^ THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID PRACTICAL OBSERVATIONS ON STRANGULATED HERNIA, AND SOME OF THE DISEASES OF THE URINARY ORGANS. BY JOSEPH PARRISH, M. D. KEY & BIDDLE, 23 MINOR STREET. 1836. N.\ . Entered according to the act of Congress, in the year 1835, by Key & Biddle, in the Office of the Clerk of the District Court, of the Eastern District of Pennsylvania. Philadelphia: T. K. ^^^ for diet, oatmeal- gruel, tapioca, &c. 3d. Pulse 80, soft and full; tongue clean; skin natural. The wound has partly healed by the first intention, and the remainder is suppurating. The patient is permitted to lie on her side, and to eat the soft part of an oyster every hour. 4th. Pulse 80; skin natural; tongue clean. The pa- tient has had three evacuations since the last report. The abdomen is flaccid, and entirely free from pain on pressure. This patient perfectly recovered. CASE XXV. Strangulated Femoral Hernia — Dark and hardened Omentum — Excision — Cure. 11th mo. 29th, 1823. A poor widow, aged about sixty-four years, was attacked about a week ago, with strangulated hernia, which was regarded by her medical attendant as colic, until, finding his remedies fail, he was led, after several days, to make a closer investiga- tion of the case; when he discovered a tumour in her left groin. I saw her, for the first time, yesterday afternoon and evening. Her stomach had been retentive for two days previously; it even retained castor oil very well; but her bowels were obstinately constipated. There was no tension or unusual tenderness of the belly, although she complained of pain and distress high up in the abdo- ENTERO-EPIPLOCELE. 151 men. Her pulse was rather frequent; but her tongue and countenance had not an unfavourable appearance. At our last visit in the evening, the patient seemed to expect an evacuation from the bowels, and we concluded to exhibit some castor oil, with an opiate, and to leave the case till morning. On visiting her this morning, we found that she had vomited the oil, and her whole aspect was more unfa- vourable. I therefore gave her an opiate, and proceeded to the operation, assisted by Drs. Uhler and Hewson. The tumour was rather large for a femoral hernia. I made a crucial incision, dissected back the corners, and divided the layers of fascia3 with considerable expedition, by the aid of the director, assisted occasionally by the handle of the scalpel. The sac was opened in the usual manner, and a small portion of bloody fluid escaped. On enlarging the orifice, some very dark-coloured and hard omentum came into view, one portion of which felt almost like bone; but no intestine was apparent. I turned aside the omentum, and then discovered a small portion of very dark-coloured bowel. As the omentum was considerably in the way, I cut it off. It did not bleed, and yet there was not the least cadaverous smell from the sac. On examining the stricture, it was found very firm. I very cautiously divided it with the blunt- pointed bistoury, until I could pass my finger into the abdomen. It was now found that the omentum about the stricture was firmly adherent to the intestine. With my finger, I cautiously separated the adhe- sions, and returned the parts into the abdomen. I also separated some adhesions within the cavity. The wound was dressed with adhesive strips. The patient bore the operation well. 152 ENTERO-EPIPLOCELE. Evening. The patient presents rather a discouraging appearance. Her countenance is more sunken, and her tongue somewhat dark. She has slept almost constantly since the operation. Pulse firm, about 100. There is still great uneasiness in the abdomen, with weakness of stomach, and considerable inclination to vomit. The bowels have not been opened. 30th. Morning. Pulse 100, full and soft; temperature natural; tongue moist, furred, and less dark; counte- nance improved. The patient vomited twice during the night, and also discharged flatus per anum twice. She slept well, but still complains of pain, and a sense of fulness in the stomach and abdomen. She took one grain of opium, and three-fourths of a Seidlitz powder, during the night. Directed one-fourth of a Seidlitz powder to be taken every half hour. — Evening. Pulse 112, less full and regular. The patient has slept considerably, has vomited twice, and has had one fecal discharge. The pain in the abdomen continues. 12th mo. 1st. The patient has had five evacuations. She took one grain of opium since last visit. Pulse 100; tongue moist. Pressure on the abdomen gives her pain, but the belly is flaccid. — Evening. Pulse 96; tongue furred; no tension of the abdomen. The last stool took place about 9 o'clock this morning. The Seidlitz pow- der has been given regularly, and the patient has taken one grain of opium. She complains of great pain about the umbilicus. Ordered to continue the Seidlitz powder until the bowels are moved, and to take a grain of opium every six hours, if restless. 2d. Pulse 100; tongue somewhat dark and dry; face flushed; some tension of the abdomen, but no pain. The patient complained of difficulty in passing urine, and the ENTEllO-EPll'LOCELli. 153 catheter was introduced. Ordered to omit the opium and continue theSeidhtz powder. — Evening. Pulse 112; tongue moist; skin natural; tension and pain in the ab- domen; no stool. Ordered castor oil, a table-spoonful every two hours, and an opiate, if restless. 3d. Pulse, tongue, and skin continue in the same state. The patient vomited once in the night, passes urine freely, and has had natural stools. The abdomen is less tense, but is still painful. Treatment continued. Evening. The patient has passed a considerable amount of flatus, but has had no stool. The pain in the abdo- men slight. Treatment continued, and an enema of flaxseed-tea directed. 4th. Pulse 100; skin natural; tongue somewhat dry. The patient has had three stools. The pain and tension of the abdomen slight. Treatment continued. Ordered a diet of chicken-water, whey, &c. The wound dressed with simple cerate. 5th. Pulse 112; skin and tongue as at last visit. The patient has had about five discharges from the bowels. The tension of the abdomen is diminished, but the pain continues. Ordered to omit the oil, but to continue the Seidlitz powder, and if necessary, the opiate. — Evening. Tension and pain diminished; pulse 100. The patient has had several stools without medicine. Treatment continued. 6th. Pulse 100; skin natural; tongue rather dark and dry; slight pain in the umbilical region; very little tension of the abdomen. The patient had one stool last evening. She rested well through the night. The wound is suppurating moderately. Ordered the Seid- litz powder to be taken three times a day. Treatment and regiincn continued. 20 154 ENTERO-EPIPLOCELE. 7th. Pulse 100; the tension and pain have ceased; the bowels act freely. Treatment continued. 