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M. CIVIALE ON NEURALGIA OF THE NECK OF THE BLADDER, &c.

This is an affection which is not unfrequently idiopathic and unconnected with any other diseases of the urinary organs, according to the experience of M. Civiale. It occurs in both sexes, but is much more frequent in the male; it is occasionally observed in young persons, but generally in adults and in those of advanced years. It may be induced by a variety of causes; either general, such as emotions of the mind, excesses in venery, or in the use of spirituous drinks; or local, such as retaining the urine too long, various lesions of the rectum or womb, a calculus in the bladder, constipation, &c. It is usually accompanied with frequent calls to pass water; with an uneasiness rather than an actual pain in doing so, and thus extending to the pubis, epigastrium, and umbilicus, or to the loins and down the thighs and with more or less anxiety of mind in almost all cases. It may be either single and exist by itself; or it may be complicated with contraction of the urethra, swelling of the prostate, calculus or catarrh of the bladder, &c. The catarrh of the bladder is often secondary to the neuralgic affection of its cervix, according to the experience of M. Civiale. One of the least variable of all the symptoms is unquestionably the intermittent character of the vesical distress. It seems, however, to us, that our author is disposed to regard neuralgia of the bladder as more frequently idiopathic and unconnected with any other existing disease of the urinary organs, than most surgeons will admit. He acknowledges himself that in those cases in which the affection is complicated with stricture of the urethra, it will generally cease spontaneously when the disease is successfully treated. We know, too, that, in spite of the great improvements which have been effected of late years in the diagnosis of the diseases of the prostate and of the cervix vesica, these are sometimes so obscure in their early stages that they may be readily overlooked. We state this, not with the view of questioning the accuracy of the data furnished by M. Civiale, but only to account for the repugnance which some may feel to admit as a distinct entity a morbid condition, which has generally been attributed to various organic lesions either of the bladder itself, or of the contiguous organs. Indeed we are willing to give great praise to him for having drawn the attention of medical men, in so able a manner, to an affection of the urinary passages, which has been too much overlooked, and which according to his experience may exist quite independently of any organic lesion. The treatment, recommended by M. Civiale, consists in the introduction daily or every second day of a wax bougie into the bladder, to be left in for from three to ten minutes at a time; in the use of injections of cold or of tepid water into the bladder; the use of douche baths; the external application of the tartaremetic ointment to the pubic region; the regulation of the bowels, the use of a mild diet, and the avoidance of stimulating drinks.

Diseases of the Vesicula Seminales, &c.

These organs, with the excretory ducts leading from them, are unquestionably subject to various morbid states, all of which usually take their origin in a subacute inflammation of their structures. M. Civiale describes three stages or degrees of this disease; but it is to be remembered that there is always considerable ambiguity in the symptoms.

In the first stage, the erections of the penis are more or less imperfect, the emission of the semen hurried and precipitate, aad the sensation which accompanies the act, sharp or even painful. Under such circumstances the daily use of warm hip-baths, and mild enemata, and the occasional introduction of soft bougies along the urethra, may be resorted to with advantage. But the most important means of cure is unquestionably abstinence from sexual connexion; and unfortunately it is the very one which is least likely to be followed by the

patient. To persuade a man in the vigour of age, and in whom, in consequence of the disease, the passion is more than ordinarily strong, that his desires are owing, not to an exuberance of vitality, but to a local irritation of his generative organs, is no easy thing.

Perhaps the best mode of effecting our object, is to direct the patient's attention to the effects which are usually the result of sexual indulgence in his own case; and he will confess that, after coition, he almost always experiences a prolonged exhaustion of strength, an unusual tendency to drowsiness, lassitude and sense of cold over the whole body.

In the second stage, the continued discharge from the urethra, when it does exist, becomes more abundant, coition is impossible, the semen escapes during the relaxation of the penis, and it is thin and inodorous. The use of cold applications to the pubis and perineum, of sulphureous douche-baths, of regular bodily exercise in the open air, of mild aperient enemata, and of some of the mineral tonics, constitutes the best treatment in such cases. M. Lallemand strongly recommends the occasional application of caustic to the deep-seated portion of the urethra: this, no doubt, is a valuable remedy; but it must be employed with caution.

In the third stage, all sexual desire is entirely abolished, and the erection of the penis is impossible; and the general health is almost always so much impaired, that local treatment holds out no prospect of doing any good. It is by fortifying the strength of the constitution, by travelling much in the open air, by a nutritious but mild regimen, and by living entirely en garçon, that any benefit may be expected to be derived. M. Civiale has given many valuable instructions both to patients and to medical men, clothed, too, in language altogether worthy of a delicate-minded gentleman, on the general management of cases of this description.

