Imatges de pàgina
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wise so varying a symptom as a discharge from a morbid surface appears to be an imperfect source of discrimination and nosological arrangement. And hence, indeed, the table of contents of this first part or volume, comprises a number of diseases, which have scarcely any common circumstance of approximation; for it includes disorders of the bladder and rectum, as well as those of the uterus and vagina. Hæmorrhoids and ascarides, therefore, stand between inversion of the uterus, and cancer of the same organ. This, however, is a mere question of arrangement, and does not materially affect the value of a practical work, where there is much information and accuracy in the detail.

The first chapter describes the natural secretions that take place from the uterus, vagina, lacunæ of the os externum, and the mucous membrane of the urethra. Among the first are the catamenia; the mucus of the lining membrane of the uterus, and Fallopian tubes; and the viscid secretion from the glands in the cervix, chiefly produced after impregnation. The second is the mucous discharge from the rugous membrane of the vagina, varying with the age, and health, and the various degrees of employment, which is given to that organ.

In the second chapter, Mr Clarke treats of the morbid discharges from the vagina, (which have been variously named by writers,) under the title of Profluvium vaginale." After quoting the descriptions of Sydenham, Mead, Čullen, Denman, Heberden, La Motte, and Hamilton, and objecting to the names of fluor muliebris, fluor albus, leucorrhoea, sexual weakness, whites, &c. which have been appropriated to this " vaginal discharge," as he prefers to call it, he informs us that it is merely symptomatic, and should not be treated as a specific disease, and defines or describes it as follows; "It is a discharge of a fluid flowing from the vagina, varying in its consistence, quantity, and colour; either produced by weakness of the constitution, or by a change in the structure, position, or action of the neighbouring parts, such change being the effect of natural or morbid causes."-The nature of the cause, therefore, will determine the choice of the treatment.

"If the discharge is the effect of weakness, and if by its continuance the original weakness is increased, tonics will be required. If it depends upon some tumour in the vagina, the removal or support of this will also remove the discharge. If it arises from inflammatory action, this must be removed before any endeavour to restrain it is employed; for as the discharge during its continuance lessens the violence of the disease which produced it, it should not be checked till such inflammatory action is diminished. Nothing can be more inju

rious under such circumstances, than the exhibition of tonics and stimulants, as cantharides, turpentine, and steel." p. 32.

The last observation is doubtless correct; but this seems to be rather a left-handed explanation of the injury committed. We are told that we should not check an effect of inflammation, while the inflammation continues; which, in fact, is really impracticable. Whereas the manifest injury of these stimulants, is, that they do not restrain, but aggravate both the cause and effect; or if they restrain the discharge, it is only by aggravating the inflammation to that high degree, at which the secretions are suspended. We doubt whether in many cases it is injurious to restrain the discharge from the parts," by properly removing the cause, " without substituting some other secretion for it," for we believe, that a little attention to diet and regimen will prevent most of these anticipated evils, even where the anticipation is not altogether groundless, which it commonly is.

The author next remarks, that there are three varieties of discharges which occur in different diseases of the female organs, but which do not occur in any one patient at the same time; these are the mucous, purulent, and watery discharges. To these he afterwards adds the sanguineous; and he subdivides the mucous discharges into transparent and white mucous discharges, thus making five distinct heads. He admits, however, -"that there are mixed cases, where the discharges vary from their usual appearance; moreover, a discharge of one kind will mark one stage of a disease, and a discharge of another kind a different stage. As happens in other discases of the body, one disease is also blended with another, and the discrimination of these modifications and irregularities, constitutes no small part of the skill of the practitioner." p. 33.

But we feel a little inclined to be sceptical respecting the importance assigned to this discrimination of mixtures of mucus with pus, and serum, and white mucus with transparent mucus; especially since we so well know the changes that take place in the discharges from other mucous membranes, from water to mucus, and mucus to pus, and how difficult it often is to say, what is mucus and what is pus; as for example, in a common coryza, or catarrh. As this volume contains only the two mucous classes of disease, the author principally defines these sub

stances.

"By transparent mucous discharge is meant that which is gelatinous, nearly transparent, and capable of being coagulated.-The white mucous discharge is opake, of a perfectly white colour; and it resembles, in cousistence, a mixture of starch and water made with

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out heat; or thin cream. This discharge is easily washed from the finger after an examination; and it is capable of being diffused through water, rendering it turbid. A morbid state of the glands in the cervix of the uterus probably gives rise to this discharge, &c." p. 35.

Before the author commences his account of the diseases accompanied by mucous discharges, he gives, in the 3d and 4th chapters, some "general observations on sexual diseases, and on the necessity and mode of making an examination per vaginam," and "on sympathies." The principal object of the former of these chapters is to urge the necessity of resorting to that examination, as affording, in the author's opinion, the only means of diagnostic in these diseases. "The existence of these diseases and their kind can only be known by an examination per vaginam." We hope and trust that this is not true to the letter; otherwise not only ourselves, but almost all our tribe, in all ages and countries, must have been, and are still, committing the sin of ignorance and malpractice in all these maladies, and no prescription can be right, but by accident. We suspect, indeed, that we should be very seldom consulted on these complaints, interesting as they are to the patients, if such was to be the discipline that every delicate woman should be required to submit to; and that the practice in these cases would at length be left in the hands of old women, or of those members of the profession who approximate nearest to that character. Surely the nature of any discharge may be equally well ascertained, without collecting it upon the finger, and then transferring it to a napkin, according to the directions here given. It is principally regarding the nature of tumours that any satisfactory information can be thus obtained. The analogies advanced in support of making this practice general, are not quite relevant. "Is it usual to prescribe for a sore throat, without looking at the fauces?" Certainly not; but what information respecting the nature of an ulceration would be gained, in the dark, by poking your finger into the patient's throat? Yet in many cases of diseased uterus, surely the nature of the discharge, with the progress and other symptoms, afford all the information for practical purposes that can be procured. We think, therefore, that both delicacy and practical propriety conspire to limit such examinations to cases, in which all the other sources of information have left the practitioner in a state of uncertainty, or in which the anxiety of the patient may induce her to determine a question of doubt by that means.