8th. Pulse 90; wound suppurating moderately. Every thing looking favourably. Treatment continued. This patient recovered perfectly. CASE XXVI. Irreducible Enter o-Epiplocele — Stercoraceous Vomiting Operation — Death. 2d mo. 15th, 1819. I was called by Dr. Dewees to see, with him, a widow lady aged sixty-seven years. She had been afflicted with hernia since the birth of her first child, which must have been many years ago. She represented that she had always, since that time, had a tumour in the part, which was generally about the size of an Ggg, but sometimes larger. She had been labour- ing under strangulation since the evening of the tenth instant, when, in a fit of coughing, the part became strangulated. Dr. Dewees had ascertained the existence of hernia, a few hours before I was called, and imme- diately requested a consultation. On examination, at this time, he found the matter which she had thrown from her stomach, stercoraceous. On my first visit I was struck with the peculiar situa- tion of the tumour. It appeared to be in the upper part of the thigh, extending across it, and I could trace it along the internal abdominal ring, as is usual in ingui- nal hernia. I was strongly inclined to believe that it ENTERO-EPIPLOCELE. 155 was femoral, but the size of the tumour exceeded that of any femoral hernia I had ever seen before. After dehberating on the case, Dr. Dewees and my- self concluded to recommend the operation at once^ and it was most readily submitted to by the patient. An anodyne enema was given, and two grains of opium were administered by the mouth. At this time the pa- tient had a tolerably good pulse, and no cold or clammy sweats; her tongue was rather dark; and her bowels somewhat tender to the touch. I made a crucial incision through the integuments, and dissected up the four flaps; then, principally by the aid of the grooved director, I divided several layers of fascia, and after dissecting carefully downward, I at last opened the sac, and exposed a large mass of omen- tum. I found considerable difficulty in this part of the operation, in consequence of there being no fluid be- tween the sac and the omentum. After I had fairly un- covered the omentum, still greater difficulties assailed me; for I found this mass firmly impacted together by pretty strong bands of adhesion: there was no appear- ance of intestine. I had no doubt of the existence of strangulated bowel, but the question was, where to find it; and I concluded that the only way to get at it was to lay open the omentum. After having penetrated for some depth through the centre of the mass, I at last found an aperture, through which I pushed my finger, and felt the bowel, contained as it were, in another sac. I now dissected through the omentum more freely, and brought a portion of intestine into view. It was of a very dark colour. Some fluid, of a bloody colour, was contained in this inner sac, hut it was free from the cada- verous smell of a mortified part. I pushed my finger 156 ENTERO-EPIPLOCELE. down by the side of the bowel and felt a stricture, which I divided inwards, in a direction towards the pubis, and pretty readily returned the bowel into the abdominal cavity. The vomiting ceased, and her distress left her im- mediately afterwards, yet her strength gradually de- clined. She was much disposed to coma. Surgical aid, in this case, came too late; for, though the patient was certainly relieved by the operation, in forty-eight hours afterwards she died. The omentum was per- mitted to remain where we found it. No post mortem examination took place. CASE XXVII. Irreducible Enter o-Epiplocele — Stercoraceoiis Vomiting — Operation — Intestine black — Death, 11th mo. 20th, 1822. I was called this day, in con- sultation with Drs. Griffith and Hewson, to see the Widow L., an elderly woman who had been affected with an irreducible femoral hernia of the left side, for nineteen years. It was unusually large, and of an ob- long shape, extending, I suppose, at least eight or ten inches from above downward, and about six inches in width. At its lower part it formed an irregular apex. On the morning of the 17th instant, as she rose from her bed, she was suddenly attacked with severe pain, and an additional descent and sudden strangulation took place. Immediately after this, she had an evacua- ENTERO-EPIPLOCELE. 157 tion from the bowels. Various attempts were made by Drs. Griffith and liewson to reduce the part, but with- out success; and ultimately I was called in consultation. When I saw the patient, her countenance was good and lively; her tongue moist, slightly furred, and rather whitish than dark. The abdomen was soft and natural, and was very little sensible to pressure, except in the vicinity of the stricture. The tumour was painful when pressed. She complained of general distress. Pulse about 130 in the minute. On examining the vomited contents of the stomach, they were found completely stercoraceous. This patient reminded me very forcibly of the preceding case. On examining the tumour, I thought I very distinctly perceived a fluctuation. As the patient at once consented to the operation. Dr. Hewson, who was the operator, commenced the neces- sary preparations. A full dose of laudanum was given. A crucial incision was made over the most promi- nent part of the tumour, but was not extended over the whole tumour. After dividing the integuments, Dr. H. soon came down upon a firm fascia, and there appeared a small point, rising rather above the general level, which, on being touched, gave the impression to the fincer of a fluctuation underneath. It was concluded to open the sac at this point, which was cautiously done. The sac was found to be remarkably thick. All the layers of fascia) appeared to be completely identified, and had formed an investment of the thickness of a quarter of an inch. This, I presume, depended on the Ions: continuation of the disease in an irreducible form. When the sac was laid open, a mass of omentum was displayed, through which several small apertures were 158 ENTERO-EPIPLOCELE. discovered, and through these apertures passed a small portion of bloody-coloured serum, such as we often find in a hernial sac. The case was less embarrassing than that just de- tailed, because the serous and bloody fluid which passed through the apertures in the omentum clearly indicated the course that ought to be pursued. The Doctor broke through the arch formed by the omentum, and brought into view a portion of intestine that, by candle-light^ appeared quite hlack and mortified; but it was destitute of any cadaverous fetor. The stricture was now divided directly upward, so that the finger could be passed into the cavity of the abdomen, by the side of the bowel; and, with rather more difficulty than common, the intestine was reduced. The patient supported the operation very well. The omentum was permitted to remain undisturbed. 