He devotes a chapter to the description of the various sorts of bridles (brides) or obstructions which are apt to be formed in and around the neck of the bladder, and which have of late years attracted a good deal of notice from pathologists. Some of them are membranous, others muscular, and a third set fungous. They arise either from inflammation of the vesical mucous membrane, or from swelling of the prostate gland. Whatever be their form or consistence, they are always situated on the lower edge of the vesical orifice of the urethra. When the obstruction is inconsiderable, the less that is done locally the better. If, however, the evacution of the urine is impeded, or threatens to be so, the steady and persevering use of soft bougies affords by far the best means of effecting a cure. Traité Pratique sur les Maladies des Organes Genito-urinaires.

SECTION OF THE MUSCLES OF THE EYE IN AMAUROSIS, &c.

M. Petrequin, chief surgeon of the Hôtel Dieu at Lyons, recently communicated the following observations to the Academy of Sciences.

"From what I had observed in several cases of squinting, I was led to suspect that amaurosis is occasionally attributable to a spasmodic state of one or more of the muscles of the eye-ball.

In the majority of persons who squint, there is at the same time a greater or less weakness of vision, especially on that side where the morbid deviation is most conspicuous. Now I have found that this visual asthenia, whether this be a primary or a consecutive affection, generally subsides after the section of one or more of the muscles, especially when the patient has recourse to orthopthalmic gymnastics. (What a phrase !) Hence the operation becomes an heroic remedy for amaurosis when it arises from this cause. The following cases will illustrate this position.

Case 1.-A young man was admitted into the hospital at Lyons for a whiteswelling of one of his fingers. He was also effected with an incomplete amaurosis of the left eye, which I could not trace to any of the ordinary causes. I remarked, however, that in certain movements of the eye there was always a tendency to a deviation inwards. Having repeated my observations during a month, I came to the conclusion that the spasm of the muscles exercised a great influence on the function of vision, and I determined to try the effect of dividing the two internal recti muscles. The sight of the left eye was immediately improved, and five weeks afterwards it was in every respect equal to that of the right one.

Case 2.-A youth, 17 years of age, was admitted with an injury of the middle finger which required to be amputated. The left eye had been for a long time almost completely amaurotic, so that he could not count my fingers held up before him; the blindness had come on without any appreciable cause.

In this case too I remarked that in certain movements of the eyes there was a tendency to them being turned inwards; and, acting on the principles which guided me in the treatment on the former occasion, I divided the two internal recti muscles. The amendment was instantaneous; and, on his leaving the hospital three weeks afterwards, the sight was so much improved that he could tell the names of large letters, and distinguish persons at a hundred paces' distance.

M. Petrequin states that he has met with equal success in a number of similar cases, since these two occurred.

He has also been led by several observations to conclude that entropion, in certain cases, arises from a spasmodic state of the orbicularis muscle of the affected eye, and that this species of the disease may be cured by the subscutaneous division of it, as recommended by MM. Cunier and Phillips. He gives the following case in which he performed the operation.

Case.-A man, 45 years of age, came to me with a complete entropion of the right eye; the lower lid was folded and rolled inwards, being curled upon itself in a concentric manner; precisely in the direction of the circular fibres of the palpebral muscle; when the finger was applied upon the part, the contraction was very sensible, epecially if a strong light fell upon the eye; the spasm was permanent. Stretching the lower eyelid at its outer angle with a pair of forceps, I passed a narrow bistoury about the middle part of the orbit, on the level of the osseous edge of the socket; then with a see-saw movement (par un mouvement de bascule) I pushed the point of the instrument as far as the free edge of the lid behind the orbicuralis muscle, and, in the act of withdrawing it, I divided its fibres completely. The lid becoming immediately echymosed-a firm compression was ordered to be kept up upon it. (The result of the operation is not stated.)

M. Petrequin closes his observations with mentioning that, in certain cases of blindness arising from opacities and other lesions of the cornea, in which the operation of making an artifical pupil is usually recommended, very decided benefit to vision may be obtained by dividing one of the muscles of the eye-ball, and thus inducing a certain degree of squinting, so that a transparent portion of the cornea may be brought into the axis of the organ. M. Cunier has the merit of having first suggested this new method of treatment; and M. Petrequin has adopted it in one case, where he divided the superior rectus muscle with marked advantage.

DIVISION OF THE MUSCLES OF THE EYE IN CERTAIN CASES

OF BLINDNESS.

When the central portion of the cornea has become so opaque as to prevent the transmission of the rays of light through the pupil, remaining sound, we may displace the axis of the eye, by dividing one or more of its muscles, so as to induce a certain degree of squinting, and thus bring a transparent part of the cornea in the direct line of vision. Such an operation is much more simple, and greatly less hazardous, than any of the modes which have been proposed to form an artificial pupil.