There is nothing worthy of remark in the chapter on sympathies; and we come, in Chap. V. to the description of " certain diseases attended by a mucous discharge from the vagina;"

the first four of which consist of the displacement of parts, and are the procidentia or prolapsus of the uterus, bladder, or vagina, and inversion of the uterus. The account of the procidentia uteri, its progress, symptoms, and causes, which occupies Chap. V., is exceedingly full and perspicuous. The description of the natural position of the uterus and its various degrees of displacement, with the means of ascertaining them, is obviously from the pen of an accurate observer, very familiar with the healthy and morbid positions of that important organ. One observation might not immediately occur to the practitioner, which is of importance if it be deemed necessary to introduce the catheter while the prolapsus remains; viz. that the bladder, being dragged down with the prolapsed uterus, instead of being contained in the pelvis, falls down into and forms a part of the external tumour, dragging with it the meatus urinarius; "so that in order to introduce a catheter into the bladder, the point of the instrument must be turned towards the knees of the woman; for, being placed in the usual manner in which that instrument is introduced, it will enter the passage, but cannot be made to pass into the bladder in that direction," p. 64. This is rendered very clear by the engraving in Plate III.

Ample and judicious directions are detailed in Chapter VI. and VII., in regard to the "Treatment of Procidentia Uteri," the indications of cure being to increase the strength of the parts which are weak, and to afford a support to the tumour, the descent of which produces the symptoms. The author premises, however, that if a woman having this disease should again become pregnant, and will consent, after her labour, to a confinement for some weeks in a horizontal posture, the parts may regain their tone, so as to render any artificial assistance unnecessary. Cold and astringent applications are chiefly to be relied on for restoring the tone of the relaxed parts; and Mr Clarke recommends cold water to be applied to the pudenda, abdomen, and back, with a sponge, three or four times a-day, and to be thrown into the vagina by means of a syringe. This plan, with the horizontal position, will remove the incipient symptoms of prolapsus uteri. Among the astringent applications, he prefers alum to the metallic astringents, which are too irritating if used sufficiently strong; but speaks with some praise of the astringent powers of decoctions of galls and oak-bark. At the same time the stomach is to be invigorated by bitters, and regularity of bowels to be insured by rhubarb or senna, with some aromatic; and the cold-bath may be resorted to with advantage, where no other circumstance contraindicates its use. Much importance is ascribed to the constant resort to a bed or

sofa, for the sake of the horizontal posture, and the use of a mattrass is preferred to that of a soft bed.

Where a complete procidentia has taken place, however, mechanical support, by means of a pessary, is commonly resorted to; and Chapter VII., which treats " of the mode of supporting the uterus," is in fact an essay on the shape, size, and proper materials of pessaries, and on the mode of introducing them. These observations are very clear and judicious, and may be studied with advantage by those who are in need of advice upon this subject. The author properly discards cork, wax, sponge, and other substances, and employs only box-wood, as combining lightness, with firmness and closeness of texture; and he distinctly demonstrates the peculiar advantages of particular forms and sizes, under obvious changes of circumstances, preferring the oval generally to the circular, and limiting the globular to cases in which the perinæum has been lacerated, and to those in which the prolapsus has been complete, and reduced: Upon the caution necessary to determine the propriety of attempting reduction, the author has stated some good practical observations.

In Chapter VIII. the characteristic symptoms of procidentia vesicæ are very clearly stated, as the means of distinguishing this from prolapsus of the uterus itself, and the mode of relief is pointed out. The tumour, in this case, necessarily varies with the distention or emptying of the bladder, though this is never completely effected. There is also an absence of those symptoms of deranged stomach which occur in the other case; and in the projecting tumour, at the lower part, there is of course no opening, which the os uteri occasions in the former. But the author remarks, that the peculiar symptom, which distinguishes this prolapsus from that of the uterus, is a pain referred to the navel, which is greatest, when the bladder contains the largest quantity of urine; and which he ascribes to the attachment of the superior ligament of the bladder to that part. Procidentia ve-icæ is best remedied, the author affirms, by hollow pessaries of a globular or egg-shape. All straining should be avoided, the bowels kept open, and the urine frequently evacuated.

The disease which the author calls procidentia vaginæ, is probably very uncommon, and not very manageable when it occurs. It appears, indeed, to be the result rather of over-distended and morbidly-relaxed rectum, than a disorder of the vaginæ itself, and it is chiefly to the restoration of the gut, that the author directs his remedies. The effect is a corresponding "relaxation of the posterior part of the vagina, so that this part is lower than the natural defined edge of the perinæum,"

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