XV. ON THE PRESENCE OF OXALATE OF LIME IN The author observes that the appearance of octohedral crystals in the urine appears first to have been described by M. Vigla. Dr. Bird in England, and afterwards M. Donné in France, recognised the very frequent occurrence of such crystals, and by re-actions observed by the microscope, inferred that these crystals were oxalate of lime. A case occurred to Dr. Jones, in which, from the quantity of octohedral crystals passed, he was able to examine the sediment in nearly the usual method. He remarks: "The states of the system in which octohedral crystals are seen, vary exceedingly. In acute rheumatism and gout, chronic rheumatism, aggravated hypochondriasis and hysteria, and diabetes, I have found such crystals. In one case in which the rheumatism was slight, the influence of diet and exercise on the mixed deposit of urate of ammonia and oxalate of lime was made the subject of experiment. In other cases in which these octohedral crystals occurred, the symptoms were altogether different; irritation of the urinary organs being the most prominent. The concretion of the crystals, into oxalate of lime-gravel, seemed in one patient to be the cause of this diversity of symptoms. "The connection observed by MM. Donné and Rayer, between seminal weakness and oxalate of lime, I found in two cases; and in a third, where three small oxalate of lime calculi had been passed at long intervals, and octohedral crystals were constantly found in the urine, on one examination a few dead spermatozoa were seen." 147. John Saunders, æt. 47, formerly a soldier, was admitted an out-patient of St. George's Hospital. The deposit which had been continually observed in the urine was examined in March 1843, and found to consist of innumerable crystals of uric acid mixed with octohedral crystals. For twenty years he had suffered more or less from urinary disorders. 1828 he had rheumatic fever, and was confined to bed eleven weeks. The small joints of the fingers are larger and stiffer than natural, and occasionally very painful. In "The urinary sediment was thrown on a filter and washed with distilled water. The red residue was dried, reduced to a fine powder, and treated with dilute hydrochloric acid, which left most of the uric acid undissolved. The acid liquid was filtered, and ammonia gave a very considerable precipitate, when added in excess. When evaporated to dryness, and heated on platinum, the muriate of ammonia was driven off, and the residue effervesced strongly when thrown into dilute acid, and left an alkaline ash when heated more highly. The ash was with difficulty soluble in water, and gave a precipitate with oxalate of ammonia. Hence some organic acid salt of lime was present; and as oxalate of lime is known to occur in octohedral crystals, the conclusion that these crystals were oxalate of lime is most probable." 148. The author examined the urine of a patient of Mr. Cutler's, and at the same time three small renal calculi which passed in July, August, and September, and afterwards another which passed in October. The urine under the microscope contained multitudes of octohedræ mixed with some crystals of uric acid. All the calculi were found to consist of oxalate of lime mixed with uric acid. He examined the urine in cases of acute rheumatism, and always detected the presence of these octohedral crystals. This deposit is also frequently found mixed with urate of ammonia in chronic rheumatism. In one case he was enabled to make some experiments regarding the effect of diet and exercise on the deposit, and he observed that the octohedral crystals seemed to vary in quantity at different periods of the day. Then follow the daily results of this experiment, which are given very minutely for the four weeks during which it lasted. The author states that it would be easy to multiply examples of the connection between octohedral crystals and rheumatism; but, as no variation in the treatment of ordinary rheumatism seems to be thereby indicated, the fact seems only interesting, as showing the close connection between the red deposit and octohedral crystals. He adds, octohedral crystals in the urine, and symptoms of a totally different kind frequently occur together. The patient complains of pain in one or both loins, of frequent desire to pass his water, which is sometimes in very small quantity; at other times so much as to simulate diabetes. There are sudden calls to empty the bladder, and if it is delayed, considerable pain is produced. The urine when examined contains only a slight cloud, which does not disappear with heat. In other respects is appears natural. When examined with the microscope, the cloud is seen to consist sometimes entirely of octohedral crystals. More frequently of these crystals mixed with globules of mucus, and sometimes with large and small scales of epithelium." The above symptoms closely resemble those produced by a small calculus in the kidney, and in one case they suddenly ceased after sharp pain in the course of the right ureter, and slight retraction of the testicle. Dr. Jones concludes by remarking, that the treatment which proved most beneficial in these cases of irritation was that which improved the general health. In two of Mr. Cutler's patients the symptoms followed mental anxiety. Medicines had little effect, but as the causes for anxiety disappeared, the symptoms ceased. This paper is a valuable contribution to our knowledge of urinary disorders. We shall return to this important volume in our next number. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. By Samuel Ashwell, M.D., Member of the Royal College of Physicians, London; Obstetric Physician and Lecturer to Guy's Hospital. 