21st. I saw her again in consultation. She had passed a more comfortable night than might have been expected, but still the bowels were not opened, and yet the sufferings of the patient were greatly dimi- nished. 22d. We found her this morning, in articulo mortis. She has had no evacuation of the bowels since the operation. This patient lived, contrary to all expectation, for several days longer, but finally died. MORTIFIED OMENTUM. The several methods of treatment, which relate to the excision of expatriated omentum, have also been ENTERO-EriPLOCELE. 159 proposed, when this part is in a state of mortification. These have been so fully examined in the preceding section, that it is deemed unnecessary to recapitulate them. Believing that the excision of a large mass of omentum is attended with risk by any method, I have pursued the practice of leaving the mortified portion in the wound, relying upon the efforts of nature to effect its separation from the sound parts. This process may be assisted by the gradual, yet very gentle pressure of a ligature around the root of the diseased mass, in such a manner that the patient may at any moment unloose it, if he should feel pain or sickness. This plan has been strongly recommended by Hey, and pursued by him successfully in three cases detailed in his valuable work. A case fell under my care some years ago, in which this practice was successfully adopted. It was pub- lished in the Eclectic Repertory, Vol. I. p. 13, from which it has been extracted. CASE XXVIIT. Entero-Epiplocele — Mortified Omentum — SlougMng of the mortified mass — Recovered. On the third day of the Third month (March,) 1810, my immediate attendance in consultation was requested by my friend Dr. Samuel Tucker, of Burlington, N. J. The patient was a farmer of middle age, who led a laborious life, was of temperate habits, and the parent of six children. 160 ENTERO-EPIPLOCELE. He had been occasionally afflicted with scrotal her- nia for fifteen years, but had never worn a truss, or disclosed his situation to any person. When it proved troublesome, he had been in the practice of reducing it ivithout difficulty. On the morning of the 28th of Second month, while in the act of lifting a heavy log, a portion of the abdo- minal contents was suddenly protruded through the ring, and became strangulated. He had an alvine dis- charge immediately after. From the period that Dr. Tucker first saw him, until I was called, he had diligently resorted to the most ap- proved plans of reduction; viz., taxis, venesection, applications of ice to the tumour, tobacco injections, warm bath, &c. &c., but all without effect. When I saw him, his chief distress appeared to arise from vomiting and hiccough; the latter always occurred after drinking. His pulse was remarkably tranquil; tongue moist, and but slightly furred; no tension or ten- derness in the abdomen; and it was not until the latter part of that day that he was sensible of darting pains, which occasionally extended from the strictured part towards the abdominal cavity. The tumour was of con- siderable size, and rather firm to the touch. As Dr. Tucker had decided on the necessity of the operation previously to sending for me, it only remained for us to obtain the patient's consent; but this was rather difficult, for he was very indecisive, sometimes partly consenting, and then refusing. It was night when I visited him, and under all circumstances, it ap- peared as if nothing could be done until daylight. The mildness of his symptoms reconciled us more readily to this conclusion. He had slept well the preceding ENTERO-EPIPLOCELE. 161 night without an anodyne. A small enema containing tincture of opium was given him, and directions were left to repeat it in an hour, if the patient should be rest- less. Dr. Tucker and one of his friends saw him about sunrise. He walked from his bed-chamber into the common room, handed chairs, invited them to sit down, said he had passed a good night, and in fact had quite abandoned the idea of having any operation performed. I saw him soon after; and we again endeavoured to explain to him the extreme danger of his situation, and he at last consented to the operation. An opiate was exhibited, and he was placed on a table. An incision was made through the skin, suffi- ciently large to allow a free examination of the parts about the neck of the hernial sac. While carefully dissecting through the integuments, three arteries were divided and secured by ligatures; the largest was found running directly across and just below the neck of the tumour. Several tendinous stricturing bands were brought into view and divided; but after every apparent external cause of stricture was removed, the prolapsed parts were still irreducible. The incision was extended alono- the scrotum nearly to the bottom of the tumour, and the hernial sac was laid open. A fluid of a bloody colour issued from it. It was now evident that the chief seat of the stricture was in the neck of the sac; it was contracted firmlv round the protruded parts. The tip of my finger was introduced as a director for the blunt-pointed bistoury, with which it was readily divided. Its contents consisted chiefly of omentum, of which 21 162 ENTERO-EPIPLOCELE. there was a much larger portion than would have been imagined from the size of the tumour. I should guess there might have been nearly eight ounces. Along with this, and lying in the very centre of the omentum, was a portion of intestine, which passed about an inch and a half beyond the stricture. It appeared nearly natu- ral, but the omentum was in a very different state; a considerable part of it was sphacelated, particularly its exterior surface, which was quite black, and its vessels were greatly distended with coagulated blood. Some other portions were of a light mahogany colour, and were brittle when placed between the fingers. The cen- tral part of the mass was chiefly natural. The intestine was speedily reduced; but for reasons to be hereafter assigned, the omentum was left in the wound. Three sutures were used in uniting the lower part of the incision, so as to close it as nearly as was practicable without compressing the omentum. Soft and light dressings were applied over the whole. The patient appeared faint about the close of the operation; he was presented with a little wine and wa- ter, but it was rejected by the stomach. He was now placed in bed, and soon sunk into an easy and profound sleep. He was in this state when I left him, about an hour and a half after the operation. His pulse was fuller and yet free from tension. A very light diet of chicken-liquor, barley-water, &c. was directed. Also ol. ricini, half an ounce every two hours until it operated. In a letter from Dr. Tucker, he reports: " Our patient rested well the night after the opera- tion. He took four or five spoonfuls of castor oil; it ENTEUO-EPIPLOCELE. 