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ual dilatation, electrolysis, divulsion, and result in the eyes of the patient But if in a urethrotomy; internal and external, according few hours, toxic symptoms arise and death to the location of the stricture. Resorting to supervene, would you not censure yourself dilatation the canal is gradually restored to its for not being more conservative? Again, exnatural size by absorption of a portion of the tensive cutting of the anterior urethra leaves stricture tissue, each time the instrument is the canal defective in expulsive power. used. The explanation of this absorption, The urine dribbles away from these widely which certainly does follow, is this, that at cut canals at the end of each act of urination, each instrumentation the sound ruptures some more than from the normal urethra, and many of the fibres, and also some adjacent capillar- patients complain of the inconvenience. If ies, allowing the lencocytes to escape and in- any instrument can be passed at all, the steel vade the tissues, thus causing a minute inflam- sound is the best, safest, and leaves a more matory process, which absorbs a small portion normal canal. When pursued with gentleness of the stricture. This is repeated from time the patient need not be confined to the house to time until all or a major part of the band for an hour, nor lose a day from business and disappears. The most important feature in the risk of exciting complications is at a minithe treatment by dilatation is a proper regula- mum. The treatment is longer surely, but if tion of the intervals to be allowed between the surgeon will imagine what his own wish the sittings. The rule is, “ that it is bad sur- would be were he in the patient's situation, he gery to re-introduce an instrument, unless it will not hesitate to adopt the safer, but more be filiform-before the lapse of at least seven tedious method. ty-two hours, and that more progress will be When a stricture becomes SO contractile made by waiting till after ninety-six hours,often and dense that dilatation is out of the question, even until the sixth, seventh, or eighth day." then the open method of treatment is the
So far as electrolysis is concerned, I cannot safest, best and will yield the most permanent satisfy myself that any current which could results. By this I mean the perineal section with safety be used in the urethra, could have of Syme, or a modification of it, such as Harany effect in so dense and unyielding a tissue rison's combined method of internal and exas stricture tissue. It is possible that the cur- ternal urethrotomy. In this way you can cut rent may add to the effect of the sound a cer- your stricture through and through and with a tain'stimulating action, and in this way be of hole in the perineum for drainage, we have a some value. But I have classed electrolysis as plan which has proved both safe and satissimply a modification of gradual dilatation. factory. Divulsion I do not favor, as it is an unneces
If there is any force in the observations I sarily rough procedure, is attended by danger have brought before you to-day they are these, and does not cure radically, as the sound has first, that gradual dilatation is still the most to be used afterwards.
approved method of treating urethral stricture. There are strictures so tough and resilient Second, the importance of applying to the that the sound has no effect on them whatever. treatment of wounds of all kinds involving They are not necessarily extremely hard the urethra, those principles which are the strictures, but are very tough and elastic, so basis of Listerism, namely, drainage and that the passage of a full sized sound will not
cleanliness. There is no part of the human rupture any of the fibers. These can be cured body to which disregard of these conditions is by dilating urethrotomy, if in the pendulous more likely to be attended with disastrous urethra, and if in the deep urethra by com- consequences. bined internal and external urethrotomy. In
In conclusion, gentlemen, most speakers these days of the heroic use of the knife, begin with a text; I prefer to end with one; many surgeons, following the teachings of urine can spoil tissue as well as blood. Otis--whose dictum is too dogmatic and applied too sweepingly-lay open the urethral Read the new advertisements in this issue canal indiscriminately, and marvelous is the of the JOURNAL.
Neuralgia and its Treatment. enfeebled action in the cells there will be
electrical disturbances in the nerve centers, Read before the Topeka Academy of Medicine which will be manifested as a hyperaesthesia and Surgery, at Topeka, Kansas, October of the peripheral terminations. 7, 1890.