8vo. Part III. London, 1844. Highley. HAVING formerly spoken of this work very highly, our task will not now be a difficult one, especially as the present and concluding part is not only equal but superior in practical excellence and research to its predecessors. We have often had occasion, during the last twelve or fifteen years, to remark, that there was no lack of diligence or talent in the obstetric department of medicine, and the book of Dr. Ashwell, although we do not always agree with him, fully sustains its reputation. It is clear he intended it to be a safe guide in practice, and while he has proved himself thoroughly acquainted with the controverted pathology of female disease, he has avoided obscuring his own views by any forced attempt to make them harmonise with the opinions of others. His work is eminently his own; he has seen frequently that about which he has written; he has tested the worth of his diagnostic precepts by constant and accurate observation, and his treatment of the various maladies is evidently the result of most extensive and often very successful practice. Nor is there any dogmatism or vanity about his writing. The style is plain and forcible; without any dark passages, incomprehensible either by himself or his readers. In some places, however, Dr. Ashwell takes a little too much for granted; he supposes that others are as fully acquainted with female disease as he is, and therefore occasionally neglects a full exposition of his prognosis and remedial management. We are glad Dr. Ashwell has had courage and candour enough to confess that, even with all the advantages of Guy's Hospital and a very extensive private practice, he has seen but few examples of some of the very rare diseases: this is as it should be, and affords a striking and instructive contrast to some of the French writers, who, as in M. Lisfranc's instance, exhaust the credulity of their readers by announcing the startling fact, or rather falsehood, that they have seen "hundreds of cases of a disease," (anteversion of the womb,) which, even in the largest fields of observation, occurs only extremely rarely. We congratulate the author on another important point-the authentication of his cases. We are aware this cannot always be done, but certainly it is a matter of great moment. The case is the portraiture of the history of the disease, and as there are false facts in philosophy, so there may be false cases in medicine. Dr. Ashwell has given great additional authority to his work by an admirable selection of cases; the truth and reality of which no one can doubt. Let us not be misunderstood: we say again it cannot always be done; but we are sure it is often neglected where no real difficulty exists. Dr. Bright, a distinguished colleague of the author, and some other writers, have advantageously availed themselves of a similar verification of their reported cases, and we trust ere long to see it far more generally adopted. The chapter on polypus contains an excellent summary, not only of the practice, but likewise of the pathology, of this important disease. Dr. Ashwell has not failed to embody some of the peculiar views of Lisfranc, nor has he hesitated to express his disapprobation of some of his measures. We agree with him in his incredulity about such frequent "enucleation," and in his condemnation of severe and violent efforts to abstract polypi while still high up in the uterine cavity. There is much force in Dr. Ashwell's remark," such things don't require to be done in England." But we think the author is yet too cautious and careful about removal by the knife, as we are confident, in many instances, it is far better and safer than the ligature. We shall, as in our former reviews, allow the author to speak for himself in an extended analysis, assenting or dissenting as we proceed. The following is his definition of polypus : "A firm and insensible tumour, usually round and smooth, and growing by a NEW SERIES, NO. I.-I. D stalk either from the mucous lining of the uterus, or the structure beneath; its chief symptom being hemorrhage. It commences in the cavity of the womb, in the channel of the cervix, or from the os. It is often of fibrous texture, not malignant, and rarely ulcerates. It is covered by mucous membrane, and sometimes by an adventitious coat, the product of inflammation. There is little pain, menstruation is excessive, and conception may occur." Dr. Ashwell observes that polypus of the uterus, while it is not an uncommon disease, is certainly far more rare than cancer. In the following remarks we entirely concur. "There is no malady more certainly curable than polypus, although many patients have died from its accompanying bleedings, without its existence ever having been suspected, much less ascertained. The necessity for vaginal examination, where profuse uterine bleedings resist the remedies employed for their suppression, cannot be too strongly urged. In the hemorrhages of polypus, astringents are useless-the only effectual remedy is removal. "Pain can scarcely be said to be a symptom, and the first suspicion of the disease is excessive menstruation, or bleeding occurring in the catamenial intervals. Although the evacuation of the bladder or intestines is seldom prevented, it is not impossible that a large polypus, by pressure on the urethra or rectum, or both, may obstruct their functions. Hence, if the patient be strong, the loss of blood seldom attracts notice, till some of its injurious effects begin to be realized. When the digestion becomes impaired and there is leucorrhoea, deadly sallowness, difficult respiration, and other evils, then anxiety begins, and it is not long till a reluctant permission is granted to examine the state of the womb." There is considerable variety in the