cause, few authors seem to have paid much attention to i.t, oc opening. I attempted to pass the smallest bougie or probe I to the valuable cases brought forward by the late Dr. Macinhad, and found a great difficulty in getting it beyond half an tosh, but on what grounds it is difficult to conceive, when he inch forward. Contented with this, as a cause of the disease, brings beforethe profession twenty-four decided cures out of I determined to pass the bougies two or three times a week. twenty-seven instances he met with and treated, where he For the first week I was obliged to keep to the same-sized believed the cause to be entirely the result of a contracted as instrument, which, however, I was able to pass along, each or strictured canal. Capuron, in his writings, believes ill the time, considerably further; after which I was able to increase cause, but considers it a rare one. Ryan, Churchill, Aslkwell, the size (had I wished it, or thought it desirable) every third and Waller, all mention the subject, the latter, however or fourth time. only to remark,We cannot speak of this plan from personal The first period after the treatment was commenced passed experience, never having given it a fair trial, but it seems difficult to explain the effect by the cause supposed." Drover with as much, if not more, of pain, which I attributed to the irritation and swelling produced; but it was satisfying Ashwell, in his very able treatise, states " that he believes to my mind that the pain was considerably diminished after the views of Dr. Macintosh are more correct than are genethe first two days, which had not been the case formerly. rally supposed, and should not be disregarded." He speaks The next period was attended with a much less degree of of one case where he satisfied himself that narrowing of the pain, which put my patient in good heart with the treatment canal existed, which he cured, but without relieving the dyfithat was being pursued, and gave her encouragement to put menorrhoea, as just mentioned, and he remarks, " in another case I was more successful, and Dr. Ryan entirely cured one up with it. It will not be necessary to detail the case more minutely; of the very bad forms." I have now treated with success fom sufficient to say, that the uterine passage, in the course of cases where the disease was clearly referable to this cause, but three months, was considerably and permanently dilated, and my experience would lead me to say, that as a cause it is not that the dysmenorrhoea diminished with the dilatation. At so frequent as the second and third. I have at the present the end of four months (during the latter month the bougie time under my notice, two cases (in sisters) suffering from was only passed occasionally) she considered herself well, the dysmenorrheea from this cause, but who will not submit to last period having given her but trifling annoyance. On two any but palliative treatment. Professor Simpson, my respected subsequent occasions, also, I am informed the same freedom midwifery instructor, has, I am informed, in some cases where from pain existed. The only internal remedies given were dilatation has proved difficult, had recourse to incision of the tonics, with liquor-potassae at first, subsequently combined neck of the uterus. Of this plan I have no experience whatwith one of the mineral acids, and an occasional pill of hen- ever, nor can I imagine a case where it can be necessary, (and surely such an operation ought not slightly to be takea bane, colocynth, and blue-pill. the sound or bougie is steadfastly emCASE 6.-The above case introduced me to another similar, ployed, and the lunar caustic used occasionally, to aid. in a young lady, of twenty-one years of age. The Of the second cause, I have met with several rhoea, without membrane, had existed from the commencement above briefly related, being one. The symptoms of her menstruating life, (which was late, being beyond ninethe the commencement of the dysmenorteen years old,) but had increased during the twelvemonth. The uterine passage in this case was likewise much con- rI’oea were those of ulceration of the cervix, and without cloubt extending into the uterine neck. Although in this case tracted, but not quite so much as in the above, yet I found a were no indications of present inflammation at the greater difficulty in dilating the passage. I consequently had recourse to the nitrate of which had the desired effect, of my first seeing her, yet it is worthy of remarks, that the but with the annoyance of at first occasioning a good deal of case under the bougie alone did not go on satisfactorily. It is therefore, in these instances alone, sufficient to cure the pain and irritation in the system; this, a cessation for a not, strictured part, for if it depends, as I believe, upon prior an with the exhibition of occasional week, night, put a an end to. This case terminated favourably, but still not and although you may cure the contracted quite so satisfactorily as the other. She has since had some condition of therefore, the cervix yet the next period may give rise to little annoyance, although only for a few hours prior to mensame effects, membrane is altered in its action struation none, however, as before, during the some means, and I believe the nitrate of silver, locally by week. This patient’s health considerably improved, and the to be the best. It will be seen that in the foregoing discharge has increased in quantity and improved in appearance. applied, cases I have used the nitrate in the solid form, or that at Remarks.—I have met with and treated another case of ointment. At first, I used it as an injection, with extract of dysmenorrho3a with membranous formations, of which I have conium, but found frequently such severe pains to follow from notes, but being, in most of its particulars, so similar to those the distention of the womb, that I have entirely laid them above given, I feel it would be but repetition of language to aside. In the womb never impregnated, the ointment or relate it; suffice it to say that I satisfied my mind that the solid nitrate will not produce (generally speaking) one half internal membrane of the body and neck was in a diseased the painful effects of an injection of three grains of the same state, accompanied, at the periodical flow, with an almost to an ounce of water. On using the latter for the first time,. I closed condition of the whole cavity, and that the use of the have, with one exception, found it to produce a smart attack nitrate of silver, together with the employment of the bougie, of pain, lasting many hours, precisely similar to that of dyshad effected a cure, not forgetting, however, to lay due stress menorrhcea. Whilst speaking on this matter, I may remark, on the internal administration of mercury, and vaginal supwhat has been omitted in the cases, that I have found it -a-dvisable to commence the treatment a day or two after menpositories of iodine and mercury. My opportunities have not been few of seeing this disease struating, and, for the first time at all events, to desist fraas. iluring the past eight or nine years, and my observation it at least from four to seven days prior to an expected re-