163 began to operate at four o'clock in the morning, and relieved his bowels five or six times. I left directions in the evening, that if the oil operated excessively, it should be checked by taking five drops of laudanum. His wife gave him the laudanum about noon the next day. " Monday evening, 5th. His bowels had not been moved since noon. I directed him to take the oil again until it operated. No fever; pulse 75. " Tuesday morning, 6th. Rested well last night; no fever or pain; pulse 75. Castor oil has operated twice. " Evening — the same. " Wednesday morning. Did not sleep well last night. When disposed to sleep, started, which gave him some pain, and prevented its recurrence for some time. He does not, however, appear to be worse. No fever; pulse 75. Takes chicken-broth, barley-water, &c." On the 11th of the month I visited him in company with Dr. Tucker. He was then perfectly free from pain and fever; no tension or tenderness in the abdomen; union, by the first intention, had taken place in the part of the wound approximated by sutures; and the living omentum situated within the wound, and in contact with the edges, appeared to have adhered to them, and to have closed the cavity of the abdomen. Subsequent information from Dr. Tucker enables me to state, that on the 18th the last portion of the un- sound omentum sloughed away, leaving the living part divided into two distinct portions, suspended from the wound by two necks. On the 21st, a ligature was applied to one half the omentum, in the manner recommended by Hey; viz., 164 ENTERO-EPIPLOCELE. rather slight at first, and increasing gradually as the patient could bear it. On the 25th it Avas perfectly black and flaccid, and was removed by scissors. On the 26th a ligature was applied to the remainder, and at this time the wound had cicatrized, except where the tumour was suspended from it. In both cases there was a considerable oozing of blood after the omentum be- came black, but surrounding the part with lint put a stop to it. On the fifth day from the application of the last ligature the tumour was removed. In about five weeks after the operation the patient began to walk about the house; and in eight weeks he resumed his agricultural avocations, and ploughed a large field for the reception of Indian corn. Since this period he has enjoyed very excellent health, and wears a truss to guard him from future danger. It has been urged against this practice, that the sloughing of a large mass of omentum may cause great derangement of the parts within the abdominal cavity. That the adhesions formed about the ring, may draw the stomach and arch of the colon out of their natural position, and the patient may ever after be subject to those, afflictions which depend on a displacement of vital organs. Instances are on record of patients who have been obliged to walk with the body bent forward, from this cause; and who have been obliged to take their meals in this posture, to prevent the immediate rejection of their food. These cases are, however, exceedingly rare, and are not even noticed by many experienced authors who ENTERO-EPIPLOCELE. 165 have written on hernia. Numerous instances of irre- ducible hernia present themselves, in which large por- tions of omentum have been firmly fixed in a hernial sac for many years, without producing these distress- ing consequences. Is it not rational to conclude, that in a large majority of cases of this kind, the system exerts that wonderful power with which it is endued, of eluding difficulties, and becoming inured to conditions which a priori we might suppose highly injurious? It is not intended, however, to convey the idea, that this practice is entirely free from objections; but that it is attended with less risk than any other plan which has been proposed. It has been previously stated, that a portion of bowel frequently descends behind an irreducible omental rup- ture, and there becomes strangulated. If the surgeon should succeed in reducing the intestine by taxis, the omentum which remains in the sac may still be sub- jected to a stricture, by which its vitality will be de- stroyed. Under these circumstances, an abscess is formed, through which the diseased mass is discharged. The inflammation which attends this process, may produce adhesions about the neck of the sac by which it will be effectually closed, and a radical cure thus effected. A case of this description fell under the care of my friend and former pupil. Dr. Thomas Yardley. An account of which he has kindly furnished me for pub- lication. 166 ENTERO-EPIPLOCELE. CASE XXIX. Gangrenous Omentum discharged by Abscess — Radical Cure. "3nsult Dr. Physick; he was affected with the usual symptoms of a calculus in the bladder. Dr. Physick did not examine him particularly, but recommended him to my care, as a proper patient for the Pennsylvania Hospital, where he might undergo the operation of lithotomy. After his admission, on attempting to sound him, he complained very much of exquisite pain; the parts were irritable to an unusual degree. No stone was disco- vered by the examination. My colleagues joined me in efforts to discover a stone by the usual means, but without success. The patient suffered from agonizing pain, which attacked him in frequent paroxysms, and resembled exactly " fits of the stone." After remaining for a considerable length of time in the Hospital, and undergoing a variety of treatment, he was discharged without being materially benefited, and returned to his friends. The final issue of the case I never heard. CASE XXIX. I was called to visit a middle aged married lady in this city, who was affected with similar symptoms. She was naturally of a very delicate constitution, and of a nervous temperament, and had borne a number of children. URINARY BLADDER. 311 She was attacked with this affection of the bladder, soon after the birth of a child. Her paroxysms of pain were violent, and resembled exactly the symptoms pro- duced by stone. She was repeatedly sounded, but no cal- culus was ever discovered. Aftersuffering intensely from these paroxysms for several months, her symptoms dis- appeared, and siie was restored to her usual health. I am aware that the above cases do not afford con- clusive evidence of the existence of this disease. Pa- tients may labour under stone in the bladder, and may be repeatedly sounded, before it is discovered. Yet the examination may ultimately prove successful. The cal- culus may be removed by an operation, and the patient be finally restored to health. A case of this kind once occurred in my own practice. It may also happen that a calculus will become en- cysted, and in this way the symptoms will disappear, leaving the impression on the mind of the surgeon, that the symptoms arose from some other cause. The question can only be settled by post