In disturbed electrical conditions of an ex
hausted center, altered electrical currents will BY R. E. M'VEY, M. D., OF TOPEKA.
transverse the nerve, sometimes producing PROFESSOR OF CLINICAL MEDICINE IN KANSAS MEDICAL coarse stabbing pains, these coarse pains, tem
porarily overcoming the sensibility of the
nerve filament, and we have in the affected In considering the treatment of neuralgia nerve, hyperästhesia alternating with anæs
thesia. the subject will be confined to what may be regarded as the curable forms of the disease,
Pains produced in any portion of the nerve leaving out the question of organic affections filaments a re referred to their terminations, of the brain and spinal cord, and the neural- but the central cells in the grey matter of the gias caused from periosteal and osteal diseases cord are the receivers of sensations, painful or and from tumors.
otherwise. This fact is well illustrated in amIn the treatment of any disease some knowl- putation of the leg. When the stump of the edge of its pathology and general behavior is divided nerve is irritated, the disturbance is necessary for the intelligent guidance of the referred by the patient to the foot or toes, the physician. The pathological lesion of a central cells not correcting the error . until neuralgia may be both central and peripheral. either the sense of sight or touch is brought The sensory nervous filaments originate in into requisition. In obstinate and protracted the grey substance of the nervous centers and neuralgias of the fifth pair, painful branches terminate in the sensitive membranes of the distributed to the face have been divided, withperiphery. The neurilemma of the nerve out any permanent benefit to the sufferer, trunks are penetrated by blood vessels, for showing the disease to be central. After the retheir nutrition.
moval of the ovaries for ovarian neuralgia, Neuralgic disease may be regarded as the when caused from excessive sexual excitement result of trophic and circulatory changes the disease often returns after the operation brought on by an exhausted condition of some when the marital relations are re-established, part of the nervous system. Exhaustion in the disease not being in the ovaries but in the the nervous centers may be produced by over- central cells of the cord. The nerve trunks powering mental influences or by sexual ex- are subject to vaso motor disturbances, from cesses and by whatever overtaxes the nervous central causes, which either constrict or dilate energies.
their blood vessels. In the long continued and intractible forms If there is insufficient blood in the nervous of the disease, it may be assumed that there centers, there will be irritability with functionare atrophic changes in the central cells of al disturbances in the organs of the body, the grey matter in the posterior columns. If which are called upon to perform some extra the central cells in the posterior columns are exertion. The blood may be sufficient in subjected to long and protracted excitation quantity but deficient in quality or contain their receptive faculties undergo alterations, foreign elements, specific poisons, as malaria by which ordinary sensations are grossly ex- or syphilis or the poison of rheumatism and aggerated, and normal stimuli may be received gout, either of which cause neuralgic pains and transmitted in such a way as to cause in the branches of the fifth pair, which are pain, which is referred to the peripheral ter- distributed to the face. Neuralgias of the minations of the nerves. When the heart is lumbar region and of the sciatic nerve are exhausted its action is quickened, as in an ex- often found to be of rheumatic origin. haustion of the cells of the posterior columns, In the peripheral forms of neuralgia, the their molecular action is enfeebled and with blood supply of the terminal sensory fila
ments are affected by sudden lowering of the douloureaux and sciatica. Two grains may temperature, either alone or accompanied by be given every hour until fifteen grains have dampness, which chills and depresses the capil-, been given. If atrophic changes in the cenlary circulation in the exposed parts. The tral cells are suspected strychnia in very small terminal sensory filaments are affected by al- doses, thy of a grain may be given twice terations in blood supply, by vascular con- daily. strictions they are rendered anæmic and by If there are atrophic alterations in the tervascular dilations, hyperæmic. A man lies minal filaments the at night with one side of his chest exposed to Alkaloid strychnia grains 1. a cold draught of air from an open window,
ounces 12. the next day he finds he has a pleurodynia. may be rubbed over the anæsthetic surfaces, The surface vessels of that side of the chest have been chilled. There is diminished blood twenty-five drops at a time, and the parts then
covered with oiled silk. supply, in the parts and pain has been pro
A five per cent. solution of the hydrochlorduced as a result.
ate of cocaine, may be applied locally over the TREATMENT.
sensitive foci in facial neuralgia, and its abLocal pains are best treated by hypodermic sorption promoted by a compress saturated medication, this treatment being quick and with chloroform. certain. The introduction of medicine hypo- The positive galvanic sponge electrode, dermically, may be done safely if the needles saturated with a five per cent. solution of and syringe be kept aseptic.
cocaine and applied over the painful surface By the use of hypodermic medication we will often give relief. Dr. Richardson was know exactly the amount that reaches the the first to recommend the induction of anæstissues and circulatory system. Neuralgic thesia by the use of a chemical in conjunction patients who have taken large doses of narcot- with the galvanic current. As the retention ics, without benefit, are sometimes cured by a of the medicine in the affected parts is of few hypodermic injections of appropriate great advantage, in holding the pain in check, medicines. The injections should be made in bandages should be applied over the affected the tissues surrounding the affected nerve. parts for this purpose.