dysmenorrhoea
dysmenor-
past
in hand,) provided
case No. 2, of patient prior to
tirne
there
silver,
opiate at
commencing;
having been peculiarly directed towards it, I have been led to believe that dysmenorrhœa depends upon the following pathological causes: -
instances;
inflam-
mation, tendency to such may still exist at the monthly periods, the
unless the
turn.
With respect to the third cause, it, with the foregoing, consider by far the most common of dysmenorrhœa; certain
398 it is that I have met with the membranous formations alone with this third cause, whether the individual has been ple-
habit, or the contrary. Inflammatory congestion and ulceration, however, of the lining membrane of the uterus is not sufficient of itself to produce dysmenorrhosa. I have had thoric in
many, many cases which prove this. One case of a lady on whom I was called in consultation by Dr. Bowie, of Bath, and whom I subsequently attended since my residence in London, showed this; the whole of the lining membrane of the cervix was diseased, and the disease I have reason to believe extended into the body. The whole uterus was enlarged and indurated. The uterine canal, however, was large, so that the largest Hexible male bougie I had, passed readily. This lady, neither at the monthly periods nor at other times, complained of acute pains of any kind; in fact, I used to tell her I thought her case went to prove there were no such things as uterine nerves at all ! for although I repeatedly introduced ten, fifteen, and twenty grains of nitrate of silver into the uterus, by means of the yet no pain or uneasiness was In cases 3 and 4, the cause was evidently ever complained of. traceable to inflammatory congestion, &c.; both were accompanied with the expulsion of membranous shreds, the true nature of which has engaged much discussion. For my own part, I look upon them as the proceeds of a diseased mucous taking on the same peculiar form of action which is sometimes seen in other mucous membranes, to wit, those of the urethra, trachea, and intestines, and producing effusion of organizable lymph. The case No. 4 presents the more chronic form of the disease, and, as is not unusual, had induced an indurated condition of the cervix, which can alone be to a chronic form of inflammation. It is well to bear this ascribed in mind in cases of habitual dysmenorrhœa in individuals at all possessed of a cancerous diathesis. I cannot help feeling convinced, from the experience I have had, that all these cases with membranous formations are traceable to the third cause specified; for although, during the periodical intervals, the inflammatory condition is not in an active state, yet the disordered condition of the mucous membrane, I believe, does ,exist in a quiescent form. Now it is known to every one that at the monthly periods, the uterus, even in a healthy condition prior to, and during the time of its parting with, its periodical -flow, is in a congested state; this, therefore, independently of other causes, will suffice to light up the inflammatory mischief, the whole mucous membrane swelling and assuming that peculiar action which produces these anomalous formations. In each of the cases of this kind that I have examined, I have found the uterine passage blocked up by inflammatory I believe I am supported swelling; and in favour of my by almost all authors in asserting, that the pains are almost invariably more severe in proportion to the size and number of the masses thrown off. In turning consideration to the character of the pains, it is next to impossible not to observe that they present almost all the characters of those of the womb, in its efforts to expel its natural burden. " They resemble those of labour; the patient bears down with considerable effort, and after many abortive attempts, a paroxysm of uterine suffering is relieved by the expulsion of a small concrete clot,
porte-caustique,
membrane,
views,
detached portion of membrane."* In reference to the cause No. 4, one case alone has occurred under my care, but which I took but little notice of at the time: it was in a young woman about the age of thirty. She had for a year or two complained of weakness, lumbar pain, with leucorrhcea, for which she had been under treatment without benefit. Within three or four months of my seeing her, she had suffered pains at her period of menstruation, sometimes more severe than at others, but not sufficient to lay her by. The menses had been both more frequent and copious during the prior eight months. On examining, I found .a small polypoid growth about the size of a hazel nut, blocking up the os. It was attached about quarter of an inch up the passage. I at once removed it by torsion, applying caustic to the root. My patient got well, and with its removal ceased the monthly pains. Now whether the obstruction was the cause of the pains, or the irritation produced by its presence, it is difficult to say. I am inclined to think that both operated to induce the effect. It appears to me unnecessary to extend this paper (which is intended alone as a practical one) by any remarks as to the modus agendi of the nitrate of silver upon the mucous membrane of the womb. Its action in other parts is sufficiently well known, and the same is applicable here, especially in most diseases of the mucous tissues atlecting secretion, and also in - external ulcerations. It has long been known to cure " that r a
* Ashwell, Dicases cf Females.