mortem examination, and an opportunity has been furnished me of testing it by this method. I have also the plea- sure of adding Dr. Physick's testimony to my own, on this point. In conversation with him some years since on this subject, he informed me, that he had a gentle- man under his care, who was affected with clearly marked symptoms of stone in the bladder. Dr. P. sounded him frequently without being able to discover a calculus. The patient finally died. On examination after death, the bladder was found to be healthy, and no stone could be found. After stating this case, the Doctor very emphatically 312 -TIC DOLOUREUX OF THE said, " The disease is tic doloureux of the bladder." The definition appeared truly concise and appropriate, and 1 have therefore adopted it. Since that period a case has fallen under my own observation, which is very conclusive, and has con- firmed me in the opinion, that the urinary bladder is the subject of an extremely painful nervous affection, which cannot be designated by a term more appropriate than that which is here adopted. The following case is a fair example of this disease. CASE XXX. Tic Doloureux of the Bladder. 1th mo. 4th, 1822. Died this morning in the Pennsyl- vania Hospital, R. N., a young woman who has been an inmate of the institution for several years, during which time her sufferings have been extreme. She was afflicted with violent paroxysms of pain, exactly resembling fits of the stone. She also appeared to labour under disease of the uterus; had obstinate amenorrhoea; sometimes a vomiting of blood. Various expedients were tried for her relief — in fact, it seemed as if all the medical and surgical skill of the institution was fairly exhausted on this afflicted, but patient sufferer! She was placed under the care of phy- sicians as well as surgeons. Among the palliative reme- dies in her paroxysms of agony, for so they may be called, venesection and opiates afforded most relief. Toward the conclusion of her disease, she had two URINARY BLADDER. 313 attacks of dysentery, and was happily released from her troubles in the last attack. The symptoms of stone in the bladder were so strongly marked in this case, that the patient was often sounded. I beheve all the surgeons searched for stone. I did, repeatedly, and even proposed dilating the ure- thra, with the sponge-tent, in order to introduce the finger into the bladder. To conclude, it may be said, that I never witnessed a case of more severe and protracted suffering, nor one in which the symptoms of calculus in the bladder ap- peared to be more clearly marked. And now, behold the humiliating evidence of the fallibility of human judgment, as displayed in the dissection of R. N. Examination — Post mortem. The bladder contained no stone, and, Avith the kid- neys and ureters, presented a perfectly natural appear- ance! The stomach, liver, lungs, and uterus, all healthy! The intestines gave some signs of recent disease. The pancreas was indurated. The muscles red and firm. There was a considerable amount of fat over the abdo- men, and on the omentum, although the patient had a very bloodless aspect. I was informed by Dr. John Rhea Barton, who was present at the dissection with Dr. Price and others, that if he had been called upon, in the dissecting room, to select a subject whose viscera, generally, presented a sound and natural appearance after death, he could scarcely have selected one better adapted to the purpose than the mortal remains of the deeply afflicted R. N. 40 CHAPTER V. NEPHRITIS. The occurrence of nephritic affections, especially in gouty patients, is familiar to most medical men, and in the usual course of practice, cases of this kind require their care. The seat of this painful affection is primarily in the kidneys, and from thence is propagated to contiguous parts. It is caused by the formation of small calculi in the kidney. Should one of these pass through the ure- ter into the bladder, a train of most painful symptoms ensue, often causing great alarm to the patient and his friends; but seldom being really dangerous. The disease is generally marked by some peculiari- ties which enable the practitioner to form a correct diagnosis, by referring to the anatomical and relative position of the parts. The pain is referred to the hy- pogastric region, having an obliquity in its course, cor- responding to the passage of the ureter from the kid- ney to the bladder. The testis on the affected side is frequently retracted and painful. This fact admits of a ready explanation, when it is recollected, that the ure- ters and vasa deferentia decussate each other in the neighbourhood of the part where the former enter the bladder; hence, irritation and pain in the one, can readily be propagated to the other. The bladder and urethra, like continuous hnks in the chain, may experience the NEPHRITIS. 315 effects of morbid association. The whole nervous sys- tem may be brought into sympathy. That important viscus, the stomach, may largely participate, and be- come involved even in convulsive action, manifested by severe retchings and vomiting. At the very onset of the disease, the patient is often instantaneously affected with great prostration of system, pallor and coldness of surface, and feebleness of circulation. I have known syncope to take place at the accession of the attack. In illustration I will state a case. CASE XXXI. A merchant of middle age, a strong, well-built man, of temperate habits, and possessing considerable firm- ness of disposition, went to bed in usual health. He awoke in the night, and felt a disposition to urinate. He rose from bed for the purpose, and was instantly seized with such intense pain, that before his w ife could assist him, he sunk on the floor in a state of syncope. The alarm of his family can be easily imagined. I saw him shortly after the attack. His skin was cold; his pulse very feeble; and his pain was agonizing. Under proper treatment he speedily recovered. In the early part of my practice, I once saw this dis- ease assume an intermittent form. As the case was un- usual in its character, I will detail it from my note book. 316 NEPHRITIS. CASE XXXII. In the winter of 1806, 1 was called one night from my bed, to visit J. R., a very respectable man, who had exchanged the active life of a farmer for the more easy situation of a citizen. I found him sitting in a chair before the fire. The pain corresponded with the course of the ureter. The testis participated. He had a scalding sensation when he attempted to pass water, accompanied with tenesmus, nausea, and vomiting. The case was clearly marked, and depended upon the pas- satre of a calculus through the ureter. I directed a dose of calomel and opium, and was about to put other plans in operation, when, before even taking the medicine, he said he felt relieved, and that he thought something had