Imatges de pàgina

fraud, which, in the present day, is not very uncommonthat of dressing up the opinions of others in his own words. The practical part of this book, although brief, is valuable; he has evidently extensive opportunities of witnessing disease, and is not without the requisite ability and industry to enable him to profit by his experience. Should a more systematic work on inflammation ever issue from the same pen, which is indirectly promised in the preface to the present Essay, we venture to predict, with much confidence, that it will not only reflect credit upon the author, but confer a benefit upon the profession in general.

In looking over other works, which have been fortunate enough to gain the Jacksonian prize, we have occasionally been struck with a glaring inadvertency in the authors, from which Mr. James is entirely exempt. We have seen cases detailed with the names of the patients and consulting surgeons at full length, although the latter would, in all probability, be one of those who would ultimately decide upon the comparative merits of the work. This is improper in every point of view; it discloses the author as effectually, as if the regulations of the College with respect to the candidate Essay were paid no attention to, and may even create a suspicion of an undue bias and favour on the part of those, whose decisions, we are quite certain, are influenced only by the strictest impartiality.

XI. On the re-establishment of a Canal in the place of a portion

of the Urethra which had been destroyed. By HENRY EARLE, Esq. Surgeon to the Foundling Hospital, and Assistant Surgeon to St. Bartholomew's Hospital. Quarto, pp. 13. From the Philosophical Transactions, 1821.

The male urethra, as Mr. Earle justly observes, being a part which is called into action after very short intervals of repose, any impediment to its functions must be productive of constant sufferings. Aflections too of the urinary organs, exert a more than commonly depressing influence on the buman mind, since these organs are destined to perform a double office in the animal economy, one of which is no less than the propagation of the species. In the following case the patient was raised from a state of great despondency to comparative happiness. " Case. John Whittaker, a seaman, fell with one leg on

each side of the gunwale of a boat, in May, 1813, by which accident the urethra was so injured in the perineum, that he was forced to have the catheter introduced for six weeks. From that time he continued to experience more or less difficulty in discharging bis urine ; and in May, 1819, he was attacked with a sudden ischuria, which was soon followed by an extensive effusion into the cellular substance. Mortification took place, and the integuments in the perineum, with about an inch of the canal of the urethra, sloughed away. A free vent being thus obtained, the mischiet did not extend itself to the scrotum. Several upsuccessful attempts, by the gentleman in attendance, were made during the healing process, to unite the integuments over the catheter. In the month of August following, the patient came under the care of our author in St. Bartholomew's hospital, with a large smooth cicatrix occupying the urethra, no vestige of which remained at that part. The mucous membrane of the canal was distinctly visible, terminating above, and recommencing below the cicatrix. Through the posterior aperture the whole of the urinal and seminal discbarges were evacuated, the canal anterior to the breach being increased in density, contracted, and likely soon to be obliterated. Our author determined on pursuing the following plan. The integuments on the right side had suffered less than those on the left, so that when a catheter was introduced, that portion which passed across the cicatrix could be about half covered by drawing the skin and cicatrix from the right towards the opposite side. Our author's first attempt was to encourage this disposition in the integuments to fold over; and, as some delay was required to dilate the anterior part of the urethra with bougies, he was directed to remain in bed with his knees tied together over a pillow, and a truss was so applied as constantly to press the integunents from the right to the left side.

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“ After some weeks the urethra being sufficiently dilated to ad. mit a moderate sized catheter, I determined to attempt the following operation. The smooth cicactrized surface having become insensible to the irritation of the urine, I resolved to employ it in the formation of a canal, and to endeavour to connect by it the two portions of the urethra : for, as many months had elapsed since the healing of the wound, all contraction in the cicatrix bad ceased, and it was probable that a passage formed of such parts would not be liable to any farther diminution in its calibre.

“On the other hand, I had to contend with two great difficulties: in the first place, the portion of cicatrized integument intended to be separated, was not of original formation ; consequently, it was endued with less vital energy, and possessed fewer bloed-vessels: econdly, it was not possible to allow the parts to be at rest for the completion of any curative process for many hours together : the force also with which the orine was expelled, and the acrid pature of that discharge, were alike unfavourable to the cure by adhesive inflammation. All these circumstances having been well considered, a portion of integument was removed about an inch and a half long, and one third of an inch in width, on the left side of the cicatrix ; the groove thus formed being intended to receive the edge of skin to be detached from the opposite side. An incision was then made across the perineam above and below, so as to pare away the callous edges of the urethra. The cutis was next dissected off from a portion of integument on the right side of the perineum, about an inch and a half in length and half an inch broad, leaving a smooth space of rather more than an inch between the cut surfaces, which was intended to form the lining of the per canal. The integuments on the right side were now dissected up, turned over a catheter, and brought in contact with the opposite groove. The detached portion of cicatrix bled little during the operation, and before it could be applied to the groove, the edge had so livid an appearance as to create an apprehension that it must perish. Two ligatures were employed to assist in retaining it in the desired position, and some straps of adhesive plaster and a bandage completed the dressings. The day following the operation, it was evident that some urine had escaped by the side of the catheter ; and on the third day, when it became necessary to remove the dressings, it was found that the portion of the flesh which had been denuded of skin had sloughed, but that a sufficient quantity had united above and below to form a canal open at one side, and large enough to include the whole catheter." 7.