inflammation of the cervix uteri depending on increased irritability of the part." I am inclined to think that the nitrate of silver acts as a local tonic, of no small importance in the cure of the above disease. Upper George-street, Bryanstone-square, March, 1849.
REMARKS ON CONSTITUTIONAL SYPHILIS.
By GEORGE
L.
COOPER, Esq., F.R.C.S.E.,
SURGEON TO THE BLOOMSBURY (Continued from
p.
DISPENSARY, &c.
422, vol. ii.
1848.)
IN a former paper, I endeavoured to lay before the profession few incidental remarks on constitutional syphilis; and on proceeding with the subject its interest much increases, but intricacies and difficulties by no means diminish; yet notwithstanding the curious and perplexing histories which have been written on this form of disease, it behoves every admirer of science and philanthropy to think and speak for himself, "laudatur ab his, culpatur ab illis," in other words, to exercise those faculties, the gift and blessing of our divine Creator, whereby the depths of learning have been fathomed, and the hidden treasures of knowledge and experience unfolded to the human eye. How often do we see those whose opportunities are most frequent and brilliant, not only cast aside the proffered gem of observation, but close their powers of comparison and description against a searching and inquiring world: humble may be the produce of his labours, and far distant any hopes of success, as in the words of the immortal
a
Shakspere :The ample proposition that Hope makes In all designs begun on earth below, Fails in the promised largeness; checks and disasters Grow in the veins of actions highest reared, As knots, by the conflux of meeting sap, Infect the sound pine, and divert his grain, Tortive and errant, from his course of growth."
The subject of constitutional syphilis, although abstruse, is yet important in the highest degree to the welfare and happi. ness of the general community. Notwithstanding the deep
unflinching attention it industry, how much remains
has received at the hands of investigated, which time alone, aided by the exertions of talent, can ever unfold, or unravel those mysteries of Nature; still Science, like the morning sun, must shine, and cast into the lowest abyss, to rise no more, the ignorant, and the perverter of truth and honesty. The contagiousness of constitutional syphilis, under circumstances, as explained on a former occasion, will scarcely admit a dissenting voice, but many points relating to this matter require further consideration prior to a final decision: indeed, little do I uphold, with any certainty, the theory entertained by a distinguished author on this subject, expressive of a latent morbid poison traversing the circulating channels of a male once affected by secondary syphilis, but subsequently, regardless of time or appearance, capable of engenderiing a similar disease in the foetus, should pregnancy follow a connexion, the female escaping contamination, is not in accordance with experience or practical observation, for every surgeon must have witnessed, and can bear ample testimony to, facts in refutation of this doctrine. Indeed, without entering into the theory of absorption by the uterus or Fallopian organs, daily occurrences on this point at once demonstrate and settle the question. Numerous instances to the reverse I could produce, were it requisite, showing the offspring of a father free from, and who were never affected by, the syphilitic taint. The fact of infants exhibiting veneral spots and fissures at an early period after their births, is unfortunately of too common occurrence; but inquiry leads to the development of truth, and generally points out the origin and source of this evil to be nearer home. I am fully aware that constitutional syphilis will lie latent for many years without any ostensible appearance, and at the expiration of a lengthened period, burst forth with much virulence; but the question of contagiousness in a latent and tranquil condition requires proof for our satisfaction or belief. If credited as a genuine fact, and worthy of record, no quarantine laws could enforce a sufficient purification, where demanded, previous to the sacred ties of matrimony. The susceptibility of some persons more than others to the ravages of constitutional syphilis, is a well-known circumstance, inasmuch as we find habits and temperaments so widely differing, more or less influencing the tone and general health of the individual, independent of the treatment exercised whilst under the primary forms of syphilis; and I firmly believe that with respect to all the appearances of this disease, and
to be