passed from " a small passage into a larger one." I now obtained from him a clear history of the case. His first attack was some days before I saw him; it took place while on a journey from New England to Philadelphia. It came on about 3 o'clock in the morn- ing and lasted about two hours. It had recurred regu- larly every succeeding night since, about the same hour, and its duration was nearly the same. When the attack commenced, he always found that he was more easy in the erect, than in the recumbent posture; and it was his uniform practice to rise from bed, and set before the fire until it went off. At the time he sent for me, the pain was more violent than he had ever before ex- perienced. This proved to be the last paroxysm. Nephritic cases are often sudden in their accession, and speedy in their termination. The patient is in- NEPHRITIS. • 317 stantly sensible of relief when the calculus falls into the bladder. I have met with some cases where the disease as- sumed a more chronic form, confining the patient to his room and bed, and attended with inflammation and fever. It would seem as if the calculus was too large readily to pass, and considerable time was required be- fore this could be accomplished. Treatment. The course of treatment to be pursued in the acute form of nephritis is worthy of close consideration. I feel more inclined to examine this part of the subject, from the fact, that our practice is these cases is not uniform and settled. I believe no small injury may result from associations formed in medical minds, which must have an important bearing on therapeutics. Thus pain and inflammation are so intimately associated, that it seems in some instances impossible to dissever them. Hence, in all those cases of acute nephritis, one of the first indications founded upon this conclusion is, the free use of the lancet. And where inflammation is to be measured by intensity of pain, it may be free in- deed. Let us now advert to the circumstances which may be reasonably supposed to attend an acute attack of this disease. I^et us take the case of the merchant, who at the very onset was prostrated by syncope, almost instantaneously, on the floor of his bed-chamber. What caused this intense pain? was it not the passage of a hard and irregular shaped calculus along the extremely sensitive ureter? Was not the pain suddenly induced by the operation of a mechanical cause? That inflammation may follow as a consequence of » 318 . NEPHRITIS. contusion, or lesion of parts, is a principle fully un- derstood. But that it should be coeval with the inflic- tion of the injury, is utterly at variance with every principle of surgical pathology. Time must be allowed for the injured vessels to rally their energies, and assume those peculiar actions which constitute inflam- mation. Does the state of the system, in a case of severe ne- phritis at its commencement, warrant the conclusion that the lancet is required? Are pallor and coldness of surface, with a very feeble state of the circulation sud- denly induced, to be accepted as evidence of inflamma- tion? The answer is, no — but the reverse — a state of prostration. It may be argued, that even if inflamma- tion does not exist, free bleeding may be useful in order to prevent it. To discuss this question, would at present be out of place; were it entered upon, I think it might be shown by a reference to practical facts, that the doctrine of free bleeding as a prophylactic for inflammation, is far more vulnerable than is imagined. I regard it as un- sound. Perhaps at a proper time, an opportunity may be offered for further illustration. It may be urged that patients speedily recover after free bleeding. It may be replied with equal truth, that they speedily recover without it. The violent case of the merchant was a striking instance in point — he did not lose one drop of blood. I have long since established it as a medical axiom, when a practitioner can achieve his object by a resort to safe, yet efficient remedies, without drawing largely on the constitutional energies of his patient, it is wise to pursue the former course, and reserve the latter for NEPHRITIS. 319 those emergencies which do arise, where minor consi- derations must yield to the one all-absorbing indication, the rescue of the patient from the grasp of a fatal dis- ease. These observations may be regarded as a digres- sion; but they are felt to be due to the profession, inas- much as physicians, as well as surgeons, are deeply inte- rested in the disease now under consideration. The primary indications of treatment in acute ne- phritis, are the following: — x\llay pain and irritation by the use of opiates, having reference at the same time to the state of the bowels. If they should be confined, it is advisable to combine some purgative with the opiate. I often combine two grains of opium with ten or twelve grains of calomel made into pills. Sometimes if the symptoms are very urgent, I have given three grains of opium with the calomel. In many cases I find a dose of castor oil with laudanum, to answer quite as well as the calomel. Should the stomach reject medi- cine, I resort to anodyne injections, preceded by laxa- tive enemata, if there is reason to suppose the rec- tum contains feces. When we consider the contiguity of the rectum to the urinary bladder, it is easy to understand how a soothing impression made on the former, will be speedily propagated to the latter. Hence an anodyne injection sometimes acts like a charm. Could it be readily obtained, it might often supersede the exhibition of remedies by the mouth. Another indication consists in restoring heat and action to the surface, and particularly the lower extre- mities. Thus sinapisms maybe applied advantageously. Immersion of the feet and legs in warm, or rather hot water, to which either mustard or coarse salt is added. Spirituous fomentations to the abdomen are frequently 320 NEPHRITIS. useful. If relief is not procured, a warm bath would be clearly indicated. These means seldom fail to miti- gate the violence of the disease. The calculus passes into the bladder, and full relief is obtained. When the stomach will bear mild demulcent drinks, they should be freely used. Sometimes before a resolution of the paroxysm, reaction takes place, and fever ensues; then depletory measures are indicated. In vigorous subjects general and topical bleeding are required. In subjects of a more delicate and feeble character, cupping or leeching about the lumbar vertebrae, aided by laxatives, warm bath, and injections, may prove sufficient. Some- times I have directed large quantities of tepid flaxseed- tea to be introduced into the bowels, to act upon the principle of a warm bath internally applied. Anodyne injections, when the pain is severe, are particulary pro- per. Among the internal remedies, the spirits of turpen- tine may be noticed. One of my medical friends who has been severely afflicted with nephritis, has great con- fidence in the remedy. When he feels the least threat- ening of an attack, such as uneasiness and slight pain about his kidneys, he will alight from his carriage before the shop of any apothecary, and take twelve drops of spirits of turpentine on loaf sugar, with decided relief. Patients liable to nephritis, often consult their phy- sicians relative to prophylactic remedies. To enter fully into this subject would lead beyond my pre- scribed limits. I would briefly remark, that in some instances the uva ursi, the extra soda water, and the Saratoga water, appear to have produced a very salu- tary effect. In this city, the scabious tea is a popular remedy. It has derived much of its reputation from NEPHRITIS. 