M. Florent Cunier, a well known ophthalmic surgeon in Belgium, claims the merit of having first performed it.

A man, 25 years of age, presented himself on the 21st of June, at his ophthalmic institution, with a strabismus of the left eye, which had existed from infancy. When two years old, he had suffered from a purulent ophthalmia, which had caused the destruction of this eye, and had left on the cornea of the other a dense opacity, which covered nearly the outer two-thirds of its surface; the inner third, which remained transparent, was almost quite concealed in the angle of the orbit, and was visible at those times only when the squint was made to cease. When this was done he could see near objects, by carrying them towards the nose, and then turning the eye as forcibly as possible outwardly. The anterior chamber of the cornea was normal, and the pupil was quite free and readily contracted on exposure to light.

On the 30th of June I divided, says M. Cunier, the internal rectus muscle; and immediately the pupil occupied the centre of the orbit, and the squint vanished. The eye being, however, not sufficiently drawn outwardly to enable the patient to see objects conveniently, I denuded the sclerotic as far as the attachments of the superior and inferior recti, but without causing the slightest degree of squinting outwards. Founding my practice on the experiments made by myself and Mr. Duffin, I divided the inferior oblique muscle; this was no sooner done, than at once the eye was drawn outwards and somewhat upwards. The ecchymosed blood in the cutaneous wound was rapidly absorbed; but the healing of the conjunctival wound was rather tedious, in consequence of the very considerable retraction of the muco-serous membrane induced by the displacement of the eye-ball. Immediately after the operation, the patient was able to guide himself through my garden; and six days afterwards he came alone to my house.

He now sees so well that he can distinguish the smallest objects, when they are brought near his eye. What is remarkable is, that the pupil has become displaced in such a manner that is now immediately opposite to the transparent portion of the cornea.

Case 2.-A middle-aged man, who had been blind for twelve years, was my second patient. The left eye was completely wasted; and only a part of the outer half of the right one remained transparent. By compressing the left eye, and turning the right one forcibly inwards, he could perceive the form of large objects. I divided the external rectus muscle, and denuded the sclerotic as far as the insertion of the superior and inferior recti; the eye was immediately drawn inwards so as to cause a squint in that direction, and I was gratified to find that the patient was able to see much more distinctly. Eight days afterwards, he could spread out in the market-place his wicker-baskets, which he made to earn a subsistence.

In a third case, in which the operation for forming an artificial pupil had previously been attempted, but without success, M. Cunier divided the external

rectus; and, although the case was certainly a very unfavourable one, considerable improvement of the vision was effected.-Gazette Medicale.

Remarks. This application of ocular myotomy is certainly one of the most ingenious and scientific that has been proposed. The operation for making an artificial pupil being always hazardous, and seldom successful, surgeons will gladly avail themselves of the practice suggested by their Belgian confrere. -(Rev.)

ON THE OPERATIONS FOR THE CURE OF STAMMERING.

A well written article, in which the reader will find an accurate description of the various operations which have been recommended and practised for the relief of stammering, appears in one of the late numbers of the Archives de la Medecine Belge (an exceedingly well-conducted periodical, published at Brussels,) from the pen of Dr. Zoude. We have no intention of re-producing its contents, however valuable they are as forming an historical document, and shall merely give the sensible conclusions with which the writer closes it: they are the following:

1. Glossotomy is far from effecting a cure of stammering in all cases.

2. When stammering is owing to a disturbed innervation of the tongue, or when it depends upon a shortening of the muscular substance of the hyo-glossi, or upon other analogous lesions, myotomy is inapplicable; because, in such cases, it would be necessary to divide the entire thickness of the tongue-an operation which is always highly dangerous.

3. A surgical operation is admissible only when the stammering depends upon a shortening of the genio-glossi muscles-as certainly is the case in a great number of instances.

4. In my opinion, the subcutaneous method of dividing the genio-glossi close to their attachment to the jaw, without wounding the mucous lining of the mouth, is preferable to any other.

The following judicious remarks are appended to the memoir of Dr. Zoude, by the committee appointed by the Society of Medicine at Brussels to report upon it.

"We have read the work of the honourable member with much interest, and recommend that it should be printed in our Archives as containing a fair account of all that has been written on this operation, (which, bythe-bye, has made much more noise than done good,) and as showing most satisfactorily that the section of the muscles of the tongue is not always so innocuous as its advocates wish us to believe. We sincerely trust that the attentive perusal of Dr. Zoude's memoir will abate the zeal of those who have been so enthusiastic in the praise of myotomy, by the vain eclat which has been given to the operation, and that, at the same time, it will diminish the willingness of patients to submit to it. We are deeply convinced that, as to the pretended improvements of modern surgery, it is most necessary to guard ourselves against admitting them too readily, and not to lose sight of the truth that the insatiable desire for notoriety and temporary success often makes a man work almost entirely for his own profit, when he is pretending that all that he does is for the progress of science: Nisi utile est quod agimus, vana est gloria nostra."

We (Rev.) need not say how entirely we coincide in the justness of these observations. The doings of not a few medical men, in this country as well as on the continent, in reference to the treatment of squinting, stammering, &c., by surgical operations, have been any thing but creditable to the profession.

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