But it is not necessary to make the injec- In the treatment of long continued cases of tion over the diseased point if there are indi- neuralgia, the hydrochlorate of cocaine should cations of inflammations resulting from be used in small doses. Dr. Corning injected previous injections. Timid patients who re- hypodermically a solution of one half of one fuse to be treated hypodermically, can be re- per cent. to the amount of one hundred lieved often by the local application to the minims in sciatica, along the the course of the affected parts, of:
nerve, which relieved the pain from twelve to Morphia acetate grains 4. twenty-four hours, it being repeated if the Spts. chloroform
drams 4 pain returned. He retained the medicine in Which should be put on antiseptic cotton and the tissues by means of a tourniquet applied covered with oiled silk. For hypodermic near Pouparts ligament. In spondylalgia, Dr. treatment the sulph. morphia, grains 12, and Corning uses a fine needle about three inches the sulph. atropia, grains do, are therapeuti- in length, provided with a handle and a slidcal agents, which have long been in use and ing nut, which may be fixed at any portion of have proved efficient remedies in controlling the needle by means of a screw. This needle neuralgic pain.
he thrusts down about half an inch laterally, In visceral neuralgia the tr. nux vomica is from the spinous process of the tenth dorsal indicated, as in gastralgia and hepatalgia. The vertebra, until the bone is reached. The nut tr. gelsemium is a most valuable remedy in is then pushed till it rests upon the skin, neuralgia of the face. It should be given in when it is secured by means of the screw. small doses, not above four drops every four He then introduces a fine canula, with a slidhours. Croton chloral is efficient in tic ing nut, to the distance previously noted on
the needle. A hollow needle is now attached doses may be continued for some length of to a syringe of one-hundred minims capacity. time.
The syringe is filed with a one-half of one per In syphilitic neuralgia, the biniodide of . cent. solution of cocaine and emptied deep in- mercury is a specific. The iodide of potassium to the tissues over the cord.
also affords relief by antagonizing the syphilIn the constitutional treatment of neural- itic poison. gia a knowledge of the family history, show- Reflex neuralgias may be controlled by the ing the nervous tendencies, is necessary. sedative action of cocaine, over the central
We can not build a substantial structure nervous system, administered internally. with a faulty foundation. Where the nucleus There are various preparations made by the of the cell is faulty and unstable in its func- manufacturing pharmacists for internal use. tions little can be done toward its permanent One of these, a cordial prepared by Parke, restoration. Where there is faulty cell func-Davis & Co., contains 60 grains of coca leaves tion, there will be alteration in the blood, to the ounce and the dose is from two to four secretions, absorption, assimilation and nutri- fluid drams. This cordial represents the drug tion. Deficiences found in the blood are in a palatable form, commending it especially effects instead of causes and exist previous to for the large class of persons of delicate nerthe local pains of neuralgia.
vous organizations. In small doses cocaine is Medicines cure the affection chiefly by in- a cerebral stimulant, it increases the pulse and Auences which cause the food to be transformed respiration and raises the body temperature. into healthy blood. In the central forms of
Phosphorus is a nutrient to the nervous neuralgia with atrophic change, quinine heads system and in all cases of chronic nerve exthe list of restorative remedies. It should be haustion it is of great value. As neuralgia is given in small doses as it should be continued an expression of exhausted nerve power and for a considerable length of time. It increases
lowered vitality, the oleum phosphoratum, the blood supply of the central cells of the containing one per cent., may be given in cord.
doses of from one to two minims, or in officiAntipyrin is a doubtful remedy only in tal pills, one one-hundredth of a grain each. neuralgias of rheumatic origin. It quiets
In centric tic the drug has given very decided pain through its analgesic effect. Fifteen
relief. grain doses are generally, sufficient for neural
In the young cod liver oil is indispensable. gias of rheumatic origen, as in lumbago, It is easily digested and readily assimilated, a sciatica and the supra orbital affection.
medicine which improves nutrition and supPhenacetine may be used in neuralgia due plies deficiencies of the blood. to malaria, vaso motor disturbances and neur
In all cases of neuralgia hyper-nutrition is asthenia. The dose is from five to seven grains
the best treatment. It should be the first and repeated from .
four to six times a day, the last. Exposure and exhaustion either Phenacetine may also be used hypodermical- mental or physical, must be avoided. ly.