321 a valuable old citizen long since deceased, ^^ho was in extensive business as a biscuit baker. He was severely afflicted with the disease, and had derived such relief from the scabious, that at the proper season to gather the plant, he was in the practice of going out with his work-people, and his horse and cart, in order to collect it in the fields round the city. Having obtained a large supply, he always kept it for gratuitous distribution, humanely desiring to confer that relief on others, which he believed he had himself received from the scabious. It has been stated, that nephritic affections, depend- ing on calculi formed in the kidney, although very pain- ful, are seldom of a dangerous character. It now remains for us to consider another morbid condition of this organ, by which its structure is gra- dually altered, and the death of the patient is the re- sult. The following cases illustrate this singular form of disease. CASE XXXIII. Irritable Bladder and Urethra — Disorganization of the Kidney — Death . 4th mo. 10th, 1821. B. R., a respectable merchant, about sixty years of age, had long been subject to gout, and had lately been affected with much depression 41 332 NEPHRITIS of mind, arising from a failure in his business. For more than a year preceding his death, he had suffered grievously from an affection of the urinary organs. He was obliged to make frequent efforts to pass small quantities of urine, during the day and night. His ure- thra was extremely irritable, and the most careful at- tempts to introduce the catheter caused him great pain. I at one time suspected the presence of a calculus, but could discover nothing by sounding. Sometimes he had retention of urine requiring the use of the ca- theter. Under these circumstances, various means of relief were tried without any salutary effect. His strength gradually failed, his complexion assumed a sallow hue, and his whole aspect exhibited evidences of great bodily suffering. It was also evident, that a sensitive and upright mind participated largely in his afflictions. For several weeks before his death, he was affected with severe muscular spasms, affecting both the upper and lower extremities. There was also an evident failure in his mental faculties a short time before his death. Dissection, The body was examined by my friend Dr. Harlan. The internal surface of the bladder was interspersed with dark spots, curiously intersected by whitish bands, which did not rise above the surface of the mucous membrane. At the neck of the bladder around the opening of the urethra, there was a red spot about the size of a quarter of a dollar. The kidneys were unusually small. The infundibula NEPHRITIS. 323 of the left kidney were very large, and the pelvis of the right was very much distended, giving the idea of a stricture in the ureter, and a regurgitation of urine into the pelvis; though no stricture was discovered. The prostate gland presented a healthy appearance. From the symptoms, I had expected to find great thickening of the mucous and muscular coats of the bladder. I have extracted from my notes the following case, which, in some respects, bears a strong resemblance to the preceding. CASE XXXIV. In the autumn of 1809, 1 was consulted by an elderly and highly respectable man, from Lancaster county, who came to this city seeking relief from a very painful dis- ease. He had been for a long time affected with an irritable bladder, and an exquisitely morbid sensibility of the urethra, such as I had never seen surpassed. In his attempts to pass urine, which were frequent, he com- plained of severe pain and scalding in the canal, parti- cularly towards the arch of the pubis. The pain ex- tended from the point of the penis inwards, and ho experienced slight uneasiness about the neck of the bladder. He once had a stricture, but this had been cured. I sounded him for stone, examined the prostate, but could find nothing which satisfactorily explained the symptoms. He was under my care for many weeks, and a variety of remedie? were tried. His complaint 324 NEPHRITIS. was palliated, but he was not permanently benefitted. He used opium, hyosciamus, stramonium, colchicum, *kc., also, emollient injections into the bladder. He re- turned home for a while, and subsequently came back to the city, and placed himself under the care of seve- ral different practitioners. I was called in consultation with one of them, but, as on other occasions, no treat- ment successfully reached the case. He returned home, and died. I have been informed by one of his friends, that he was examined after death, and that one of his kidneys "was nearly wasted away." His friend was not a medical man, and of course I could not obtain the pre- cise information which I desired. The symptoms bore a strong resemblance to the preceding case, and I pre- sume depended on the same cause. In reflecting on these cases, which, so far as my ob- servation extends, are of an unusual character, I have arrived at the conclusion; that if I should again meet with a case of extreme sensitiveness in the bladder and urethra, which could not be referred to any obvious cause, as an enlarged state of the prostate, stricture of the urethra, &c., and which differed from tic doloureux of the bladder, in the permanency of the pain, and the absence of paroxysms, I should refer it to some organic lesion of one or both kidneys, depending on a gouty diathesis. Whether this disease could be eradicated by any method of treatment, pursued in the early stage, I am altogether unable to determine from experience. Per- haps the application of setons, or perpetual blisters on NEPHRITIS. 