size of these growths. Some, not larger than a garden bean, have bled alarmingly; while a polypus exceeding a Seville orange in size, scarcely bled at all, ultimately producing irritation by its pressure on the neck of the bladder, and great exhaustion by constant and large secretions of pus. We are glad Dr. Ashwell has dwelt on this fact, as the continuance of purulent discharge, and the almost entire absence of hemorrhage, has induced most injurious delay in ascertaining, by a proper examination, the existence of the disease. The protracted inclusion of a polypus within the uterine cavity is perplexing and dangerous; as a small one, especially if it be soft and vascular, may give rise to alarming and even fatal losses of blood. We insert the following case entire, as it is an instructive one, and conveys a good idea of the author's clear and forcible style of writing. "Such instances have occurred in my practice, and a hard polypus of moderate size, now in Guy's Museum, removed when it had very partially descended through the cervix, fully attests the truth of the preceding observations. This polypus grew so slowly, probably because the hemorrhages had been frequent and excessive, that three years elapsed prior to its coming within the reach of the finger. During this period, the patient had been repeatedly seen by eminent obstetric physicians, who in vain attempted to restrain the bleedings. At first, as she believed it to be entirely useless, I was not permitted to make an examination; but on my assuring her, that although the growth had not yet descended into the vagina, it might speedily do so, she consented; and I had then the opportunity of touching a small, hard, and insensible tumour, just emerging from the os. The bleeding which followed alarmed me so much, that, before leaving the house, I attempted its removal. Excision was out of the question, and with a very long instrument, I made two unsuccessful efforts before I could apply the ligature. When completed, the canule were some way within the channel of the cervix. It was an anxious case, for there were several bleedings within the first two days, and from one of them it did not seem for some hours that she would have rallied. During the twelve days the ligature was applied, the patient was never quite free from uterine pain. Often I had to loosen the whip-cord, to foment the abdomen with hot gin and laudanum, and twice a day to give an opiate. At length, however, to my great gratification, both the instrument and the polypus came away. The swollen legs and feet, the deadly paleness of the skin, and the universal anæmia gradually vanished, and the patient is now, after a lapse of several years, in confirmed health." There can be no doubt, that women have died from hemorrhage, or the diseases resulting from loss of blood, where a polypus had really descended into the vagina, which might have been early and easily removed; and many have been lost from similar bleeding, where the growth was shut up in the uterine cavity, and beyond the reach of surgical assistance. M. Lisfranc would probably deny the accuracy of this last conclusion : Dr. Ashwell, we can easily suppose, would decline an operation in cases where Lisfranc would unhesitatingly attempt one. The former practitioner would dread inflammation and gangrene as the consequence of the necessary surgical violence, M. Lisfranc would proceed regardless of such a risk, trusting, for his justification, to the certainty of death from continued hæmorrhage if the polypus were not destroyed. We do not regard our author as an infallible guide on such a point, but we confess we had rather submit to his discretion, than resign ourselves to the headlong procedure of the French surgeon. Nevertheless we do think there are cases where fatal hæmorrhage might sometimes be averted by greater boldness and an earlier operation. Dr. Ashwell has furnished a full and correct account of the various kinds of polypus, and the reader will obtain much valuable information from its perusal. The principal pathological conditions of these growths consist in their proneness to bleed, their insensibility, and their nonreproduction after removal. Our author regards the hæmorrhage from polypi as furnished by distinct blood-vessels existing in the growth itself, and of course communicating with those of the uterus. In the following remarks we concur. "Polypi are devoid of nerves, and are therefore insensible. Occasionally, however, it is probable, that portions of the uterus grow into, and form a part of the morbid structure itself; thus accounting for the continued, and sometimes severe pain produced by the first application and subsequent tightening of the ligature. It is not difficult to imagine, where a polypus has originated in the structure of the uterus, deeper than the mucous membrane lining its cavity, that for a time it will be imbedded amongst the uterine fibres; but as it grows towards the cavity, these fibres being distended and thinned, will eventually give way; and the polypus will henceforth be covered almost entirely by mucous membrane, that portion of the polypus only nearest to the uterus being invested by the proper tissue of the organ." "I may say, that I have very seldom tied a polypus where any bleeding occurred after the lapse of a few hours from the noosing. And further, that in only two or three instances after either tying or excision, has there been any alarming loss of blood. "It is not easy to understand, if the bleeding did not arise from the polypus, how Dupuytren could be correct in asserting, that, after his many operations by excision, alarming hemorrhage scarcely ever occurred. Bleeding, after either ligature or excision, will probably depend on the con |