There is nothing better for a man than that Iron and arsenious acid favor the transfor- he should eat and drink and that he should mation of food into blood and improve nutri- make his soul enjoy good in his labor. tion in the nervous centers.
Patients subject to neuralgia should eat food In prescribing the products of Manufactureasily digested and assimilated and which ing Pharmacists, we should be guided to a contains iron, phosphorus or whatever sub- great extent by the business standing of the stance is deficient.
manufacturers. No other house in the South Malarial and syphilitic neuralgia require or West has a better reputation for strict inspecific treatment. In neuralgia of malarial tegrity than the firm of R. A. Robinson & Co., origin, the sulph. of quinine is indicated and Louisville, Ky. We do not hesitate to recom, should be given in large doses and repeated mend the preparations advertised by them on until the pain is relieved, when prophylactic page ii, this issue.
Major Pelvic Troubles.
existing pelvic disease, even though slight, 110
cervical operation ought to be tried unless CERTAIN CAUSES TRACEABLE TO MINOR absolutely required by the condition of the GYNECOLOGY.
patient. Another operation which has met
with much approval in many directions, and BY JOSEPH PRICE, M. D.
which some measures of success seems to fol
low in some cases, is the forcible dilatation of [Read September 4, 1890.]
the cervix. It is feared that where there is anWith the present popular cry of “conserva- tecedent inflammation of the pelvic viscera, tism,” in reference to operation in cases where that is of the genito-urinary system, such an it is held that all treatment should be tried operation as surgical dilatation of the cervix previous to real surgical interference, it is cannot be free from danger. In order to reworth while asking whether this preliminary lieve dysmenorrhoea by this procedure, it must treatment should not itself be abandoned in evidently be due to stenosis of the os or certhe hands of those who plead most pathetical vix. The question here arises, can it be told, ly for it. Their cry is not a scientific plea, in dysmenorrhea, wherein its causes lie? Somebut in most instances a personal bid for in- times, but not infallibly. The fact is, that in dulgence while they try to accomplish some many women where a stenosis would be diagthing, without acknowledgiug on the one nosticated, there is no difficulty whatever athand that there is little or nothing to encour. tending the menstrual flux. This being the age them in their work, so far as results are case, it is evident that a diagnosis cannot be concerned; and on the other, that there are made by simple observation without a careful abundant proofs from the cases that have study of all the symptoms. Again, in many come out from under their hands, with one women the causes for this condition are comtreatment or another, that manifold really plex. It will not do to lose sight of this, and major surgical affections arise merely from conclude that because a flexion exists dilatatreatment recognized as orthodox from the tion will remedy menstrual pain. It is to be standpoint of minor gynecology. So far as remembered that if there is co-existing pelvic my own experience is concerned, I do not inflammation, dilatation will increase it, and, hesitate to put minor gynecology in a causal under certain conditions, cause it if absent. relation with a vast amount of the necessary Rapid dilatation of the cervix is a distinct major pelvic surgery coming under my atten- traumatism, and along with it run all the dantion.
gers incident to septic absorption that attend First among these causes may be mentioned any other violent procedure, and where trauthe Emmett cervical operation. Like many matism incident to natural causes is confessed other surgical operations, this, when first ex- to be the cause of so much subsequent misplained by its distinguished originator, was chief, it ought not to be expected that operative done in season and out, by everyone, without injury can be harmless.
This conclusion, the least consideration of its contra-indications. reached inferentially, has been abundantly Very many minor tears of the cervix, in which confirmed practically on the operative table a cosmetic effect only is obtained by opera-i by much of my later pelvic work. In a num tion, are made distinctly worse by operative ber of cases with a history of preceding dilainterference. In many cases the pain becomes'tation, the after-operation has exhibited an insufferable, from the lighting up of a dormant inflammatory condition of affairs as complicator unrecognized pelvic trouble, and operation ed as any other in my experience. Some of is required to undo the mischief of an unneces- the dilatations were done with pre-existing sary cervical closure. This fact has been disease, which was made worse by this interferrecognized by Emmett himself, and he has ence, while others were done simply to relieve counselled the careful selection of cases in the dysmenorrhæa, and resulted in the estaborder to escape these disastrous results. It lishment of a complicated surgical disease in should be set down that where there is pre- which operation was necessary purely to save