325 each side of the spine, or even in a remote situation, might exercise a favourable influence, by causing a weaker part in the vicinity of the affected organ, and thus acting on the principle of metastasis. The remedies adapted to the treatment of gout, when it occurs in other parts of the body, might also deserve a trial. CONCLUSIOxN. My observations on Strangulated Hernia, and some of the Diseases of the Urinary Organs, are now closed. It will be perceived, that the volume is plain and prac- tical in its character. It is said, every man who thinks theorises. Perhaps, in one sense, this may be true. It is very important, however, that theories should be based on a solid foundation. I hold myself still to be a student in the school of practical observation, and am frequently picking up useful knowledge in passing along, and am gaining much information from others. I have found out too, that it is an easy matter for an ingenious man to tell what he thinks, and sometimes very useful hints are to be obtained from the thoughts of others. Still it must be acknowledged that more is to be learned when a man, whose accuracy is to be depended on tells what he really knows. In common with the elder members of the profession, the writer has seen beautiful theories erected — the builder has ad- mired the work of his own hands — a few simple facts have undermined the foundation — the edifice has tot- tered, and fallen into ruins. It is my earnest desire to avoid every just cause for the suspicion of vanity and egotism. In putting forth this book, the writer could not gain his own consent to send it out, w'ith abun- dance of apologies for its numerous imperfections, while at the same time he did not believe such to be the fact. CONCLUSION. 327 Still he is fully aware that an author may view his first book, a little like a parent views an only child. He may see beauties where a disinterested person could not discover any thing uncommon. What is more important, there rnay be defects and blemishes, which strike the eye of a stranger very forcibly, that the parent, having the child constantly before him, is scarcely sensible of their existence. My object is the diffusion of medical information, in the hope that it may prove useful to others. Could the reverse be sup- posed, or that any one part of the work might lead to unsound conclusions, or incorrect practice, most sincerely would the author regret that any of his ma- nuscripts ever found their way into the hands of the printer. So far, then, from shrinking from criticism in the spirit of candour and kindness, it is rather invited, never expecting to be too old to learn, and always desiring to have my errors corrected, and improvements placed in their stead. It is one of the consolations of my life, to look around among an extensive acquaintance with the medical pro- fession, some of them older, but a very large majority younger than myself, and to feel that they are my bre- thren. Although we may honestly differ in some of our medical views, yet I can rejoice in extending the hand of friendship to a numerous body of fellow labourers in a profession which has for its object the mitigation of human misery, and the preservation of human life. It is a profession which is high, and ought to be dignified and honourable; but neither its dignity, nor its honour, can depend upon high sounding titles, nor upon name. It must be bottomed on solid attainments in medical science, and separated from merely sordid views. That 328 CONCLUSION. it is still associated with many of the imperfections, which are incident to humanity, is freely confessed, while it may not be arrogant to believe, that the nume- rous streams which flow forth from the fountain of medical science, are still extending their blessings over the land, carrying with them healing virtue and conso- lation to the afflicted and destitute. There is now rising around us a large body of ta- lented and enterprising young men, who have most in- dustriously engaged in the arduous and responsible duties of medical life. I view with deep interest their rising usefulness, and heartily wish them good speed. To the elder members of the profession, and to some in an especial manner, my feelings are of no ordinary character. As the circle narrows, our attachments in- crease. How many have we followed to the grave. The very hands that were so frequently stretched forth to parry the arrow of the archer, have at last fallen powerless from his wound. Some of us have stood side by side in times of public calamity, sharing a com- mon danger, while some of our brethren have fallen in the conflict. The pestilence which walketh in dark- ness, and wasteth at noon day, we have seen to come up into the windows, and to cut off the young men from our streets. We still remain — we still join in daily professional intercourse, and with entire confidence in each other, share mutual responsibility. How can it be other then, that the humble hope should be in- duljied, that when we also shall fall before the arrow of the destroyer, the spirits that are now congenial, shall still be permitted to mingle together, and enter upon a more exalted sphere of existence, where hope will be lost in fruition. FINIS. EXPLANATION OF THE PLATES. Plate I. View of the interior of the lower part of a bladder, with a diseased prostate gland, to show the effect of an enlargement of the third lobe of that gland. a, a. Section of the parietes of the lower part of the bladder, posteriorly. b, i, b, b. The diseased prostate gland greatly de- veloped. c, The third lobe of the gland enlarged and project- ing into the cervix of the bladder, where it overhangs the internal orifice of the urethra, like a valve. d, The membranous portion of the urethra. e, e. Part of a catheter introduced through the ure- thra into the bladder, lifting up the third lobe of the prostate gland in its passage. J\f. The vesical extremities of the ureters. g, g. The seminal ducts. Plate IL Interior view of the bladder, with enormous deve- lopcment of the third lobe of the prostate gland. a, a. Section of the parietes of the bladder. h, b, b. Enlarged prostate gland. c. Third lobe of the gland projecting far into the bladder. 42 330 EXPLANATION OF THE PLATES. Plate III. Section and interior view of the fundus of a bladder taken from a subject with enlarged prostate gland; show- ing the columns of the mucous coat, caused by long- continued dysuria, and resembling the muscular columns of the heart. Plate IV. Fig. 1. A canula for guiding a catheter into the bladder, in cases of enlarged prostate gland. «. The eye of the instrument. b. Two marginal notches corresponding exactly with the eye of the instrument. Fig. 2. The extremity of the same instrument, with the catheter introduced; to show the obliquity of the extremity of the latter, on passing out at the eye. a. The end of the catheter. Fig. 3. A view of Dr. Parrish's favourite bistoury for the operation on strangulated hernia. \ ■<\ a >si?^. > ■^'"^^. .# ^■^ FL J. a ^3S^£. r>rittttn fr'int ..Yirfure hu .1 n riii^ f iin ■ If/imoM y fluvfl l.!P> Pi. II. 'i t If}., . "■ 'JtJMi, ''I X / •*^i Drn'unfTO'm.lfatu.ri. hv J. Draxfton . Lo'tnun ifVutnlZitfi''-* Pi III ^ ^-■/•^T""' ^ I A J. Draulon l.f.'tnuT'^ ■* ' '^:ifuf Pi J V Fi'Si. k