This was as favourable a result as could be expected under existing circumstances. The two surfaces, from whence the integuments had been removed, were now suffered to heal, but as the cicatrix on the right contracted, it drew the newly formed canal rather to that side, and tended to increase the opening into it. . Soon after this the patient became much disordered in his health, and had an attack of lepra vulgaris, on which account nothing was attempted for some months, except several times freely excoriating the edges of the canal, and thus endeavouring to unite them by keeping them in contact. In this Mr. Earle was constantly foiled by the astowishing rapidity with which the skinving process took place from within outwards-apparently arising from the moist state in which the parts were constantly kept.*

* " In con oboration of this,” says Mr. Earle, “ I have lately employed bread and water poultices to healthy sores, which have skinned over with greater rapidity than un ler any other application. Since making these experiments, I have learnt that Professor KEBN, of Vienna, employs no other local remedy In the summer of 1820 another operation was deemed advisable.


“A deep groove was made on the right side, the surface was denuded of its cutis to some extent, a considerable portion of integument was then detached from the left side, and, in order to obtain healthy skin, I encroached a little on the thigh, and laid bare the edge of the fascia lata. Instead of passing any ligature through the detached portion, the old quill suture was employed, which was passed from the two outer cut surfaces. A pad of adhesive plaster was interposed between the ligatures and the flap of skin, to diffuse the pressure more generally ; and my patient, being now quite an adept in passing the catheter, was directed to introduce it about three times in the twenty-four hours, instead of retaining it in the bladder, which had permitted some of the urine to pass insensibly away, and had acted prejudicially in the former operation By this attempt much more was gained, and about two-thirds of the canal were completed; still, however, there remained a small aperture at the upper part. We again attempted to close this by denuding the edges with escharotics and the lancet, but it skinned over too rapidly to allow of any union between the opposite surfaces. A third operation on a smaller scale was therefore necessary, which sọ nearly completed the cure as to leave only an orifice large enough to admit a bristle, which has subsequently closed and at the present time, (March 1821, he remains perfectly well, and is able to expel the contents of his bladder pleno rivo."

P. 9.

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The above operation is very creditable to the ingenuity and perseverance of Mr. Earle. The breach in the urethra of Mr. Earle's patient appears to have been larger than in the cases operated on by Sir Astley Cooper, and published in that gentleman's Surgical Essays.

in the cure of ulcers, than water and a simple covering of linen. It is a curious fact, that in the sixteenth century, when the art of surgery was encumbered with useless nostrums and complicated instruments, and when the actual cautery and hot oils were the favourite remedies, that a similar simpli. city of treatment should have been employed by MAISTRE DOUBLET, a con. temporary of AMBROSE PAREY, of whom BRANTOME tells us,

6* Et toutes ses cures faisoit le dit Goubler par un simple linge blanc et belle eau simple de la fontaine ou des puits.'»

XII. A Treatise un Indigestion and its Consequences, called Ner

vous and Bilious Complaints ; with Observations on the Organic Diseases, in which they sometimes terminate. By A. P. W. Philip, M D.F.R.S. ED. &c. One vol. 8vo. pp. 391. Second Edition, with some additional Observations. London, 1822.

We cannot inform our readers more concisely of the changes made in the present edition of the above work, than by quoting the following short preface to this edition.

“ In revising the following Treatise, the author's only object has been 'to render it more useful to the practitioner.

“As hardly half a year has elapsed since its publication, any considerable enlargement of it is not to be expected; but he hopes that the present edition will be found in several respects improved. Many observations have been added, and an attempt has been made, in several passages, to explain more fully the principles which led to the treatment recommended in it, the author's confidence in which, he is happy to say, bas been strengthened since the appearance of the first edition, by communications from several physicians, to some of whom he has not the honour of being personally known.

“For the sake of hasty readers, who seldom see arrangement in a work where the subject is at all complicated, without numerous divisions and references, the author has introduced a greater number of these, which, to the diligent who bear in mind the plan laid down, and feel no difficulty in perceiving how the different parts of the subject arrange themselves under it, are often superfluous, and therefore unwelcome interruptions." Pref. xii.

It is impossible to follow the author through every part of the work, and note all the alterations which may be observed in it. They consist of additional observations, and the introduction of inore frequent titles, which render it more easy of reference. We shall quote from the additional observations in this edition, the following passage ou the combination of the second stage of indigestion and fever. After remarking ou the frequency of this combination, and stating his view of the general nature of fever, he observes :

“ Now, in those who labour under the second stage of indigestion, we have seen that some of those parts which greatly sympathize with the stomach, generally suffer most. These, therefore, are the weak parts which most feel the effect of the morbidly increased force of circulation in fever. Their vessels are most apt to suffer distention, producing congestion or inflammation, according as the distention is in larger or smaller vessels.

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